17  Coryneform bacteria, listeria
and erysipelothrix
Diphtheria; listeriosis; erysipeloid
J. McLauchlin and P. Riegel
KEY POINTS
• The genus Corynebacterium includes C. diphtheriae,
which causes the toxin-mediated pharyngeal
infection diphtheria. The infection has largely been
controlled by widespread use of a toxoid vaccine.
• Diphtheria toxin is encoded by a lysogenic
bacteriophage and has cardiac and neurotoxic
effects. Non-toxigenic strains are occasionally
isolated from diverse infections.
• Other medically significant corynebacteria include
C. ulcerans, which causes exudative pharyngitis, and
C. jeikeium, which is part of the normal skin flora
and is an opportunistic pathogen of hospital
(particularly neutropenic) patients.
• Listeria is a genus of environmental bacteria and
includes L. monocytogenes, an important cause of
disease in domestic animals, that also causes severe
systemic disease in the immunosuppressed and
elderly as well as the unborn or newly delivered.
• Listeriosis is transmitted predominantly by the
consumption of contaminated ready-to-eat foods;
the agent is able to grow in a variety of foods at
refrigeration temperatures.
• Erysipelothrix rhusiopathiae causes economically
important disease in domestic animals, notably pigs.
Occasional human infections occur, and present as (polymetaphosphate), which stain bluish-purple with
a cellulitis.
CORYNEFORM BACTERIA
The term coryneform is used to describe aerobic, non-
sporing and irregularly shaped Gram-positive rods.
According to this broad definition, they include bac-
teria of the genus Corynebacterium with a typically
club-shaped morphology (Greek κορσψυη = club),
environmental bacteria showing coccoid forms such
as Rhodococcus, Gordonia and Brevibacterium species,
and preferentially anaerobic bacteria of the genera
Actinomyces (see Ch. 20), Actinobaculum, Arcanobac­
terium and Propionibacterium, which exhibit some
branched forms.
CORYNEBACTERIUM DIPHTHERIAE
The major disease caused by C. diphtheriae is diphthe­
ria, an infection of the local tissue of the upper respi-
ratory tract with the production of a toxin that causes
systemic effects, notably in the heart and peripheral
nerves. Diphtheria has virtually disappeared in devel-
oped countries following mass immunization, but is
still endemic in many regions of the world. Skin infec-
tions are prevalent in some countries. Non-toxigenic
strains have been associated with endocarditis, men-
ingitis, cerebral abscess and osteoarthritis throughout
the world.
Description
C. diphtheriae, like other members of the genus, are
non-motile, non-spore-forming, straight or slightly
curved rods with tapered ends. They are Gram-
positive, but easily decolourized, particularly in older
cultures. Cells often contain metachromatic granules
methylene blue. Snapping division produces groups of
cells in angular and palisade arrangements that create
a ‘Chinese character’ effect. C. diphtheriae is aerobic
and facultatively anaerobic, growing best on a blood-
or serum-containing medium at 35–37°C with or
without carbon dioxide enrichment. On agar medium
containing tellurite, colonies of C. diphtheriae are
characteristically black or grey after 24–48 h.
Biotypes of C. diphtheriae named gravis, inter­
medius or mitis are genomically similar variants exhi­
biting distinct biochemical features and cultural
morphology. Bacilli of the gravis biotype are usually
short, whereas those of biotype mitis are long and
199
17 BACTERIAL PATHOGENS AND ASSOCIATED DISEASES
Fig. 17.1  Diphtheritic membrane on throat. From Conlon, C.,
Snydman, D 2000 Mosby’s Color Atlas and Text of Infectious Diseases.
Edinburgh: Mosby Elsevier. Courtesy of Nigel Day.
pleomorphic; biotype intermedius ranges from very
long to short rods. In broth medium, C. diphtheriae
biotype gravis forms a pellicle and a granular deposit,
whereas C. diphtheriae biotype mitis produces a
diffuse turbidity. The biotype intermedius forms no
pellicle, but a fine granular deposit can be observed.
Pathogenesis
To cause disease C. diphtheriae must:
• invade, colonize and proliferate in local tissues
• be lysogenized by a specific β-phage, enabling it to
produce toxin.
In the upper respiratory tract, diphtheria bacilli elicit
an inflammatory exudate and cause necrosis of the
cells of the faucial mucosa (Fig. 17.1). The diphtheria
toxin possibly assists colonization of the throat or
skin by killing epithelial cells or neutrophils.
The organisms do not penetrate deeply into the
mucosal tissue and bacteraemia does not usually
occur. The exotoxin is produced locally and spread by
the bloodstream to distant organs, with a special affin-
ity for heart muscle, the peripheral nervous system
and the adrenal glands.
C. diphtheriae can colonize the throats of people
who have been immunized against diphtheria or who
have become immune as a result of natural exposure,
but usually no pseudomembrane develops.
The diphtheria toxin is a heat-stable polypeptide,
composed of two fragments: A (active) and B
(binding). The toxin binds to a specific receptor on
susceptible cells and enters by receptor-mediated
endocytosis. The A subunit is cleaved and released
from the B subunit as it inserts and passes through the
lysosomal membrane into the cytoplasm. Fragment
A catalyses the transfer of adenosine disphosphate
(ADP)-ribose from nicotinamide adenine dinucle-
otide (NAD) to the eukaryotic elongation factor 2,
200
which inhibits the function of the latter in protein
synthesis. Inhibition of protein synthesis is probably
responsible for both the necrotic and neurotoxic
effects of the toxin. Production of toxin by lysogenized
C. diphtheriae is enhanced considerably when the bac-
teria are grown in low iron conditions. Other factors
such as osmolarity, amino acid concentrations and
pH have a role.
The Schick test, an intradermal injection of stabi-
lized diphtheria toxin, was formerly used to determine
individual susceptibility to the toxin. Absence of a
reaction indicates immunity. Tissue culture neutra­
lization tests, enzyme-linked immunosorbent assay
(ELISA) and passive haemagglutination assay to
measure serum antitoxin levels, are now preferred.
For epidemiological purposes the minimum protec-
tive level is considered to be 0.01 international units
(IU) of diphtheria antitoxin per millilitre in a serum
sample. A level of 0.1 IU/mL is desirable for indi-
vidual protection.
Non-toxigenic strains of C. diphtheriae may cause
pharyngitis and cutaneous abscesses. Systemic disease,
including endocarditis, septic arthritis and osteomy-
elitis, has also been reported. C. diphtheriae biotype
belfanti could be involved in the processus of a chronic
atrophic rhinitis named ozena. The virulence factors
of these strains remain unknown. Conversion of a
non-toxigenic strain to a toxigenic strain by phage
infection can occur in human populations.
Clinical features
The incubation period of diphtheria is 2–5 days, with
a range of 1–10 days. At first, patients present with
malaise, sore throat and moderate fever. A thick,
adherent green pseudomembrane is present on one or
both tonsils or adjacent pharynx. In nasopharyngeal
infection, the pseudomembrane may involve nasal
mucosa, the pharyngeal wall and the soft palate. In
this form, oedema involving the cervical lymph glands
may occur in the anterior tissues of the neck, a condi-
tion known as bullneck diphtheria.
Laryngeal involvement leads to obstruction of the
larynx and lower airways. Organisms multiply within
the membranes and toxaemia is prominent. The
patient is gravely ill, with a weak pulse, restlessness
and confusion. Intoxication takes the form of myo-
carditis and peripheral neuritis, and may be associated
with thrombocytopenia. Visual disturbance, difficulty
in swallowing, and paralysis of the arms and legs also
occur but usually resolve spontaneously. Complete
heart block may result from myocarditis. Death is
most commonly due to congestive heart failure and
cardiac arrhythmias.

Suspected diphtheria
Immunization history; Microbiological
immediate administration investigation
of diphtheria antitoxin if
clinical suspicion strong
Selective media for C. diphtheriae
Investigate other possible pathogens:
• b-Haemolytic streptococci
• Arcanobacterium haemolyticum
• Epstein–Barr virus
Isolation of C. diphtheriae
(or C. ulcerans)
Treatment Toxigenicity tests
(antitoxin if toxin (Elek test, PCR)
producing, antibiotics)
Fig. 17.2  Algorithm for the management of a suspected case of
diphtheria. Note: Antitoxin treatment should not await laboratory
confirmation, which may take several days. Photograph courtesy of Dr
A. Efstratiou, Central Public Health Laboratory, London.
Cutaneous diphtheria occurs mostly in tropical
countries. The lesion is usually characterized by an
ulcer covered by a necrotic pseudomembrane and may
involve any area of the skin. Although the organism
usually produces toxin, systemic toxic manifestations
are uncommon.
Diagnosis
The diagnosis is made on clinical grounds, supported
by a history of diphtheria among contacts, lack of
prior immunization or travel in countries where
diphtheria is endemic.
The role of the laboratory is to confirm the dia­
gnosis by recovery of C. diphtheriae in culture fol-
lowed by appropriate tests for detection of toxin
production (Fig. 17.2). The clinician should inform
the laboratory of the presumptive diagnosis of diph-
theria because isolation of C. diphtheriae requires
special media. Material for cultures should be obtained
on a swab from the inflamed areas surrounding the
pseudomembranes.
Direct microscopy of a smear is unreliable because
C. diphtheriae is morphologically similar to other
coryneforms. The recommended media include blood
agar and a selective medium containing tellurite
Coryneform bacteria, listeria and erysipelothrix 17
Prevention of secondary
cases (home, working
or school contact,
medical staff)
Fig. 17.3  Elek plate for the detection of C. diphtheriae toxin
production. Cultures are streaked horizontally, then overlaid with an
antitoxin-impregnated strip. Toxin and antitoxin diffuse into the culture
during incubation, and precipitin lines develop where toxin and
antitoxin are present in a critical ratio. Positive reactions in test
Isolate referred to cultures are indicated by precipitin lines that arc with those produced
a reference laboratory by positive controls. The C. diphtheriae cultures are (top to bottom):
National Collection of Type Cultures (NCTC) strain 10648 (positive
control); test culture (positive); NCTC 10356 (negative control); NCTC
3984 (weak positive control); NCTC 10648 (positive control); test culture
(negative); NCTC 10356 (negative control). Courtesy of Dr A Efstratiou,
Health Protection Agency, London.
and cysteine. Identification is based on carbohydrate
fermentation reactions and enzymatic activities. Com-
mercial kits such as the API Coryne strip provide a
reliable identification. Matrix-assisted laser desorption/
ionisation time-of-flight (MALDI-TOF) is also a reli-
able tool for rapid diagnosis of potentially toxigenic
Corynebacterium species.
Toxigenicity testing is essential. Production of diph-
theria toxin is demonstrated by the agar immunopre-
cipitation test (Elek test; Fig. 17.3) or by the tissue
culture cytotoxicity assay, which has replaced the viru-
lence test in guinea-pigs. The toxin gene can be detected
by the polymerase chain reaction (PCR). This test
shows excellent correlation with guinea-pig virulence,
although there is the rare possibility of a false-positive
PCR assay if the strain harbouring the tox gene is
unable to express it. The detection of the tox gene by
PCR directly from clinical specimens is feasible. All
biotypes are potentially toxigenic. Multilocus sequence
typing provides high-resolution data appropriate for
the epidemiological investigation of diphtheria.
Measurement of antibodies to diphtheria toxin in
serum collected before administration of antitoxin
may support the diagnosis when cultures are negative.
An algorithm for the management of suspect cases of
diphtheria is shown in Figure 17.2.
201
17 BACTERIAL PATHOGENS AND ASSOCIATED DISEASES
Treatment
If diphtheria is strongly suspected on clinical grounds,
treatment should not await laboratory confirmation,
which may take several days (Fig. 17.2). Diphtheria
antitoxin (hyperimmune horse serum) is given,
as antibiotics have no effect on preformed toxin
which rapidly diffuses from the local lesions and soon
becomes irreversibly bound to tissue cells. Because
antitoxin neutralizes only circulating toxin, it should
be administered promptly.
Treatment with parenteral penicillin or oral eryth-
romycin eradicates the organism and terminates toxin
production. C. diphtheriae is universally sensitive
to penicillins but some strains are resistant to eryth-
romycin, tetracyclines and rifampicin. Erythromycin
may be preferred to penicillin for elimination of the
bacilli from the throat, particularly in treatment of
persistent carriers. Some strains are tolerant to the
bactericidal action of penicillins, and treatment of
complicated infections should contain an association
with an aminoglycoside.
Patients should be placed in strict isolation,
nursed by staff whose immunization history is
documented and have daily platelet counts and
electrocardiography.
Epidemiology
Diphtheria has virtually disappeared in developed
countries following mass immunization in the 1940s,
but is still endemic in many regions of the world.
About 50 000 cases of diphtheria occurred in the
newly independent states of the former Soviet Union
during 1990–1996, leading to infection in short-term
visitors from western Europe. Other countries that
have experienced outbreaks of diphtheria in recent
years include China, Ecuador, Algeria, South-East
Asia and the eastern Mediterranean. In the USA, only
45 cases were reported during 1980–1995. In 2002, one
case of diphtheria was reported in the USA but more
toxigenic strains were referred to North American
reference laboratories. In 2003, a total of 896 cases
were reported from the World Health Organization
European Region; 99% were from Eastern Europe.
There were 102 cases of infections caused by toxigenic
corynebacteria diphtheria in the UK between 1986
and 2008: 42 C. diphtheriae, 59 C. ulcerans and one
C. pseudotuberculosis. Five fatalities were reported,
all in unvaccinated patients. Non-toxigenic strains
capable of causing mild disease continue to circulate
throughout the world. In European countries, car-
riages rates of non-toxigenic strains ranged from 0 in
Ireland to 4.0 per 1000 in Turkey.
202
Infection is confined to man and usually involves
contact with a diphtheria case or a carrier. The most
important mode of spread is person-to-person trans-
mission by aerosolized droplets when an infected
person coughs, sneezes or talks, or by direct contact
with skin lesions. Most clinical infections are proba-
bly contracted from carriers rather than symptomatic
patients. Prolonged close contact with an infected
person and intimate contact increases the likelihood
of transmission.
Acquired immunity to diphtheria is due primarily
to toxin-neutralizing antibody (antitoxin). Passive
immunity in utero is acquired transplacentally and
can last for 1 or 2 years after birth. Active immunity
can probably be produced by a mild or subclinical
infection in infants who retain some maternal immu-
nity. Unimmunized children under 15 years old are
most likely to contract diphtheria. The disease is also
found among adults whose immunization was
neglected. The mortality rate is highest among young
children and in people aged over 40 years. Skin infec-
tions caused by C. diphtheriae may result in early
development of natural immunity against the disease.
C. diphtheriae persists longer in skin lesions than in
the tonsils or nose, and cutaneous diphtheria appears
to be more contagious than respiratory diphtheria.
Untreated people who are infected with the diphtheria
bacillus can be contagious for up to 2 weeks, but
seldom for more than 4 weeks. If treated with appro-
priate antibiotics, the contagious period can be limited
to less than 4 days. C. diphtheriae can survive in
the environment in dust and on dry vomits for
several months, and transmission via vomits has been
documented. Animal-to-man transmission and food-
borne transmission by consumption of contaminated
foods such as raw milk have been described, but are
very rare.
Control
High population immunity achieved through mass
immunization (at least 95% coverage in children and
at least 90% coverage in adults) is the most effective
measure to control epidemic diphtheria. Immuniza-
tion with diphtheria toxoid was first introduced in
1923. Large-scale immunization programmes intro-
duced in the 1940s reduced the incidence of diphtheria
dramatically, although the disease was not eradicated
completely. Immunization schedules are discussed in
Chapter 70.
Prevention of secondary cases by the rapid investi-
gation of close contacts is essential. These investiga-
tions should include ascertainment of the immunization
histories of all home and school contacts. Primary
 Coryneform bacteria, listeria and erysipelothrix 17

Table 17.1  Habitat and disease associations of corynebacteria

Organism Major habitat Disease association

Corynebacterium diphtheriae Throat, skin Diphtheria (toxigenic strains), wound infections, bacteraemia,
endocarditis
C. ulcerans Human throat and skin Man: diphtheria (toxigenic strains), pharyngitis and wound infection
Animals: raw milk, dogs, cats Cattle: mastitis
C. pseudotuberculosis Sheep, horses, goats Man: lymphadenitis
Animals: abscesses and abortion
C. jeikeium Skin Bacteraemia, endocarditis; infection of foreign bodies and CSF shunts
C. urealyticum Skin, urinary tract Urinary tract infection, pyelonephritis, endocarditis
C. amycolatum Man and animals Man: bacteraemia, endocarditis, peritonitis and wound infection
Cattle: mastitis
C. glucuronolyticum Urinary tract of man and animals Urogenital tract infection
C. minutissimum Skin, urinary tract Erythrasma, bacteraemia
C. striatum Respiratory tract, skin Respiratory tract infection, wound infection, bacteraemia
C. pseudodiphtheriticum Respiratory tract Respiratory tract infection, endocarditis
C. kroppenstedtii Unknown Breast abscess, granulomatous mastitis
Arcanobacterium haemolyticum Throat Pharyngitis, skin ulcers, endocarditis
Rhodococcus equi Animals, soil Pulmonary infection and soft tissue infection

courses of immunization or a booster are given if
necessary.
OTHER MEDICALLY IMPORTANT
CORYNEBACTERIA
The non-diphtheria corynebacteria (‘diphtheroids’)
are diverse and comprise strictly aerobic bacteria
usually isolated from the environment, as well as
facultative or preferentially anaerobic bacteria, which
are commensals of the skin and mucous membranes.
The principal species involved and the main clinical
syndromes associated with infection are shown in
Table 17.1.
Corynebacterium ulcerans
C. ulcerans has been isolated from raw milk and can
cause mastitis in cattle. In man, it is seen almost exclu-
sively in cases of exudative pharyngitis, but occasional
soft tissue infections occur. C. ulcerans can produce
a toxin that is 95% identical to the diphtheria toxin,
causing a diphtheria-like illness. It seems likely that
many human infections are transmitted by a dog
or cat. Therapy involves the administration of appro-
priate antibiotics, such as penicillins or erythromycin,
and of diphtheria antitoxin in the case of diphtheria-
like disease.
Corynebacterium pseudotuberculosis
C. pseudotuberculosis is primarily an animal
pathogen and rarely infects man. It causes caseous
lymphadenitis in sheep and goats, and abscesses or
ulcerative lymphangitis in horses. Human infections
occur mainly in patients with animal contact. Infec-
tion usually presents as a subacute or chronic granu-
lomatous lymphadenitis involving the axillary or
cervical nodes, but pneumonias have been described.
Some strains are lysogenized by bacteriophages of C.
diphtheriae and thus produce diphtheria toxin, but no
clinical cases of diphtheria-like disease have been
attributed to C. pseudotuberculosis infection. Treat-
ment requires prolonged antibiotic therapy with
erythromycin, penicillins or tetracycline, and surgical
drainage or excision.
Corynebacterium jeikeium
C. jeikeium (formerly CDC coryneform group JK) is
part of the normal skin flora, particularly in inguinal,
axillary and rectal areas. Colonization by antibiotic-
resistant strains is unusual in healthy individuals, but
is common in hospital patients, particularly those who
are neutropenic or receiving antibiotics. Most infec-
tions are associated with skin damaged by wounds or
invasive devices. Such infections include:
• prosthetic valve endocarditis
• bacteraemia associated with infected long-term
intravenous cannulae
• peritonitis in patients on peritoneal dialysis
• septicaemia and local infection following insertion
of an epicardial pacemaker
• central nervous system infection in patients with
ventriculoperitoneal or atrial shunts for
hydrocephalus.

203
17 BACTERIAL PATHOGENS AND ASSOCIATED DISEASES
Most infections occur in patients in hospital for
prolonged periods and who have received broad-
spectrum antimicrobial therapy. Spread is through
environmental contamination, the hands of ward staff
or auto-infection.
Treatment
Most isolates of C. jeikeium recovered from infections
are highly resistant to penicillins and cephalosporins
in vitro. Even with susceptible isolates, penicillin
is incompletely bactericidal, but aminoglycoside-
sensitive strains can be eradicated successfully with
combined penicillin and aminoglycoside therapy. Sys-
temic amoxicillin, gentamicin, rifampicin or cipro-
floxacin can be used if the isolate is susceptible.
Resistance to aminoglycosides and macrolides has
been reported in more than 60% of isolates and resist-
ance to fluoroquinolones is variable.
Glycopeptides are the drugs of choice for treating
serious infections. C. jeikeium is sensitive to glycopep-
tides and these antibiotics are bactericidal. Combina-
tions of vancomycin with gentamicin have been used
to treat infective endocarditis. Peritonitis secondary
to peritoneal dialysis and meningitis related to shunts
can be treated with intra-peritoneal or intrathecal
vancomycin, respectively.
Corynebacterium urealyticum
C. urealyticum (formerly CDC coryneform group
D-2) is a frequent skin colonizer, mainly in hospital
patients. The groin, abdominal wall and axilla are
most frequently colonized. This micro-organism is
associated with urinary tract infections, particularly
with alkaline-encrusted cystitis and pyelitis related to
its strong urease production. Infection is a conse-
quence of the use of broad-spectrum antibiotics for
patients with underlying conditions that predispose to
urinary tract infection. The organism may also cause
pyelonephritis and is an infrequent cause of endocar-
ditis, osteomyelitis or soft tissue infection.
Like C. jeikeium, C. urealyticum is usually highly
resistant to most antimicrobial agents, except glyco-
peptides. Vancomycin, tetracyclines, erythromycin
and norfloxacin have proven effective in treatment.
Prolonged treatment with appropriate antibiotics,
acidification of the urine, and removal of crusts is
essential for proper management of encrusted cystitis.
Corynebacterium amycolatum
C. amycolatum is a human skin commensal similar to
other corynebacteria, but lacks cell wall mycolic acids.
204
Its biochemical characteristics are variable and it
is often misidentified. Strains isolated from hospital
patients may be multiresistant to antibiotics except
glycopeptides. C. amycolatum has been reported as
causing bacteraemi, endocarditis, peritonitis and
wound infection.
Corynebacterium glucuronolyticum
C. glucuronolyticum (syn. C. seminale) is most com-
monly isolated from men with prostatitis and urethri-
tis, but can be also isolated from the female genital
tract. It is commonly isolated from semen specimens,
especially in sexually experienced men. It exhibits
strong β-glucuronidase activity and some strains
produce urease. It is usually sensitive to antibiotics,
although tetracyclines and macrolides are the most
effective in vitro.
Corynebacterium minutissimum
C. minutissimum is believed to be the cause of
erythrasma, a relatively common and localized infec-
tion of the stratum corneum that produces reddish-
brown scaly patches in intertriginous sites. Lesions
usually involve the groin, toeweb and axillae, and fluo-
resce coral red when examined by Wood’s light. The
organism can be cultured from skin scrapings, but the
diagnosis is usually based on clinical aspects and the
characteristic fluorescence. More serious infections
have been described, including bacteraemia and breast
abscess. Some infections attributed to C. minutissi­
mum may have been caused by C. amycolatum.
C. minutissimum is sensitive to penicillins; suscepti-
bility to erythromycin is variable.
Corynebacterium striatum
This species is part of the normal flora of the nose and
skin. It is a rare cause of pulmonary infection, particu-
larly in patients with chronic obstructive airway
disease or those who are intubated. Transmission to
mechanically ventilated patients in an intensive care
unit has been documented. It has also been isolated
from blood, catheter tips, wounds, leg ulcers, perito-
neal fluid, urine, semen, vaginal exudate and placental
tissues. C. striatum is sensitive to penicillins and glyco-
peptides; susceptibility to aminoglycosides, cipro-
floxacin, erythromycin and rifampicin is variable.
Many isolates are resistant to cephalosporins.
Corynebacterium pseudodiphtheriticum
C. pseudodiphtheriticum is a commensal of the human
nasopharynx. It is occasionally associated with

respiratory tract infections, including tracheobronchi-
tis, necrotizing tracheitis, pneumonia and lung abscess.
Most isolates come from patients with endotracheal
tubes or chronic obstructive pulmonary disease. It has
also been reported to cause endocarditis in patients
with prosthetic valves or pre-existing valvular damage.
C. pseudodiphtheriticum is usually susceptible to most
antibiotics except erythromycin.
Corynebacterium kroppenstedtii
C. kroppenstedtii was first described in 1998, after iso-
lation of a single strain from human sputum. Later,
when an association was found between corynebacte-
rial infection and granulomatous mastitis, most of
the corynebacteria were identified as C. kroppenst­
edtii. Isolation of the species requires Tween-
supplemented media and prolonged incubation. C.
kroppenstedtii is sensitive to many antibiotics includ-
ing penicillins. Treatment of granulomatous mastitis
is usually based on steroids, but addition of antibiot-
ics is appropriate.
Arcanobacterium haemolyticum
A. haemolyticum is phylogenetically related to
Actinomyces spp. (see Ch. 20). It causes pharyngitis
and chronic skin ulcers. Cases of cellulitis, osteomy-
elitis, brain abscesses and endocarditis have occasion-
ally been described. The species produces at least
two extracellular toxins, phospholipase D and a
haemolysin.
Most patients are young adults who present with
sore throat; some have membranous exudates and
peri-tonsillar abscesses. The organism is rarely found
in healthy individuals, but occurs in about 2% of
symptomatic 15–25-year-olds with pharyngitis. Infec-
tion cannot be differentiated from streptococcal phar-
yngitis on clinical findings alone. A. haemolyticum is
often isolated in association with streptococci of the
Streptococcus anginosus group (see p. 194). A scarlati-
niform rash occurs in half of the patients with phar-
yngitis, perhaps caused by a toxin genetically related
to the erythrogenic toxin of Str. pyogenes. Erythro-
mycin or other macrolides seem to be effective in
treatment. A. haemolyticum is sensitive to penicillin,
but treatment failure has been documented.
Rhodococcus equi
R. equi is a pathogen of horses, pigs and cattle. It is a
rare cause of severe pulmonary infections in patients
with the acquired immune deficiency syndrome, neo-
plastic diseases or renal transplants. Most infections
Coryneform bacteria, listeria and erysipelothrix 17
develop insidiously, with fever and respiratory symp-
toms difficult to distinguish from mycobacterial infec-
tion. Infections are often recurrent and refractory to
treatment, and may be associated with pleural effu-
sion and bacteraemia. The diagnosis is usually estab-
lished from bronchoscopy specimens, pleural fluid
cultures or blood cultures.
R. equi is usually sensitive to tetracyclines, mac-
rolides, rifampicin, imipenem and vancomycin, but
resistance to penicillins has been reported. Treatment
includes surgical drainage when feasible and pro-
longed therapy with an antibiotic combination such
as erythromycin and rifampicin or imipenem and van-
comycin, established by in-vitro tests.
Other coryneform bacteria
• C. accolens is usually recovered from respiratory
specimens.
• C. afermentans ssp. lipophilum and CDC
coryneform groups G and F-1 may be isolated
from a variety of sources, including blood, wound,
semen and urine.
• C. argentoratense, C. propinquum, C. matruchotii
and C. durum have been isolated from the throat,
but no pathogenic role has been demonstrated.
• C. aurimucosum (syn. C. nigricans) exhibits
black-pigmented colonies. It has been isolated
from genital specimens of women with
complications of pregnancy.
• C. bovis is commonly isolated from bovine
mastitis, but is rarely encountered in human
infection.
• C. macginleyi strains have been isolated from the
eye, often in association with infection.
• C. xerosis has been confused with C. amycolatum
and is very rare.
• Rothia dentocariosa is commonly isolated from
respiratory tract specimens and has been
associated with endocarditis and brain abscess.
• Turicella otitidis and C. auris have been isolated
from ears of healthy patients and those with ear
infections.
• Several species of Arthrobacter and Actinobaculum
have been recovered from patients with urinary
tract infections.
LISTERIA
Organisms of the genus Listeria are non-sporing
Gram-positive bacilli. The genus contains eight
species (L. monocytogenes, L. seeligeri, L. ivanovii, L.
welshimeri, L. grayi, L. innocua, L. marthii and L.
205
17 BACTERIAL PATHOGENS AND ASSOCIATED DISEASES
rocourtiae), but almost all cases of human listeriosis
are caused by L. monocytogenes. The disease chiefly
affects the immunosuppressed and elderly, as well as
to a lesser extent the pregnant women, unborn or
newly delivered infants. Listeriosis is transmitted pre-
dominantly by the consumption of contaminated
food. The majority of animal listeriosis is also due to
L. monocytogenes but L. ivanovii is associated with
about 10% of infections in sheep.
Listeria spp. grows well on a wide variety of non-
selective laboratory media and some species, includ-
ing L. monocytogenes, exhibit β-haemolysis on blood
agar. These bacteria are non-motile at 37°C, but
exhibit characteristic ‘tumbling’ motility when tested
at 25°C.
LISTERIA MONOCYTOGENES
Description
L. monocytogenes is genetically similar to other Liste­
ria species, but can be differentiated by phenotypic or
genotypic tests. Thirteen serotypes (serovars) are rec-
ognized which can be further subdivided by a variety
of phenotypic and now almost exclusively genotypic
methods.
Most cases of human listeriosis are caused by
serovars 4b, 1/2a and 1/2b. Large food-borne out-
breaks have been caused predominantly by serovar
4b strains.
The properties of the organism favour food as an
agent in transmission of listeriosis. It widespread in
the environment, able to colonise places where food
is produced and grows in a wide range of foods having
relatively high water activities (aw >0.95) and over a
wide range of temperatures (0–45°C). Growth at
refrigeration temperatures is relatively slow, with a
maximum doubling time of about 1–2 days at 4°C.
Multiplication in food is restricted to the pH range
5–9. L. monocytogenes is not sufficiently heat resistant
to survive pasteurization.
Pathogenesis
L. monocytogenes is an intracellular parasite, and it is
in this environment that the pathogen gains protec-
tion and evades some of the host’s defences. However,
the host has a number of strategies to deal with such
parasites. Non-specific mechanisms of resistance are
important as first lines of defence once the mucous
membranes have been breached. Human neutrophils
and non-activated macrophages can phagocytose
and kill the bacteria. Protective immunity in humans
206
probably depends on T lymphocytes, with antibodies
playing little or no role.
L. monocytogenes enters phagocytic and non-
phagocytic cells and a listerial surface protein, inter­
nalin (reminiscent of the M protein of Str. pyogenes),
is involved with the initial stages of invasion on all
cell types. After internalization, L. monocytogenes
becomes encapsulated in a membrane-bound com-
partment. In the phagocyte, most cells in the phago-
cytic vacuole are probably killed. However, those
surviving in the phagocytic vacuole, and those in the
membrane-bound compartment of non-professional
phagocytes, mediate the dissolution of the vacuole
membrane by means of a haemolysin (listeriolysin
O), and in addition, possibly, the action of a phos-
pholipase C.
In the host cell cytoplasm, where bacterial growth
occurs, the organism becomes surrounded by polym-
erized host cell actin. The ability to polymerize actin
preferentially on the older pole of the listeria cell with
a surface protein (ActA) subverts the host cell’s
cytoskeleton and confers intracellular motility to the
bacterium. The resulting ‘comet tail’-like structure
pushes the bacterium into an adjacent mammalian
cell, where it again becomes encapsulated in a
vacuole. A listerial lecithinase is involved with disso-
lution of these membranes; the haemolysin may also
contribute in this process. Intracellular growth and
movement in the newly invaded cell is then repeated.
The genes associated with virulaence in L. monocy­
togeneces occur as homologous in L. ivanovii and
L. seeligeri.
Clinical aspects of infection
L. monocytogenes principally causes intra-uterine
infection, meningitis and septicaemia. The incubation
period varies widely between individuals from 1 to
90 days, with an average for intra-uterine infection
of around 30 days.
Infection in pregnancy and the neonate
Listeriosis in pregnancy is classified by fetal gestation
at onset, as this correlates best with the clinical fea-
tures, microbiology and prognosis. Maternal listerio-
sis occurs throughout gestation, but is rare before 20
weeks of pregnancy. The mother is usually previously
well with a normal pregnancy. Pregnant women often
have very mild symptoms (chills, fever, back pain,
sore throat and headache, sometimes with conjuncti-
vitis, diarrhoea or drowsiness), but may be asymp­
tomatic until the delivery of an infected infant.
Symptomatic women may have positive blood
 Coryneform bacteria, listeria and erysipelothrix 17

cultures. Cultures from high vaginal swabs, stool and
midstream urine samples, together with pre- or post-
natal antibody tests, are of little help in diagnosis.
With the onset of fever, fetal movements are reduced,
and premature labour occurs within about 1 week.
There may be a transient fever during labour, and the
amniotic fluid is often discoloured or stained with
meconium. Culture of the amniotic fluid, placenta or
high vaginal swab after delivery invariably yields a
heavy growth of L. monocytogenes. Fever resolves
soon after birth, and the vagina is usually culture
negative after about 1 month. Maternal infection
without infection of the foetus can occur and even
progress to placental infection without ill effects for
the foetus. Repeated pregnancy-associated infections
are exceedingly rare, and an association between lis-
teria carriage and habitual abortion has not been
substantiated.
Although the outcome of infection for the mother
is invariably benign, the outcome for the infant is
more variable. Abortion, stillbirth and early-onset
neonatal disease are common, depending on the ges-
tation at infection. Neonatal infection is divided into
disease of early (<2 days old), intermediate (3–5 days
old) and late (>5 days old) onset. Early neonatal lis-
teriosis is predominantly a septicaemic illness, con-
tracted in utero. In contrast, late neonatal infection is
predominantly meningitic and may be associated
with hospital cross-infection acquired from an early
onset neonatal case. The main characteristics of
these two forms are summarized in Table 17.2. Early-
onset disease represents a spectrum of mild to severe
infection, which can be correlated with the micro­
biological findings. Those neonates who die from
infection usually do so within a few days of birth and
have pneumonia, hepatosplenomegaly, petechiae,
abscesses in the liver or brain, peritonitis and
enterocolitis.
In late-onset neonatal disease the cerebrospinal
fluid (CSF) protein content is almost always raised
and the glucose level reduced. The total number of
white cells is increased but the counts are variable;
neutrophils usually predominate, but lymphocytes or
monocytes may be the main cell type. In about 50%
of Gram films, bacteria, which may resemble rods or
cocci, are seen.

Table 17.2  Characteristics of neonatal infection with L. monocytogenes

Type of infection

Early Late

Onset after delivery <2 days >5 days

Maternal factorsa Common Rare

Source of infection Intrauterine infection acquired haematogenously Hospital-acquired from early-onset case, post-natal
from mother environment or maternally acquired during delivery

Signs/symptoms Disseminated infection Meningitis

Cardiopulmonary distress Irritability
Central nervous system signs Poor appetite
Vomiting and diarrhoea Fever
Hepatosplenomegaly
Skin rash

Laboratory findings Leucocytosis or leucopenia Leucocytosis; occasional radiographic changes

Thrombocytopenia CSF: total protein and white cell count raised; glucose
Mottling on chest radiography level lowered
Increased fibrinogen

Sites of isolation Blood, superficial sites and amniotic fluid; less Commonly CSF; rarely blood
commonly gastric aspirate, CSF and HVS

Mortality rate 30–60% 10–12%

CSF, cerebrospinal fluid; HVS, high vaginal swab.

a
Obstetric problems; low birth-weight; maternal fever; abnormal amniotic fluid.

207
17 BACTERIAL PATHOGENS AND ASSOCIATED DISEASES
Adult and juvenile infection
Adult infection is now the most common manifesta-
tion of the disease in Northern Europe and North
America. In adults and juveniles the main syndromes
are septicaemia and central nervous system infection.
There was a dramatic increase in the incidence in liste-
rial bacteraemia in patients over 60 years of age in
Northern Europe at the start of the 21st century; the
rate in this group increased almost 4-fold in England
and Wales between 1990 and 2010. Most cases occur
in immunosuppressed patients receiving steroid or
cytotoxic therapy or with malignant neoplasms.
Autoimmune disease, diabetes, alcohol related disease
and immunosuppressive treatments are all risk factors
for listerial infection. However, about one-third of
patients with meningitis and around 10% with primary
bacteraemia are apparently immunocompetent. Liste-
riosis in children older than 1 month is very rare,
except in those with underlying disease.
Meningitis
The clinical presentation is the same in all groups, but
progression is more rapid in immunocompromised
subjects. A peripheral blood leucocytosis occurs, and
the CSF white blood cell count is raised. The CSF
glucose level is low and the protein level is raised; a
very high protein concentration may be a poor prog-
nostic indicator. Gram stains of the CSF are often
negative, and the clinical features of infection are such
that it is not possible to tell listerial meningitis from
meningococcal or pneumococcal infection. However,
L. monocytogenes is isolated from blood cultures in
most cases.
In the rare cases of encephalitis, cerebritis or cere-
bral abscesses, the CSF may be normal, but the white
blood cell count is often raised mildly and the protein
level is slightly increased, with a low glucose con­
centration. The Gram film and culture are usually
negative. Blood cultures are the main source of the
organism in many of these patients.
Bacteraemia
Primary bacteraemia is more common in men than in
women, and occurs most often in patients >60 years
of age as well as those with haematological malig-
nancy or a renal transplant. As compared to patients
with central nervous system infections, those with lis-
terial bacteraemia present more often with gastroin-
testinal symptoms, particularly those with gastric
malignancies, and treatment to reduce stomach acid
secretion.
208
Gastroenteritis
Several food-borne outbreaks of acute gastroenteritis
with fever have been described. The foods associated
with these outbreaks have been diverse, but heavily
contaminated by the bacterium. Symptoms develop in
1–2 days. Large numbers of L. monocytogenes are
present in the stool, and a few patients develop serious
systemic infection. The ability to cause gastroenteritis
may be specific to certain strains.
Other infections
Rarer manifestations of listeriosis include arthritis,
hepatitis, endophthalmitis, pneumonia, endocarditis,
cutaneous lesions and peritonitis in patients on con-
tinuous ambulatory peritoneal dialysis.
Epidemiology
Incidence
Most western countries report infection rates of 1–10
cases per million of the population per year. Preg-
nancy and neonatal disease account for about 10% of
cases. Among these, 15–25% of infections lead to
abortion and stillbirth, and about 70% are neonatal
infections. In about 5% of maternal infections bacter-
aemia occurs and the foetus is not affected.
The incidence of infection increases with age so that
the mean age of adult infections is over 55 years. Men
are more commonly infected than women over the age
of 40 years. Immunosuppression is a major risk factor
for both the epidemic and sporadic forms of listeriosis
and probably accounts for the increasing incidence
with age. Human immunodeficiency virus disease has
been reported as a predisposing factor in some areas.
The peak incidence of human disease usually occurs
in July, August or September. Most cases are appar-
ently sporadic, and the patients live in urban areas
without exposure to animals.
L. monocytogenes, like other Listeria species, has
been isolated from numerous environmental sites,
including soil, sewage, water and decaying plant mate-
rial, where it can survive for more than 2 years.
Although the true home of listeria is probably in the
environment, these organisms are also found in
excreta of apparently healthy animals, including man.
Up to 5% of healthy adults may have the organism in
their faeces. Faecal carriage in man probably reflects
consumption of contaminated foods and is likely to
be transitory.
Numerous types of raw, processed, cooked and
ready-to-eat foods contain L. monocytogenes, usually
at low levels of contamination. The tolerance of the

bacterium to sodium chloride and sodium nitrite, and
the ability to multiply (albeit slowly) at refrigeration
temperatures makes L. monocytogenes of particular
concern as a post-processing contaminant in long-
shelf-life refrigerated foods. Even when present at
high levels in foods, spoilage or taints are not gener-
ally produced. The widespread distribution of L.
monocytogenes and the ability to survive on dry and
moist surfaces favour post-processing contamination
of foods from both raw product and factory sites.
Transmission
Most cases are sporadic and in only a few is a route
of infection identified. The consumption of contami-
nated foods is the principal route of transmission.
Microbiological and epidemiological evidence sup-
ports an association with many food types (dairy,
meat, vegetable, fish and shellfish) in both sporadic
and epidemic listeriosis. Foods associated with trans-
mission often show the following common features:
• able to support the multiplication of
L. monocytogenes (relatively high water
activity and near-neutral pH)
• relatively heavily contaminated (>103  the mainstays of treatment although Gram-staining
L. monocytogenes per gram) with the
implicated strain
• processed with an extended (refrigerated)
shelf-life
• ready to eat and consumed without further
cooking.
The food type currently most commonly associated
with transmission in the UK is pre-prepared sand-
wiches served in hospitals.
Outbreaks of human listeriosis involving more than
100 individuals have occurred, some lasting for several
years. This is likely to represent a long-term coloniza-
tion of a single site in the food manufacturing envi-
ronment as well as the long incubation periods shown
by some patients. Sites of contamination within food
processing facilities involved in human infection have
included equipment, shelving, conveyor belts, conden-
sates and drains. L. monocytogenes survives well in
moist environments with organic material, and it is
from such sites that contamination of food occurs
during processing. Epidemiological typing is invalu-
able for the identification of common source food-
borne outbreaks and for tracking the bacterium in the
food chain.
Listeriosis transmitted by direct contact with the
environment, infected animals or animal material
is relatively rare. Papular or pustular cutaneous
lesions have been described, usually on the arms and
Coryneform bacteria, listeria and erysipelothrix 17
hands of farmers or veterinarians 1–4 days after
attending bovine abortions. Infection is invariably
mild and usually resolves without antimicrobial
therapy, although serious systemic involvement has
been described. Conjunctivitis in poultry workers has
also been reported.
Hospital cross-infection between newborn infants
occurs. Typically, an apparently healthy baby (rarely
more than one) develops late-onset listeriosis 5–12
days after delivery in a hospital in which an infant
with congenital listeriosis was born shortly before.
The same strain of L. monocytogenes is isolated from
both infants and the mother of the early-onset case,
but not from the mother of the late-onset case. The
cases are usually delivered or nursed in the same or
adjacent delivery suits or neonatal units, and conse-
quently staff and equipment (particularly respiratory
resuscitation equipment) are common to both. There
is little evidence of cross-infection or person-to-person
transmission outside the neonatal period.
Diagnosis and treatment
Conventional culture of blood and or CSF remain
of surface swabs and of merconium stained amniotic
fluid has been reported to have a very high predictive
value for neonatal listeriosis during outbreaks.
PCR based procedures for amplification of L.
monocytogenes-specific DNA sequences from serum
and CSF have been reported.
L. monocytogenes is susceptible to a wide range
of antibiotics in vitro, including ampicillin, penicillin,
vancomycin, tetracyclines, chloramphenicol, amino­
glycosides and co-trimoxazole. There is little agree-
ment about the best treatment, but many patients
have been treated successfully with ampicillin or peni-
cillin with or without an aminoglycoside. Cepha-
losporins are ineffective.
No significant change in the antimicrobial suscep-
tibility of L. monocytogenes has been recognized over
the past 40 years, and resistance to any of the agents
recommended for therapy is unlikely.
Prognosis
The mortality rate in late neonatal disease is about
10%. In contrast, the mortality rate in early disease is
30–60%, and about 20–40% of survivors develop
sequelae such as lung disease, hydrocephalus or
other neurological defects. Early use of appropriate
antibiotics during pregnancy may improve neonatal
survival.
209
17 BACTERIAL PATHOGENS AND ASSOCIATED DISEASES
The mortality rate in both adult meningitis and
bacteraemia is about 20–50%. Amongst patients with
meningitis, mortality is significantly less likely in
patients less than 60 years of age; however the death
rates are similar in these age groups in patients with
bacteraemia. Between 25–75% of patients surviving
central nervous system infection suffer sequelae such
as hemiplegia and other neurological defects.
ERYSIPELOTHRIX
Erysipelothrix is a genus of aerobic, non-sporing,
non-motile, Gram-positive bacilli. The genus com-
prises at least three species: E. rhusiopathiae, E.
inopinata and E. tonsillarum. E. rhusiopathiae causes
economically important disease in domestic animals,
RECOMMENDED READING
Allerberger F, Wagner M: Listeriosis: a resurgent foodborne infection,
Clinical Microbiology and Infection 16:16–23, 2010.
Cossart P, Toledo-Arana A: Listeria monocytogenes, a unique model in
infection biology: an overview, Microbes and Infection 10:1041–1050,
2008.
Begg N: Manual for the Management and Control of Diphtheria in the
European Region, Copenhagen, 1994, World Health Organization.
Brooke CJ, Riley TV: Erysipelothrix rhusiopathiae: biology, epidemiology
and clinical manifestations of an occupational pathogen, Journal of
Medical Microbiology 48:789–799, 1999.
Denny J, McLauchlin J: Human Listeria monocytogenes infections in
Europe: An opportunity for improved pan-European Surveillance,
Eurosurveillance 13:pii=8082, 2008.
Efstratiou A, George RC: Microbiology and epidemiology of diphtheria,
Reviews in Medical Microbiology 7:31–42, 1996.
Efstratiou A, Engler KH, Mazurova IK et al: Current approaches to the
laboratory diagnosis of diphtheria, Journal of Infectious Diseases
181:S138–S145, 2000.
210
notably pigs. Human infections from E. rhusiopathiae
are rare, but present as a localized cutaneous infection
(erysipeloid), which occasionally becomes diffuse
and may lead to septicaemia and endocarditis. Infec-
tion is most often associated with close animal contact
and usually occurs in such occupational groups as
butchers, abattoir workers, veterinarians, farmers,
and fish-handlers.
The organism is cultured most often from biopsies,
aspirates or blood. The bacilli are short (1–2 µm), but
may produce long filamentous forms resembling
lactobacilli. Growth is improved by incubation in
5–10% carbon dioxide. Colonies on blood agar are
α-haemolytic.
Penicillin and other β-lactam antibiotics are
effective. Erythromycin and clindamycin offer suita-
ble alternatives, but E. rhusiopathiae is resistant to
vancomycin.
Farber JM, Peterkin PI: Listeria monocytogenes, a food-borne pathogen,
Microbiology Reviews 55:476–511, 1991.
Funke G, von Graevenitz A, Clarridge JE, Bernard K A: Clinical
microbiology of coryneform bacteria, Clinical Microbiology Reviews
10:125–159, 1997.
Lianou A, Sofos JN: A review of the incidence and transmission of
Listeria monocytogenes in ready-to-eat products in retail and food
service environments, Journal of Food Protection 70:2172–2198, 2007.
Low JC, Donachie W: A review of Listeria monocytogenes and listeriosis,
Veterinary Journal 153:9–29, 1997.
Robson JM, McDougall R, van der Valk S et al: Erysipelothrix
rhusiopathiae: an uncommon but ever present zoonosis, Pathology
30:391–394, 1998.
Swaminathan B, Gerner-Smidt P: The epidemiology of human listeriosis,
Microbes and Infection 9:1236–1243, 2007.
Wagner KS, White JM, Crowcroft NS et al: Diphtheria in the United
Kingdom 1986–2008: the increasing role of Corynebacterium
ulcerans, Epidemiology and Infection 138:1519–1530, 2010.