Professional Documents
Culture Documents
Respiratory Tract Infections
Respiratory Tract Infections
John Santangelo
2011
Upper
Lower
Upper Respiratory infections
1. Streptococcus pyogenes
2. Haemophilus influenzae
3. Staphylococcus aureus
4. Streptococcus pneumoniae
5. Diphtheria
Lower Respiratory infections
1. Streptococcus pneumoniae
2. Klebsiella pneumoniae
3. Staphylococcus aureus
4. Streptococcus pyogenes
5. Haemophilis influenzae
6. Myobacterium tuberculosis (galloping consumption)
7. Bordetella pertussis
8. Mycoplasma pneumoniae
9. Coxiella burnetti
10.Chlamydia psittaci
Streptococci are a large and diverse group of gram-positive
cocci that grow in pairs or chains.
Streptococcus pyogenes (a group A Streptococcus) is a
ubiquitous organism that is known to provoke a wide variety of
diseases in humans.
Group A streptococci (GAS) are gram-positive, nonmotile,
non–spore-forming organisms that appear as pairs or short-to-
moderate–sized chains.
The individual organism is spheric or ovoid and has a diameter
of 0.6-1 µm.
The cultures on blood agar plates appear as white-to-gray
colonies 1-2 mm in diameter surrounded by zones of complete
hemolysis.
Some colonies produce large amounts of hyaluronic acid,
which appears mucoid on the culture plate.
Spectrum of diseases from group A
streptococcal infections
In the pre antibiotic era, streptococci frequently caused
significant morbidity and mortality.
in the post antibiotic period, diseases from streptococcal
infections are well controlled and uncommonly cause death.
The streptococci not only cause acute infections but are also
responsible for non suppurative postinfectious sequelae such as
rheumatic fever and glomerulonephritis.
Pharyngitis and impetigo are the common streptococcal
infections.
The suppurative (Pus forming) complications of Group A
Streptococcus tonsillopharyngitis include the following:
• Tonsillopharyngeal cellulitis or abscess
• Otitis media
• Sinusitis
• Necrotizing fasciitis (Flesh eating disease)
• Streptococcal bacteremia
• Meningitis or brain abscess (rare complication resulting
from direct extension of an ear or sinus infection or from
bacteremic spread).
The non suppurative (Non Pus forming) complications of GAS
tonsillopharyngitis include the following:
• Acute rheumatic fever
• Acute glomerulonephritis
• Streptococcal toxic shock syndrome (strep TSS)
Many strains of streptococci have a predilection for the upper
respiratory tract.
Multiple factors influence virulence and initiation of infection in
the host.
The streptococcal cell wall is resistant to degradation and may
persist indefinitely in the tissues.
The organism adheres to the mucous membranes via the
lipoteichoic acid (LTA) that is present on the cell wall of
streptococci.
LTA is cytotoxic and is capable of several different biological
activities.
Once adherence has occurred, the streptococci resist
phagocytosis, proliferate, and begin to invade the local tissues.
Most strains of Group A Streptococcus produce 2 haemolytic
toxins:
Streptolysin O and Streptolysin S.
Streptolysin is toxic to a variety of cells, including
polymorphonuclear leukocytes, platelets, and tissue culture
cells.
Measurement of antistreptolysin O antibodies in humans is
used as an indicator of recent streptococcal infection. ASOT
Pyrogenic exotoxins
Group A Streptococcus produce 3 different types of exotoxins
(ie, A, B, C).
These toxins are responsible for causing fever and scarlet
fever rash.
Additionally, these exotoxins increase susceptibility to
endotoxic shock, cause dysfunction of the reticuloendothelial
system, produce cardiac and hepatic necrosis in animals, and
depress antibody synthesis.
These toxins serve as immunomodulators of the host defense
system because they stimulate T cells to proliferate and are
referred to as super antigens.
Group A Streptococcus release a large number of proteins
into the external environment.
Two different types of streptokinase are released.
The streptokinase forms a complex with plasminogen activator
and catalyzes the conversion of plasminogen to plasmin, thus
leading to digestion of fibrin.
Acute rheumatic fever (ARF)
ARF is a delayed non suppurative sequela of a pharyngeal
infection with Group A Streptococcus.
Following the initial pharyngitis, a latent period of 2-3 weeks
occurs before the first signs or symptoms of ARF appear.
The disease might present with a combination of clinical
manifestations that may include arthritis, carditis, chorea,
subcutaneous nodules, and erythema marginatum.
Poststreptococcal glomerulonephritis
Poststreptococcal glomerulonephritis is caused by infection with
specific nephritogenic strains of Group A Streptococcus (type
12 and type 49) and might occur in sporadic cases or during
an epidemic.
The incidence of glomerulonephritis in children is approximately
5-10% with pharyngitis and 25% with skin infections.
Tonsillopharyngeal cellulitis or abscess
Streptococcal pharyngitis might lead to cellulitis or an abscess
in the peritonsillar or retropharyngeal spaces.
In these infections, Group A Streptococcus in association with
oral flora might be the culprit organisms.
Otitis media
One of the two most common suppurative complications of
streptococcal tonsillopharyngitis is caused by spread of
organisms via the eustachian tube.
However, Group A Streptococcus infections account for fewer
than 5% of overall cases of otitis media.
Sinusitis
Direct spread of organisms leads to sinusitis, a common
complication of streptococcal tonsillopharyngitis.
Acute sinusitis presents with persistent coryza, postnasal drip,
headache, and fever.
Tenderness can be elicited over the affected sinus.
Mortality/Morbidity
Group A Streptococcus bacteremia remains a serious
infection.
The mortality rate is 25-48%.
The clinical manifestations of Group A Streptococcus infection
vary and depend on the suppurative and non suppurative
complications.
Group A Streptococcus are the most common cause of acute
bacterial pharyngitis.
They can also cause a variety of cutaneous and invasive
infections (eg, pyoderma, erysipelas, cellulitis, necrotizing
fasciitis, myositis) and other complications (eg, rheumatic
fever, acute glomerulonephritis).
Erysipelas
St Anthony’s Fire
Erysipelas
St Anthony’s Fire
cellulitis
Necrotizing fasciitis (Flesh eating disease)
Rheumatic Valvulitis in Acute
Rheumatic Fever
Note the minute, firmly adherent
vegetations on the aortic valve cusps,
along the line of closure. These
vegetations, sometimes called "verrucae"
are composed of fibrin, and probably
represent friction damage of the inflamed
endocardium. These lesions rarely cause
functional problems, and usually resolve
after the acute episode of rheumatic
fever.
The test should not be done on blood agar because blood itself
contains catalase.
Pathogenesis of S. aureus infections
Staphylococcus aureus causes a variety of suppurative (pus-
forming) infections and toxinoses in humans.
It causes superficial skin lesions such as boils, styes and
furunculosis; more serious infections such as pneumonia,
mastitis, phlebitis, meningitis, and urinary tract infections; and
deep-seated infections, such as osteomyelitis and endocarditis.
S. aureus is a major cause of hospital acquired (nosocomial)
infection of surgical wounds and infections associated with
indwelling medical devices. S. aureus causes food poisoning by
releasing enterotoxins into food, and toxic shock syndrome by
release of super antigens into the blood stream.
Membrane-damaging toxins
a-toxin (a-hemolysin) The best characterized and most potent
membrane-damaging toxin of S. aureus is a-toxin.
In humans, platelets and monocytes are particularly sensitive to a-toxin.
ß-toxin is a sphingomyelinase which damages membranes rich in this lipid.
The classical test for ß-toxin is lysis of sheep erythrocytes. The majority of
human isolates of S. aureus do not express ß-toxin.
d-toxin is a very small peptide toxin produced by most strains of S. aureus. It is
also produced by S. epidermidis. The role of d-toxin in disease is unknown.
Leukocidin is a multi component protein toxin produced as separate
components which act together to damage membranes.
Coagulase is an extracellular protein which binds to prothrombin in the host to
form a complex called staphylothrombin.
The protease activity characteristic of thrombin is activated in the complex,
resulting in the conversion of fibrinogen to fibrin.
Coagulase is a traditional marker for identifying S aureus in the clinical
microbiology laboratory.
Streptococcus pneumoniae
Streptococcus pneumoniae is a normal inhabitant of the human
upper respiratory tract.
The bacterium can cause pneumonia, usually of the lobar type,
paranasal sinusitis and otitis media, or meningitis, which is
usually secondary to one of the former infections.
It also causes osteomyelitis, septic arthritis, endocarditis,
peritonitis, cellulitis and brain abscesses.
Streptococcus pneumoniae is currently the leading cause of
invasive bacterial disease in children and the elderly.
Streptococcus pneumoniae is known in medical microbiology
as the pneumococcus, referring to its morphology and its
consistent involvement in pneumococcal pneumonia.
Pneumonia is a disease of the lung that is caused by a variety of bacteria
including Streptococcus, Staphylococcus, Pseudomonas, Haemophilus,
Chlamydia and Mycoplasma, several viruses, and certain fungi and
protozoans.
The disease may be divided into two forms, bronchial pneumonia and
lobar pneumonia.
Bronchial pneumonia is most prevalent in infants, young children and
aged adults.
It is caused by various bacteria, including Streptococcus pneumoniae.
Bronchial pneumonia involves the alveoli contiguous to the larger
bronchioles of the bronchial tree.
Lobar pneumonia is more prone to occur in younger adults. A majority
(more than 80%) of the cases of lobar pneumonia are caused by
Streptococcus pneumoniae.
Lobar pneumonia involves all of a single lobe of the lungs (although more
than one lobe may be involved), wherein the entire area of involvement
tends to become a consolidated mass, in contrast to the spongy texture of
normal lung tissue.
Streptococcus pneumoniae cells are Gram-positive, lancet-
shaped cocci (elongated cocci with a slightly pointed outer
curvature).
Usually, they are seen as pairs of cocci (diplococci), but they
may also occur singly and in short chains.
When cultured on blood agar, they are alpha hemolytic.
Individual cells are between 0.5 and 1.25 micrometers in
diameter.
They do not form spores, and they are nonmotile. Like other
streptococci, they lack catalase and ferment glucose to lactic
acid.
Unlike other streptococci, they do not display an M protein, they
hydrolyze inulin, and their cell wall composition is characteristic
both in terms of their peptidoglycan and their teichoic acid.
Gram Stain of a film of sputum from a case
of lobar pneumonia. CDC.
Streptococcus pneumoniae is a fastidious bacterium, growing best in 5%
carbon dioxide.
Nearly 20% of fresh clinical isolates require fully anaerobic conditions.
The chemical basis for the difference in colony appearance is not known,
but significant difference in surface protein expression between the two
types has been shown.
Streptococcus pneumoniae is a very fragile bacterium and
contains within itself the enzymatic ability to disrupt and to
disintegrate the cells.
The enzyme responsible is called an autolysin.
The physiological role of this autolysin is to cause the culture to
undergo a characteristic autolysis that kills the entire culture
when grown to stationary phase.
Virtually all clinical isolates of pneumococci harbor this
autolysin and undergo lysis usually beginning between 18-24
hours after initiation of growth under optimal conditions.
Autolysis is consistent with changes in colony morphology.
Colonies initially appear with a plateau-type morphology, then
start to collapse in the centres when autolysis begins.
Streptococcus pneumoniae A
mucoid strain on blood agar
showing alpha hemolysis
(green zone surrounding
colonies). Note the zone of
inhibition around a filter paper
disc impregnated with
optochin.
Viridans streptococci are not
inhibited by optochin.
Streptococcus pneumoniae
Quellung (capsular swelling)
reaction can be used to
demonstrate the presence of
a specific capsular type of
the bacterium.
Capsule
A capsule composed of polysaccharide completely envelops
the pneumococcal cells.
During invasion the capsule is an essential determinant of
virulence.
The capsule interferes with phagocytosis by preventing
complement C3b opsonization of the bacterial cells. 90
different capsule types of pneumococci have been identified
and form the basis of antigenic serotyping of the organism.
Anti-pneumococcal vaccines are based on formulations of
various capsular (polysaccharide) antigens derived from the
highly-prevalent strains.
Pneumococci spontaneously cause disease in humans,
monkeys, rabbits, horses, mice and guinea pigs.
Nasopharyngeal colonization occurs in approximately 40% of
the population.
Pneumonia and otitis media are the most common infections,
meningitis being much more variable.
The rabbit and the mouse have been used extensively as
animal models of disease, leading to a reasonable
understanding of many of the pneumococcal determinants of
virulence.
Hydrogen peroxide
H2O2 produced by the pneumococcus causes damage to host
cells and has bactericidal effects against competing bacteria
such as Staphylococcus aureus.
Streptococcus
pneumoniae
meningitis
Streptococcus pneumoniae
Corynebacterium diphtheriae
Corynebacteria are Gram-positive, aerobic, nonmotile, rod-
shaped bacteria classified as Actinobacteria.
Corynebacteria are related phylogenetically to mycobacteria
and actinomycetes.
They do not form spores or branch as do the actinomycetes,
but they have the characteristic of forming irregular, club-
shaped or V-shaped arrangements in normal growth.
They undergo snapping movements just after cell division,
which brings them into characteristic forms resembling Chinese
letters or palisades.
Stained Corynebacterium cells. The "barred" appearance
is due to the presence of polyphosphate inclusions called
metachromatic granules. Note also the characteristic
"Chinese-letter" arrangement of cells.
Diphtheria is an upper respiratory tract illness characterized by
sore throat, low fever, and an adherent membrane (called a
pseudomembrane) on the tonsils, pharynx, and/or nasal
cavity.
Diphtheria toxin produced by C. diphtheriae, can cause
myocarditis, polyneuritis, and other systemic toxic effects. A
milder form of diphtheria can be restricted to the skin.
Because the cells are hydrophobic and tend to clump together, they
are impermeable to the usual stains, e.g. Gram’s Stain.
Known as "acid-fast bacilli" because of their lipid-rich cell
walls, which are relatively impermeable to various basic dyes
unless the dyes are combined with phenol.
Once stained, the cells resist decolorization with acidified
organic solvents and are therefore called "acid-fast".
(Other bacteria which also contain mycolic acids, such as
Nocardia, can also exhibit this feature.)
Ziehl-Neelsen (ZN Stain) acid-fast staining procedure.
Symptoms of tuberculosis include:
Whooping cough
(pertussis) is caused
by the bacterium
Bordetella pertussis,
B. pertussis is a very
small Gram-negative
aerobic coccobacillus
that appears singly or
in pairs.
The disease pertussis has two stages.
The first stage, colonization, is an upper respiratory disease with
fever, malaise and coughing, which increases in intensity over
about a 10-day period.
During this stage the organism can be recovered in large
numbers from pharyngeal cultures, and the severity and duration
of the disease can be reduced by antimicrobial treatment.
The second or toxaemic stage of pertussis follows relatively non
specific symptoms of the colonizaton stage.
It begins gradually with prolonged and paroxysmal coughing that
often ends in a characteristic inspiratory gasp (whoop).
B. pertussis produces a variety of substances with toxic activity in
the class of exotoxins and endotoxins.
Antibiotic therapy may ameliorate symptoms and minimise
transmission of the organism to susceptible contacts, but only
if commenced within 21 days of onset of symptoms.
Treatment includes:
Azithromycin 500 mg (child ≥ 6 months: 10 mg/kg up to
500 mg) orally on day 1, then 250 mg (child ≥ 6 months:
5 mg/kg up to 250 mg) orally for a further 4 days, or child
< 6 months: 10 mg/kg orally, daily, for 5 days.
OR
Clarithromycin 500 mg (child > 1 month: 7.5 mg/kg up to
500 mg) orally, 12-hourly, for 7 days.
OR
Erythromycin 250 mg (child > 1 month: 10 mg/kg up to 250
mg) orally, 6-hourly, for 7 days or erythromycin (ethyl succinate
formulation) 400 mg (child > 1 month: 10 mg/kg up to 400 mg)
orally, 6-hourly, for 7 days.
Colonies of Bordetella pertussis
Pertussis Coccobacillus
Gram
Mycoplasma pneumoniae
Mycoplasma pneumoniae is a common cause of community-
acquired pneumonia, and, usually, the disease has a
prolonged, gradual onset.
M pneumoniae was first isolated in cattle with pleuropneumonia
in 1898.
The responsible organism, M pneumoniae, is a pleomorphic
organism that, unlike bacteria, lacks a cell wall, and unlike
viruses do not need a host cell for replication. The prolonged
paroxysmal cough seen in this disease is thought to be due to
the inhibition of ciliary movement. The organism has a
remarkable gliding motility and specialized filamentous tips end
that allows it to burrow between cilia within the respiratory
epithelium, eventually causing sloughing of the respiratory
epithelial cells.
In almost all patients, the pneumonia resolves without any
serious complications.
M. pneumoniae can cause severe pneumonia in children and
has recently been associated with acute chest syndrome in
patients with sickle cell anaemia.
Mycoplasmal pneumonia is a disease of gradual and insidious onset of several
days to weeks. The patient's history may include the following:
Fever
Malaise
Persistent, slowly worsening dry cough; absence of cough makes the diagnosis of
M pneumoniae unlikely
Headache
Chills, not rigors
Scratchy sore throat
Sore chest and tracheal tenderness (result of the protracted cough)
Pleuritic chest pain (rare)
Sputum Gram stains and cultures usually are not helpful, since M
pneumoniae lacks a cell wall and cannot be stained.
Coxiella burnetti
Q fever is a zoonotic disease caused by Coxiella burnetii, a
species of bacteria that is distributed globally.
Cattle, sheep, and goats are the primary reservoirs of C. burnetii.
Infection has been noted in a wide variety of other animals,
including other species of livestock and in domesticated pets.
Coxiella burnetii does not usually cause clinical disease in these
animals, although abortion in goats and sheep has been linked to
C. burnetii infection.
Organisms are excreted in milk, urine, and feces of infected
animals. Most importantly, during birthing the organisms are shed
in high numbers within the amniotic fluids and the placenta.
A zoonotic disease is an infection which can be
transmitted from animals to humans.
The organisms are resistant to heat, drying, and many common
disinfectants.
These features enable the bacteria to survive for long periods
in the environment.
Infection of humans usually occurs by inhalation of these
organisms from air that contains airborne barnyard dust
contaminated by dried placental material, birth fluids, and
excreta of infected herd animals.
Humans are often very susceptible to the disease, and very few
organisms may be required to cause infection.
Other modes of transmission to humans, including tick bites
and human to human transmission, are rare.
Chronic Q fever, characterized by infection that persists for
more than 6 months is uncommon but is a much more serious
disease.
Patients who have had acute Q fever may develop the chronic
form as soon as 1 year or as long as 20 years after initial
infection.
A serious complication of chronic Q fever is endocarditis,
generally involving the aortic heart valves, less commonly the
mitral valve.
1%-2% of people with acute Q fever die of the disease.
Confirming a diagnosis of Q fever requires serologic testing to
detect the presence of antibodies to Coxiella burnetii antigens.
In most laboratories, the indirect immunofluorescence assay
(IFA) is the most dependable and widely used method.
Coxiella burnetii may also be identified in infected tissues by
using immunohistochemical staining and DNA detection
methods.
Doxycycline is the treatment of choice for acute Q fever.
Antibiotic treatment is most effective when initiated within
the first 3 days of illness.
Coxiella burnetii is a highly infectious agent that is rather
resistant to heat and drying. It can become airborne and
inhaled by humans. A single C. burnetii organism may
cause disease in a susceptible person.
Chlamydia psittaci
also referred to as Psittacosis, Parrot Fever or
chlamydiosis.
The word Psittacosis comes from the Greek word Psittakos,
meaning parrot.
Chlamydia are gram negative, spherical, (0.4-0.6 micron
diameter), intracellular parasites
In birds, C. psittaci may manifest itself as an upper
respiratory infection with nasal, and or ocular discharge,
diarrhea, or a combination of all three. In some cases, birds
may be infected but show no signs. These cases are of
concern because these birds may become carriers and
shed the organism.
*C. psittaci is related to Chlamydia trachomatis, the most
common human STD, and Chlamydia pneumonia, a cause of
human pneumonia.
Chlamydia pneumonia is also being investigated as possibly
being associated with cardiovascular disease in humans.
Transmission of this organism from one host to another is
primarily through the air.
The bacteria is shed from an infected bird in the nasal and or
ocular secretions, fecal material, and feather dust.
The organism remains remarkably stable outside the host body
and dries as a dusty substance.
This dust or aerosol contaminates the air that is then inhaled by
another possible host.
The disease has a greater chance of spreading in
overcrowded conditions, stale air environments, nest-
boxes, and brooders.
Pet shops, bird marts, and quarantine stations are also
high risk areas.