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Virology Flashcards

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1
Q

Viral genetics: Reassortment

A

When viruses with segmented genomes (e.g influenza virus) exchange genetic material
E.g. H1N1 influenza A pandemic emerged via complex viral Reassortment of a gene from human, swine and avian viruses. Has the potential to cause antigenic shift

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2
Q

Viral genetics: Complementation

A

When 1 of 2 viruses that infect the cell has a mutation that results in a nonfunctional protein, the nonmutated virus “complements” the mutated one by making a functional protein that serves both viruses.
E.g. HepD virus requires the presence of replicating HepB virus to supply HBsAg, the envelope protein for HDV

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3
Q

Viral genetics: Phenotypic mixing

A

Occurs with simultaneous infection of a cell with 2 viruses. Genome of virus A can be partially or completely coated (forming pseudovirion)with the surface proteins of virus B. Type B protein coat determines the tropism (infectivity) of the hybrid virus. However, the progeny form this infection have a type A coat that is encoded by its type A genetic material

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4
Q

Live attenuated vaccines

A

Induce a humoral and cell-mediated immunity but have reverted to virulence on rare occasions.
Live attenuated: Smallpox, yellow fever, rotavirus, chickenpox, Sabin polio virus, MMR, Influenza (intranasal) –> Live! One night only! See small yellow rotating chickens get vaccinated with Sabin and MMR! It’s INcredible!
No booster needed.
Dangerous to give live vaccines to immunocompromised patients. Close contact may be can instead with live vaccines (except polio or influenza)

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5
Q

Killed viral vaccines

A

Rabies, influenza (injected), Salk Polio, and HAV vaccines
Killed/inactivated vaccines only humoral immunity but are stable
SalK = Killed; RIP Always

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6
Q

Subunit vaccines

A

HBV (Ag = HBsAg), HPV (types 6,11,16,18)

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7
Q

DNA viral genomes

A

All DNA viruses except the parvoviridae are dsDNA
All are linear except papilloma-, polyoma- and hepadaviruses (circular)
All are dsDNA (like our cells) except part-of-a-virus (parvovirus) is ssDNA
Replicated in the nucleus (except poxvirus)

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8
Q

RNA viral genomes

A

All RNA viruses except Reoviridae are ssRNA
Positive strand RNA viruses: I went to a retro (retrovirus) toga (togavirus) party, where I drank flavored (flavivirus) Corona (coronavirus) and ate hippie (Hepevirus) California (Calicivirus) pickles (picornavirus)
Replicated in the cytoplasm (except influenza virus and retroviruses)

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9
Q

Naked viral genome infectivity

A

Purified nucleic acids of most dsDNA (except poxviruses and HBV) and + strand ssRNA (mRNA) viruses are infectious.
Naked nucleic acids of - strand ssRNA and dsRNA viruses are not infectious but require polymerase a contained in the complete virion.

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10
Q

Viral envelopes

A

Naked (non-enveloped) viruses include Papillomarvirus, Adenovirus, Parvovirus, Polyomavirus, Calicivirus, Picornavirus, Reovirus and Hepevirus
Give PAPP smears and CPR to a naked hippie (Hepevirus)
Generally enveloped viruses acquire their envelopes from plasma membrane when they exit the cell. Exceptions include herpesviruses, which acquire envelopes from the nuclear membrane

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11
Q

DNA virus characteristics

A 
Are HHAPPPPy viruses (*Hepadna, Herpes, Adeno, Pox, Parvo, Papilloma, Polyoma*)
Are double stranded (except Parvo = ssDNA)
Have linear genomes (except papilloma and polyoma - circular, supercoiled) and Hepadna (circular, incomplete)
Are icosahedral (except pox - complex)
Replication in the nucleus (except pox - carries own DNA dependent RNA polymerase)
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12
Q

DNA virus: Herpesviruses

A

Envelope: yes
DNA structure: DS & linear
Medical importance: HSV-1 & HSV-2

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13
Q

DNA virus: Poxvirus

A

Envelope: yes
DNA structure: DS & Linear (largest DNA virus)
Medical: smallpox eradicated worldwide by use of the live-attenuated vaccine
-cowpox (“milkmaid blisters”)
Molluscum contagiosum - flesh colored papule with central umbilication

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14
Q

DNA virus: Hepadnavirus

A

Envelope: yes
DNA structure: Partially DS & circular
Medical: HBV - acute or chronic hepatitis, not a retrovirus but has reverse transcriptase

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15
Q

DNA virus: Adenovirus

A

Envelope: no
DNA structure: DS & linear
Medical: febrile pharyngitis (sore throat), acute hemorrhagic cystitis, pneumonia, conjunctivitis

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16
Q

DNA virus: Papillomavirus

A

Envelope: no
DNA structure: DS & circular
Medical: HPV-warts (serotypes 1,2,6,11), CIN, Cervical cancer (16,18 most commonly)

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17
Q

DNA virus: Polyomavirus

A

Envelope: no
DNA structure: DS & circular
Medical: JC virus - progressive mutilfocal leukoencephalopathy (PML) in HIV; BK virus - transplant pts commonly targets kidney
JC: Junky Cerebrum; BK: Bad Kidney

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18
Q

DNA virus: Parvovirus

A

Envelope: no
DNA structure: SS & linear (smallest DNA virus)
Medical: B19 virus - aplastic crisis in sickle cell disease, “slapped cheek” rash in children (erythema infectiosum/fifths disease)
RBC destruction in fetus leads to hydrops fetalis and death, in adults leads to pure RBC aplasia and rheumatoid arthritis-like symptoms

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19
Q

Viral genetics: Recombination

A

Exchange of genes between 2 chromosomes by crossing over within regions of significant base sequence homology

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20
Q

Herpes simplex virus-1

A

Enveloped, DS and linear
Transmission: respiratory secretions, saliva
Clinical: gingivostomatitis, keratoconjuntivitis, herpes labialis, hermetic whitlow on finger, termporal lobe encephalitis
Most common cause of sporadic encephalitis –> can present as altered mental status, seizures, and/or aphasia

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21
Q

Herpes simplex virus-2

A

Enveloped, DNA, linear
Transmission: sexual contact, perinatal
Clinical: Herpes genitalis, neonatal herpes
Latent in sacral ganglia. Viral meningitis more common with HSV-2 than with HSV-1

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22
Q

Varicella-Zoster Virus (HHV-3)

A

Enveloped, DNA, linear
Transmission: respiratory secretions
Clinical: varicella-zoster (chickenpox, shingles), encephalitis, pneumonia; most common complication of shingles is post-herpetic neuralgia
Latent in dorsal root or trigeminal ganglia

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23
Q

Epstein-Barr virus (HHV-4)

A

Enveloped, DNA, linear
Transmission: respiratory secretions, saliva (kissing disease - common in teens/young adults)
Clinical: mononucleosis (fever, hepatosplenomegaly, pharyngitis, lymphadenopathy esp posterior cervical LNs); avoid contact sports until resolution due to risk of splenic rupture; associated with lymphomas (eg endemic Burkitt lymphoma), nasopharyngeal carcinoma
Infects BCs through CD21.
Atypical lymphocytes on peripheral blood smear - not infected BCs but reactive CTCs
+ monospot test - heterophile Ab detected by agglutination of sheep or horse RBCs

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24
Q

Cytomegalovirus (HHV-5)

A

Enveloped, DNA, linear
Transmission: congenital, transfusion, sexual contact, saliva, urine, transplant
Clinical: mononucleosis in immunocompotent pts (monospot -), infection in immunocompromised pts (esp pneumonia in transplant pts), AIDS retinitis (sightomegalovirus), hemorrhage, cotton-wool exudates, vision loss; Congenital CMV
Infected cells have characteristic “owl eye” inclusions. Latent in mononuclear cells

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25
Human herpes virus 6&7
Enveloped, DNA, linear Transmission: saliva Clinical: Roseola infantum (exanthem subitum): high fevers for several days that can cause seizures, followed by diffuse macular rash HHV-7-less common cause of roseola
26
Human herpesvirus 8
Enveloped, DNA, linear Transmission: sexual contact Clinical: Kaposi sarcoma (neoplasm of endothelial cells). Seen in HIV/AIDS and transplant pts. Dark/violaceous plaques or nodules representing vascular proliferation so Can also affect GI & lungs
27
HSV identification
Viral culture for skin/genitalia CSF PCR for herpes encephalitis Tzanck test (*Tzank heavens I do not have herpes*) - a smear of an opened skin vesicle to detect multinucleated giant cells commonly seen in HSV-1,2 & VZV infection Intramuscular inclusions also seen in 1,2&VZV
28
Receptor used by CMV
Integrity (heparin sulfate)
29
Receptor used by EBV
CD21
30
Receptor used by HIV
CD4, CXCR4, CCR5
31
Receptor used by Rabies
Nicotinic AChR
32
Receptor used by Rhinovirus
ICAM-1
33
RNA viruses: Reovirus
Envelope: No RNA structure: DS linear, 10-12 segments Capsid: Icosahedral (double) Medical: Coltivirus (Colorado tick fever); rotavirus (number one cause of fatal diarrhea in children)
34
RNA viruses: Picornavirus
Envelope: No RNA structure: SS + linear Capsid: Icosahedral Medical: (*PERCH*) - Poliovirus (polio-Salk/Sabin vaccines-IPV/OPV); Echovirus (aseptic meningitis); Rhinovirus (common cold); Coxsackievirus (aseptic meningitis; herpangina-mouth blisters, fever; hand foot and mouth disease; myocarditis, pericarditis); HAV (acute viral hepatitis)
35
RNA viruses: Hepevirus
Envelope: No RNA structure: SS + linear Capsid: Icosahedral Medical: HEV
36
RNA viruses: Caliciviruses
Envelope: No RNA structure: SS + linear Capsid: Iscosahedral Medical: Norovirus (viral gastroenteritis)
37
RNA viruses: flavivirus
Envelope: Yes RNA structure: SS + linear Capsid: Icosahedral Medical: HCV; yellow fever, Dengue, St. Louis encephalitis, West Nile virus
38
RNA viruses: Toga virus
Envelope: Yes RNA structure: SS + linear Capsid: Icosahedral Medical: Rubella, Eastern equine encephalitis, Western equine encephalitis
39
RNA viruses: Retrovirus
Envelope: yes RNA structure: SS + linear, 2 copies Capsid: Icosahedral (HTLV), complex and conical (HIV) Medical: have reverse transcriptase, HTLV (TC leukemia); HIV/AIDS
40
RNA viruses: Coronavirus
Envelope: yes RNA structure: SS + linear Capsid: helical Medical: Common cold, SARS, MERS
41
RNA viruses: Orthomyxoviruses
Envelope: yes RNA structure: SS - linear, 8 segments Capsid: Helical Medical: Influenza virus
42
RNA viruses: paramyxovirus
Envelope: yes RNA structure: Capsid: Medical: Parainfluenza (croup), RSV (brnochiolitis in babies with Ribavirin as treatment); measles, mumps
43
RNA viruses: Rhabdoviruses
Envelope: yes RNA structure: SS - linear Capsid: helical Medical: Rabies
44
RNA viruses: Filoviruses
Envelope: yes RNA structure: SS - linear Capsid: Helical Medical: Ebola/Marburg hemorrhagic fever - often fatal/
45
RNA viruses: Arenaviruses
Envelope: yes RNA structure: SS + or - circular, 2 segments Capsid: helical Medical: LCMV (lymphocytic choriomeningitis virus); Lassa fever encephalitis (spread by rodents)
46
RNA viruses: Bunyaviruses
Envelope: yes RNA structure: helical Capsid: SS - circular, segments Medical: California encephalitis; sandfly/Rift Valley fevers; Crimean-Congo hemorrhagic fever; Hantavirus (hemorrhagic fever, pneumonia)
47
RNA viruses: Delta virus
Envelope: yes RNA structure: SS - circular Capsid: uncertain Medical: HDV is a "defective" virus that requires the presence of HBV to replicate
48
Negative stranded viruses
``` Must transcribe - strand to + Virion brings its own RNA-dependent DNA polymerase *Always Bring Polymerase Or Fail Replication* Arenaviruses Bunyaviruses Paramyxoviruses Orthomyxoviruses Filoviruses Rhabdoviruses ```
49
Segmented viruses
``` All are RNA viruses *BOAR* Bunyaviruses Orthomyxoviruses (influenza) Arenaviruses Reoviruses ```
50
Picornavirus
Includes: *PERCH* Poliovirus, Echovirus, Rhinovirus, Coxsackievirus, HAV RNA is translated into 1 large polypeptide that is cleaved by proteases into functional viral proteins. Can cause aseptic (viral) meningitis (except rhinovirus and HAV) All are enteroviruses (fecal-oral) except rhinovirus
51
Rhinovirus
A picornavirus Nonenveloped RNA Cause of the common cold with over 100 serologic types Acid-labile so destroyed by stomach acid; therefore does not interfere with GI tract
52
Yellow Fever Virus
A flavivirus (also an arbovirus) transmitted by Ades mosquitos Virus has monkey or human reservoir Symptoms: high fever, black vomitus, jaundice May see councilman bodies (eosinophilic apoptotic globules) on liver biopsy
53
Rotavirus
Most important global cause of infantile gastroenteritis Segmented dsRNA virus (reovirus) Major cause of acute diarrhea in the USA during winter, esp in day care centers, kindergartens Villus destruction with atrophy leads to decreased absorption of Na+ and loss of K+
54
Influenza virus
Orthomyxoviruses. Enveloped - ssRNA viruses with 8 segment genome Contain hemagglutinin (promotes viral entry) and neuraminidase (promotes progeny virion release) Ag Pts at risk for fatal bacterial superinfection, most commonly S.aureus, S.pneumoniae, H.influenzae
55
Influenza vaccine
Reformulated vaccine contains viral strains most likely to appear during the flu season due to the virus' rapid genetic change Killed viral vaccine is the most commonly used Live attenuated vaccine contains temperature-sensitive mutant the replicates in the nose but not the lung: administered intranasally
56
Genetic/Antigentic shift
Causes pandemics Reassortment of viral genome segments, such as when segments of human flu A virus reassort with swine flu A virus *Sudden Shift is more deadly than a graDual Drift*
57
Genetic/Antigenic drift
Causes epidemics | Minor (antigenic drift) changes base on random mutation in hemagglutinin or neuraminidase genes
58
Rubella virus
Togaviruse Causes rubella (German measles): fever, postauricular and other lymphadenopathy, arthralgias, and fine confluent Rays that starts on face and spreads centrifugally to involve trunk and extremities. Causes mild disease in children but serious congenital disease (a ToRCHeS infection) Congenital rubella findings include "blueberry muffin" appearance due to dermal extra medullary hematopoiesis
59
Paramyxovirus
Disease in children: parainfluenza (Croup: seal-like barking cough), mumps and measles, RSV (can lead to URI --> brnochiolitis, pneumonia) in infants All contain surface F (fusion) protein, which causes respiratory epithelial cells to fuse and from multinucleated cells. Palivizumab (monoclonal Ab against F protein) prevents pneumonia by RSV infection in premature infants
60
Croup (acute laryngotracheobronchitis)
Cause by parainfluenza viruses (paramyxovirus) Results in seal-like barking cough and inspiratory stridor Narrowing of upper trachea and subglottis leads to characteristic steeple sign on XR Severe croup can result in pulsus paradoxus secondary to upper airway obstruction
61
Measles (rubeola) virus
Paramyxovirus Presentation: prodromal fever with cough, coryza and conjunctivitis then eventually Koplik spots (bright red spots with blue-white center on Buccaneers mucosa) followed 1-2 days later by a maculopapular rash that starts at the head/neck and spreads downward Lymphadenitis with Warthin-Finkeldey giant cells (fused lymphocytes) in a background of paracortical hyperplasia SSPE (subacute sclerosing panencephalitis - occurring years later), encephalitis and giant cell pneumonia (rarely - immunosuppressed) are possible sequelae
62
Mumps virus
Paramyxovirus uncommon due to effectiveness of MMR vaccine Symptoms: parotitis, Orchitis (inflammation of testes), aseptic meningitis, pancreatitis Can cause sterility esp after puberty
63
Rabies virus
Bullet shaped virus Negri bodies (cytoplasmic inclusions) commonly found in Purkinje cells of cerebellum and hippocampal neurons Rabies has a long incubation period (weeks to months) before symptom onset Post-exposure prophylaxis is wound cleaning plus immunization with killed vaccine and rabies immunoglobulin (passive-active immunity) Travels CNS by migrating retrograde fashion up nerve axons after binding to ACh receptors Progression of disease: fever, malaise --> agitation, photophobia, hydrophobia, hyper salivation --> paralysis, coma --> death Infections more commonly from bat, raccoon, and skunk bites than from dog bites in USA Aerosol transmission also possible (bat caves)
64
Ebola virus
A Filovirus that targets endothelial cells, phagocytes, hepatocytes Following an incubation period of up to 21 days, presents with abrupt onset of flu-like symptoms, diarrhea/vomiting, high fever, myalgia Can progress to DIC, diffuse hemorrhage, shock Diagnosed with RT-PCR within 48 hours of symptom onset High mortality rate Transmission: direct contact with body fluids, fomites (including dead bodies), infected bats or primates, high incidence of nosocomial infection Supportive care, no definitive treatment; strict isolation of infected individuals and barrier practices for health care workers are key to preventing transmission
65
Hepatitis virus
Signs and symptoms of all: fever, jaundice, increased ALT/AST; Naked viruses (A&E) lack an envelope and are not destroyed by the gut (*vowels hit the bowels*) HBV DNA polymerase has DNA and RNA dependent activities. Upon entry into nucleus the polymerase completes the partial dsDNA. Host RNA polymerase then reverse transcribes mRNA from viral DNA to make viral proteins. The DNA polymerase then reverse transcribes viral RNA to DNA, which is genome of the progeny virus HCV lacks 3'-5' exonuclease activity --> variation in antigenic structures of HCV envelope proteins. Host Ab production lags behind production of new mutant strains of HCV
66
HAV
Family: RNA picornavirus Transmission: fecal-oral (shellfish, travelers, day care) Incubation: short (weeks) Clinical Course: Asymptomatic (usually) or Acute Prognosis: Good HCC Risk: No Liver biopsy: Heptocyte swelling, monocytes, infiltration, councilman bodies Notes: No carrier state (*Alone*)
67
HBV
Family: DNA hepadnavirus Transmission: patenteral (Blood), Sexual (Baby-making), perinatal (Birthing) Incubation: Long (months) Clinical Course: Initially like serum sickness (fever, arthralgias, rash) may progress to carcinoma Prognosis: most adults have full resolution , minority have chronic infection HCC Risk: yes Liver biopsy: granular eosinophilic "ground glass" appearance; CTC mediated damage Notes: Carrier state common
68
HCV
Family: RNA flavivirus Transmission: primarily blood (IVDU, post-transfusion) Incubation: long Clinical Course: may progress to Cirrhosis or Carcinoma Prognosis: majority develop stable, Chronic hepatitis C HCC Risk: yes Liver biopsy: Lymphoid aggregates with focal areas of macrovesciular steatosis Notes: Carrier state common
69
HDV
Family: RNA delta virus Transmission: parenteral, sexual, perinatal Incubation: superinfection - HDV after HBV = short; coinfection (HDV with HBV = long Clinical Course: Similar to HBV (initially like serum sickness; may progress to carcinoma) Prognosis: superinfection --> worse prognosis HCC Risk: Yes Liver biopsy: similar to HBV (granular eosinophilic) Notes: Defective virus, Depends on HBV
70
HEV
Family: RNA Hepevirus Transmission: Fecal-oral (esp waterborne) Incubation: Short Clinical Course: Fulminant hepatitis in Expectant (pregnant) women Prognosis: High mortality rate in pregnant women HCC Risk: No Liver biopsy: patchy necrosis Notes: Enteric, Epidemic, no carrier state
71
Hepatitis serological markers: Anti-HAV (IgM)
IgM Ab to HAV | Best test to detect acute hepatitis A
72
Hepatitis serological markers: Anti-HAV (IgG)
IgG Ab indicates prior HAV infection and/or prior vaccination Protects against reinfection
73
Hepatitis serological markers: HBsAg
Ag found on surface HBV | Indicates HBV infection
74
Hepatitis serological markers: Anti-HBs
Ab to HBsAg | Indicates immunity to hepatitis B
75
Hepatitis serological markers: HBcAg
Ag associated with core of HBV
76
Hepatitis serological markers: Anti-HBc
Antibody to HBcAg; IgM = recurrent infection (may be the sole + marker during window period) IgG = prior exposure or chronic infection
77
Hepatitis serological markers: HBeAg
Secreted by infected hepatocytes into circulation Not a part of mature HBV virion Indicates active viral replication and therefore high transmissibility
78
Hepatitis serological markers: Anti-HBe
Ab to HBeAg | Indicates low transmissibility
79
HIV
Diploid genome (2 molecules of RNA) 3 structural genes -env (gp120 & gp41): formed from cleavage of gp160 to form envelope proteins --gp120 attaches to host CD4+ TCs --gp41 promotes fusion and entry -gag (p24 & p17): capsid and matrix protein -pol: reverse transcriptase (synthesizes dsDNA from genomic RNA --> dsDNA then integrates into host genome), Aspartate protease, integrase Virus binds CD4+ as well as core captor, either CCR5 on MPs (early infection) or CXCR4 (late infection) on TCs Homozygous CCR5 mutation = immunity Heterozygous CCR5 mutation = slower course
80
HIV diagnosis
Presumptive diagnosis made with ELISA (sensitive, high false + rate and low threshold) + results then confirmed with Western Blot assay (specific, low false positive and high threshold, rule in test) Look for Ab to viral proteins; these tests are often falsely - in the first 1-2 months of HIV infection and falsely positive initially when babies are born to mothers (anti-gp120 crosses placenta)
81
HIV/AIDS diagnosis & viral load
Viral load tests determine the amount of viral RNA in the plasma High viral load is associated with poor prognosis Also used to monitor effect of drug therapy AIDS diagnosis:
82
Time course of untreated HIV infection
Four stages of untreated infection 1. Flu-like (acute) 2. Feeling fine (latent) - replicates in LNs 3. Falling count (immunocompromised
83
Common diseases of HIV+ adults
as CD4+ cell count decreases, risk of reactivation of past infections (TB, HSV, shingles), dissemination of bacterial infections and fungal infections (coccidiodomycosis) and non-Hodgkin lymphoma increases
84
CD4+ count
Oral thrush | Scrapable white plaque, pseudohyphae on microscopy
85
CD4+ count
Oral hairy leukoplakia | Unscrapable white plaque on lateral tongue
86
CD4+ count
Bacillary angomatosis | Biopsy with neutrophilic inflammation
87
CD4+ count
Kaposi sarcoma | Biopsy with lymphocytic inflammation
88
CD4+ count
Chronic, watery diarrhea | Acid-fast oocytes in stool
89
CD4+ count
Squamous cell carcinoma, commonly of anus (men who have sex with men) or cervix (women)
90
CD4+ count
Dementia
91
CD4+ count
Progressive multifocal leukoencephalopathy | Nonenhancing areas of demyelination on MRI
92
CD4+ count
Pneumocystis pneumonia | Ground glass opacities on CXR
93
CD4+ count
Hemoptysis, pleuritic pain | Cavitation or infiltrates on CXR
94
CD4+ count
Meningitis | Encapsulated yeast on India Ink stain or capsular Ag +
95
CD4+ count
Esophagitis | White plaques on endoscopy, yeast and pseudohyphae on biopsy
96
CD4+ count
Retinitis, esophagitis, colitis, pneumonitis, encephalitis Linear ulcers on endoscopy, cotton wool spots on fundscoptic exam Biopsy reveals cells with intranuclear (owl eye) inclusion bodies
97
CD4+ count
B-cell lymphoma (eg. Non-Hodgkin lymphoma, CNS lymphoma) | CNS - ring enhancing, may be solitary (vs. toxoplasma)
98
CD4+ count
Fever, weight loss, fatigue, cough, dyspnea, nausea, vomiting, diarrhea Oval yeast cells within MPs
99
CD4+ count
Nonspecific systemic symptoms (fever, night sweats, weight loss) or focal lymphadenitis
100
CD4+ count
Brain abscesses | Multiple ring-enhancing lesions on MRI
101
Prions
Prion disease are caused by the conversion of a normal (predominantly alpha-helical) protein termed prion protein (PrP) to a beta pleated form, which is transmissible via CNA-related tissue (iatrogenic CJD) or food contaminated by BSE-infected animal products (variant CJD). Resists protease degradation and facilitates the conversion of even more protein into the beta form. Resistant to standard sterilizing procedures, including standard autoclave. Accumulation of beta sheets results in spongiform encephalopathy and dementia, ataxia and death
102
Prion Diseases
Creutzfeldt-Jakob disease - rapidly progressive dementia, typically sporadic (some familial forms) Bovine spongiform encephalopathy (BSE) - aka mad cow disease Kuru - acquired from prion disease noted in tribal populations practicing human cannibalism

Microbiology (8 decks)

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