Chapter 24

Chlamydia, Rickettsia, and

Similar Organisms

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 1

Comparative Properties of
Microorganisms

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 2

 General Characteristics of
Chlamydiae
 Obligate intracellular parasites
 Two forms
 Elementary body (EB)
• Infectious
• Major outer membrane protein (MOMP)
 Detected by monoclonal antibodies
 Reticulate body (RB)
• Noninfectious

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 3

General Characteristics

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 4

Life Cycle of Chlamydia
Organisms

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 5

Reticulate and Elementary
Bodies

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 6

 Chlamydia trachomatis
 Three biovars
 Trachoma, lymphogranuloma venereum, mouse
pneumonitis
 Obligate intracellular pathogenic bacteria
 Symptoms of trachoma biovar
 Urethritis with purulent discharge
 Cervicitis, salpingitis (inflammation of fallopian tubes)
 Eye infections: conjunctivitis and scarring of the eye
(mechanical deforming of eyelashes)
 Neonatal: eye infections and pneumonia

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 7

Human Diseases Caused by
Chlamydiaceae Species

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 8

Conjunctival Scarring and
Hyperendemic Blindness

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 9

 Lymphogranuloma Venereum
(LGV)
 C. trachomatis serovars L1, L2, L2a, L2b, and
L3
 LGV
 Also linked to Parinaud oculogladular conjunctivitis
 Survive in mononuclear cells
 Bubo formation then can rupture lymph node
 Uncommon in the United States
 Tropics and subtropical areas abroad

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 10

Inguinal Swelling and
Lymphatic Drainage

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 11

 Other Urogenital Diseases
 Majority of infections are asymptomatic
 Serovars D through K
 Men
• Nongonococcal urethritis (NGU)
• Epididymitis
• Prostatitis
• Conjunctivitis

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 12

Other Urogenital Diseases (Cont.)
 Serovars D through K (cont.)
 Women
• Urethritis
• Folicular cervicitis
• Endometritis
• Proctitis
• Salpingitis
• Pelvic inflammatory disease (PID)
• Perihepatitis
 Reiter syndrome
 Urethritis, conjunctivitis, polyarthritis, and mucocutaneous
lesions

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 13

 Chlamydia Infection in the
Newborn
 Conjunctivitis
 Nasopharyngeal infection
 Pneumonia
 Otitis media
 Less frequent
 Erythromycin eyedrops are used to prevent
eye infections.

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 14

Inclusion Conjunctivitis in the
Neonate

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 15

 Laboratory Diagnosis
 Test selection depends of the following
factors
 Knowledge of population at risk
 Capability and facilities available for testing
 Cost of assays
 Ability to batch specimen types
 Experience of the laboratory scientist

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 16

 Laboratory Diagnosis (Cont.)
 Specimen
 Dacron, rayon, calcium alginate swabs scraping
mucosa
• Wooden shafts are toxic; use plastic or metal.
 Need scraping; discharge not enough
 First morning urine and vaginal swabs are
excellent specimens.

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 17

 Appropriate Specimens for
Detection of Chlamydial Infections

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 18

 Laboratory Diagnosis (Cont.)
 Direct detection
 Cytologic methods of trachoma and inclusion conjunctivitis
• Technically demanding but sensitive
 Antigen detection
• Enzyme-linked immunosorbent assays (ELISAs), direct fluorescent
antibody (DFA) from swabbed material transferred to slide
 McCoy, HEp-2, HeLa, and buffalo green monkey kidney cell
cultures: “gold standard”
• Shell vials usually in conjunction with DFA staining
 Serology

 Molecular methods
 DNA probes
 Nucleic acid amplification tests

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 19

 Cytologic Endocervical
Specimens for C. trachomatis

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 20

 Antibody Detection
 Micro-immunofluorescence
 Infections of the upper genital tract
 Would not be detected in cultures or swabs
• Antibodies still present
 Complement fixation
 Helpful in identification of LGV

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 21

Appropriate C. trachomatis Assays
for Selected Patient Population

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 22

Detection Capabilities of
Various Methods

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 23

Detection of Chlamydia Species
by Various Serologic Methods

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 24

 Results Reporting
 Agree in advance with obstetrics/gynecology
(OB/GYN) and emergency departments on
test profiles
 Report test performed and not performed
 Report unusual observations
 Pure cultures of pseudomonas, Haemophilus,
N. meningitidis, and yeast

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 25

 Chlamydophila pneumoniae
 Formerly Chlamydia sp., strain TWAR
 10% of world’s pneumonia
 Diseases
 Acute respiratory disease
 Pneumonia
 Pharyngitis and otitis media
 Risk factor for Guillain-Barré syndrome (GBS)
 Also possible relationships
 Sarcoidosis, asthma, and cardiovascular disease

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 26

Summary of Epidemiologic and
Clinical Features

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 27

 C. pneumoniae
 Clinical picture
 Biphasic clinical course
 Phase 1
• Sore throat and hoarseness
 5 to 7 days
• Flulike lower respirator tract symptoms
 8 to 15 days
 Phase 2
• Pneumonia and bronchitis
 Third most common cause of infectious
respiratory disease

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 28

Who to Evaluate for
C. pneumoniae

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 29

 Laboratory Diagnosis
 Specimens
 Sputum
 Bronchoalveolar lavage (BAL)
 Nasopharyngeal aspirates
 Throat washings and swabs
 Culture
 Human lines and Hep-2
• Detect via monoclonal antibody
 Serology
 Microimmunofluorescence (MIF)
 ELISA

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 30

Detection of C. pneumoniae by
Fluorescent Antibody

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 31

 Chlamydophila psittaci
 Formerly Chlamydia psittaci
 Bird chlamydia
• Parakeets, turkey, other psittacine birds
 Parrot fever or psittacosis
 Causes pneumonia in humans
• Usually mild chronic pneumonia
• Can culture
 Not recommended
• Serology
 Current method of choice

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 32

 Rickettsiae
 Rickettsiae and Orienta
 Obligate intracellular bacteria
 Gram-negative bacilli (0.8-2.0 µm by 0.3-0.5 µm)
• Grow in cell lines
 Most are arthropod-borne
 Transmission
 Transovarial transmission in ticks
 Infection through feeding
 Exception
 R. prowazekii
• Humans are reservoir
 Transmitted by body lice

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 33

 Spotted Fever Group
 Rocky Mountain spotted fever (RMSF)
 R. rickettsii
 Humans are accidental hosts
• Usually transmitted by D. variabilis and D. andersoni
ticks
 Clinical manifestations
 Flulike symptoms
• Fever, headache, myalgia, nausea, and vomiting
• Rash
 Erythematous patch on ankles or wrists
– May extend to hands and soles of the feet but not the face

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 34

 Dorsal View of
Dermacentor variabilis

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 35

 Boutonneuse Fever
 Mediterranean spotted fever
 Reservoirs include ticks and dogs
 Similar to RMSF
 Rash involves the palms and soles of the feet and
the body and face
 Taches noires
• Black spots at primary site of infection

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 36

 Typhus Group
 Endemic typhus
 Also known as murine typhus
• R. typhi
 Epidemic louse-borne typhus
 Primarily in Africa and Central and South America
 Also known as Brill-Zinsser disease
• R. prowazekii

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 37

Female Head Louse

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 38

 Murine Typhus
 Vector
 Oriental rat flea: Xenopsylla cheopis
 Cat flea: Ctenocephalides felis
 Reservoir
 Rat and transovarian transmission
 Infection
 Occurs when flea defecates on skin
• Scratching infects the bite.
 Symptoms
 Fever, headache, and rash

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 39

 Epidemic Louse-Borne Typhus
 Vector
 Human louse: Pediculus humanus
 Squirrel flea: Orchopeas howardii
 Squirrel louse: Neohaematopinus sciuriopteri
 Occurs in areas of sanitation disruption
 Infection
 Defecates into the bite wound via scratching
 Symptoms
 Rash affects the body, including the face
 Recrudescent typhus
• Lies dormant in lymph tissue and reactivates occasionally

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 40

 Rickettsialpox
 R. akari
 Reservoir is the common house mouse
 Vector is the mouse mite Liponyssoides
sanguineus
 Clinical manifestations
 Papule forms at bite and progresses to a pustule
• Pustule becomes an indurated eschar
 Other symptoms
• Headache, nausea, and chills
• Rash on face, trunk, and extremities but not palms or soles

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 41

 Scrub Typhus
 Causative agent is Orientia tsutsugamushi
 Vector
• Chigger: Leptotrombidium deliensis
• Transovarial transmission between chiggers
 Reservoir
• Rat
 Symptoms
 Tache noire at the site of inoculation
 Fever, headache, and rash that does not involve
the palms, the soles of the feet, or the face

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 42

 Family Anaplasmataceae
 Genera Ehrlichia, Anaplasma, Neorickettsia
 Ehrlichia
• Dogs infected with brown dog ticks died.
 Rickettsial-like inclusions in the monocytes

 Human ehrlichiosis
 Many are asymptomatic.
• Fever, headache, malaise, and myalgia but may have
nausea, vomiting, diarrhea, cough, joint pains, confusion,
and occasionally rash

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 43

 Morulae

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 44

 Ehrlichia chaffeensis
 Human monocytic ehrlichiosis (HME)
 E. ewingii produces indistinguishable disease
 Natural hosts
• Dogs, deer, and humans
 Primary vector
• Lone star tick: A. americanum

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 45

 HME
 Many are asymptomatic.
 Fever, headache, malaise, and myalgia but may have
nausea, vomiting, diarrhea, cough, joint pains, confusion,
and sometimes rash
 Can have leukopenia and neutropenia, thrombocytopenia,
and elevated liver enzymes
 Severe complications possible
• Toxic shock-like syndrome, central nervous system (CNS)
involvement, acute respiratory distress syndrome (ARDS)
 Nucleic acid amplification testing
 Most frequent of detection
 Serology
 Indirect fluorescent antibody (IFA)

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 46

 Human Granulocytic
Anaplasmosis
 Anaplasma phagocytophilum
 Incubation period 5 to 11 days with similar symptoms to
HME
• Endemic to upper Midwest and Northeast United States
 Rarely have a rash
 Morulae in granulocytes
 Reservoirs
 Deer, rodents, horses, cattle, and humans
 Vectors
 Ixodes scapularis
 Ixodes pacificus
Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 47
 Coxiella
 Coxiella burnetii
 Causative agent of Q fever (Query fever)
• Potential bioterror agent
 Reservoirs
 Cattle, sheep, goats, dogs, cats, deer, fowl, and humans
• Exposure in vet or animal handlers
 Inhalation of dried birthing fluids or ingestion of
unpasteurized milk
 Symptoms
 Only half of infections are symptomatic.
 Acute influenza-like illness
• Prolonged fever, headaches, cough, myalgia, and arthralgia

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 48

 Coxiella (Cont.)
 Laboratory diagnosis
 DFA of infected tissue
 Nucleic acid amplification testing
 Highly contagious, so culture only in biosafety
level 3 (BSL3)
 EIA kits

Copyright © 2015 by Saunders, an imprint of Elsevier Inc. 49