Microbiology Summary Part #1 Price: 10

Lecture 1 / Bacteria

Ziad Al-Nasser

Dima Bani-Eisa

Group B hemolytic Streptococci

General Characteristics Gram positive cocci, in chains, that form larger colonies and less distinct (fainter) hemolysis compared to their friends of Group A. Encapsulated. The capsule is formed of Sialic acid of 9 different types (Ia, Ib, II, VIII ...) Found in GIT and Vagina normal flora (10-30% of the women are carriers). We need to screen pregnant ladies for GBh strep. Because we are afraid of Neonatal Septicemia and Neonatal Meningitis. These diseases are associated with high mortality and have high chance to occur in the case of Premature Rupture of Membranes*, especially if the rupture exceeds 18 hours, and this is what we scare the most. And if the lady is found to be positive [carrier], we should give her antibiotics as prophylaxis.
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Pathogenesis Host factors: if the baby immature, premature or immune-compromised, the risk will be higher. Sialic acid capsule. It is anti-phagocytic and it binds to factor H and interferes with the function of the complement system. Anti-bodies are needed for the classical pathway activation of the complement system as long as the other pathways cannot be activated without factor H- . It has an enzyme called C5a peptidase blocks the C5a and interferes with phagocytosis.
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Clinical aspects Clinically, we cannot judge that this is GBH strep. We treat empirically based on the age of the patient; if we have newborn meningitis then its either group B, Listeria, or members of the enterobacteriaceae This is the role of the thumb! Symptoms include: Respiratory distress, septicemia, fever and lethargy. Babies can develop pneumonia and skin infections. 5-10% of the total number of meningitis cases can be related to GBH strep. and mortality rate approaches 20% if its not treated. There is a condition called Peripartum Choriomeningitis in which the organism gets access to the chorion in case of membranes rupture. Diagnosis: we do Blood culture and CSF culture. Direct detection from vagina is not effective, because it is part of the normal flora; we don't look for it routinely unless there is an indication for that. Treatment: lactam antibiotics such as Penicillin are still the drug of choice. And, in case of less susceptibility, we have to use combination therapy with aminoglycosides. Prevention: 1) Reducing contact and eradicating the carriers. 2) Intrapartum chemoprophylaxis of lactams during devilry. 3) Premature babies are more susceptible. 4) Purified GBS polysaccharide vaccine which is under trial.
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Listeria Monocytogenes
General Charactaristics Gram-positive rod and non-spore forming. Beta hemolytic and can be mistaken with GBH strep. So, to differentiate between them we do Catalase test. Listeria is Catalase positive and GBH strep. is Catalase negative. Grows at cold enrichment; at 1 C. And Show funny type of motility at 25 C called tumbling motility. Also they show umbrella type of motility in semisolid media. We have 3 serotypes, based on Teichoic Acid. It is environmental microorganism which is found in the GIT of animals mainly and can be transmitted from animal to humans, especially through dairy products, such as soft cheese that is not prepared properly and non-pasteurized milk to mothers then transmitted to babies transplacentally. And sometimes it is part of the normal flora in our bodies. We think of Listeria in fetus, newborn meningitis and still birth [the baby is born dead of Listeriosis]. It is very important to remember that infected babies will be born having multiple Granulomatosis lesions all over the body; this condition is called Granulomatosis Infantiseptica. So, when we see Multiple Granulomatosis in a baby that is born, we have to think of Listeria. Extreme age groups are affected the most; old people and newborn.
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Pathogenesis Cell mediated immunity is the most important and activated macrophages are needed. So in compromised patients, such as AIDS patient, listeriosis is common. Evasiveness Internal and invasion through actin rearrangement: They attach to phagocytes through a protein called Internalin. It produces a toxin known as listeriolysin O LLO which makes it penetrate through the vacuole and escape to cytosole. ActA and Gelsolin proteins are going to cause actin polymerization at the end of the organism then actin polymerization will form the actin tail and make the organism act as a rocket. So it survives intracellularly and will be fired from one cell into the other without being exposed to our immune system.
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Clinical Aspects The mode of transmission is by food. Patients could have GIT manifestations, like abdominal pain, diarrhea and vomiting. They have CNS predilection; new born meningitis and encephalitis. It can cause Neonatal and puerperal sepsis. Elderly and immunocompromised, like Women in late pregnancy and AIDS patients, are highly susceptible. Diagnosis: by blood culture and CSF culture. Treatment: we can give Penicillin (very sensitive), ampicillin, TMP-SMX [co-trimoxazole], or combination of ampicillin and gentamycin. Prevention: Done by screening of food products. We dont have vaccine for Listeria.
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Mycobacterium Leprae
General features: Acid-Fast Bacillus that fails to grow on an artificial media in the lab. Instead, we grow them on foot pads of mice, or armadillos (.) Causes slow type of infection, with long incubation period (2-7 years) and the generation time of the organism is 12 14 days. Humans act as Reservoirs. Structurally similar to TB. They differ in Phenolic Glycolipid I (PGL-1). This structure is classic or pathognomonic for M.Leprae. It is only found in M. leprae. Causes chronic granulomatous disease of peripheral nerves and superficial tissues; it targets the terminal nerve endings damaging them and then granuloma will develop. For example, it can affect the palm of the hand or the face and sometimes these granulomas can cause severe disfigurement of the face; the facial expressions and the recognition features of the face can disappear and after the treatment the face could come back to its normal look. The mode of transmission is unknown, it could be through droplets, direct contact, nasal spray, minor trauma, or tattoos.
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Pathogenesis This organism multiplies in the host cells like macrophages or Schwann cells. It is obligate intracellular and purely human-pathogen; we cannot grow it outside. The Phenolicglycolipid 1 (PGL-1) and the Lipoarabinomannan (LAM), facilitate the survival intracellularly. So you require activation with cytokines in order for macrophages to be activated and kill this organism. It goes to the peripheral nerve endings of the sensory nerves and you will get patchy anesthesia. Two types: 1- Tuberculoid leprosy: that is localized. This type stimulates cell-mediated immunity, we see granulomatous and epithelioid lesions, giant cells and lymphocytosis, and if you do skin testing like the PPD test it will be positive, we call it Lepromin test. 2- Lepromatous leprosy: that it is so generalized and massively-diffused all over the body that will induce immune suppression (cell mediated immunity will be suppressed), and PPD will be negative (the lepromin test is negative). Delayed-type hypersensitivity to lepromin is the pathology. Negative in lepromatous and positive in Tuberculoid.
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Clinical aspects Diagnosis: It is simply by taking a biopsy and looking for the acid-fast bacilli, and we look for the specific substance PGL-1 for the serological test. Treatment: Sulphones (dapsone) combined with Rifampin are used for the Tuberculoid type, and we add a third drug called Clofazimine for the Lepromatous type. Chemoprophylaxis: 1) Anybody who is exposed to a patient with leprosy should take Dapsone. 2) The BCG vaccine (bacillus of calmette and Guerin), which is used in the treatment of bladder cancer, can activate macrophages, that can act against mycobacterium leprae. (this is like nonspecific therapy)
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Clostridium Tetani
General Charactaristics Gram positive bacilli and spore-forming bacteria. The spore is located in the terminal end and it will look like drumstick under the microscope. Motile, strict anaerobe and soil bacteria. So, we expect to see it in dirty-type of wounds and dirty type of professions, like: people working with soil, soldiers, mechanics and also in debilitated and crush-type of injury. Also it is part of the normal flora of the lower GIT of animals and humans, so stool-contaminated wounds could develop tetanus. It produces a neurotoxin called Tetanospasmin which is responsible for muscle spasm. It is a metalloproteinase. It prevents the release of pre-synaptic inhibitory afferent neurotransmitters. It is transported to the CNS retrogradly through the axons of the peripheral nerves then into the anterior horn cells where this toxin causes blockage of postsynaptic inhibitory impulses leading to muscle spasm. Heat labile. Also, we can make *toxoid, which is used for vaccination, if we treat it with formaldehyde.
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Tetanus It is simply a severe muscle spasm that is caused by the exotoxin of Cl.Tetani. If that affects the involuntary muscles like: respiratory muscles, the patient is going to suffocate and die. Sometimes, if striated muscles undergo severe contraction, bones could be fractured. For example: the spinal column could be fractured. There is no inflammation. We could get it through: - Wounds contaminated with soil, like soldiers. - Unskilled abortion. - Scarification in trying to abort babies that are dead. - Female circumcision (.) - In non-sterile surgery. - Low oxidation reduction potential areas, deep tissues and areas that support anaerobic type of growth.
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Clinical Aspects: Incubation period: Around 4 days to several weeks; it depends on the site of infection. If it is close to the CNS, the incubation period will be shorter. Patients are going to have muscle spasm. 1) Trismus and the contraction of the masseter muscles first (the patient will look as he is smiling but in reality he is not. We call it Sardonic Smile and this is almost pathognomonic of tetanus) 2) then the other muscles, especially the muscles of the back, and the patient goes into what we call Opisthotonus Position. Patients die from respiratory failure and fatigue.
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 Sometimes, neonates could die of respiratory failure in a condition called Tetanus Neonatorum if the mother gives birth in a dirty area. Diagnosis: We rarely manage to isolate the organism in a pure culture and the diagnosis is mainly clinical; because, it is intoxication and the patient's signs and symptoms are related to the effect of the toxin. Treatment: First, we have to maintain airway. The patient has to be put in a dark room and in calm and quiet environment and must take muscle relaxants till the effect of the toxin fades away and the patient will recover completely without any sequel of infection. And we give the anti-toxin which is Human Tetanus ImmunoGlobulin (HTIG). We can get this HTIG from people who are vaccinated. This HTIG will neutralize the toxin before it gets fixed in the anterior horn cells. But if the toxin is already bound to the area we can do nothing actually. Do we give antibiotics?? This is a toxin effect as we said, but physicians say that they have to give antibiotics to clear any free clostridium circulating around. And still Penecillin is the drug of choice. Prevention: DTaP (Diphtheria Tetanus acellular Pertussis) vaccine is very effective. We use penicillin in severe wounds to clear the infection.
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Clostridium Botulinum
General Charactaristics Large spore-forming gram positive bacilli. The spores are sub-terminal. They like to grow in neutral or alkaline type of food like: canned fruits and vegetables, beans and mushroom. Toxin is the most potent in nature. Less than 1 g can kill a human being!! And we talked about this in biological warfare and bioterrorism. The mechanism of action of Cl.botulinum toxin is completely the reverse of Cl.tetani. It is metalloproteinase which acts on pre-synaptic membranes of neuromuscular junctions preventing the release of acetylcholine. So, flaccid paralysis will take place. There are so many different serotypes from A to G and we can identify those serologically. It is heat labile which means that it can be inactivated by heat. So, if you boil the can at least for 10 minutes, the toxin will be inactivated and you will be in the safe side. So, never ever taste the can before you boil it! It is acid resistant. So, it can pass through the stomach and get absorbed easily into the CNS.
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Botulism It is caused by the toxin of Clostridium Botulinum. It is simply a food poisoning but you could have wound botulism if the wound is contaminated with the spores of these organisms. Also, we could get them from soil and ponds. Remember that there is no change of food taste, color or odor and the alkaline type of food which is not heated enough. The only thing that you can see is that the can is inflated or injured. Food intoxication suppresses acetylcholine transmission in the neuromuscular junction plus other transmitters. Then, it could cause cardiac arrhythmias, heart failure, lowering of blood pressure and autonomic nervous system effects. In weaning ( ,)they try to let the baby lick some honey. If the honey is contaminated with the spores of Cl.botulinum, they can easily get absorbed because the GIT of the baby does not have that much of normal flora. So, the baby starts to develop squint and his eyes start moving anyway. Then, he could develop respiratory arrest and death. Those babies are diagnosed as Sudden Infant Death Syndrome (SIDS). So, honey is the most common one that we see. And remember that if you are not sure of the source of honey, don't ever give that to babies. Adults may not be affected as much as babies because their microflora protects them from botulism.
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Clinical Aspects:

It is food borne. 12 36 hours after ingestion of the toxin. It may start with nausea, dry mouth, blurred vision and diplopia, pupillary dilatation and

nystagmus. Then paralysis. Cocaine users may use the same needle which can be contaminated. Diagnosis: We just look for the toxin in blood, GIT or food. We can culture the stool and isolate the organism. Treatment: The most important thing is the respiratory paralysis. So, the baby has to be intubated and [1]maintaining airway is essential. We give [2]anti-toxin to neutralize any toxin that is not fixed to neuromuscular junction. We give [3]antibiotics (Pencillin) for any free bacteria that still circulating around. We use [4]pressure cooking. If you boil the food, you will never inactivate the spores. But if you use the pressure cooker and raise the temperature beyond 121C for minimum of 15 to 20 minutes, you can inactivate those spores.
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By: Dima Muhammad Bani-Eisa

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