TORCH

Pathway of HSV infection

(PICTURE) 1) Herpes virus enters body through skin or ucous membranes 2) After intiial infection, HSV settles in nerves near the spine 3) HSV travels along the nerves, back to the skin to form new blisters

An reverse approach: use treponemal EIA to screen

(PICTURE) Traditional versus Reverse sequence

EIA tests: Syphilis

+ Automation- run more tests without adding staff + Fewer false positives + No false negatives due to protozone + Automated readout with hardcopy of results + May detect late latent or late syphilis - Treponemal antibodies remain for life in most patients - Can't be used to determine adequacy of treatment - May be less sensitive than RPR or FTA-ABS in primary - May not detect the chronic false positive

HSV Seroloy

+ active lesion or infecton not required + once infected, antibodies persist for life + less expensive than cultue or PCR - cannot discern site of infection - must NOT automatically assume a genital lesion found in a seropositive individual is due to HSV - time lag between infection and antibody production

Darkfield for Syphilis

+ can be done while patient awaits + relatively inexpensive - requires living, motile treponemes - requires large number of organisms - not specific

DFA for Syphilis

+ highly specific + does NOT require living organisms + can be done on same smear as darkfield + can be done off-site - requires fluorescent microscope in good working order - numbers dependent - takes considerably longer than Darkfield

Primary genital herpes

- "Classic" presentation > characteristic vesicular lesions > tender inguinal nodes > headache, photophobia, neck stiffness - no clinical distinction between primary episodes casued by HSV-1 versus HSV-2

Impact of gential herpes: neonatal herpes

- 1 in 3000 births in US Northwest - may cause permanent neurological damage despite appropriate antiviral theraphy - highest risk of transmission associated with new maternal infection late in gestation - often transmitted during delivery - most severe cases due to HSV-2 but HSV-1 can also cause neonatal herpes

Congenital Rubella Syndrome (CRS)

- 20% of the CRS children suffer severe congenital abnormalities > neurosensory deafness > blindness > congenital heart disease > microcephaly with mental retardation > growth retardation > hepatosplenomegaly - 10-20% die within first year of life - risk warrants vaccination >= 3 months prior to conception

How is Zika diganosed?

- A doctor or other healthcare provider may look for similar types of infections - A blood or urine test can confirm a Zika infeciton if specimens are collected early in a person's infection > PCR (early) > IgM (later)

Where has Zika been found?

- Before 2015, Zika outbreaks occured in Africa, Southeast Asia, and Pacific Islands - currently outbreaks are in many countries an territories

Syphilis: Methods for Detection

- Darkfield - Direct fluorescent antibody (DFA) - Immunohistochemical staining (IHC) - PCR - Rabbit infectivity testing

Why differentiate between HSV1 and HSV2?

- HSV1 and HSV2 have diffferent rates of recurrence HSV1 - 55% experience at least one recurrence annually - not likely to shed virus in absence of symptoms - episodic antiviral therapy as outbreaks occur HSV2 - >95% experience at least one recurrence annually - very likely to shed virus in absence of symptoms - continous suppressive antiviral theraphy Improved Dx —> Improved Patient Management

Toxoplasma Serology

- IFA and EIA tests for IgG and IgM antibodies are the test most commonly used today

Toxoplasma serology

- IgG anibodies usually appear within 1 to 2 weeks of infection - peaks within 1 to 2 months, fall at variable rates and usually persist for life - titer does not correlate with th eseverity of illness

CMV: Serology

- IgG appears 6-8 weeks following primary infection, then remains detectable for life - IgM produced during primary infection; in some individuals, remain detectable for up to a year - IgM may also be produced during reactivation - DETECTION OF CMV IGM is NOT DIAGNOSITC OF PRIMARY OR EVEN RECENT, INFECTION

HSV IgG Response

- IgG to type-COMMON antigens by 1-6 weeks - IgG to type- SPECIFIC antigens appears y 1-3 months in nearly all patients - in a very small subset of HSV-2 infected patients, type-specific IgG may take 6 months to appear

Serology Toxopamsa: IgM

- IgM -: excludes recent infection - IgM +: difficult to interpret (LACK OF SPECIFICITY) - toxoplasma specific IgM antibodies may be detected by EIA for as long as 18 months after acute acquired infection

Immunoglobulin Response in HSV infection

- IgM arrives ~7 days before IgG - IgM can reappear during recurrences

Indirect treponemal detection (Syphilis)

- Nontreponemal tests - Treponemal tests

Zika Diagnosis: Molecular detection

- RNA NAT (nucleic acid testing)- serum collected during first two weeks after symptom onset - also performed on urine samples collected less than 14 days after symptom onset - (+) RNA NAT- confirms Zika virus infection and no additional testing - (-) RNA NAT- does NOT exclude Zika virus infection and serum should be analyzed by IgM antibody (serologica) testing

Why measure type-specific antibodies? (HSV)

- Stop the spread of HSV (asymptomatc or unrecognized infection) - Allow for proper diagnosis and treatment - Decrease the risk of HIV transmission by individuals co-infected with HIV and genital herpes - Identify uninfected women at risk of acquiring HSV during pregnancy - Identify pregnant women with HSV2

Toxoplasma

- Toxoplasma gondii- protozoan parasite that infects most species of warm blooded animals including humans causing the disease toxoplasmosis - definitive host: Felidae (CAT family) - 22% seropositive rate in U.S. - most persons asymptomatic

Clinical Features: Toxoplasma chorioretinits (ocular toxoplasmosis)

- acquired infection with Toxoplasma in immunocompetent persons - asymptomatic - 10% to 20% with acute infection may develop cervical lymphadenopathy and/or flu-like illness - clincal course is benign and self-limited; symptoms resolve within a few months to a year - Immunodeficient patients- CNS disease but may have retinochoroiditis or pneumonitis - AIDS patient: toxoplasmci ecephalitis- most common cause of intracerebral mass lesions and is thorught to be caused by reactivation of chronic infection - Immunisuppressive drugs: newly acquired or reactivated latent infection

TORCH Epidemiology

- affect 1-5% of all live births - General symptoms: Premature birth Growth retardation Neuorlogical abnormalities Damage to ee, liver, heart and ear bone lesions Microcephaly, hydrocephaly, seiures and psychomotor retardation accompany these malformations

Treponemal Tests

- antibody detection specific to treponemal organism Examples: - FTA-ABS - Treponema pallidum particle agglutination (TP-PA) - Enzyme immunoassay > whole treponemes > cloned antigens - Hemagglutinations (TPHA)- replaced by particle agglutination - Western blot

Why switch to EIA/CIA? Syphilis

- automated (high throughout) - low cost in high volume settings - less lab occupational hazard (pipetting) - no false negatives due to prozone reaction - objective results - some EIA/CIAs detect IgM antibodies (diagnosis of early syphilis)

IgG avidity: what is it? (CMV)

- avidity: strenght with which IgG binds to antigen - increases with lenght of tme since primary infection - measurement based on differential elution of antigen-bound IgG (wash buffer containing urea compared to wash buffer alone) - low avidity usually indicates infection within the previous 5 months - high avidity essentially excludes the possibility of primary infection within previous 4 months

Epidemics and Outbreaks (Rubella)

- before vaccine become available in 1969, rubella epidemics occured every 6-9 years - children ages 5 to 9 were primarily affected and many cases of congenital ruella - currently, rubella infects mostly young immunized adults rather than children (~10% of young adults currently susceptible to rubella)

How does Zika affect pregnancies?

- can pass from a pregnant women to her utersu during pregnancy or around the time of birth - not known how often this happens - can cause microcephaly and other severe brain defects

Non-type specific serologic assays (HSV)

- commercally avaialable - inexpensive - Dual ELISA system > one plated coated with crude lysate of HSV1 infected cells > another plate coated with crude lysate of HSV2 infected cells > both type-common and type-specific antigens present

HSV Antigen Detection

- commercially available - inexpensive, quick - sensitive variable (35-100%) - requires lesion

Syphilis

- corkscrew- shaped bacterium (spirochete), Treponema pallidium - Other subspecie cause different disease: > pertenue- yaws > carteum- pinta > endemicum- bejel

HSV PCR

- extremely sensitive (3 to 10X more sensitive) - test of choice for CSF - can subtype - expensive, techinically difficult - serum from infected adolescent/adut rarely, if ever, positive - no FDA-cleared product available

What are the symptoms of Zika?

- fever - rash - joint pain - conjunctivitis (red eyes) - muscle pain - headache

Gential herpes- atypical symptoms

- fissures (vullvular, penile, perianal) - reddening on buttocks, thighs - back pain - painful urination - arthralgia

Sporozoites

- go through differentation into tachzoites once the infection is ready to take place

HSV Culture

- gold standard - requires live virus, infected cells and special care to retain viability during transport - false negative culture = ~50% of the time since virus only shed from a recurrent lesions fro 2-3 days - expensive, TAT 2-3 days - not useful for asymptomatic patients - ELVIS Shell vials faster and cheaper

Serolog Toxoplamsa: IgG

- immune status - positive IgG titer- infection with the organism some time - IgG +: IgM test with minimal nonspecific reactions such as IgM-capture EIA

Rubella Clinical Features

- incubation period: 14 days (12-23 days typically) - prodrome of low grade fever - lymphadenopathy in second week - maculopapular rash 14-17 days after exposure

Cytomegalovirus (CMV)

- infects epithelial cells of many organs: kidney, liver, salivary glands, gut, lung and pancreas - infects monocytes, neutrophils, lymphocytes, endothelial cells - infection rate 70% in US cities, >99% in parts of Africa - major routes of transmission are transmisison are intimate contact (saliva) and blood transfusion

Rubella Laboratory Diagnosis

- isolation of rubella virus from clincal specimen (nasopharynx, urine) - significant rise in rbella IgG by any standard serological assay - (+) serologic test for rubella IgM antibody

Herpesviridae (herpesvirus)

- large family of DNA virus that cause diseases in animals - derived form Greek word HERPEIN ("to creep") - cause latent, recurring and/or lytic infections (once infected always infected) Cytomegalovirus and Herpes Simplex Virus

Rubella

- latin word "little red" - German measles - primarily affects the skin and lymph nodes - caused by rubella virus (NOT the same virus that causes measles) - transmitted by secretions from nose or throat - generally mild disease in children - primarily medical danger is INFECTION OF PREGNANT WOMEN

Rubella Disease

- less severe in children than adults - transmissable between 1 week before rash onset and 1-2 weeks after the rash disappears - less contagious than rubeola (measles) - lifelong immunity to the disease follows infection - safe and effective vaccine available

Rubella Vaccine

- live virus (RA 27/3 strain) - 95% effective (range, 90-97%) - lifelong immunity - one shot at 15 months, another at 5 years - administered with measles and mumps as MMR

Type-specific assays: Western blot

- looks for differences in reactivity pattern to really many HSV1 and HSV2 proteins seperate on the basis of molecular size - pretreatment of serum with HSV1 or HSV2 lysates sometimes required to facilitate interpretation of difficult samples - require a remarkably high level of technical and interpretative expertise - gold standard - complicated and expensive; not commercially available

Toxoplasma IgG avidity

- low avidity: infection within previous 5 months; however, low avidity IgG sometimes fond more than 8 months after infection - high avidity esentially excludes the possibility of primary nfection within previous 4 months - low avidity index: <0.20 - intermediate avidity index: 0.20-0.25 - high avidity index: >0.25

Diagnostic dilemma: CMV IgG+IgM+

- may indicate mom infecterd after conception; increased risk of congenital infection - infection may occur prior to conception; CMV IgM may last >1 year, and sometimes appears during reactivation of latent infection - IgG avidity- apporoximating time of infection

Diagnostic dilemma: IgG+IgM+

- may indicate mother infected after conception, increased risk of congenital infection - alternativelym infection may have occured prior to conception; Toxoplasma IgM may last up to 2 years - Toxoplasma IgG avidity- best tool for approxiamting time of infection

Rubella Virus

- member of TOGAVIRIDAE (RNA VIRUS) - spherical with diameter of 60-70 nm - single stranded RNA genome - only one serotype of the virus is known; no cross-reaction with other togaviruses - rapidly inactivated by chemical agents, low pH, heat, UV light

How is Zika spread?

- mosquito bites - pregnant woman to her fetus - sex with an infected person - laboratory exposure - spread through blood transfusion - no reports of infants getting Zika through breastfeeding

CMV and pregnancy

- mother to child transmission during pregnancy can lead CMV infection of fetys - if child survives can show mental retardaion, hearing loss, small head - cases of CMV transmission due to non-primary infection (1-2.2% casees) - primary maternal CMV infection carries a risk of mother to child transmission (24-75%) - assessed by measuring CMV IgG and IgM at prenatal visit - detection of IgG but not IgM = infection occurred prior to conception; change of congenital infectio very low

Syphilis Transmission

- mucous membrane contace > sexual intercourse - congenital - transfusion - accidental

Bradyzoites

- multiply slowly n tissue cysts

Prevention

- no drugs - freezing foods (to 10.4 degrees F) and cooking foods to an internal temperature of 125 deg F to kill cysts - santirary kitchen techniques - pregnant women and children away from household cats and cat litter - disposing cats litter daily (oocysts do NOT become infective till after 24 hourS) - feeding cats dry, canned, or boiled food and discouriging hunt and scavenge - washing hands

Toxoplasma Treatment

- not needed for healthy person who is not pregnant - symptoms usually go away within a few weeks - recommendeed for pregnant women or persons who have weakend immune systems

Toxoplasma Laboratory Diagnosis

- observation of parasites from patient specimen - isolation of parasites from blood or other body fluids by intraperitoneal inoculation into mice or tissue culture - mice should be tested in the peritoneal fluid 6- 10 days post inoculation - no organisms are found, serology can be performed on the animals 4 to 6 weeks post inoculation - detection of parasitic genetic maerial by PCR- detecting congenital infections in utero - Serological testing- rroutune method of diagnosis

Reactivation stimuli (HSV)

- physical or emotional stress - fever - exposure to UV light (sunlight) - tissue damage - immunosuppression

Prevention (Zika)

- protect from mosquitos

Maculopapular Rash (Rubella)

- rash can look like many other viral rashes - pink or light red spots which may merge to form evenly colored patches - itchy, lasts up to 3 days

Asyptomatic viral shedding (HSV)

- reflects virus reactivation and shedding in the absence of lesions or symptoms - higher the clinical recurrence rate, the higher the rate of asymptomatic shedding - couples discordant for HSV2 infection, 70% of transmission events occured when source partner was asymptomatic

Rubella pathogenesis

- respiratory transmission of virus - replication in nasopharynx and regional lymph nodes - viremia 5-7 days after exposure with spread to tissues - placenta and fetus infected during viremia

Tachyzoites

- responsible for acute infection by rapidly mulitplying inside a host whic causes overall population of parasite to grow (more agressive paraste stage - moves around the body and invades target host cells) - multiply within a cell until cell lysis and new parasites can move on to infect more target host cells - mainly found in

Congenital Toxoplasmosis (Clinical Features)

- result form acute primary infection acquried by mother during pregnancy - incidence and severity vary with the trimester during which infection is acquired - most infants with subclinical infection at birth will subsequently develop signs or symtpms of congenital toxoplasmosis (blindness, mental retardation) unless the infection is treated - Ocular Toxoplasma0 retinochoroiditis, frequent result of congenital infection - patients are often asymptomatic until second or thrid decade of life, when lesions develop in the eye - maternal immune status assessed by measuring Toxoplasma-specific IgG and IgM at first prenatal visit - detection of IgG but not IgM- infection occured prior to conception; chance of congenital infection very low

Sabin Feldman Dye Test

- serological test to diagnose toxoplasmosis - sensitive and specific neutralizatio test - live organisms are lysed in the presence of complement and IgG T.gondii- speicific antibody - detect certain antibodies that prevent methylene blue dye from entering cytoplasm of Toxoplasma organisms - patient serum treated with T.trophozzoites and complements as activator and then incubated - after incubation, methylene blue added - if anti-Toxo antibodies are present in the serum (activated by complements and lyse parasite membrane, Toxoplasma trophozoites are not stained (positive result)) - no antibodies, trophozoites with intact membrane are stained and appear blue under microscope (negative result)

Most common tissue sites

- skeletal muscle - myocardium - brain May remain throughout life of the host

What is Zika Virus?

- spread to people primarily through the bite of an infected Aedes species mosquito (Ae. Aegypti and Ae.albopictus) - usually no symptoms or mild symptoms - during pregnancy can cause microcephaly and other severe brain defects

Nontreponemal tests (Syphilis)

- standardized preparation of cardiolipin, cholesterol, and lecithin is used in nontreponemal tests today - Nontreponemal tests used today: VDRL, USR, RPR, TRUST - RPR and TRUST- either charcoal or paint pigment to visualize reaction - Particles get caught in lattice formed by antigen- antibody reaction - RPR currently most widel used nontreponemal test Advantages: + inexpensive + titered to follow treatment efficacy + frequently seroverts following adequate treatment + chronic biological false positive (BFP): indicator of autoimmune disease Disadvantages: - high rates of false positives in some population - prozone reactions (strongly positive= overwhelms) - affected by temperature (62C) - may be nonreactive in early & late infection

IgG avidity

- strength where IgG binds to antigen - inreases with length of time since primary infecion - measurement based on differential elution of antigen-bound IgG using wash buffer + urea vs wash buffer alone

Clinical presentation: recurrent genital herpes versus primar

- symptoms typically less severe - number of lesions typically fewer - time of viral shedding shorter (2-5 days vs 12 days in primary)

Herpes Simplex Virus

- two specific types: HSV-1 and HSV-2 each containing A) type-common antigens (for example gC, gE, gH) B) type-specific antigens (gG1, gG2)

Disadvantages of non-type-specific serologic tests

- typing results reliable only when one ELISA is (+) and other (-) - Infecting HSV type based on relative reactivities of dual-posiitve specimens (incorrect for 38-48%) - major problem identifying new HSV2 infectin in HSV1 positive patients- memory response to type common antigens

Does Zika cause Guillain- Barre syndrome (GBS)?

- uncommon illness of the nervous system in which a person's own immune system damages the nerve cells causing muscle weakness amd sometimes paralysis - strongly associated with Zika but only a small proportion of people with recent Zika infection get GBS - CDC is continuing to invesitgate the link between GBS and Zika to learn more

Factors in transmission of gential HSV infections

- unrecognized infection - asymptomatic viral shedding

Zika Diagnosis: Serological detection

- virus specific IgM and neutralizing antibodies typically develop toward the end of the first week of illness - IgM (+)- four post onset of syptoms and continuing for 12 weeks - RNA NAT (-) on serum and urine= serum IgM antibody testing for Zika dengue and chikungunya virus infections should be performed - Serum samples collected >=14 days after symptom onset, with no earlier samples collected should be tested for anti-Zika virus, anti-dengue and anti-chikungunya virus IgM antibodies - qualitative detection of Zika virus IgM antibodies in serum - cross reaction with other flaviviruses and possible nonspecific reactivity - presumed positive, equivocal, or inconclusive - confirm by plaque-reduction neutralization testing (PRNT), confirm presumptive positive, equivocal, or inconclusive IgM results

How does Zika affect people?

- will no have symptoms or will only have mild symptoms - symptoms last several days to a week - people usually don't get sick enought to go to the hospital - people vary rarely die of Zika

Serology: problem situtation

1. IgM (+) but IgG (-) > IgM (+): suspicion > blood should be withdrawn to weeks later and tested together with the 1st specimen > if the 1st specimen was from early infection: patient should have highly positive IgG and IgM antibodies in the 2nd sample - if the IgG (-) and IgM (+) in both specime, the IgM is a FALSE POSITIVE 2. IgG (+) and IgM (+) - seoncd specimen should be drawn - both specimens submitted together to a reference lab which employs a different IgM testing system for confirmation

Human infection may be acquired in several ways:

1. Ingestion of undercooked infected meat containing Toxoplasma cysts 2. Ingestion of the oocysts from fecally contaminated hands or food 3. Organ transplant or blood transfusion 4. Transplacental transmission 5. Accidental inocuation fo tachyzoites > Parasites form tsse cysts, most commonly in skeletal muscle, myocardium and brain; these cysts may remain throughout the life of the host

Indirect treponemal antibody EIA principle:

1. Treponemal antigen bound to microtiter well 2. Antibody in serum binds to antigen 3. Enzyme labeled antihuman IgG binds to serum IgG bound to antigen 4. TMB substrate reacts with enzyme, producing color read spectrophotometrically at 450 nm

HSV IgG EIA principle (HerpesSelect)

1. Type-specific HSV recombinant antigen bound to microtiter well (gG1 or gG2) 2. Antibody in serum binds to antigen 3. Enzyme labeled antihuman IgG binds to serum IgG bound to antigen 4. TMB substrate reacts with enzyme producing color read spectrophotmetrically at 450 nm

Toxoplasmosis

1. Unsporulated oocysts are shed in the cat's feces 2. Although oocysts are usually shed for 1-2 weeks, large numbers may shed. Oocusts take 1-5 days to sporulate in the environment and become infectiove. Intermediate hosts in nature become infected after igesting soil, water or plant material contmainated with oocysts 3. Oocysts tranform into tachyzoites shortly after ingestion. These tachyzoites localize in neural tissue and develop into tissue cyst bradyzoites 4. Cats become infected after consuming intermediate hosts harboring tissue cysts. Cats may also become infected directly by ingestion of sporulated oocysts. 5. Animals bred for human consumption and wild game may also become infected with tiisue cysts after ingestion of sporulated oocysts in the environment. Humans can become infected by any of several routes: 6. Eating undercooked meat of anumals harboring tissue cysts 7. Consuming food or water contaminated with cat feces or by contaminated environmental samples 8. Blood transfusion or organ transplanatation 9. Transplacentally from mother to fetus 10. In the human ost, the parasites form tissue cysts, most common in skeletal muscle, mycocardium, brain and eyes; these cysts may remai throughout the life of the host 11. Diagnosis is usually achieved y serology although tissue cysts in staied biopsy. Diagnosis of congenital infections can be achieved by detecting T.gondii DNA in amniotic fluid sing molecular methods

CMV IgG avidity ELISA

Avidity index interpration: < = 0.50 Low avidity 051-0.59 Intermediate avidity > = 0.60high avidity

CMV: Clinical

CMV causes 10-20% of all infectious mononucleosis cases - heterophile antibody negative (used to distinguish from EBV IM) - sore throat much milder in CMV IM vs EBV IM Major problem in HIV infected individuals - CMV retinitis in 30% of untreated HIV patients - In patients treated with antiviral drugs, incidence of CMV retinitis decreases to <5% Most common life-threatening complication in transplant recipients - CMV reactivation in 70% of kidney transplant recipients - in bone marrow transplant recipients, most common manifestation is pneumonia; 84% fatality rate

CheapTorches

Chickenpix and Shingles Hepatitis C,D,E Enterovirus AIDS (HIV infection) Paravirus B19 Toxoplamsosis OTher (GBS, Listeria, Candida, Lyme Disease) Rubella Cytomegalovirus Herpes simplx Everything else sexually transmitted (Neisseria gonorrhea, Chlamydia, Ureoplasma urealyticum, human papillomavirus) Syphilis

Routine infectious disease screening (US, pregnant women)

Hepatitis B virus carrier status HIV infection Group B streptocoocal colonization Rubella immunity Syphilis infection

Syphilis Clinical Stages

Incubation: 3-90 days (average 21) Primary- lesion at inoculation site Secondary- disseminated Latent- no clinical signs Tertiary- clinically apparent disease (occurs in 3% of untreated patients)

Syphilis Array of CNS disorders (NOT DONE)

Meningitis - occur within 5 years of person contracting the infection Inflammatory vasculitis (meningovascular syphilis) - produce infarction in virtually any are of CNS

Serological diagnosis of syphilis

Nontreponemal tests - Rapid plasma reagin (RPR) test - Venereal Disease Research Laboratory (VDRL) test - Toluidine red unheated serum test (TRUST) Treponemal tests - Fluorescent treponemal antibody absorbed (FTA-ABS) test - Treponema pallidium article agglutination (TP-PA) test - Enzyme Immunoassays (EIAs) > Trep-Chek > Trep-Sure - Chemiluminescence immunoassays (CIAs) > LIASON > Architect - Microbead immunioassays (MBIA) > BioPlex 2200 Syphilis IgM and IgG

Antibodies in Syphilis

Nontreponemal tests - detect antibodies to biomarkers that are released during cellular damage that occurs from the syphilis spirochete Treponemal tests - antibodies that are direct result of the infection and bind to antigens from the spirochete * Anti-treponemal IgG, IgM and to a lesser degree IgA

Why not screen TORCH?

Routine screening for TORCH infections as a package is NO VALUE in pregnancy and can lead to harmful interventions - CMV hyhperimmune globulin (CMV HIG)- promise in reducing the risk of perinatal transmission (secondary prevention)

Parasite form and Location

Tachyzoites and Bradyzoites: body tissues Oocysts (cysts containing a zygote formed by a parsitic protozoan- malaria): cat feces

Dilemma of HSV IgM testing

The good: found in primary infection The bad: produced during reactivation The ugly: IgM recognizing one HSV type produced during reactivation of the other type

TORCH

Toxoplasma Other (Syphilis) Rubella Cytomegalovirus Herpes Simplex Virus

What people think they have

Women: - yeast infection - vaginitis - urinary tract infection - heat rash - allergy to condoms, spermicide, elastic/pantyhose - irritation from: shaving, douching Men: - folliculitis - jock itch - zipper burn - allergy to condoms - irritation from: tight jeans, sexual intercours, bike seat - insect or spider bites