MICROBIOLOGY

Spirochetes I (Treponema)
Dr. Santos, Camilo
TAXONOMY
Family: Spirochaetaceae
Genus: Treponema
Borrelia
Family: Leptospiraceae
Genus: Leptospira

SPIROCHAETACEAE
1. Treponema
Four Subspecies:
1. T. pallidum subspecies perenue – YAWS
2. T. pallidum subspecies carateum – PINTA
3. T. pallidum subspecies endimicum – BEJEL
4. T. pallidum subspecies pallidum – SYPHILIS/GREAT POX

2. Borrelia
1. Borrelia burgdorferi – LYME DISEASE/BORRELIOSIS
2. Borrelia recurrentis – EPIDEMIC RELAPSING FEVER

LEPTOSPIRACEAE
1. Leptospira
1. Leptospira interrogans – LEPTOSPIROSIS (Weil’s Disease)

GENERAL CHARACTERISTICS OF TREPONEMA

 Spirochete – Greek work “coiled hair”
 Treponemes – Trepos = turn: Nema = thread
Pallid = pale
= :pale turning thread”
 Transverse Fission
 Gram negative (-) bacteria, thin, helical
 Motile, rotational, forward movement
 Tightly coiled (Corkscrew), tapered or pointed ends spirals with
regular intervals

PHYSIOLOGY AND STRUCTURE

 TCA cycle is missing
 Slow growing organism
 Dependent on host cells for Purines, Pyrimidines, and most amino
acids
 Microaerophilic or Anaerobic
 Extremely sensitive to oxygen toxicity
 Not grow on cell free media

 Motile – due to Periplasmic/Endoflagella or Axial fibril

o Outer sheath encloses Axial fibril
Axial fibrils – originates from insertion pores at both
poles of cell
May overlap at center of cell in Treponema and
Borrelia, but not Leptospira
Number of endoflagella varies – Genus & species

 Generation Time: 30-33 hours

 Incubation Period: 10-90 days

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 MICROBIOLOGY
Spirochetes I (Treponema)
Dr. Santos, Camilo
ETIOLOGIC ORGANISM  Propagated by inoculation in:
Not grow in cell free media:
1. Testes of rabbits
2. Anterior chamber of eye

PATHOGENESIS
 Infectious Dose???
o In rabbits – experimental infection induced with as few as
– 4 spirochetes
o Estimated average inoculum 500-1000 in humans
o Infective dose: 60 Treponemes infecting 50%
 Inoculation – occur at any body site
o External genitalia – most frequent
o Mouth, anus, cervix quite common
o Other sites also well described
 Travels from site on infection → draining lymph nodes (30 mins) →
Blood stream → adherence to CHON of endothelial cells →
SPIROCHAETALES ASSOCIATED WITH HUMAN DISEASES ENDARTERITIS → moves into circulation and multiplies
 Main lesion of syphilis
 Leads to: scarring, intense inflammatory reaction, extensive tissue
necrosis
 Most prominent histopathologic findings: Arteritis and periarteritis
in affected tissues

Tissue Destruction and Lesions:

 Primary a consequence of Patient’s Immune Response
 Disease of blood vessels and of the perivascular areas
 Early stage –Inhibition of CMI
 Late stages – Inhibition of CMI abates, Lesions in the late stages
tend to be localized

T. Pallidum ssp. pallidum Pathogenesis and Host Response:

 Gram (-), slender spirals; actively motile or flexible, corkscrew-  Untreated Syphilis
shaped o Marked by 3 Clinical stages:
 Has axial fibrils/endoflagella – rotation and flexion 1. Primary
 With outer sheath or glycosaminoglycan coating 2. Secondary
o Outer membrane located within outer sheath → contains 3. Tertiary
peptidoglycan  Spirochete appears in lesions and blood during → First 2 stages =
o Periplasmic space encased by outer membrane HIGHLY COMMUNICABLE
 Endoflagella (axial filaments) – flagella-like
organelles in the periplasmic space VIRULENCE FACTORS
Inner membrane (cytoplasmic membrane) Lack Species-Specific Ag on their surface – able to evade the immune system
located inside endoflagella → provide 1. Outer Membrane Proteins (OMP) – promote adherence
osmotic stability 2. Hyaluronidase – facilitate perivascular infiltration
 Microaerophilic (3-5% oxygen) 3. Antiphagocytic coating of Fibronectin
 Can only be grown in tissue culture 4. Tissue destruction and lesion – Immunopathology, primarily a result
 All species are morphologically identical → elicit the same serological of host’s immune response
response from humans 5. Hemolysins
o Can only be differentiated from one another by
epidemiology and clinical manifestation of their disease

Physiologic Properties:
1. Microaerophilic, aerobic, or anaerobic (depending on the species)
2. Growth – tissue culture
3. Part of microbiota; some free-living

 All are morphologically identical

 Same serologic response in humans
 Susceptible to penicillin

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 MICROBIOLOGY
Spirochetes I (Treponema)
Dr. Santos, Camilo
CLINICAL DISEASE Neurosyphilis:
A. ACQUIRED SYPHILIS Late Neurosyphilis
 Infection limited to human host  Develops in about 1/6 untreated cases, usually > than 5 years
 MOT: sexual contact after initial infection
 Penetrate intact mucous membranes or enter through breaks in the  CNS and Spinal cord involvement
skin  Dementia, seizures, wasting, etc.
 Phases:
Cerebral Atrophy
1. Primary phase (2-10 weeks after infection)
 Most prominent in frontal lobes seen in General paresis
 Papule at site of entry → hard chancre
 Chancre – ulcerated, indurated, well
Course of Untreated Syphilis
circumscribed, painless lesion. Heralding
primary onset of syphilis
 Highly infectious
 Heals spontaneously
2. Secondary phase (2-10 weeks after primary)
 Maculopapular rashers (anywhere in body
including hands and feet)
 Condyloma (pale papules in anogenital region,
axillae & mouth)
 May also manifest with meningitis,
chorioretinitis, hepatitis, immune complex
nephritis or periostitis
 Spontaneously subside but still highly
infectious
Clinical Signs: B. CONGENITAL SYPHILIS
- Malaise and low grade fever  16 weeks AOG and up – crosses the placental barrier
- Lymphadenopathy  25% = of infected fetus die in utero
- Alopecia areota  25% = die shortly after birth
- Mucocutaneous eruption – palms & soles
 Surviving babies – severe congenital & developmental anomalies
- Condylomata lata
 Most distressing and dangerous form of syphilis
 Most people build sufficient immune  Penetrates placental barrier – 3rd or 4th month (10th-15th weeks)
response – disease cured spontaneously  Results from → Transplacental infection
 13-15% - Untreated SY – progress to Latency  Septicemia – in developing fetus and widespread dissemenation
SY
Addition information from manual:
3. Latency phase  Transplacental transfer → in utero infection
 2 years is the usual benchmark  Early congenital – 10th-15th weeks AOG
 Depending on how much time has elapsed o Fetal death, miscarriage or stillbirth
since the chancre  Later congenital – infant born alive
 Asymptomatic but (+) serologic test results o Most born without clinical evidence of disease →
a. Early Latent Syphilis develop rhinitis and maculopapular rash
b. Late Latent Syphilis o Interstitial keratitis, Hutchinson’s teeth, saddle-nose
deformity, periostitis
4. Tertiary phase
 Granulomatous lesions (gummas) in skin, Clinical Manifestations:
bones, liver  IUGR – Intrauterine Growth Retardation
 Neurosyphilis/CNS degenerative changes  Rhinorrhea
(meningovascular, paresis, tabes dorsalis)  Hepatosplenomegaly – hyperbilirubinemia – jaundice
 Cardiovascular syphilis/Cardiovascular lesions  Lymphadenopathy
(aortitis, aortic aneurysm, aortic valve  Skeletal abnormalities – Sabre Chin
insufficiency)  Craniofacial Alterations – prominent frontal region, short maxilla,
 Treponemes rare; manifestations due to saddle nose, Mulberry teeth
hypersensitivity reactions to the organism
 Teratiary phase is not infectious

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 MICROBIOLOGY
Spirochetes I (Treponema)
Dr. Santos, Camilo
B.1 Early Congenital Syphilis Epidemiology of T. Pallidum:
a) Skin: rash → Maculopapular rash  Long Incubation period – during which time host is non-infectious
b) Mucosal Lesion: Mucocutaneous lesions o Useful epidemiologically for contact tracing and
c) Hepatosplenomegaly administration of preventive therapy
d) Lymphadenopathy  Prostitution for drugs and money
o To purchase drugs remains central epidemiologic aspect
Congenital Syphilis – Nasal discharge, skin eruptions, bone deformities, nervous of transmission
system abnormalities
Mode of Transmission
B.2 Late Congenital Syphilis 1) Direct Sexual Contact (90-96%)
 Hutchinson’s Teeth (Notching of the incisor teeth) 2) Congenital – from mother to fetus
 Mulberry molar (Moon’s molars) 3) Blood transfusion
 Saddle nose 4) Contact lesion → accidental contact e.g. medical personnel
 Sabre Shin (tibia) → Source of T. pallidum: Primary & Secondary SY
 Interstitial keratitis, Blindness, Deafness
o Hutchinson’s Triad Notched-peg teeth  Not Highly Contagious
o Interstitial keratitis o 30% chance – of acquiring after single exposure to
o 8th Nerve deafness infected partner
o Transmission rate dependent upon stage of disease
EPIDEMIOLOGY
 Mode of Transmission: Contributing Factors to Persistent Infection
1. Direct sexual contact 1) Delayed synthesis of protective IgG Abs
2. Transplacental o Allows infection of tissues inaccessible to immune system
3. Accidental contact with lesions o E.g. spinal column, eye
- Laboratory workers, hospital personnel
4. Blood transmission 2) CMI not characterized as protective
 Immunity:
o Production of Antiphospholipid Antibodies – initial 3) Organisms are covered by fibronectin
response o Enhance attachment to endothelium
o Temporary depression of CMI o Protective barrier against immune system
o IgG Antitreponemal ABS – immobilize and kill organisms
LABORATORY DIAGNOSIS
1. Darkfield Microscopy
o Live, highly motile organism
o Primary Syphilis – exudate from chancre
o Secondary Syphilis – mucous path exudate

2. Serologic Tests
o Non-Treponemal Test (Non Specific)
Antigen: Cardiolipin
Antibody: IgG and IgM
1. Wasserman Test – complement fixation test,
detects IgG
2. VDRL & RPR – Flocculation Test – detects IgM & IgG
– Early in infection

o Specific Treponemal Tests

Antigen: T. pallidum organisms
Antibody: Specific Treponemal Abs
1. FTA-ABS
2. TPI
 Humans – only known hosts 3. MHA-TP
 3rd most common STI (bacterial) in U.S. 4. TP-PA – most widely used
 2000 – 2010 – Doubled = 14,000 cases (2010)
o Homosexual
o At risk of having HIV
 Contagiousness – determined by stage of the disease
 40,000 – cases annually in U.S.
 12 million – cases annually worldwide

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 MICROBIOLOGY
Spirochetes I (Treponema)
Dr. Santos, Camilo

Microscopy:
 Darkfield microscopy
 Direct Fluorescent antibody staining
o Definite Diagnosis if (+)

Culture:
 NOT AVAILABLE
 Needs living tissue
A. NON-TREPONEMAL TESTS (Reaginic)
Characteristics of T. Pallidum  Presumptive serologic screening test for syphilis
Can be seen by:
 Darkfield microscopy 1. VDRL & RPR Test – Non-specific
o Detects antibodies to Cardiolipin - lecithin-cholesterol
 Phase Contrast Technique
o Quite SENSITIVE but NOT SPECIFIC
o Screening purposes
Can be stained by:
o Titers decrease in Tertiary Syphilis or with treatment
 Giemsa Stain – light rose-red
o Titers – useful to monitor successful therapy
 Silver impregnation
o Antibody titer decreases with effective treatment
 Fontana’s Staining Method – for staining films
 Levaditi’s Method – for tissue sections
2. Rapid Plasma Reagin Test (RPR)
 Gram Stain
o Cardiolipin – cholesterol-lecithin acts as antigens
 Fluorescent Antibody Technique o Reagin –mixture of IgG/IgM
o Colored compound is attached with antigen
Serology o (+) Result:
A. NON-TREPONEMAL TESTS  Visible Clumping occurs in minutes. Antigen-
 Venereal Disease Research Laboratory (VDRL) antibody complex visible on card
 Rapid Plasmin Reagin (RPR Test)
 Wasserman Test

B. TREPONEMAL TESTS
 FTA-ABS – Fluorescent Treponemal Antibody Absorption
 MHA-TP – Microhemagglutination Test for T. Pallidum
 TPI – Treponema Pallidum Immobilization Test
 Enzyme-Linked Immunoassay

C. DNA ANALYSIS OF TISSUES – Tertiary SY

D. NUCLEIC ACID AMPLIFICATION – PCR

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 MICROBIOLOGY
Spirochetes I (Treponema)
Dr. Santos, Camilo
Continued….. o Erythromycin
 Positive 2-3 weeks in Primary Untreated Syphilis  Follow up at 3, 6, 12 months with VDRL or RPR
 Highly Positive in Secondary Syphilis
 Becomes Negative 6-8 months after treatment Secondary and Tertiary Syphilis
o Quantitative test – response to therapy  Penicillin x 21 days usually by 10 injection at weekly intervals
 Positive RPR late after therapy
o Means ineffective treatment Tertiary & Neurosyphilis
o Re-infection  Aqueous Penicillin G – Large doses – poorly penetrate the brain
 False Positive  Allergy?? Desensitization
1. Infections (infectious mononucleosis)
2. Bacterial infections (e.g. pneumonia, TB) Complications of Treatment:
3. Chronic disease (e.g. RA, SLE)  Jarisch-Herxheimer Reaction
4. Elderly & Pregnancy o Attributed to the lysis of the treponemes and the release
of endotoxin-like substances
B. TREPONEMAL TESTS o Fever, chills, myalgia, flu-like symptoms – Few hours
 Confirmatory test for Syphilis after administration
 More SPECIFIC but NOT to Sensitive o Also occurs after treatment of other spirochetal diseases
 Used only to confirm appositive Non-Treponemal test  Lyme disease
 Leptospirosis
a) FTA-ABS  Relapsing Fever
b) TPHA
c) Immunoassays T. pallidum ssp. endemicum
d) Western Blot Test  Bejel – Endemic Syphilis
 Common in young children
 Titers remains positive for life even with proper treatment o Initial lesions: Nondescript Oral lesions
o Secondary lesions: Oral papules and mucosal patches
Conditions Associated With False Positive Serological Tests for Syphilis o Late: Gummas (granulomas) of skin, bones &
nasopharynx
 After latent period → destructive bone and cartilage involvement +
chronic skin ulcerations
 Transmission: Person-to-person by contaminated eating utensils
 Primitive Tropical/Subtropical areas: Africa, Asia & Australia
 Treatment: Penicillin

T. pallidum ssp. pertenue

 Yaws: Frambesia (Granulomatous disease)
 Early: Skin lesions
 Late: Destructive lesion – skin, lymph nodes & bones
 Children <15 y/r
 Transmission: Direct contact to lesions containing abundant
spirochetes
 Primitive Tropical areas: S. America, Central Africa, SE Asia
 Papillomatous lesions – painless nodules widely distributed over
TREATMENT body with abundant contagious spirochetes
Adult Syphilis  (+) cross-immunity with syphilis → diagnostic procedures and
1. Less than 1 year of Disease – Single IM dose treatment similar to syphilis
2. More than 1 year of Disease – IM Benzathine penicillin once a
week x 3 weeks T. pallidum ssp. carateum
3. Later stages –admitted IV Penicillin round the clock x 10 days  Pinta: Carate or Mal de pinto
 Primarily restricted to skin : Incubation: 1-3 weeks
Primary & Secondary Syphilis  Initial lesions: Small pruritic papules
 DOC: Benzathine penicillin (2.4 million units) ,IM once weekly for 3  Secondary: Enlarged plaques persist for months to years
weeks  Late: Disseminated, recurrent hypopigmentation or depigmentation
o Less than 1 year duration – 2.4 M units single IM of skin lesion scarring & disfigurement
 MOT: Direct contact with skin lesisons
 Alternative Drugs:  Primitive Tropical Areas: Mexico, Central & South America
o Doxycycline – 100 mg BID – for patient allergic to  Hypopigmented Skin Lesions: depigmentation is commonly seen as
penicillin x 15 days a late sequel with all Treponemal diseases
o Azithromycin  Diagnosis and treatment same as syphilis

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