1
Q
Clinical presentation of Mycoplasma genitalium in men?
A
Asymptomatic (70%)
Urethritis
Proctitis
2
Q
Clinical presentation of Mycoplasma genitalium in women?
A
Asymptomatic (40-75%)
Vaginal discharge
Dysuria
Cervicitis
Post coital bleeding
Lower abdominal pain
3
Q
Complications of Mycoplasma genitalium in men?
A
Epididymitis
Conjunctivitis
Reactive arthritis
4
Q
Complications of Mycoplasma genitalium in women?
A
- PID
- Tubal infertility
- Adverse pregnancy outcome
5
Q
What is gold standard diagnostic test for Mycoplasma genitalium ?
A
NAAT
6
Q
What is best specimen to send for NAAT testing for M genitalium ?
A
FVU: Men or women
vaginal swab +/- endocervical swab
7
Q
What are the indications of Mycoplasma genitalium testing ?
A
- Non-gonococcal urethritis
- Epididymitis
- Sexually acquired proctitis
- PID
- Mucopurulent cervicitis
- Contacts of a known case
- TOC 5 weeks after start of Tx
8
Q
Screen for STIs if pt present with urethritis, including:
A
1-NAAT - Gonorrhoea / Chlamydia /Mycoplasma
2-If NAAT is not available locally, take a urethral swab for gonorrhoea culture
3-Trichomoniasis - urethral swab and/or FVU sample for culture and/or microscopy
9
Q
Virulence factors of Mycoplasma genitalium ?
A
1- Adhesines
2- Antigenic variation
3-Gliding motility
4- Intracellular
5- Toxin: Nuclease
6- Immune-mediated damage
10
Q
Treatment of uncomplicated Mycoplasma genitalium urogenital infection (urethritis, cervicitis)?
A
Doxycycline 100mg bd for 7 days, followed by:
1- Azithromycin 1g orally as a single dose, then 500mg po od for 2 days (if known macrolide S or unknown) OR:
2- Moxifloxacin 400mg orally once daily for 7 days if known to be macrolide-resistant or failed treatment with azithromycin
11
Q
Treatment of complicated Mycoplasma genitalium (PID, epididymoorchitis)?
A
Moxifloxacin 400mg orally once daily for 14 days
12
Q
Treatment of uncomplicated Mycoplasma genitalium urogenital in Pregnancy or breastfeeding?
A
Azithromycin 1gm PO for 3 days.
13
Q
When treating Mycoplasma genitalium why to give doxycycline lead-in treatment?
A
reduces the bacterial load
14
Q
T/F:
TOC is recommended for all patients with confirmed M. genitalium?
A
T
5 weeks after the start of treatment
15
Q
Virulence factors of Chlamydia trachomatis ?
A
1- Prevent phagolysosome
2- Modification of membrane to avoid detection
3- Inhibits apoptosis
4- Downregulation of MHC class I and II expression
16
Q
What is the clinical syndrome caused by Chlamydia trachomatis serovars A , B & C?
A
Trachoma
“Chronic follicular conjunctivitis with corneal scarring and blindness”
17
Q
What is the clinical syndrome caused by Chlamydia trachomatis serovars D–K ?
A
Urogenital trachoma
Commonest bacterial STI in the UK
18
Q
What is the clinical syndrome caused by Chlamydia trachomatis serovars L1, L2 &L3?
A
Lymphogranuloma venereum (LGV)
More invasive, affecting lymphatics
Recent outbreaks among MSM in UK
Requires extended treatment
19
Q
Disease caused by Genital Trachoma (Serovar D-K)?
A
1-Genital tract infections:
Urethritis, cervicitis, endometritis, salpingitis
Pelvic inflammatory disease (PID)
Epididymo-orchitis
Proctitis (particularly MSM)
—————
2- Others:
Adult inclusion conjunctivitis (autoinoculation)
Neonatal conjunctivitis (ophthalmia neonatorum)
Neonatal pneumonia
20
Q
Asymptomatic genital trachoma infection contributes significantly to undetected transmission, what is the rate in male and female?
A
70% of women
50% of men
21
Q
Complications of untreated chlamydia trachomatis in female ?
A
PID
Perihepatitis (Fitz-Hugh–Curtis)
Tubal factor infertility
A 6-10 fold increased risk of ectopic pregnancy
22
Q
Commonest presentation of chlamydia trachomatis genital infection in men ?
A
Non-gonococcal urethritis (NGU)
Asymptomatic 50%
———-
Clear or white urethral discharge
Dysuria
Testicular pain and swelling (in epididymo-orchitis)
Rectal symptoms in MSM (pain, discharge, bleeding)
23
Q
T/F:
Reactive arthritis develops in 1-3% of chlamydia trachomatis genital infections?
A
Mainly in HLA-B27 positive individuals
Asymmetric oligo-arthritis
Predominantly affecting the lower limbs
24
Q
What is the Classical presentation of LGV?
A
- Primary:
Painless genital ulcer - Secondary:
Painful inguinal lymphadenopathy (‘buboes’) - Tertiary:
Lymphatic obstruction, genital elephantiasis
25
What is the Ophthalmia neonatorum?
Mother with a gonorrhoea or chlamydia during birth
5-14 days after birth
Symptoms: Conjunctival inflammation and discharge
Complications: Corneal scarring
26
What is the best sample type to send for NAAT for chlamydia trachomatis?
Female:
Self-collected or clinician-collected vulvovaginal swab (preferred)
First-void urine
Endocervical swab
---------
Male:
First-void urine (first 10-20ml)
Urethral swab if discharge present
---------
MSM:
Urine
Rectal swab
Pharyngeal swab
Multi-site testing is recommended regardless of symptoms
27
T/F:
For LGV diagnosis, a two-step approach is required?
Positive C. trachomatis NAAT from the affected site
Specific LGV typing (PCR for LGV biovar)
28
Standard Tx options for genital Chlamydia trachomatis D-K?
First-line :
Doxycycline 100mg twice daily for 7 days
Alternative:
Azithromycin 1g orally as a single dose
Other alternatives:
Erythromycin 500mg twice daily for 14 days
29
Standard Tx options for genital Chlamydia trachomatis D-K in pregnancy?
First-line:
Azithromycin 1g orally as a single dose
Alternatives:
-Amoxicillin 500mg three times daily for 7 days
-Erythromycin 500mg four times daily for 7 days or
-Erythromycin 500mg twice daily for 14 days
30
What is the highest risk of syphilis transmission during pregnancy
If occurs in the third Trimester
If 1ry or 2ry syphilis
If treated < 30 days before delivery
31
List the possible features of 2ry syphilis?
- Mucocutaneous rash
- Condyloma lata
- Lymphadenopathy
- Systemic:
1-hepatitis
2-glomerulonephritis
3-CNS
32
What are the manifestation of 3ry syphilis?
Gummatous disease (15% of patients)
Cardiovascular syphilis (10%)
Late neurological disease (7%)
33
What are the features of Cardiovascular syphilis ??
10 - 30 years - Aortitis (usually ascending):
substernal pain
aortic regurgitation
heart failure
angina
aneurysm
34
What are the features of Parenchymatous neurosyphilis (tabes dorsalis)?
15–25 years
Inflammation of the spinal dorsal column/nerve roots
lightning pains
Areflexia
Sensory ataxia Charcot’s joints
Optic atrophy
Argyll-Robertson Pupil
35
What are the features of Parenchymatous neurosyphilis ( general paresis)?
10–20 years
Gradual decline in memory
emotional lability
psychosis
dementia
seizure
hemiparesis
----------------
MRI: Cerebral atrophy, T2 hyperintensity in hippocampus/ frontotemporal regions
36
Meningovascular syphilis ?
5-12 years
Focal arteritis & Infarction
meningeal inflammation
Headache
Emotional lability, insomnia
37
What are the diagnostic CSF features in neurosyphilis ?
CSF RPR Positive : High specificity when positive
CSF TPHA >1:320 : Supporting evidence
38
What is the recommended treatment of Early Syphilis(1ry , 2ry , early latent) ?
Benzathine penicillin 2.4 MU IM single dose with lidocaine
Alternative :
-Procaine penicillin G 600,000 units IM OD for 10 days
-Doxycycline [100 mg po BD for 14 days]
-Ceftriaxone [500 mg–1 g IM or IV OD for 10 days]
-Amoxicillin [500 mg PO QDS] PLUS probenecid [500 mg QDS for 14 days]
Macrolides no longer recommended
39
What is the recommended treatment of Syphilis (Late latent, cardiovascular and gummatous syphilis)?
Benzathine penicillin 2.4 MU IM weekly for 3 weeks (three doses)
Alternative:
Doxycycline [100 mg PO BD for 28 days.]
Amoxicillin [2 g PO three times daily] (TDS) PLUS probenecid [500 mg QDS for 28 days].
Ceftriaxone [2 g IM or IV for 10–14 days]
Steroids should be given with all anti-treponemal antibiotics for cardiovascular syphilis; 40–60 mg prednisolone OD for 3 days starting 24 h before the antibiotic.
40
Treatment of Neurosyphilis including neurological involvement in
early syphilis?
1. Procaine penicillin 1.8–2.4 MU IM OD PLUS pro
benecid 500 mg PO QDS for 14 days
2. Benzylpenicillin 10.8–14.4 g OD, given as 1.8–2.4 g
IV every 4 h for 14 days
------
Alternative regimens:
1. Ceftriaxone 2 g IM or IV for 10–14
days
2. Doxycycline 200 mg PO BD for 28 days
3. Amoxycillin 2 g PO TDS PLUS probenecid 500 mg
PO QDS for 28 days
--------
40–60 mg prednisolone OD for 3 days starting 24 h before the antibiotics
41
What is the recommended timing of follow up in case of treated syphilis ?
At 3, 6 and 12 months then six monthly until RPR negative or serofast
42
What is the Tx recommendation for a confirmed congenital syphilis ?
1- First 7 days IV Benzylpenicillin (50mg/kg twice daily) for7 days
2- If >7 days (term infants) IV Benzylpenicillin 50mg/kg three times daily (total 10 days)
43
Diagnostic features of congenital syphilis ?
Infant serum TP Syphilis IgM positive, AND/OR
Sustained elevation (two samples) showing four-fold or greater RPR titre difference above maternal level
44
What are the complications of Gonorrhoea ?
A. Transluminal:
1-Epididymo-orchitis
2-Prostatitis
3-Pelvic inflammatory disease
------
B. Disseminated Gonococcal Infection (DGI):
1-Triad of tenosynovitis, polyarthralgia, and dermatitis
2-Purulent arthritis
3-Pericarditis, Vasculitis, Endocarditis& Meningitis
45
What are the risk factors of developing disseminated gonococcal infections?
1-Pregnant
2-Cisgender woman
3-Terminal complement deficiency
4-Eculizumab
46
T/F:
In managing gonorrhoea , Patients should be advised to abstain from sexual intercourse until 24h after they and their partner(s) have completed treatment
F
7 days
47
What is the Tx recommendation for Uncomplicated gonorrhoea?
First line:
Ceftriaxone 1g IM stat dose
Alternative:
1-Cefixime 400mg orally, followed 400mg dose 6-12 hours later; plus azithromycin 2g orally
2-Gentamicin 240mg IM as a single dose plus azithromycin 2g orally
3-Azithromycin 2g as a single oral dose
48
T/F:
Test of cure (TOC) is not routinely necessary for Treated gonococcal infections?
T
49
Indications for TOC post gonococcal treatment?
Persistent symptoms
pharyngeal infection
Susceptibility is unknown
Treated with anything other than ceftriaxone
Pregnant
50
What is the optimal method and timing of gonococcal TOC ?
If symptomatic: Culture -performed at least 72 h post -treatment
---
Asymptomatic : NAAT followed by culture if NAAT-positive-2 weeks post-treatment
51
how to manage gonococcal
contacts?
1-For those presenting after 14 days of exposure: treatment only following a positive test
2-For those presenting within 14 days of exposure: considering treatment
52
List 5 prevention strategy of gonococcal infections?
1-sexual health education
2-Promotion of barrier methods
3-Regular screening of high-risk groups
4-Partner notification and treatment
4-Surveillance of resistant strains through GRASP
53
Selective agar media for gonococcal growth?
Modified Thayer-Martin
New York City
GC agar
54
What are the virulence factors of gonococcal bacteria?
1-Pili
2-Opacity (Opa) proteins: (invasion of epithelial)
3-Lipooligosaccharide
4- IgA1 protease
5-Porin proteins (Por)
6-Reduction-modifiable protein (Rmp)
7-Transferrin-binding proteins
55
Mechanism of Antimicrobial Resistance in Neisseria gonorrhoea?
Penicillin:
-Plasmid-mediated (beta-lactamase)
-Chromosomal (altered PBP)
-----------
Tetracycline:
Plasmid-mediated (tetM) or chromosomally mediated
------------
Fluoroquinolone:
Chromosomal mutations in gyrA and parC
-------------
Macrolide: Chromosomal mutations or efflux pumps
-----------
Extended-spectrum cephalosporin: mosaic penA alleles, often with additional mutations in porB and mtrR
56
Treatment gonococcal ocular infection?
1-Ceftriaxone 1g IM as a single dose Plus:
2- Adjunctive cefuroxime 5% eye drops
(Hourly day and night for 48 hours, then hourly daytime only for 5 days then Maintain four times daily until complete resolution)
57
The cause of Donovanosis?
Klebsiella granulomatis
58
What are the Amsel criteria to diagnose Bacterial vaginosis?
- Thin, white, homogeneous discharge
- Clue cells on microscopy of wet mount
- pH >4.5
- Fishy odour on adding alkali (10% KOH)
59
What is the Tx of choice of Bacterial vaginosis?
First line:
Metronidazole 400mg twice daily for 5-7 days (A)
or
Metronidazole 2 g single dose
----------------
Alternatively:
Tinidazole 2G single dose
or
Clindamycin 300 mg twice daily for 7 days
60
What is the definition of UTI?
The presence and multiplication of microorganisms in one or more structures of the urinary tract, with associated tissue invasion.
61
What is Pyuria?
Presence of ≥10 WBCs/mm³ in urine (typically indicates inflammation)
62
What is sterile pyuria?
Persistent WBCs in urine without growth on routine media
Causes:
- Fastidious organisms
- Prior antibiotics
- TB
63
What is Meares-Stamey 4-glass test?
- It is a diagnostic procedure used to identify the source of UTI.
- Mainly in cases of suspected chronic prostatitis
- 4 sample:
#First Voided Urine
#Midstream Urine
#Expressed Prostatic Secretions (EPS)
#Post-Massage Urine (VB3):
64
1ry UTI test pannel for Enterobactracae ?
Amoxicillin
Cefpodoxime
Nitrofurantoin
Trimethoprim
Fosfomycin
Pivmecillinam
65
Supplementary (2ry) UTI test pannet for Enterobactracea?
Cefalexin
Cefotaxime/ Ceftriaxone
Ciprofloxacin
Amikacin
Gentamicin
Co-amoxiclav
Meropenem
66
When to give Abx prophylaxis for kids with VUR?
- Recurrent UTI with significant impact on quality of life
- Grades IV-V VUR
- Children awaiting surgery
67
What Abx to give as prophylaxis for kids with VUR and for how long?
- Trimethoprim or nitrofurantoin at 1/3 to 1/2 treatment dose OD
- Cephalexin for infants<3 m
-----#
Duration : 3-6 m
68
69
Manifestation of early congenital syphilis?
(First 2 years)
- Snuffles
- Perioral fissures
- Cataracts
- Rash & Condylomata lata
- Hepatomegaly & Jaundice
- Growth retardation
70
What is the doubling time of treponema pallidum ?
30-hour
71
T/F:
Treponema Lacks lipopolysaccharides, few surface proteins.
T
72
73
Ultrasound findings suggestive of fetal syphilis infection?
- Placentomegaly
- Hepatomegaly
- Skin edema
- Polyhydramnios
- Oligohydramnios
- Pericardial effusion
- Fetal anemia/ Hydrops
74
Situations where risk of congenital syphilis is very high?
- Early maternal infection (1ry / 2ry syphilis)
- Late gestational period
- Delivery is within 30 days of maternal treatment
- VDRL/RPR titre of >/= 8
75
What is the cause of Yaws?
T. pallidum subsp. pertenue
76
Early
congenital syphilis manifests within two years of birth. Symptoms might include:
snuffles, perioral fissures, hepatomegaly and jaundice, cataracts, growth
retardation, rash, mucous patches and condylomata lata.
77
What can be used as Self-applied treatment for Anogenital warts HPV?
- Podophyllotoxin (preferred)
- Imiquimod
78
What can be used as Self-appliedClinicailn applied treatment for Anogenital warts HPV?
- Laser / Cryotherapy
- Electrosurgery
- Surgical excision (preferred)
- Trichloroacetic acid (TCAA)
79
Commonest anaerobic bacterial cause of bacterial vaginosis ?
Gardnerella vaginalis
Atopobium vaginalis
80
Risk factors of bacterial vaginosis?
Black race
Recent change in sex partner
Smoking
Other STI e.g. chlamydia or herpes
81
Symptoms of BV?
Offensive fishy smelling vagina
No soreness, itching, or irritation
82
Recommended diagnostic method for BV as per BASSH/ SMI?
Hay/Ison criteria
83
Amsel criteria to diagnose BV?
- Thin, white discharge
- Clue cells
- pH >4.5
- Fishy odour By adding 10% KOH
84
what is the Clue cells ?
It is an epithelial cells to which Gram variable rods are attached in large numbers, obscuring the cell border
85
What treatment options for BV ?
1- metronidazole
2- Tinidazole (2G single dose)
3- Clindamycin 7/7
86
Recurrent BV treatment Options?
- Suppressive 0.75% metronidazole vaginal gel
- Probiotic lactobacilli applied daily on days 1 -7 and 15 -21
- Lactic acid gel
87
Gonnococci attach itself to epithelial cells using...?
- Pili
- Opacity-associated proteins (opa)
- Lipooligosaccharide (LOS)
88
Neisseria spp are oxidase positive and
catalase positive , except ....?
Neisseria elongata
89
What is the nitrocefin test ?
It is a rapid method for detecting beta-lactamase enzymes
90
How to test for Azithromycin MIC for gonococci as per EUCAST?
Test azithromycin based on ECOFF, and it is 1 mg/L.
Release with a comment :
" azithromycin should always used in conjunction with another effective agent"
91
Gonorrhea Test of cure?
- If Symptomatic patient - culture at 72 hours after completion of therapy
- If Asymptomatic patient - NAAT/PCR, if positive, culture 7-14 days
92
T/F:
Partners of patients diagnosed with DGI within 2 months should be contacted and treated
T
For uncomplicated gonococcal infection , partners within 2 weeks
93
Diagnosis of Donovanosis (granuloma inguinale )?
- Direct microscopy and Giemsa staining Donovan bodies:
( large mononuclear cells with intracytoplasmic cysts within macrophage filled with deeply stained Gram-negative rods with a safety pin appearance)
- PCR
94
Tx of Donovanosis?
- Azithromycin 1g weekly or 500mg daily orally 3 weeks or until heals
- Or: cotrimoxazole / doxycycline
95
Cause of Donovanosis and Chancroid?
Donovanosis: Klebseilla granulomatis
Chancroid: Haemophilus ducreyi
96
Chancroids?
- Painful ulcers
- Opposite kissing ulcers’.
- Inguinal lymphadenitis, usually unilateral and painful
- May form bubo
- NAAT/PCR
- Ceftriaxone stat or Azithromycin
97
Treatment of Lymphogranuloma venereum?
- Doxycycline 100 mg bd orally for 21 days
- Erythromycin 500mg four times daily orally for 21 days
- Azithromycin 1g weekly for 3 weeks
98
Tx of HSV genital herpes?
- Aciclovir 400 mg three times daily
- Valaciclovir 500 mg twice daily
99
What is LGV?
- Small painless ulcers
- Prominent inguinal LN
- Chlamydia trachomatis L1–L3
100
Diffrence B/W LGV and Donovanosis?
- LGV Painless ulcers with prominent LN
- Donovanosis Painless ulcers & no LN
101
Prophylaxis of neonate born to mum with donovanosis ?
Azithromycin orally once daily for three days
102
What is Yaws
- Treponema pallidum
subsp pertenue
- Wet, humid, tropic
-
- Tx:
1st line: Azithromycin single dose
2nd: Benzathine penicillin single IM
103
What is Bejel?
- T. pallidum
subsp endemicum
- Usually children 1 - 15y
- Tx:
1st line : Benzathine penicillin
2nd: Azithromycin
104
What is pinta?
- Treponema carateum
- Usually children 1 - 15y
- South America
- Tx:
1st line : Benzathine penicillin
2nd: Azithromycin
105
2 diagnostic serology tests for confirming neurosyphilis ?
- RPR ≥1:32 increases the likelihood of neurosyphilis.
- CSF TPHA titre >1:320 is sensitive and specific for neurosyphilis, even if RPR negative.
106
Significance of RPR in CSF when diagnosing Neurosyphilis ?
CSF RPR it is insensitive
Negative test may not exclude neurosyphilis
A positive RPR, in the absence of evidence of blood contamination of the CSF sample, is diagnostic of neurosyphilis.
107
What is the significance of TPHA positive in CSF?
CSF TPHA - negative CSF TPHA makes a diagnosis of neurosyphilis unlikely.
A CSF TPHA titre >1:320 is sensitive and specific for neurosyphilis
108
Drug of choice for Neurosyphilis / ocular syphilis ?
- Procaine penicillin 1.8 MU–2.4 MU IM OD plus probenecid 500mg PO QDS for 14 days
- Or: Benzylpenicillin 1.8–2.4g IV every 4h for 14 days
- ----
- Plus:
40–60 mg prednisolone OD for 3 days starting 24 h before the antibiotics.
109
Tx of choice of neurosyphilis if penicillin allergy?
- If anaphylaxis :
Doxycycline 200mg PO BD for 28 days
- If Rash:
Ceftriaxone 2g IM or IV for 10–14 days
110
Hay/Ison criteria of BV Diagnosis ?
- Grade 1 : Lactobacillus morphotypes predominate
- Grade 2 : Mixed flora with some Lactobacilli + Gardnerella or Mobiluncus
- Grade 3 : Predominant Gardnerella /
Mobiluncus + rare Lactobacilli
111
Possible foetal outcome as result of maternal syphilis?
Congenital infection
Stillbirth or fetal death
Preterm delivery and low birth weight
Hematological abnormalities
Ascites, hydrops
112
Ultrasound findings suggestive of fetal syphilis infection ?
- placentomegaly
- hepatomegaly
- skin edema
- polyhydramnios
- fetal anemia & hydrops
- pericardial effusion.
113
Which gestational age has highst risk of faetal transmission of congenital Toxo and Syphilis?
- Late gestitional age
- Mainly if 1ry infection
114
What is the Parrot’s pseudoparalysis?
It is a feature of congenital syphilis
painful periostitis
115
Features of congenital syphilis?
Hepatomegaly, jaundice
Rhinitis ("snuffles")
Perioral fissures
Maculopapular rash (palms, soles)#
Condylomata lata
Generalized lymphadenopathy
Painful periostitis
Sawtooth metaphysis
Cataracts
Growth restriction
116
What is the LIM broth media ?
it is broth & selective enrichment medium with antibiotics, designed to culture Group B Streptococcus (GBS) from vaginal and anorectal swabs in pregnant women
- Antibiotics:
10µg/mL colistin - or 8µg/mL gentamicin and 15µg/mL nalidixic acid.
117
Strawberry cervix appearance + characteristic vaginal discharge - frothy, yellow-green, or grey in coloration + unpleasant odor.
Trichomonas vaginalis
118
Tx of richomonas Vaginalis ?
MTZ 500 po bd for 7 days
119
120
What is the definition of bacterial vaginosis?
It is an overgrowth of anaerobic organisms
(Gardnerella vaginalis, Prevotella species, Mycoplasma hominis and Mobiluncus
species) often replacing normal commensal lactobacilli.
121
Investigations in Proctitis?
* Neisseria gonorrhoeae- NAAT
and culture
* Chlamydia trachomatis- NAAT
* Herpes simplex virus / varicella
zoster virus NAAT
* Treponema pallidum (Syphilis)
serology and NAA
* Mycoplasma genitalium- NAAT
* Mpox- NAAT
* Lymphogranuloma venereum -
NAAT (if Chlamydia trachomatis
NAAT positive
FRCpath microbiology part 2
flashcards
Decks in class (18)
# Cards
-
Antimicrobial resistance167
-
Mycobacterium83
-
1- General infection174
-
2- General infection182
-
Vaccine19
-
Treatment172
-
Bacterial biochemical tests and agars 2119
-
bacterial biochemical test and agars137
-
Atypical pneumonia65
-
Gram negative145
-
Gram positive Cocci173
-
Gram Positive Bacilli167
-
Microbiology Laboratory35
-
Antibiotics82
-
STI121
-
IPC117
-
Vaccine7
-
MOA35
