Viral Respiratory Tract Infections

Question 1

List upper respiratory tract infections

Upper resp tract

Answer 1

Common cold  / Coryza ;Covid-19
Influenza / Flu
Acute tonsillitis
Acute pharyngitis ( Sore Throat )
Acute otitis media
Acute sinusitis

Nasal cavity
Oral cavity
Pharynx
Larynx

Question 2

Coryza/ Common cold causitive agents

Answer 2

Adults & Children - Rhinovirus ,
Coronavirus ( COVID -19 ) ,
R.S.V.- ( Respiratory Syncytial Virus ).

Question 3

Clinical features of Coryza/ common cold

Surfactant - explain term

Type 1 pneumocyte function

SARS-CoV-2 Pathogenesis

Answer 3

Fatigue 
Feeling cold 
Nose burning , Obstruction , Running of nose  
Sneezing 
Fever

Increased surface tension increases cohesion within the alveoli, pulling the alveoli closed.
The alveolar cells produce a specialized liquid, surfactant, that decreases the surface tension in the airways reducing the amount of energy required to expand the lungs.

Gas exchange

Pathogenesis
Virus attaches to Type 2 pneumocytes (f’n to produce surfactants) in alveoli
Virus spike protein (S spike) binds to ACE2 on membrane
Virus enters cell and releases +sense ssRNA
Virus uses ribosomes to convert mRNA to proteins via translation
RNA dependent RNA polymerase makes more mRNA
Polyproteins formed which are then cleaved by proteinases to form essential viral protein components
(cleaves the precursor viral polyprotein to produce functional proteins and enzymes)
Virus copies exit cell

– Type 2 pneumocyte becomes damaged and releases IFN-gamma which stimulates macrophages to respond (DAMPs released from within cell)
– Macrophage secretes :
IL-1, IL-6, TNF-alpha
– These cytokines travel to capillary and act as inflammatory mediators
(Inflammatory mediators = vasodilation + increased capillary permeability)
– Fluid leaks to outside alveoli and compresses alveoli
(Water has high surface tension b/c of H+ bonding btw H2O
Surfactant lines alveoli to prevent collapse due to high surface tension
Fluid moves into alveoli and drowns out surfactant thereby increasing the surface tension inside alveoli)
– Alveoli collapse + fluid surrounding alveoli impairing gas exchange = Hypoxemia (low O2)
This can lead to Acute respiratory distress syndrome (ARDS) (rapid onset of widespread inflammation in the lungs)

– Neutrophils come to area and destroy pathogen via ROS (e.g. proteases) which causes cell damage (type 1 and 2 pneumocyte) as well = less surfactant production + alveoli collapse
– Alveoli will contain cell debris of type 1 and 2, macrophages, neutrophils, fluid = lung consolidation
( occurs when the air that usually fills the small airways in your lungs is replaced with something else )
– Gas exchange process altered = hypoxemia

Productive cough (from consolidation)

– IL-1, IL-6, TNF-alpha travel to brain if in high amts and go to hypothalmus causing fever

– Low partial pressure of O2 stimulates chemoreceptors which causes SNS to be stimulated which causes increased heart rate
chemoreceptor detects changes such as > in blood levels of CO2 (hypercapnia) or < in O2 (hypoxia), and transmits info to CNS which engages body responses to restore homeostasis.

– Inflammation can spread through entire circulatory system causing increased capillary permeability and fluid leakage into surrounding tissues = low blood volume
– Vasodilation occurs = Lowered total peripheral resistance
(resistance of the arteries to blood flow. As the arteries constrict, the resistance increases and as they dilate, resistance decreases)
– Low blood volume + low peripheral resistance = low bp
– Low bp leads to low perfusion i.e. less blood moving to organs = multi system organ failure

Question 4

Syndrome - define

Answer 4

group of symptoms which consistently occur together

Question 5

COV-19 caused by

Answer 5

severe acute respiratory syndrome coronavirus 2 ( SARS-CoV-2 )

Question 6

COV-19 spread via

Answer 6

Via respiratory droplets ( coughing , sneezing ) during face-to-face exposure or by surface contamination.

Question 7

Most common symptoms of Cov-19

Answer 7

fever ,
cough ,
shortness of breath - (weakness , fatigue , nausea vomiting , diarrhea)

Question 8

Lab ID - COV-19

Answer 8

PCR / RT-PCR testing of nasopharyngeal swab

Question 9

Treatment - COV-19

Answer 9

Supportive care . Recent trials – dexamethasone decreases mortality , supplemental oxygen / ventilator .

Question 10

COV-19 prevention methods

Answer 10

Face masks , 
N95 respirators , 
Physical social distancing , 
Hand washing / sanitizer , 
Travel restrictions , 
Isolation of patients , 
Quarantine of exposed people , 
Avoiding personal contact with pts. , 
PPE – healthcare workers

Question 11

Causative organisms for (influenza) flu in order of prevalence

Answer 11

Influenza virus 80 %
Parainfluenza 2-9 %
Adenovirus 4 %

Question 12

Features of (influenza) flu

Answer 12

Causes Epidemics and Pandemics

Highly contagious - viral infection.

Question 13

Myxoviruses are divided into two families

Answer 13

1 ) Orthomyxoviridae e.g. Influenza viruses ;

2 ) Paramyxoviridae e.g. Parainfluenza virus and ( Mumps virus , Measles virus , Respiratory syncytial virus ).

Question 14

Flu (Influenza) features

Answer 14

Common cold symptoms - because of HA binding to mucin receptors on RBC + epithelial cells of resp tract
Sudden onset after 12 - 24 hrs incubation
General weakness & fatigue
Feeling cold , shivering , temp.- Up to 39-40 C
No sore throat or No running nose
Severe back , muscle and joint pain

Question 15

Influenza viruses are a member of Orthomyxoviridae

Answer 15

Spherical,
80 – 120 nm,
Helical nucleocapsid symmetry and surrounded by an lipoprotein - envelope.
Nucleic acid – negative sense single stranded RNA.

Structural proteins:

• PB1, PB2, PA - RNA transcription and replication
• NP - nucleoprotein (gives rise to nucleocapsid with helical symmetry)
• Matrix proteins: M1 - shell, M2 - ion channel
• Hemagglutinin (HA) and Neuraminidase (helps virus to pass through cell layer) - glycoproteins inserted in lipid envelope
• Non-structural proteins NS1 - interferon antagonist + inhibits pre mRNA splicing ; NS2 - export of molecules across the nucleus

Question 16

Transmission - influenza

Answer 16

– cough , sneeze, contacts , fomites

Question 17

Target cells to enter

Answer 17

–alveolar cells

Question 18

Influenza multiplies locally where?

Answer 18

–respiratory epithelial cells

Question 19

Influenza spreads to where?

Answer 19

–lower respiratory tract

Question 20

Incubation period - influenza

Answer 20

18-72 hrs

Question 21

Symptoms - influenza

Answer 21

chills , headache ,dry cough ,fever ,anorexia.

Question 22

Specimen - influenza

Answer 22

Nasophyryngeal swab , kept at 4 C

Question 23

Isolation of virus

Answer 23

In embryonated eggs and primary monkey kidney cell lines

Growth is detected by hemadsorption , hemagglutination test .

Question 24

Molecular methods

Answer 24

Real time RT PCR : detects viral RNA

Question 25

Antibody detection

Answer 25

ELISA

Question 26

Treatment of Influenza

Answer 26

``` Neuraminidase inhibitor ( Zanamivir , Oseltamivir –[ Tamiflu ] for influenza A and B and also for H1N1- 2009 flu , H5N1 avian flu ) MoA- Blocks NA from allowing escape of virus from host cell to infect other cells so virus components stick to cell surface. ``` Matrix protein M2 inhibitor ( Amantadine and Rimantadine – for influenza A infection )

Question 27

Neuraminidase inhibitor - MoA

Answer 27

Block the function of viral neuraminidases of the influenza virus, by preventing its reproduction by budding from the host cell.

Question 28

Matrix protein M2 inhibitor - MoA

Answer 28

During viral entry, the intake of a proton via an M2 protein induces unfolding of the HA protein such that the fusion peptide is activated. Thus Matrix protein M2 inhibitor blocks viral entry (Amantidine - very successful in influenza A)

Question 29

Prevention - influenza

Answer 29

Strict hand hygiene , isolation , use mask , remain at home and Vaccination prophylaxis .

Question 30

EBV is mostly asymptomatic (T/F) The manifestation of symptoms in EBV is referred to as ? EBV- [Epstein –Barr virus] - Kissing Disease signs and symptoms

Answer 30

True Infectious mononucleosis Fever, Headache, Pharyngitis, Cervical lymphadenopathy, exaggerated fatigue Splenomegaly - Stores many B cells so infected B cells will go there and CD8 T cells will follow to destroy infected cells causing swelling of spleen

Question 31

Another name for Infectious Mononucleosis

Answer 31

Glandular Fever

Question 32

Prevalence for Infectious mononucleosis

Answer 32

Among adolescents & Young adult

Question 33

Clinically useful Laboratory tests : For - Epstein-Barr Virus

Answer 33

Heterophilie antibody : ( Paul - Bunnel Test - sheep RBCs) Monospot test –modified heterophile agglutination test –hourse RBCs IgM antibody to Viral Capsid Antigen ( VCA ) Atypical Lymphocyte ( Abnormal )

Question 34

Heterophile antibody test

Answer 34

Heterophil antibodies have the ability to agglutinate red blood cells of different animal species. The Paul-Bunnell test uses sheep erythrocytes; the Monospot test, horse red cells.

Question 35

Monospot test

Answer 35

Monospot test - form of the heterophile antibody test, is a rapid test for Epstein–Barr virus (EBV). - It is an improvement on the Paul–Bunnell test

Question 36

IgM antibody to viral capsid antigen (VCA)

Answer 36

Presence of VCA IgM antibodies indicates recent primary infection with Epstein-Barr virus (EBV). The presence of VCA IgG antibodies indicates infection sometime in the past.

Question 37

Atypical lymphocytes EBV affects which cells? EBV pathogenesis

Answer 37

Normal lymphocyte - Small nucleus + little cytoplasm Atypical lymphocytes - Bigger nucleus + more cytoplasm - Reactive CD8 T cells killing infected B cells A few atypical lymphocytes are probably of little clinical significance. A large number of atypical lymphocytes are often found in viral infections like mononucleosis (many B cells need to be killed), cytomegalovirus infections and hepatitis B. Epithelial cells, B cells, T cells 1. Transmission via saliva 2. Virus infects epithelial cells of mouth then replicates and goes to oral pharynx (back of throat) 3. Virus moves to lymphoid tissues of oral pharynx i.e. tonsils where B cells and T cells are and infects them 4. B cells spread through lymph to other lymphoid tissues and infect those B cells 5. Infection is eventually controlled with antibodies binding free floating virus + CTLs killing infected B cells

Question 38

Molecular methods for EBV

Answer 38

– Detects EBV DNA by PCR .

Question 39

Transmission - EBV

Answer 39

transmitted through salivary contact

Question 40

EBV is a member of?

Answer 40

Herpesviridae

Question 41

Treatment of EBV

Answer 41

Supportive such as analgesics used in infectious mononucleosis . Acyclovir is antiviral drug used in treatment .

Question 42

Prevention of EBV

Answer 42

Patient isolation

Question 43

Sore throat/ Pharyngitis - causative organisms Pharyngitis vs Tonsillitis

Answer 43

- Epstein-Barr virus - Adenovirus - Influenza A , B - Respi .syncytial virus - Parainfluenzae Both cause inflammation. If tonsils are affected - tonsillitis. If the throat is affected - pharyngitis.

Question 44

Signs and symptoms of pharyngitis/tonsillitis

Answer 44

``` Sore throat Fever > 38 C Difficulty in swallowing Enlargement of tonsils Congested tonsils and pharynx Headache , fatigue Muscle pain ``` Tonsillar hyperemia / exudates Soft palate petechia Absence of nose drip Enlarged tonsillar lymph nodes

Question 45

Middle Respiratory Tract Infections

Answer 45

``` Epiglotitis Laryngitis Croup Tracheatitis Bronchitis Bronchiolitis ```

Question 46

Contributing factors to middle respiratory tract infections

Answer 46

Smoking , previous lung damage , atmospheric pollution & cold damp weather

Question 47

Epiglotitis - organisms

Answer 47

H influenzae, S pneumoniae, C diptherae

Question 48

Laryngitis (inflammation of larynx/voicebox), Croup - organisms

Answer 48

Parainfluenza virus, influenza virus, adenovirus, occasionally RSV

Question 49

Tracheitis - organisms

Answer 49

Parainfluenza virus, influenza virus, adenovirus, occasionally RSV

Question 50

Bronchitis, Bronchiolitis

Answer 50

Parainfluenza virus, influenza virus, resp syncitial virus, adenovirus Bordetella pertussis, H influenzae, Mycoplasma pneumoniae, Chlamydia pneumoniae

Question 51

Human parainfluenza viruses are one of the major causes of middle and lower respiratory tract infection in adults. (T/F)

Answer 51

Human parainfluenza viruses are one of the major causes of middle and lower respiratory tract infection in young children.

Question 52

Parainfluenza virus morphology Transmission of parainfluenza virus

Answer 52

Unsegmented, -ve sense, ssRNA, enveloped, helical Transmission by respiratory route ( by direct salivary contact or by large- droplet aerosols ).

Question 53

Incubation period - parainfluenza virus

Answer 53

The incubation period is 5 - 6 days

Question 54

Parainfluenza virus - does it multiply locally? What kinds of manifestations appear?

Answer 54

Virus multiplies locally and causes various respiratory manifestations

Question 55

Clinical manifestations of parainfluenza virus

Answer 55

a ) Mild common cold syndrome like rhinitis (inflammation + irritation inside mucus membranes of nose) and pharyngitis . b ) Croup / Laryngotracheobronchitis – involves children between 1-4 yrs age . c ) Pneumonia or Bronchiolitis – involve infants below 6 months of age.

Question 56

Otitis media – it is most common complication of parainfluenza virus inf . (T/F)

Answer 56

True

Question 57

Parainfluenza viruses are important cause of outbreaks in paediatric wards , day care centers and in schools . (T/F)

Answer 57

True

Question 58

Lab Diagnosis - parainfluenza viruses

Answer 58

I] Antigen detection : Viral antigens from nasopharynx detected by direct IF –( ImmunoFluorescence ) test by specific monoclonal antibodies . 2] Viral isolation : Specimen – nasal washes ,lung tissue & bronchoalveolar lavage fluid can be used. Primary monkey kidney cell line is most sensitive . 3] Serum antibodies measured by ELISA – IgM Ab rise indicate active infection . 4] Reverse transcriptase PCR assays are highly specific and sensitive but available only in limited settings .

Question 59

Laryngitis - define

Answer 59

Inflammation of the voice box, or larynx , often viral.

Question 60

What can cause dangerous complications in children regarding laryngitis?

Answer 60

Several forms of laryngitis occur in children that can lead to dangerous complications

Question 61

What are these forms of laryngitis?

Answer 61

These forms include: Croup Epiglottitis

Question 62

What is Croup ? | What is Epiglottis?

Answer 62

Croup is breathing difficulty accompanied by a "barking" cough , swelling around the vocal cords Epiglottis - Abnormal high pitched breathing, severe sore throat

Question 63

In what age group is croup common?

Answer 63

Common in infants and children ( 1- 4 years ).

Question 64

Most common parainfluenza viruses

Answer 64

Influenza viruses , Respiratory syncitial virus ( RSV ) , Adenovirus

Question 65

Symptoms of Croup

Answer 65

A cough that sounds like a seal barking . Later the child may have labored breathing or stridor ( a harsh , crowing noise made during inspiration ) . Fever Upper resp tract inf for few days - Low grade fever + coryza Virus then infiltrates larynx and trachea Infiltration causes release of WBCs to area = pain + edema Swelling = airway obstruction + turbulent noisy air flow (stridor) (Stridor occurs during inhalation due to the swollen area being lower in partial pressure compared to outside cause collapse of airway causing turbulent flow of air through airways)

Question 66

How long does Croup last?

Answer 66

5 or 6 nights

Question 67

What is Epiglottis?

Answer 67

Inflammation & oedema of epiglottis and soft tissue above vocal cords

Question 68

Age group for Epiglottis

Answer 68

Children 2- 6 years

Question 69

Clinical manifestations of Epiglottis

Answer 69

Fever Difficulty in breathing because of respiratory obstruction , swelling , Reddening of epiglottis.

Question 70

Causative organisms of Epiglottis

Answer 70

Haemophillus influenzae. Corynebacterium diphtheria . Strepto .pneumoniae / Diplococcus pneumoniae

Question 71

Infections of trachea and bronchi

Answer 71

Bronchitis - Inflammation of the bronchial tubes Bronchiolitis - Inflammation of bronchioles Tracheobronchitis – Inflammation of tracheobronchial tree

Question 72

Bronchitis - define

Answer 72

Inflammation of the bronchial tubes

Question 73

Bronchiolitis - define

Answer 73

Inflammation of bronchioles

Question 74

Tracheobronchitis - define

Answer 74

Inflammation of tracheobronchial tree

Question 75

Bronchitis is characterized by ?

Answer 75

inflammation of bronchus

Question 76

Viral causes of bronchitis

Answer 76

Rhinovirus , Parainfluenza virus , Respiratory Syncytial Virus - RSV , Influenza virus , Adenovirus

Question 77

Sources of secondary bacterial overgrowth in bronchitis

Answer 77

Haemophilus influenzae Streptococcus pneumoniae Staphylococcus aureus

Question 78

Symptoms of bronchitis

Answer 78

Fever Dry & painful cough initially Later cough becomes productive Expectoration of yellow green sputum

Question 79

Treatment for bronchitis is used to treat secondary bacterial overgrowth (T/F)

Answer 79

True

Question 80

Respiratory Syncytial virus - causes what in children and infants?

Answer 80

Young children and bronchiolitis and pneumonia in infants

Question 81

RSV - transmission

Answer 81

Direct contact/ droplets via inhalation

Question 82

Incubation period - RSV

Answer 82

Incubation : 3-5 days

Question 83

Symptoms - RSV

Answer 83

Begins with running nose , fever , wheezing , dyspnea and cough - Beings in upper resp tract - with rhinorrhea (runny nose), congestion, sneezing - Within 1-3 days it spreads to lower airways causing swelling of terminal bronchioles = cough - Bronchioles swollen + plugged with mucus = harder to move air = Tachypnea (fast breathing) - Retractions (area between the ribs and in the neck sinks in due to person working hard to breathe) If virus gets to alveoli = pneumonia

Question 84

Infections are not common in over-crowded communities for Respiratory Syncytial Virus. (T/F)

Answer 84

False, they are common in overcrowded areas.

Question 85

Lab ID - RSV

Answer 85

Antigen detection - Direct IF immunofluorescence test Virus isolation – HeLa and Hep-2 cell lines for RSV –[CPE] cytopathic effect , syncytium formation seen . RT-PCR . Antibody detection by ELISA .

Question 86

Direct IF Immunofluorescence test

Answer 86

DIF involves the application of antibody–fluorophore conjugate molecules to biopsy sample. Antibody–fluorophore conjugates target abnormal depositions of proteins in the patient’s tissue. When exposed to light, fluorophore emits its own frequency of light, seen with a microscope. Staining pattern and abnormal protein deposition seen

Question 87

HeLa cell line - define

Answer 87

HeLa cell line - cultivated from tumor cells obtained from cervical cancer patient

Question 88

Hep-2 cell line - define

Answer 88

Human epithelial type 2 (HEp-2) cells, considered to originate from a human laryngeal carcinoma

Question 89

What are cytopathic effects?

Answer 89

Cytopathic effects (CPEs) are distinct observable cell abnormalities due to viral infection. CPEs can include: Loss of adherence to the surface of the container, Changes in cell shape from flat to round, Shrinkage of the nucleus, Vacuoles in the cytoplasm, Fusion of cytoplasmic membranes Formation of multinucleated syncytia, inclusion bodies in the nucleus or cytoplasm, Complete cell lysis

Question 90

RT-PCR uses

Answer 90

RT-PCR differs from PCR in that the enzyme reverse transcriptase (RT) is used to make a cDNA from the small amount of viral RNA in the specimen. The cDNA can then be amplified by PCR.

Question 91

ELISA - uses

Answer 91

used to measure antibodies, antigens, proteins and glycoproteins in biological samples

Question 92

DoC - RSV

Answer 92

Ribavirin

Question 93

Rhinovirus - transmission, causes what

Answer 93

Transmitted by respiratory route and cause common cold

Question 94

Incubation period - rhinovirus

Answer 94

2-4 days

Question 95

Symptoms - rhinovirus

Answer 95

sore throat , sneezing , nasal discharge , nasal obstruction but no fever

Question 96

Lab ID - rhinovirus

Answer 96

Grown in human diploid cell lines WI-38 is a diploid human cell line composed of fibroblasts derived from lung tissue of a 3-month-gestation female fetus. MRC-5 is a diploid cell culture line composed of fibroblasts, originally developed from the lung tissue of a 14-week-old aborted Caucasian male fetus.

Question 97

Treatment

Answer 97

Symptomatic

Question 98

Adenovirus - viral characteristics/morphology

Answer 98

Space vehicle shaped . dsDNA - linear, non enveloped , icosahedral capsid symmetry.

Question 99

Adenovirus - can cause

Answer 99

URI (upper respiratory infection/common cold) and pneumonia

Question 100

Specimen - adenovirus

Answer 100

Throat swab

Question 101

Virus isolation - adenovirus

Answer 101

Hep-2 ,HeLa , KB , A549 cell line –shows CPE –rounding and grape-like clustering of swollen cells .

Question 102

Treatment

Answer 102

Only symptomatic, no antibviral

Question 103

Lower respiratory tract infections include Lower respiratory tract

Answer 103

``` Diseases of lungs including alveolar space & terminal bronchioles Acute pneumonia Chronic pneumonia Pleural effusion ( empyema ) Lung abscess ``` Bronchi Bronchioles Alveolus

Question 104

Pneumonia

Answer 104

Inflammation of the alveoli of the parenchyma of the lung with - consolidation and exudation (leaking fluid)

Question 105

Exudate - define

Answer 105

any fluid that filters from the circulatory system into lesions or areas of inflammation. It can be a pus-like or clear fluid - it leaks out of the blood vessels and into nearby tissues. -- composed of serum, fibrin, and leukocytes.

Question 106

Consolidation in pneumonia - define

Answer 106

Condition where lung tissue becomes firm and solid rather than elastic and air-filled because it has accumulated fluids and tissue debris.

Question 107

Symptoms - Pneumonia

Answer 107

Fever & chills , head ache , malaise , generalised myalgia. Pleuritic chest pain , Tachycardia & tachypnoea. Shortness of breath , difficulty & pain on breathing. Cough :- Initially non productive , subsequently productive , mucopurulent yellow or green sputum.

Question 108

Bacterial causes of Pneumonia

Answer 108

``` Streptococcus pneumoniae Staphylococcus aureus , Haemophilus influenzae , Klebsiella pneumonia , Mycobacterium tuberculosis, , Mycoplasma pneumoniae. ```

Question 109

Parasitic causes of Pneumonia

Answer 109

Pneumocystis carinii. | Strogyloides stercoralis.

Question 110

Fungal causes of pneumonia

Answer 110

Histoplasma capsulatum Coccioides immitis Cryptococcus neoformans Aspergillus species

Question 111

Viral causes of pneumonia

Answer 111

Influenzae A & Influenzae B , Adenovirus , Parainfluenzae , Resp.Syn.Virus ( RSV ) & COVID-19

Question 112

Collection of specimen - Pneumonia

Answer 112

Mucopurulent or purulent (containing pus) sputum in early morning. Pleural fluid (build-up of excess fluid between the layers of the pleura outside the lungs) Transtracheal aspirate ( collection of bronchial secretions -- useful when standard sputum collection has not provided adequate material) Blood culture Resp. Specimens / Blood for viruses & mycoplasma Skin test for Tuberculosis : Mantoux test .

Question 113

Lab ID methods

Answer 113

Gram staining - Bacteria & Candida Z-N stain- M tuberculosis & Auramine-rhodamine stain . Giemsa stain - for Pneumocystic carinii Culture- Blood agar , MacConkey’s agar & selective media. Lowenstein–Jensen ( L.J. ) medium for M .tuberculosis Sabouraud’s dextrose agar - for Fungi. Tissue culture , Embryonated egg , Animal - for Viruses .

Question 114

Automated lab ID methods

Answer 114

Automated Methods :- BACTEC ; SEPTICHEK ; BacT/ALERT ; VersaTek . Rapid Test :- PCR ; GeneXpert ( RT-PCR ) ; Interferon Gamma Release Assay ; ELISA –QuantiFERON –TB Gold assay .

Question 115

Antigen detection methods

Answer 115

Antigen detection: - Immunoelectrophoresis- H influenzae , Pnemococci( Str.pne.) - Latex agglutination - H influenzae , Pnemococci /strepto.pne. - PCR / RT- PCR = Rapid .