Chlamydiae

and
Rickettsiae

Suzan Matar (PhD Medical Microbiology and Immunology)

Department of Clinical Laboratory Sciences
 Chlamydiae are obligate intracellular organisms,
that is, they can grow only within cells.

Diseases

- Chlamydia trachomatis causes eye, respiratory, and

genital tract infections.
- C. trachomatis is the most common cause of
sexually transmitted disease
- Infection with C. trachomatis is also associated with
Reiters syndrome, an autoimmune disease.
- Chlamydia pneumoniae causes atypical pneumonia.
- C. psittaci causes psittacosis
 Species Disease Natur Mode of Number Diagnosis
al Transmission to of
Hosts Humans Immunol
ogic
Types

C. Urethritis, Human Sexual contact; More than Inclusions in

trachomatis pneumoniaconj perinatal 15 epithelial cells
unctivitis, transmission seen with
lymphogranu- Giemsa stain or
loma by immunofluo-
venereum, rescence; also
trachoma cell culture

C. Atypical Human Respiratory 1 Serologic test

pneumoniae pneumonia droplets

C. psittaci Psittacosis Bird Inhalation of dried 1 Serologic test

(pneumonia) bird feces (cell culture
rarely done)
Chlamydiae have a replicative cycle

1. The cycle begins when the extracellular, metabolically

inert, sporelike elementary body enters the cell and
2. reorganizes into a larger, metabolically active
reticulate
body .

The latter undergoes repeated cycles of binary fission

to form daughter reticulate bodies, which then develop
into elementary bodies, which are released from the
cell.

Within cells, the site of replication appears as an

inclusion
body, which can be stained and visualized
microscopically.
 Laboratory diagnosis

- is frequently made by direct staining of

genital tract specimen with fluorescence-
conjugated monoclonal antibodies.

- Group specificlipopoysaccharides
complement fixation
- Species specific and immunospecific
antigens (proteins) Immunofluorescence

Nucleic acid amplification tests (NAATs)

using the patients urine are widely used
to diagnose chlamydial sexually
transmitted disease
 Serologic tests are used to diagnose infections
by C. psittaci and C. pneumoniae but are rarely
helpful in diagnosing disease caused by C.
trachomatis because the frequency of infection
is so high that many people already have
antibodies.
 Transmission
C. trachomatis infects only humans and is usually
transmitted by close personal contact (e.g., sexually or
by passage through the birth canal).

Individuals with asymptomatic genital tract

infections are an important reservoir of infection for
others.

Trachoma is a leading cause of blindness in those

countries.
Patients with a sexually transmitted disease are
coinfected with both C. trachomatis and Neisseria
gonorrhoeae in approximately 10% to 30% of cases.

In trachoma, C. trachomatis is transmitted by finger-to-

eye or fomite-to-eye contact.
 C. pneumoniae infects only humans
and is transmitted from person to
person by aerosol.

C. psittaci infects birds (e.g.,

parrots, pigeons, and poultry, and
many mammals). Humans are
infected primarily by inhaling
organisms in dry bird feces.
Pathogenesis & Clinical Findings
Chlamydiae infect primarily epithelial
cells of the mucous membranes or the
lungs.

They rarely cause invasive,

disseminated infections.
 Clinical Manifestations

Clinical Syndromes Caused by C. trachomatis

Local Infection Complication Sequelae

Conjunctivitis Chronic arthritis
Reiters syndrome
Men Urethritis (rare)
Epididymitis
Prostatitis Infertility (rare)
Infertility
Conjunctivitis Endometritis
Ectopic pregnancy
Urethritis Salpingitis
Women Chronic pelvic pain
Cervicitis Perihepatitis
Chronic arthritis
Proctitis Reiters syndrome
(rare)
Conjunctivitis
Infants Chronic lung
Pneumonitis Rare, if any
Pharyngitis disease?
Rhinitis
 Clinical Manifestations

C. trachomatis Syndromes Seen

in Men or Women
Non-LGV serovars
Conjunctivitis
Proctitis
Reiters Syndrome

LGV serovars
Lymphogranuloma venereum- STD with lesions
on genitalia and in lymph nodes.
 Treatment

All chlamydiae are susceptible to

tetracyclines, such as doxycycline,
and macrolides, such as
erythromycin and azithromycin.
 Prevention
There is no vaccine against any chlamydial disease.

- Sexual contacts should be traced, and those who had contact within
60 days should be treated.

- Oral erythromycin given to newborn infants of infected mothers can

prevent inclusion conjunctivitis and pneumonitis caused by C.
trachomatis.

- Psittacosis in humans is controlled by restricting the importation of

psittacine birds, destroying sick birds, and adding tetracycline to bird
feed.

- Domestic flocks of turkeys and ducks are tested for the presence of
C. psittaci.
 Rickettsia Family

Includes the genera:

- Rickettsia, Orientia, Coxiella, Ehrlichia,
Bartonella

- Obligate intracellular parasites EXCEPT Coxiella

General characteristics
Humans are accidental hosts

Cell wall is composed of peptidoglycan & LPS (similar

to gram negative bacteria)

Consists of 3 genera
Rickettsia
Ehrlichia
Coxiella

Intracellular location
Typhus group cytoplasm
Spotted fever group nucleus
Coxiella & Ehrlichia cytoplasmic vacuoles
Microscopic figure
 Diseases Caused by Rickettsiae
Family
Spotted fever group (R. rickettsii)
Typhus group
(R. prowazekii, R. typhi)
Scrub typhus group
(Orientia tsutsugamushi)
Q fever group (C. burnetti)
 Rickettsias
Most are pathogens that alternate
between mammals and fleas, lice or ticks

No Human to human transmission.

The rickettsiae circulate widely in the

bloodstream (bacteremia), infecting
primarily the endothelium of the blood
vessel walls (brain, skin and heart).
Rickettsial infections are generalized
infections with RASH.
 The exception to arthropod transmission is C.
burnetii, the cause of Q fever, which is
transmitted by aerosol and inhaled into the lungs.

Virtually all rickettsial diseases are zoonoses (i.e.,

they have an animal reservoir), with the
prominent exception of epidemic typhus,
which occurs only in humans.

It occurs only in humans because the causative

organism, R. prowazekii, is transmitted by the
human body louse.
 Rickettsia inside the
host cell

TICK FLEA LICE MITE

22
 Pathogenesis

Rickettsia is unstable and die quickly outside

host cells.
Coxiella highly resistant to desiccation, remain
viable in environment for months to years.
No toxins, no immunopathology

23
24
 Rocky Mountain Spotted Fever

Ixodid tick transmission

Infects vascular endothelial cells

Skin rash, extremities

Fever
High mortality if untreated
 Typhus
There are several forms of typhus,
namely,
- louse-borne epidemic typhus caused
by R. prowazekii, (Unsanitary conditions)
- flea-borne endemic typhus caused by
Rickettsia typhi,
- chigger-borne scrub typhus caused by
R. tsutsugamushi
 a maculopapular rash
begins on the trunk
and spreads
peripherally.

Rash begins on the

trunk and spreads
peripherally but
spares the face,
palms, and soles
Epidemic Typhus
Epidemic typhus (classical typhus)
Cause: Rickettsia prowazekii

Vector:
Human body louse
Human head louse
LICE

Symptoms
Severe headache
Chills
Generalised myalgia
High fever (39-410C)
Vomiting
Macular rash after 4-7 days
Lacks conciousness.
Brill Zinsser/ Recrudescent typhus
This occurs after the person is recovered from
epidemic typhus and reactivation of the Rickettsia
prowazekii.

The rickettsia can remain latent and reactivate

months or years later, with symptoms similar to or
even identical to the original attack of typhus,
including a maculopapular rash.

This reactivation event can then be transmitted to

other individuals through fecal matter of the louse
vector, and form the focus for a new epidemic of
typhus.

Mild illness and low mortality rate.

 Q Fever
Tick (animals), aerosols, infected milk
Animal exposure (skins, dust, excreta)
The main organ infected is the lung
In general, Q fever is an acute disease, and
recovery is expected even in the absence of
antibiotic therapy.
Rarely, chronic Q fever characterized by life-
threatening endocarditis occurs.
 Q Fever: Clinical Presentation

Highly contagious
Febrile illness, rash is rare
Primarily pneumonia
Granulomatous hepatitis, bacterial
endocarditis
Association of hepatitis and pneumonia
 Complications of rickettsial diseases

- Bronchopneumonia
- Congestive heart failure
- Multi-organ failure
- Deafness
- Disseminated intravascular coagulopathy
(DIC)
- Myocarditis (inflammation of heart
muscle)
- Endocarditis (inflammation of heart
lining)
 LABORATORY DIAGNOSIS

- Isolation from experimental animals

- Serology

Specimens:
Blood collected in febrile illness

Note: Rickettsia is highly infectious so

specimens should be handled very carefully.
 ISOLATION

Blood is inoculated in guinea pigs/mice.

Observed on 3rd 4th week.
Animal responds to different rickettsial species
can vary

Symptoms:
Rise in temperature all species.
Scrotal inflammation, swelling, necrosis
Serologic test
Weil-Felix test
Antibody detection
Based on cross-reactivity between some strains of Proteus & Rickettsia

Complement fixation
Not very sensitive & time consuming

Indirect fluorescence (EIA)

More sensitive & specific
Allows discrimination between IgM & IgG antibodies which helps in early
diagnosis

Direct immunofluorescence
The only serologic test that is useful for clinical diagnosis
100% specific & 70% sensitive allowing diagnosis in 3-4 days into the
illness
 WEIL-FELIX TEST
Heterophile agglutination test using
non motile proteus strains (OX 19, OX 2, OX
K) to find rickettsial antibodies in patients
serum.
Procedure:
Serum is diluted in three separate series
of tubes followed by the addition of equal
amount of OX19,OX2,OXK in 3 separate
series of tubes.
Incubation at 370C for overnight.
Immunofluorescent antibody technique

Immunofluorescent Antibody Technique

(utilizes fluorescent antibody to detect rickettsial antigen in infected tissues)
 Treatment

Treatment should be started

early in the first week of
illness.
Doxycycline (first choice)
Tetracycline (alternate)
Prevention

- Frequent examination of the skin for ticks is important

in preventing Rocky Mountain spotted fever; the tick must
be attached for several hours to transmit the disease.

- Prevention of typhus is based on personal hygiene and

delousing with DDT.

-A typhus vaccine containing formalin-killed R. prowazekii

organisms is effective and useful in the military during
wartime.

- Persons at high risk of contracting Q fever, such as

veterinarians, shepherds, abattoir workers, and laboratory
personnel exposed to C. burnetii, should receive
the vaccine that consists of the killed organism.