Mycobacterium tuberculosis 1

Mycobacterium tuberculosis and HIV

Stephanie Ruble

Microbiology 31 #38090 PM
Mrs. Nuria Denis-Arrue
20 July 2015

Mycobacterium tuberculosis 2
In 1999, in South Carolina, a prison that housed inmates with HIV experienced an
outbreak of Tuberculosis. Although they were screened by skin test and chest x-ray upon
admission, one inmates infection was not detected. The 34-year-old man had complained of
fever, abdominal pain, and cough ongoing for 2 weeks when he was seen at the prison hospital.
He had a chest x-ray that came back negative for TB. However, a sputum sample was not
obtained, and therefore not tested for Acid Fast Bacilli (AFB). Without a diagnosis, the inmate
was released back into the HIV dormitory. About a month later, the inmate, still complaining of
symptoms, was seen at a civilian hospital where an AFB test was performed and came back
positive for active TB. An investigation later determined that 31 other HIV infected men out of
323 had also contracted TB. Five of those men had been released from prison before the initial
patient had been diagnosed.
Mycobacterium tuberculosis is a small, 2-5 micrometers in length and 0.2-0.5
micrometers in width, non-motile, slender rod that tends to grow in clumps, and sometimes
forms filaments. It is a very slow growing (15-20 hours per generation, as compared to the 20
minute per generation Escherichia coli) obligate aerobe. On the surface of plated media, M.
tuberculosis growth tends to look like mold. Hence, its family name prefix Myco, which means
fungus. This mycobacterium does not have the chemical properties of either Gram-positive or
Gram-negative bacteria. It is deemed Gram-resistant due to its unusually waxy walls made from
mycolic acid. If Gram stained however, it produces a very weak Gram-positive result. It is acidfast positive since it is resistant to decolorizing by acid after staining with carbolfuchsin. M.
tuberculosis uses a very large portion of its enzymes solely for lipogenesis and lipolysis.
(Definition of Mycobacterium tuberculosis, 2012; Dylan Tierney, 2014; Todar; Tortora, Funke, &
Case, 2013).

Mycobacterium tuberculosis 3
Mycobacterium tuberculosis is the organism responsible for the infectious disease and
most cases of Tuberculosis (TB). Tuberculosis, formerly known as Consumption was also called
the White Plague in the 17th and 18th century in Europe (Todar). The illness is chronic and
progressive with a period of latency followed by infection of the lungs. TB is one of the leading
infectious causes of morbidity and mortality of adults in the world (Dylan Tierney, 2014).
Transmission of TB happens when droplet nuclei become airborne and are then inhaled.
Sputum from the host becomes aerosolized when they cough, sneeze, sing, or speak, or by any
other forced respiratory maneuvers. Respiratory particles can even remain airborne in a room air
current for several hours. Once a droplet has landed though, it is very difficult to resuspend it,
such as in shaking out the bed sheets. If the droplet lands on food or a hard surface, it is not
likely that such fomites can spread contamination (Dylan Tierney, 2014). According to the
Centers for Disease Control and Prevention (CDC), TB is not spread through shaking hands,
sharing food or drink, touching contaminated bed linens or toilet seats, sharing toothbrushes, or
kissing (2012).
Many people are exposed to TB, but not everyone who inhales droplet nuclei becomes
infected with TB. Only about 5-10% of healthy adults become infected after exposure with active
TB. Most of the time, after being exposed, your body is able to fight off infection. While the
nuclei are in your body and your immune system is fighting it off, you have what is called latent
TB. Latent TB has no signs or symptoms and is not infectious. However, if left untreated, latent
TB can become active TB. It is not until your body cannot fight off the invasion, that you
become infected with active TB.
Tuberculosis is said to be one of the principle diseases of poverty, meaning that it is more
common in underdeveloped countries and areas with poor living conditions and inadequate
health care. Quite a few risk factors can make you more susceptible to TB infection. HIV
infection is the number one risk factor for contracting TB. Ten percent of all HIV patients have

Mycobacterium tuberculosis 4
TB. If you are immunocompromised by such diseases as diabetes, kidney disease, silicosis, or
are on immunosupressive therapy after any kind of transplant, you are at risk. People who work
in close quarters such as hospitals, prisons, nursing homes, or in homeless shelters are at risk.
Those who abuse drugs, alcohol, and even smokers are twice as likely to become infected when
exposed to TB. Immigrants from countries where TB is prevalent, the elderly, and children all
have a higher risk. Long-term corticosteroid use, those who have undergone surgeries such as
gastric bypass, and those under a normal body weight are more susceptible to TB infection.
There may even be a genetic susceptibility that makes you predisposed to an active TB infection
(CDC, 2012; Dylan Tierney, 2014; Definition of Mycobacterium tuberculosis, 2012; Todar;
Tortora, Funke, & Case, 2013).
Active TB signs and symptoms may include, but are not limited to; initially just not
feeling well, loss of appetite, weakness or fatigue, weight loss, a cough with or without bloody,
yellow, or green sputum, chest pain, shortness of breath, rapid heart rate, fever, chills, night
sweats, nail clubbing, and swollen lymph nodes. Coughing may become so severe that tissues are
damaged causing blood vessels to rupture and hemorrhage, resulting in death if not immediately
and properly treated (CDC, 2012; Dylan Tierney, 2014; National Cancer Institute (NCI), 2014;
Tortora, Funke, & Case, 2013).
Detection and diagnosis of active TB can be done with a few different tests. First, a
patients history is taken and a physical exam is done. Patients at a high risk for TB are given the
Mantoux tuberculin skin test (MTST) made from a purified protein derivative (PPD). This test is
relatively quick with results in 48-72 hours. However, this test can give false-positive and falsenegative readings, especially if the patient has just been exposed to TB but not infected, or if one
had an active TB infection in the past. Chest radiography is done to visualize the lungs and
confirm the presence of tubercles, hence the name, tuberculosis. However, the MTST may also

Mycobacterium tuberculosis 5
give false readings. LED-FM or light-emitting diode fluorescence microscopy has shown
promise in being more effective than culture and staining techniques since culturing the bacteria
can take up to a month. However this is a more expensive practice and still in testing as to its
efficacy. IGRA or interferon-gamma release assays are whole blood tests to detect how strongly
the immune system responds to TB, which is good for immunocompromised patients. It is also
for those who have already been vaccinated, but does not differentiate between latent and active
infections. NAAT, which stands for nucleic acid amplification test, tests for drug susceptibility
and genotyping, but can take 2-3 weeks for liquid cultures, and up to 3 months for solid cultures.
PCR or polymerase chain reaction tests amplify DNA for quick detection of TB antigens. Xpert
MTB/RIF is a new automated PCR test that can detect M. tuberculosis within an hour and a half.
At the same time, it determines resistance to Rifampin, a major TB antibiotic. Unfortunately, this
test is very expensive. A lower cost test, the MODS (microscopic observation drug susceptibility)
assay test, uses a liquid culture medium, which gives results in about 10 days and reports
susceptibility to Rifampin and Isoniazid, is also available and will be further discussed later on
(Dylan Tierney, 2014; Lora, 2015; National Cancer Institute (NCI), 2014; Tortora, Funke, &
Case, 2013).
Regardless of the test used to detect the presence of M. tuberculosis, the patient will
begin treatment, unless a drug resistance is known. Multi-drug therapy is needed to effectively
kill TB, thereby reducing drug resistance. Four drugs that are used together are Isoniazid (INH),
Rifampin (RIF), Ethambutol (EMB), and Pyrazinamide (PZA). INH inhibits the synthesis of
mycolic acid. RIF inhibits RNA polymerase activity. EMB inhibits RNA synthesis. It is not
known exactly how PZA works, but it is thought to work on cell metabolites, inhibiting cell
metabolism. PZA is the only drug that is effective against the dormant bacillus and requires up to
130 doses. Prolonged treatment, up to 9 months, is necessary because the bacilli grow very

Mycobacterium tuberculosis 6
slowly or may lie dormant. With such a long treatment time, compliance can dwindle, leading to
resistance. Multi-drug resistant TB (MDR-TB) is resistant to INH and RIF. Second-line drugs are
used in case of resistance to first-line drugs, but are either less effective, have toxic side effects,
or are unavailable in some countries. Streptomycin was the first effective antibiotic against TB in
1944, but is considered a second-line drug today. Other second-line drugs include, but are not
limited to; Kanamycin, Capreomycin, Levofloxacin, Moxifloxacin, Amikacin, Paraaminosalicylic acid (PAS), and some Aminoglycosides.
However, some strains have developed resistance to all of these drugs. When a strain
develops resistance to first-line and second-line drugs, it is known as extensively drug-resistant
(XDR). XDR strains are emerging worldwide and are practically untreatable. Now, take into
consideration the weakened immune system of the HIV patient. Anywhere from 30-90% of
patients with TB also have HIV. HIV patients with XDR-TB can die within 3 months of
diagnosis. Fortunately, clinical trials are underway to find new drugs (Tortora, Funke, & Case,
2013).
Of course, there are special considerations when it comes to treating certain populations,
such as children, pregnant women, the elderly, and HIV patients. In addition, complications may
arise with the TB disease that can be mild to severe and even cause death. Some complications
can include, lung function damage, kidney and/or liver malfunction, meningitis, bone pain
mainly in the spine, ribs, and joints, visual disturbances and cardiac tamponade (Definition of
Mycobacterium tuberculosis, 2012).
General measures to prevent the spread of TB include staying home when sick and
avoiding visitors, covering coughs and sneezes, and avoiding TB patients who have been on
antibiotic therapy for less than 2 weeks. In health care facilities, prompt identification of
contagious patients, airborne-precautions, and specialized treatment of confirmed or suspected
TB patients is necessary. Hospitalized TB patients should be given private, negative-pressure

Mycobacterium tuberculosis 7
rooms that vent to the outside of the hospital. Health care workers who encounter TB patients are
required to wear respiratory protective equipment such as N95 or better respirator masks. In
addition, persons who visit certain areas, or travel abroad to regions where TB is prevalent
should frequently be tested by their health care provider (CDC, 2012; Definition of
Mycobacterium tuberculosis, 2012; National Cancer Institute (NCI), 2014).
There is a vaccine for TB, but it is not for everyone. The BCG vaccine is a live culture of
Mycobacterium bovis that has been made avirulent. The vaccine is only given to infants and
children in areas of the world where TB is common. It is not widely used in the United States.
The children must be in high-risk situations such as living with a parent who has active TB.
However, before receiving the vaccination, the children must have a negative skin test. After
being vaccinated, the BCG vaccine can cause positive skin tests. The vaccine also does not
protect from latent TB infection, only active TB disease, but the vaccine is only 60-80%
effective. Sadly, the children who need the vaccine the most, those infected with HIV, most likely
develop a fatal infection from it. BCG vaccine is rarely given to adolescents or adults, as it has
almost zero effectiveness. Rather, it is reserved for health care workers who meet a very specific
set of requirements regarding their work conditions (CDC, 2012; Definition of Mycobacterium
tuberculosis, 2012; National Cancer Institute (NCI), 2014; Todar; Tortora, Funke, & Case, 2013).
TB has been shown to increase HIV viral replication and may accelerate HIV
progression, increasing mortality rates. Bolivia has the highest rate of active TB in South
America, and one of the highest in the world. TB is difficult to diagnose, let alone in resource
limited areas such as Bolivia. A recent study conducted in Bolivia compared the diagnostic
testing of Microscopic Observation Drug Susceptibility liquid culture (MODS) to traditional
Ziehl-Neelsen smear staining (ZN) and the Lowenstein Jensen solid culture (LJ) of TB and
MDR-TB in HIV patients. The researchers obtained sputum samples from 127 patients by way of

Mycobacterium tuberculosis 8
spontaneous sputum production, induced sputum production, string test, or all three.
Spontaneous sputum was collected from coughing patients. Sputum was induced from patients
by nebulizer treatment. The string test involves having the patient swallow a capsule containing a
nylon string. One end of the string is attached to the patients cheek while the weighted end is
swallowed. The capsule dissolves and the string remains in place for one hour. The string collects
gastric contents, which include M. tuberculosis. The specimens were then all tested for the
presence of TB by ZN smear, LJ culture, and MODS liquid culture, which tests for drug
resistance as well. The MODS culture grew positive results around 10 days as compared to the
LJ culture, which was 34 days. About half of the time the ZN smears did not detect M.t. whereas
MODS detected it in 94.4% of the patients. Neither the ZN smear nor LJ culture can detect drug
susceptibility in M.t. However, MODS does detect sensitivity to Rifampin and Isoniazid.
In many parts of the world, HIV is no longer a death-sentence, but has become a
manageable chronic disease due to increased detection and wider availability of effective
treatment. However, in countries with limited resources, like Bolivia, delay in detection and
treatment can have deadly consequences. The results of this study stresses the need for rapid TB
detection among HIV/AIDs patients as evidenced by the fact that almost half of the study
participants died within 60 days of detection. MODS provides that rapid detection and drug
susceptibility for a lower cost than the Xpert MTB/RIF currently promoted by the World Health
Organization (Lora, 2015).

Mycobacterium tuberculosis 9

Questions
1. What is a tuberculin skin test?
The Mantoux tuberculin skin test (MTST) is made from a purified protein
derivative (PPD), and is administered subcutaneously in the forearm. A wheal is
formed, and then measured 3 days later. This test is relatively quick with results in
48-72 hours. However, this test can give false-positive and false-negative
readings, especially if the patient has just been exposed to TB but not infected, or
if one had an active TB infection in the past.
2. What does a positive test indicate?
A positive test may indicate latent or active TB. Further testing is required. A
positive skin test may also indicate the presence of BCG vaccine.
3. What characteristic of AFB makes them difficult to treat?
Acid Fast Bacilli are difficult to treat do to their mycolic acid content making
them virulent. Also, Mycobacterium tuberculosis is especially difficult to treat due
to its lengthy generation time and ability to lay dormant.
4. What characteristics of Mycobacterium tuberculosis result in the requirement for longterm multidrug therapy?
Its lengthy generation time and ability to lay dormant require lengthy treatment
with many drugs to effectively kill M. tuberculosis. Pyrazinamide is the only drug
that is effective against the dormant bacillus and requires up to 130 doses.
5. What type of results would be expected in a chest X-ray of a person who had active TB?
Tubercles would be present in the lungs. Tubercles are round nodules that contain
the macrophages that house M. tuberculosis.
6. How did the inmates living on the opposite side of dormitory A contract TB?
I suspect that since respiratory particles can remain airborne in a room air current
for several hours, the inmates may have been exposed that way. On the other
hand, while inmates were interacting with each other, as it does not state that they

Mycobacterium tuberculosis 10
were prevented from doing so, droplet nuclei may have been passed from person
to person.
7. How does a persons HIV status influence the risk of acquiring TB?
HIV patients are immunocompromised and are therefore more susceptible to
contracting the disease. In addition, their living situation or lifestyle may
contribute to their exposure.

Mycobacterium tuberculosis 11
References
CDC. (2012, March 13). Basic TB Facts. Retrieved from Centers for Disease Control
and Prevention : http://www.cdc.gov/tb/topic/basics/default.htm
Definition of Mycobacterium tuberculosis. (2012). Retrieved from MedicineNet.com:
http://www.medicinenet.com/script/main/art.asp?articlekey=26602
Dylan Tierney, E. A. (2014, February). Tuberculosis (TB). Retrieved from Merck
Manual Professional Edition/ Infectious Diseases/ Mycobacteria:
http://www.merckmanuals.com/professional/infectiousdiseases/mycobacteria/tuberculosis-tb
Lora, M. H.-M. (2015). Evaluation of Microscopic Observation Drug Susceptibility
(MODS) and the string test for rapid diagnosis of pulmonary tuberculosis in
HIV/AIDS patients in Bolivia. BMC Infectious Diseases, 15(1).
doi:10.1186/s12879-015-0966-0
National Cancer Institute (NCI). (2014, June 14). Tuberculosis (TB) - Topic Overview.
Retrieved from WebMD: http://www.webmd.com/lung/tc/tuberculosis-tb-topicoverview?page=2
Todar, K. (n.d.). Mycobacterium tuberculosis and Tuberculosis . Retrieved from
Todar's Online Textbook of Bacteriology:
http://textbookofbacteriology.net/tuberculosis.html
Tortora, G. J., Funke, B. R., & Case, C. L. (2013). Microbiology An Introduction (11th
ed.). Glenview, IL: Pearson Education Inc. Retrieved July 17, 2015