SECTION 8 Clinical Microbiology: Bacteria

179 
Neisseria
TONE TØNJUM  |  JOS VAN PUTTEN

KEY CONCEPTS bacter, Vogesella, Vitreoscilla, Chromobacterium, Aquaspirillum, Pro-

linoborus, Formivibrio and Iodobacter (Figure 179-1).1 The taxonomy
• The main neisserial diseases are gonorrhea and meningitis, with of the family has been extensively revised over the past decades, mainly
or without sepsis. based on 16S rRNA gene sequence analysis and whole genome sequenc-
• Commensal neisserial species are common human mucosa ing, even though these methodologies do not reflect all the complex
colonizers, rarely causing infections. levels of relationships between these heterogeneous polyphyletic
entities.
• Neisserial pathogenicity is mediated by various virulence The members of the genus Neisseria are typically gram-negative
factors, but no exotoxins.
cocci. The bacteria appear in pairs (diplococci). Diplococci have
• Main neisserial virulence factors include capsule, adhesins, flattened opposing sides, imparting the characteristic kidney or coffee-
immune evasion molecules and endotoxins. bean appearance seen in stained smears. Some species are medium-
to-large plump rods that sometimes occur in pairs or short chains (N.
• Due to their capsule, meningococci can survive in the blood-
stream and cerebrospinal fluid. elongata, N. weaveri, N. bacilliformis and N. shayeganii). Several
species possess capsules and are fimbriated (piliated). Endospores
• Large scale genomics impact on how public health institutions and exotoxins are not found and flagella are absent. Some Neisseria
interpret neisserial epidemiology and pathogenicity. spp., including N. gonorrhoeae and N. meningitidis, may show surface-
• Meningococcal conjugated capsule and recombinant/outer bound twitching motility due to pilus retraction. All species are
membrane vesicles (OMV) vaccines are in use; however, there aerobic.
is no vaccine against gonorrhea. N. gonorrhoeae and N. meningitidis are genetically very closely
related human pathogens (Figure 179-1). The genus Neisseria is com-
• The rise of ciprofloxacin-resistant Neisseria gonorrhoeae war-
posed of 17 species that may be isolated from humans and six species
ranted the introduction of ceftriaxone and azithromycin for
gonorrhea treatment globally. that colonize various animals (Table 179-1).2 N. lactamica and N.
cinerea are most closely related to the pathogenic Neisseria, and fre-
• Meningococcal infections are treated with cefotaxime/ quently colonize the nasopharynx of children and adults. The saccha-
ceftriaxone or penicillin when susceptible. rolytic Neisseria (N. polysaccharea, N. subflava, N. sicca and N. mucosa)
are more distantly related to the other Neisseria and colonize humans
less frequently. Commensal Neisseria species are widespread in animals
and non-mammalian hosts and are even more distantly related to the
human pathogens.2
Nature
The genus Neisseria was named after Albert Neisser who observed
gonococci (Neisseria gonorrhoeae) in leukocytes in urethral exudates
from patients with gonorrhea in 1879. Eight years later Weichselbaum TABLE
isolated meningococci (Neisseria meningitidis) from six of eight cases 179-1  Members of the Genus Neisseria
of primary sporadic community-acquired meningitis. The gonococcus NEISSERIA SPECIES
and the meningococcus are exclusively human pathogens and the most
studied neisserial species. Humans Animal Hosts Only
Neisseria gonorrhoeae is an obligate pathogen that causes gonor- Urogenital Tract Oropharynx Host/Species
rhea, a sexually transmitted disease. Gonorrhea was named by Galen
N. gonorrhoeae N. meningitidis Dogs/N. weaveri, N.
in CE 130 after the Greek words gonor (seed) and rhoia (flow), suggest- N. lactamica flavescens, N. animaloris,
ing that the disease was related to the flow of semen. In the 13th N. gonorrhoeae N. mucosa, N. flavescens,
century, Maimonides recognized that the urethral discharge of male N. animaloris N. sicca, N. canis,
gonorrhea patients was not semen, but a sexually transmitted disease. N. bacilliformis N. shayeganii, N.
N. cinerea zoodegmatis
In 1885 Bumm proved gonococci as the cause of gonorrhea by inocu- N. elongata Guinea pigs/N. animalis,
lating human volunteers. subsp. elongata N. denitrificans
Neisseria meningitidis is an opportunistic pathogen that can cause subsp. glycolytica Cow/N. dentiae
endemic and epidemic meningitis and/or sepsis worldwide. Epidemic subsp. nitroreducens Cat, leopard, lion, tiger/N.
N. flavescens animaloris
meningococcal meningitis was first described by Vieusseaux in 1805 N. mucosa Iguanas/N. igaunae
in Geneva. Throughout the 19th century periodic epidemics occurred, var. mucosa Dolphins/N. mucosa var.
involving mainly young children and adolescents including military var. heidelbergensis heidelbergensis
recruits. In 1896 Kiefer described the nasopharyngeal meningococcal N. polysaccharea Monkeys/N. macacae
N. sicca Vulture/N. sicca
carrier state among healthy people. N. subflava Duck/N. mucosa
bv. flava Mosquito, fly, tick/
TAXONOMY bv. perflava Neisseria spp.
The family Neisseriaceae consists of the genus Neisseria as well as the bv. subflava Honey bee/N. meningitidis
N. zoodegmatis Louse/N. perflava, N.
heterogeneous genera (in order of decreasing relatedness to genus N. weaveri mucosa, N. flavescens
Neisseria) Kingella, Eikenella, Alysiella, Simonsiella, Microvirgula, Lari-
1553
1554 SECTION 8  Clinical Microbiology: Bacteria

Neisseria species as depicted by phylogenetic

analysis of 16S rRNA gene sequences

N. animalis ATCC 19573

N. denitrificans ATCC 14686
N. elongata subsp. glycolytica ATCC 29315
N. elongata subsp. elongata ATCC 29295
N. elongata subsp. nitroreducens ATCC 49377
N. weaveri CDC 8142
N. lactamica NCTC 10617
N. mucosa subsp. heidelbergensis ATCC 25999
N. macacae ATCC 33926
N. subflava biovar. flava U40
N. sicca Q28
N. mucosa ATCC 19696
N. mucosa subsp. mucosa LNP405
‘N. pharyngis’ NCTC 4590
N. sicca Q29
N. iguanae ATCC 51483
N. subflava biovar. subflava U37

N. subflava biovar. perflava U15

N. flavescens ATCC 13120
N. cinerea LNP1646
N. cinerea F3
N. cinerea 159/62
N. polysacchareae P7
N. polysacchareae ATCC 43768
N. polysacchareae NCTC 11858
N. gonorrhoeae NCTC 83785
N. gonorrhoeae 76993
N. meningitidis HF46
N. meningitidis M1080
N. meningitidis HF130
N. meningitidis B4055/75
N. meningitidis B17
N. meningitidis HF116
N. meningitidis M470
N. meningitidis 1000
N. meningitidis S3446
N. meningitidis N94ll
N. meningitidis 8698
N. meningitidis H44/76
N. meningitidis N.60/94
N. canis ATCC 14678
N. dentiae V33 1% divergence

Figure 179-1  Neisseria species as depicted by phylogenetic analysis of 16S rRNA gene sequences. (Redrawn from Tønjum.1)

GROWTH CHARACTERISTICS N. gonorrhoeae are 0.5–1 mm in size. Colonies of N. meningitidis are

Neisseria spp. grow best aerobically in an atmosphere containing
5–10% carbon dioxide at a temperature of 89.6–98.6°F (32–37°C) and
a pH of 7–7.5. Cell size ranges from 0.6 to 1.5 mm depending upon
the species source of the isolate and the age of the culture.
Neisseria spp. are fastidious. Blood agar and chocolate medium
(blood heated at 176–194°F/80–90°C) are suitable growth media. Bac-
terial colonies usually appear after 24–48 hours of growth. Colonies of
usually larger (1–2 mm) and flatter. Colonies of the nonpathogenic
Neisseria spp. are similar in size, appearance and consistency, except
for the saccharolytic Neisseria spp. (N. subflava, N. sicca and N. mucosa)
that are larger (1–3 mm), more convex and smooth (N. mucosa). Colo-
nies of N. subflava and N. sicca are opaque and have varying consis-
tency. N. sicca adhere to the agar surface and become wrinkled with
prolonged incubation. Some nonpathogenic Neisseria spp. form a
 Chapter 179  Neisseria 1555

yellow pigment (N. flavescens) or a greenish-yellow pigment (N.
mucosa, N. subflava).
Neisseria spp. are oxidase positive and catalase positive, except N.
elongata, which is catalase negative. All species produce acid from a
few carbohydrates by oxidation. The ability to produce polysaccharide
from sucrose, to produce catalase and deoxyribonuclease, to reduce
nitrate and nitrite, and to oxidize the tributyrin fatty acid can also be
used to identify Neisseria spp.
GENOME DYNAMICS
The size of the Neisseria chromosome is approximately 2.2–2.3 Mb.
The average G+C content is 48–56 mol%. N. meningitidis and N. gon-
orrhoeae share about 95% of their gene content.1 The vast majority of
genes are also present in nonpathogenic N. lactamica, but gene regula-
tion may be different in pathogenic and commensal strains.3 Due to
genetic instability, the Neisseria spp. have hyperdynamic genomes.4
The genome plasticity contributes to adaptation and immune evasion
and thereby to the pathogenic potential of N. meningitidis and N.
gonorrhoeae and the development of hypervirulent lineages. The most
important sources of neisserial genome instability (Figure 179-2) are
as follows:
• Phase variation, i.e. variable protein expression due to slipped-
strand mispairing of nucleotide runs found within or close to the
promoter region (affect transcription) or within open reading
frames (affect translation). There are more than 100 phase-
variable genes in the pathogenic Neisseria spp.5
• Recombination, i.e. the genetic exchange or rearrangement of
DNA from external or internal sources. This may, for example,
lead to the generation of millions of variants of pilin subunits.
• Horizontal gene transfer, i.e. the introduction of genes predomi-
nantly via natural transformation (mediated by the DNA uptake
sequences, DUS) and integration into the chromosome by RecA-
mediated homologous recombination. Neisseria spp. are natu-
rally competent for transformation throughout their growth
cycle.
• Hypermutation, i.e. increased global mutation rates often associ-
ated with DNA repair deficiencies, replication infidelity or over-
expression of DNA translesion polymerases.
The pathogenic Neisseria spp. share several genomic regions, including
up to nine prophage and eight genetic islands, that are absent from N.
lactamica.6 There are no classic pathogenicity islands as are present in
many other bacterial species. N. meningitidis-specific DNA sequences
include the cps locus encoding the polysaccharide capsule, genes that
encode the RTX family of toxins and an ortholog of the filamentous
hemagglutinin of Bordetella pertussis. Certain hypervirulent lineages
contain the filamentous prophage Nf1.7 About 80% of the gonococcal
clinical isolates and N. meningitidis strains of serogroups W135, H and
Z contain the ‘gonococcal genetic island’ (GGI, 57 kb).6 This often
chromosomally integrated conjugative plasmid encodes a type IV
secretion system involved in DNA secretion. The genome of Neisseria
spp. has a variable number of noncoding repeat arrays and insertion
(IS) elements among which IS1655 appears unique to N. meningitidis.
Most isolates of N. gonorrhoeae but not N. meningitidis carry plas-
mids.8 Nearly all gonococcal strains carry a 4.2 kb cryptic plasmid of
unknown function and many strains carry plasmids encoding
β-lactamase causing resistance to penicillin.
Genome-based phylogenetic reconstruction indicates that some
hundreds of years ago pathogenic N. meningitidis emerged from a

Mechanisms contributing to genetic instability of the Neisseria species

1. Phase variation 2. Antigenic variation

pilS
pilE
-35 -10 RBS ORF
nnnnnnnnnnnnnnnnnnnnnn ATG nnn nnn nnn nnn +
GGGGGGGGG

TAATAATAATAA CCCCCCCCCC +
Transcription

Transcription Translation

Genetic
instability
3. Transformation 4. Mutators

b.
Outer DNA repair deficiency
membrane e.g. mutS, mutL

Inner Low global

a. membrane mutation
frequency High global
mutation
c. frequency

Figure 179-2  Mechanisms contributing to genetic instability of the Neisseria species. (Redrawn from Davidsen et al.4)
1556 SECTION 8  Clinical Microbiology: Bacteria
Worldwide distribution of major meningococcal serogroups and serogroup B outbreaks
Norway, 1969
B:B:15:P1.7,16
Oregon, Spain, 1974
1994 B, C, Y B:4:P1.9,15
B:15:P1.7,16
Cuba, 1980
B:4:P1.19,15
A, W-135, C, X
Brazil, 1985
B:4:P1.19,15
Chile, 1985
15:P1.3 B, C
Figure 179-3  Worldwide distribution of major meningococcal serogroups and serogroup B outbreaks (in purple). The meningitis belt (dotted line) of sub-Saharan
Africa and other areas of substantial meningococcal disease in Africa are shown. (Redrawn from Stephens et al.12)
common unencapsulated ancestor by acquisition of capsule genes,
probably from members of the family Pasteurellaceae.9
Epidemiology
GONORRHEA
Gonorrhea is a common sexually transmitted disease worldwide. N.
gonorrhoeae infection is the second most common notifiable disease in
the USA, with 333 004 cases reported in 2013.10 Incidences in Europe
and in the developing world are 10–30 and 4000–10 000 per 100 000
population, respectively.11 The actual disease burden is probably
higher due to underdiagnosis and underreporting. The highest attack
rates occur in 15–25-year-old men and women. In regions where col-
lected statistics include sexual orientation, rates of gonococcal infec-
tion more than quadrupled from 1995 to 2013 among men who have
sex with men (MSM).
Gonococci are exclusive human pathogens. The risk of acquiring a
urethral infection for men is approximately 20% after a single vaginal
exposure to an infected woman, rising to 60–80% after four or more
exposures. The transmission rate from male to female is approximately
50% per contact, rising to 90% after three exposures. Gonococci are
transmitted by orogenital contact or rectal intercourse. Perinatal trans-
mission may also occur. Although gonococci can survive for brief
periods outside the human reservoir, extracorporeal transmission is
extremely rare.
The major reservoir for continued spread of gonorrhea is the
asymptomatic patient. Among infected women, 30–50% are asymp-
tomatic or show no symptoms associated with a sexually transmitted
disease.11 Among infected men, only 5–10% are asymptomatic.
Asymptomatic women and men remain infectious for months. Main-
tenance and transmission of gonorrhea are also related to a social
subset of ‘core transmitters’ who have unprotected intercourse with
multiple new partners and either are asymptomatic or choose to ignore
symptoms. The average incubation period for developing gonorrhea
is 2–7 days but can vary between 1 and 14 days.
A, C
B, C
Japan, 1979
B:15:P1.7,16
Australia, 1982
B:15:P1.7,16
B, C
South Africa, 1980
B:4:P1.19,15
New Zealand, 1992 to present
B:4:P1.4
MENINGOCOCCAL DISEASE
Meningococcal disease is a global major health problem (Figure 179-
3).12 The annual number of invasive disease cases worldwide is esti-
mated to be at least 1.2 million, with 135 000 deaths related to invasive
meningococcal disease.13 Disease patterns differ among populations
and infecting strains and can be endemic, hyperendemic, epidemic and
pandemic. The case fatality rate is 5–10% in industrialized countries,
and 10–20% of survivors develop permanent sequelae. Transmission
of meningococci occurs by respiratory aerosol droplets and hand-to-
mouth contact in children, requiring close contact. Invasive disease
occurs particularly when bactericidal antibodies against the invading
strain are lacking.14 Concurrent viral or mycoplasmal respiratory tract
infections facilitate systemic invasion.
The major virulence factor of disease-associated meningococci is
the polysaccharide capsule.14 Most infections are caused by strains
belonging to serogroups A, B, C, Y and W135 (see Figure 179-3).11 In
Western Europe and the Americas, meningococcal disease is endemic
and caused mainly by serogroups B or C with incidences of 1–3/100 000.
Periodically, local hyperendemic outbreaks occur when new lineages
spread through the population. A serogroup B infection has spread
worldwide, culminating in outbreaks in Australia and New Zealand in
2001–2006.11 In China, the Middle East and parts of Africa, serogroups
A and C predominate. Large epidemics are attributed predominantly
to serogroup A strains. In the African ‘meningitis belt’, major periodic
epidemics of serogroup A disease occur every 5–12 years, with attack
rates of 500/100 000 population or higher.15 The emergence and global
importance of serogroups W135, X and Y has been recognized only in
the last 10 years. Serogroup W135 was identified in 2002–2003 as a
major threat and the main pathogen during outbreaks in Africa. An
unprecedented incidence of serogroup X meningitis was observed in
Niger in 2006.16 Occasionally, particularly virulent strains arise that
cause pandemic outbreaks across continents.12 In the USA, Israel and
Sweden, disease due to serogroup Y strains has increased.17
The occurrence of meningococcal disease varies with climate, age
and social behavior. Serogroup A and C disease increases during the

TABLE
179-2  Neisserial Virulence Factors
Virulence Factor Function
Lipopolysaccharide Lipo-oligosaccharide (LOS) has endotoxin activity
(LPS/LOS) and is released as bacterial outer membrane
vesicles (blebs) or through cellular lysis. LOS is
responsible for toxic damage to the human
tissue, development of septic shock and
disseminated intravascular coagulation (DIC)
through interactions with Toll-like receptors
(TLR4) and cytokine induction
Polysaccharide Polysaccharide surface component which works
capsule (N. as a protective shell and blocks the insertion
meningitidis only) of the membrane attack complex of the
complement system and protects the bacteria
from phagocytosis. The capsule is the main
component enabling bacterial survival in blood
and resisting bactericidal antibodies. The
serogroup B capsule can also mimic human
antigens
Type IV pili Major adhesins that mediate initial attachment to
non-ciliated human cells. Also required for
efficient transformation of DNA
Outer membrane Dominant antigens. Porin proteins promote
proteins (OMP) intracellular survival. Opacity proteins mediate
firm attachment to eukaryotic cells. RmpM
protein may protect other antigens from
bactericidal interactions with antibodies.
Frequent antigenic variation makes it difficult
for the host immune system to recognize the
porin and opacity protein antigens
Iron-binding proteins Transferrin-, lactoferrin- and hemoglobin-binding
proteins. Pathogenic Neisseria spp. are
dependent on a constant iron supply for
growth
IgA1 protease Destroys mucosal IgA which is a part of the local
immune system
β-Lactamase An enzyme that hydrolyzes the β-lactam ring of
penicillin. Important for antibiotic resistance
development in Neisseria spp.
dry season in Africa. The number of serogroup B and C cases peaks
during the winter months in higher-income countries.11 In the men-
ingitis belt, young school-aged children represent the peak age group.
In higher-income countries, children aged between 1 and 4 years
account for the majority of cases with a second peak among teenag-
ers.11 Young adult smokers who socialize frequently at discos and
parties may be particularly at risk.12 Passive smoking predisposes chil-
dren to contract meningococcal disease.12 The attack rate among
family members of a clinical case is 1000-fold higher than in the
general population. The acquisition of meningococcal disease requires
a combination of a pathogenic organism, a susceptible host, and pos-
sibly coincidental mucosal damage by other infections, nutrition or
low humidity. Hereditary factors such as late complement deficiencies
and receptor polymorphisms may be additional predisposing
factors.12,18
Pathogenicity
GONOCOCCAL PATHOGENESIS
At the cellular level, a large repertoire of often phase-variable adhesins
and invasion-promoting surface factors enables gonococcal infection
of different niches and with different cell tropism (Table 179-2).19 The
first step in gonococcal infection is the type IV pilus-mediated attach-
ment to mucosal cells (Figure 179-4).20 Once attached, PilT-mediated
pilus retraction brings the bacteria into intimate contact with the cell
surface and stimulates mechanosensitive host cell signaling pathways.21
Shortly after initial attachment Opa proteins interact with carcinoem-
Chapter 179  Neisseria 1557
Neisserial infection of mucosal cells
Pilus-mediated
attachment Tight
adherence
Internalization
Inflammatory response
• Cytokine production
• PMN/monocyte infiltration
• Tissue damage
Figure 179-4  Neisserial infection of mucosal cells.
bryonic antigen-related cell adhesion molecules (CEACAM) and/or
heparan sulfate proteoglycan (HSPG) receptors.22 Different Opa pro-
teins bind to distinct receptors types. In vitro Opa-receptor interac-
tions result in efficient internalization of the gonococci by host cells
(Figure 179-4).19 PorB-IA expressing strains also efficiently invade cells
in the absence of Opa proteins.22,23 Bacteria carrying distinct lipo-
oligosaccharide (LOS) variants may invade through binding of lectin
receptors.24 Bacteria with sialylated LOS variants are impaired in inva-
sion but more resistant to killing by complement. Gonococci induce
recruitment of and show intimate association with polymorphonu-
clear leukocytes (Figure 179-4). Type IV pili and distinct Opa proteins
confer non-opsonophagocytosis.19 Some of the gonococci ingested
may resist killing by phagocytes.
The presence of N. gonorrhoeae is sensed by the host innate immune
system. Neisserial LOS is recognized by the Toll-like receptor (TLR)4–
MD2 complex. Porins interact with the TLR2 receptor complex. Pep-
tidoglycan fragments activate the cytoplasmic Nod-1 receptors. These
interactions induce the secretion of cytokines, chemokines and anti-
microbial peptides.
Gonococcal infection elicits a strong humoral immune response.
Dominant antigens are PorB, Opa proteins, RmpM, LOS and iron-
regulated proteins. Nevertheless, the antibodies provide limited pro-
tection due to bacterial surface variation and bacterial immune evasion
mechanisms (see Table 179-2). The extensive phenotype variation and
immune escape mechanisms are major obstacles in the generation of
a broadly protective gonococcal vaccine.
MENINGOCOCCAL PATHOGENESIS
Meningococcal colonization of the nasopharynx largely resembles the
events following gonococcal infection (see above).19 Type IV pili facili-
tate initial adherence, and opacity-associated proteins (Opa and Opc)
and PorB trigger uptake of the bacteria into the cells largely via similar
types of receptor (CEACAM, HSPG). Particular sets of Opa protein
variants are found in hyperinvasive meningococcal lineages. Opa and
Opc proteins that bind heparan sulfate and thus are able to recruit
heparin-binding proteins such as vitronectin and fibronectin enter
cells via integrin receptors. This is accompanied by a downregulation
of pili and capsule, enabling optimal contact between bacterial adhes-
ins and the host mucosa. Transferrin (TbpA, TbpB) and hemoglobin
(Hbp) binding proteins recruit the iron sources required for growth.25
Ciliated mucosal cells may be damaged by released peptidoglycan frag-
ments and LOS. Meningococcal (and gonococcal) infection of the
oropharynx is usually entirely asymptomatic, possibly because of the
relatively high threshold for activation of an inflammatory response
in the oropharynx compared to more sterile anatomic niches such as
the urethra.
1558 SECTION 8  Clinical Microbiology: Bacteria

Steps in pathogenesis of N. meningitidis infection

CSF Mucus Epithelium Blood CSF

The pathogen Oropharyngeal colonization Occasional tissue invasion and dissemination to blood and CSF

Figure 179-5  Steps in pathogenesis of N. meningitidis infection. (Redrawn from Davidsen et al.26)

The mechanism of meningococcal penetration and passage of the

mucosa is only partially understood.20 The major difference in patho- Architecture of the neisserial cell wall
genesis between gonococci and meningococci is the ability of distinct
meningococcal lineages to survive in the bloodstream and to access the Cytoplasmic
cerebrospinal fluid (CSF) (Figure 179-5).26 The few phylogenetic membrane
groups of N. meningitidis that cause meningococcal disease often carry
Periplasmic
a filamentous prophage in their genome that is released from the
Cytoplasmic- membrane
bacteria via the type IV pilus secretin.7 The prophage may promote the
membrane Outer
development of new epidemic clones. Meningococci survive and mul-
proteins membrane
tiply during epithelial cell traversal. The IgA1 protease and PorB
may promote survival on mucosal surfaces and inside epithelial cells,
respectively. Meningococci isolated from the bloodstream invariably
produce polysaccharide capsule. The capsule protects the bacterium
from phagocytosis and complement-mediated lysis by preventing
insertion of the terminal complement attack complex. Invasive menin-
gococci express sialylated LOS which influences binding of C4b, while
the proteins PorA and GNA1870 recruit the negative regulators of
complement activation C4BP and factor H.18 Individuals with inher-
ited deficiencies in the late complement components (C6–C9) have a
high risk of developing meningococcal disease. Intriguingly, they
acquire the infection at a much later age, have frequent recurrences, Outer membrane
and the fatality rate is much lower than for normo-complementemic proteins
individuals.18 This may be because the complement deficiency results Capsular
in less effective cell lysis and therefore less endotoxin release.27 polysaccharide
(serogroup)
STRUCTURE AND VIRULENCE FACTORS
Neisseria spp., like other gram-negative bacteria, have a cell wall that Lipo-
consists of two membranes separated by a thin peptidoglycan layer oligosaccharide
(Figure 179-6). The inner cytoplasmic membrane consists of proteins Pilus
embedded in a phospholipid bilayer that is impermeable for hydro-
philic compounds. The outer membrane is an asymmetric bilayer Peptidoglycan
composed of phospholipids in the inner leaflet and LOS in the outer
leaflet. The LOS renders the outer membrane relatively resistant to Figure 179-6  Architecture of the neisserial cell wall. (Redrawn from Stephens
detergents and is semipermeable due to the presence of protein chan- et al.12)
nels, called porins. Other surface-exposed outer membrane proteins
and extracellular appendages such as capsular structures and type IV
pili particularly contribute to neisserial survival and virulence.19 Neis-
serial outer membrane vesicles (OMVs, blebs) that contain nucleic divided into at least 13 serogroups (A, B, C, D, 29E, H, I, K, L, W135,
acids, protein and high levels of LOS are continuously shed by the X, Y and Z). Serogroups A, B, C, Y and W135 cause more than 90%
bacteria. of meningococcal disease. Capsular types are normally stable but
strains can acquire variant capsule gene alleles by transformation.28
Capsules Serogroup B can thus switch to C or vice versa. The serogroup A
N. meningitidis produces a polysaccharide capsule (see Figure 179-6). capsule contains N-acetyl-mannosamine-1-phosphate. The capsules
On the basis of structural differences in capsule, meningococci are of the serogroups B, C, Y and W135 consist of polymers of

N-acetylneuraminic (sialic) acid. The B polysaccharide resembles
structures present in human neural tissues, limiting its immunogenic-
ity and vaccine potential. The carbohydrates can be variably O-
acetylated. Isolates from healthy carriers are frequently unencapsulated
due to reversible changes in capsule gene expression. A substantial
proportion of meningococcal carrier isolates are incapable of capsule
production due to deletions in or a lack of capsule genes. Isolates from
the bloodstream or CSF are invariably encapsulated.
N. gonorrhoeae does not produce a polysaccharide capsule.
However, both meningococci and gonococci are covered with a loosely
adherent capsular-like structure containing high-molecular weight
polyphosphate. This layer provides protection against environmental
stress.
Pili
Pili are hair-like fibers consisting of thousands of protein subunits
(pilin, 16–20 kDa).20 Pathogenic Neisseria spp. have long pili (up to
4300 nm in length), termed type IV pili, that protrude from the bacte-
rial surface (see Figure 179-6). Nonpathogenic Neisseria spp. may
express both long and short pili (175–210 nm in length). Type IV pili
confer bacterial cell-to-cell interactions and twitching motility – a
form of locomotion that is powered by extension and retraction of the
pilus filament.19 Pili are essential for adhesion to epithelial and endo-
thelial cells and impart tissue tropism.19 Expression of type IV pili is
also required for transformation of DNA.4
During infection pilins undergo rapid phase shifts and antigenic
variation. The single pilE expression locus is changed by unidirectional
donation of coding sequences from multiple silent partial pilS
genes in a process similar to gene conversion (see Figure 179-2), pro-
ducing an extensive repertoire of antigenic variants.20 The frequency
of antigenic pilus variation may be as high as 103. Pilin can be post-
translationally modified with phosphorylcholine, phosphoethanol-
amine and variable acetylated O-linked glycans.29,30
N. gonorrhoeae produces one type of pili (class I). N. meningitidis
can express class I or class II pili which are antigenically and structur-
ally distinct, while commensals express only class II pili. Class II undergoes high-frequency phase and antigenic variation due to fre-
pili are encoded by a different pilE gene that has no silent cassette
counterparts.
Surface Proteins
The repertoire of the meningococcal and gonococcal surface proteins
is very similar.19 Trimeric protein channels (porins) confer transport
of low-molecular nutrients across the outer membrane. The principal
gonococcal porin is PorB (formerly protein I). The gonococcal PorB
porin is essential for bacterial survival. Gonococci express either of two
PorB isotypes, termed PorB-IA and PorB-IB. The proteins are stably
expressed and display interstrain variation due to amino acid differ-
ences in surface-exposed regions. The antigenic heterogeneity is the
basis for gonococcal PorB-based serologic typing. PorB-IA strains are
resistant to normal human serum and can cause disseminated gono-
coccal infection.
N. meningitidis can express two types of porins simultaneously:
PorA and PorB. PorA (class 1 protein, 44–47 kDa) is variably expressed
and PorA-negative variants can be isolated from patients.11 Expression
of at least one of the porin types is required for meningococcal survival.
PorA antigenic differences serve as the basis for serologic subtyping of
meningococci. Meningococcal PorB is equivalent to the gonococcal
PorB protein and is present as either PorB-IA (class 2 protein) or
PorB-IB (class 3 protein).11 Serotyping of meningococci is also based
on antigenic differences in PorB.
The neisserial RmpM protein (formerly protein III or class 4
protein) is complexed to and likely stabilizes outer membrane protein
complexes including porins.31 The protein is stably expressed by gono-
cocci and meningococci. Its C-terminal periplasmic region resembles
Escherichia coli OmpA domains and interacts with peptidoglycan.
Rmp-specific antibodies may interfere with the bactericidal activity of
antibodies directed to other surface antigens and increase the risk of
infection.31
Chapter 179  Neisseria 1559
Both pathogenic Neisseria spp. can express different opacity (Opa)
proteins (formerly protein II or class 5 proteins, 20–28 kDa).19 Colo-
nies of gonococci expressing Opa proteins often have a more opaque
appearance. In meningococci colonial opacity is most evident at 88°F
(31°C) when capsule production is low. The gonococcus contains up
to 11 different opa genes. The meningococcal genome contains three
to four opa genes. The expression of each Opa protein can indepen-
dently be switched on and off, enabling expression of multiple proteins
simultaneously.19 This phase and antigenic variation limits their
vaccine potential.
In addition, both pathogenic Neisseria spp. express more than
80 other outer membrane proteins, among which the pilus-related
secretin complex PilQ is the most abundant.4 Protein expression may
vary, depending on the bacterial growth conditions. Iron-regulated
proteins are essential for survival of gonococci and meningococci in
vivo.26 The transferrin-binding proteins (Tbp-1 and Tbp-2) and the
lactoferrin-binding proteins (Lbp) are scavenger proteins that mediate
internalization of iron into the bacterium. Conserved surface-exposed
proteins such as NspA, NadA, GNA1870 (factor H binding protein)
and GNA2132 (hypothetical lipoprotein) are recognized vaccine
antigens.32
Lipo-Oligosaccharide
Approximately half of the neisserial surface comprises lipid-anchored
oligosaccharides (LOS) (see Figure 179-6). Neisserial LOS is com­
posed of hexa-acylated lipid A, two keto-deoxyoctulosonate, a carbo-
hydrate (KDO) molecules, and one or more carbohydrate chains
of 8–12 saccharide units, the core oligosaccharide. Lipid A anchors
LOS in the outer membrane and is one of the most potent bacterial
endotoxins.24,33
The core oligosaccharide of neisserial LOS is divided into an inner
and an outer core region. The composition of the inner core is hetero-
geneous due to variable substitutions (phosphoethanolamine, glycine,
glucose, O-acetyl groups).24 This variation in glycoforms is partially
regulated by environmental cues. The outer core is highly variable and
quent nucleotide mismatching during replication of LOS biosynthesis
genes and horizontal gene transfer.24 A single strain can simultaneously
express up to six related LOS structures. The terminal structure of
neisserial LOS is the target for sialylation by bacterial sialyltransferase.
Gonococci utilize host sialic acid (CMP-NeuNAc) to modify their
LOS. Meningococci produce their own CMP-NeuNAc. The terminal
LOS of the pathogenic Neisseria spp. often shares epitopes with host
glycolipids.25 This molecular mimicry is exploited by the pathogens to
interact with host cell lectin receptors and limits the vaccine potential
of the LOS.
Peptidoglycan
Neisserial peptidoglycan consists of long chains of repeated disaccha-
ride units cross linked via peptide bridges.34 Peptidoglycan metabolism
is a dynamic process involving coordinated activity of lytic and syn-
thetic enzymes. The peptidoglycan is synthesized by up to four
penicillin-binding proteins (PBPs). O-acetylation of peptidoglycan
protects against autolysis by endogenous lytic transglycosylases and
host lysozymes. Released peptidoglycan fragments activate the innate
immune response and contribute to the inflammatory response.
Secreted Factors
Meningococcal and gonococcal genome analyses predict the presence
of autotransporter-, two-partner-, type I and type II secretion mecha-
nisms.35 The pathogenic Neisseria spp. secrete immunoglobulin A1
(IgA1) protease. This serine protease directs its own transport across
the outer membrane and secretion into the environment. The enzyme
cleaves in the hinge of IgA1 separating the Fab and Fc regions, making
IgA ineffective. IgA protease also cleaves other proteins such as
endosomal Lamp1, which is important for intracellular vesicle traffick-
ing. The function of the other secreted proteins including the filamen-
tous hemagglutinin (FHA)-like protein TpsA and FrpA/C is largely
1560 SECTION 8  Clinical Microbiology: Bacteria
unknown. A subset (≈80%) of gonococcal strains secrete DNA via a
type IV secretion system.36 Neisseria spp. lack a type III secretion mech-
anism which is present in many other pathogens.
Prevention
GONOCOCCAL INFECTION
Condoms provide a high degree of protection from acquisition of
gonorrhea, as well as other sexually transmitted diseases (STDs). Other
preventative measures are early diagnosis and treatment, partner noti-
fication and screening, and case finding. A new approach is the use of
topical microbicides for intravaginal or intrarectal use.
Attempts to develop a gonococcal vaccine have been hampered by
the multitude of gonococcal immune evasion strategies including a
high degree of antigenic variability in pili, outer membrane proteins
and LOS during the natural course of infection. Transfected animals
expressing human proteins involved in Neisseria infection such as
transferrin receptors, CR3, CD46, CEACAMs and Toll-like receptors
may aid vaccine development.
MENINGOCOCCAL DISEASE
Prevention of meningococcal disease is based on chemoprophylaxis
and vaccination.33
Chemoprophylaxis
The aim of chemoprophylaxis is to reduce secondary cases of menin-
gococcal disease and to arrest outbreaks. The risk of a secondary case
among close contacts in the household setting is 150–1000 times
higher than that in the general population. Children are at greatest
risk, but secondary disease can occur at all ages. Risk is maximal in the
week following recognition of the index case but extends for several
weeks.
Ceftriaxone as a single intramuscular dose is 97% effective in
household contacts 1–2 weeks after infection. The advantage of ceftri-
axone is that it can be used in pregnancy and in small children. Many
antibiotics used for therapy do not effectively eradicate or prevent
carriage of meningococci because of inadequate levels in oropharyn-
geal secretions. Rifampin, ceftriaxone, azithromycin and the quino-
lones are effective against meningococci in the naso- and oropharynx.12
However, rifampin and quinolone resistance can develop rapidly in
meningococci. Chemoprophylaxis is recommended only for close
household contacts of cases and other intimate contacts.
Vaccines
Polysaccharide meningococcal vaccines against serogroups A, C, W135
and Y conjugated to tetanus toxoid are available and used successfully
worldwide. The immunogenicity of polysaccharide vaccines is greatly
improved by chemical conjugation to a protein carrier. These vaccines
are safe and immunogenic, are anticipated to provide long-term pro-
tection (as they induce a T-cell-dependent response) and are also
effective in young children.37 Introduction of the C conjugate menin-
gococcal vaccines in 2000 markedly reduced the incidence of sero-
group C disease in the UK and other European countries with estimated
vaccine efficacies of 88% in young children and 95% in young adoles-
cents. Immunization also decreased nasopharyngeal carriage by 66%
and transmission of the pathogen (herd immunity).38 These conju-
gated vaccines are also used to contain outbreaks of meningococcal
infections in MSM in Europe and the USA.
A polysaccharide vaccine against serogroup B meningococci is not
available due to carbohydrate mimicry and poor immunogenicity.
However, a universal vaccine that protects against N. meningitidis sero-
group B, which causes most cases of disease in temperate countries, was
released for use in 2014.32 Relevant conserved candidate vaccine anti-
gens were identified by the ‘reverse vaccinology’ approach.39 In the
current vaccine against serogroup B meningococcal disease recombi-
nant NHBA (Neisseria heparin binding antigen), NadA (Neisserial
adhesin A) and fHbp (factor H binding protein) in combination with
OMV (with PorA P1.4 2) are included (Bexsero, GlaxoSmithKline).39
The absence of an efficient serogroup B vaccine until very recently has
limited the effective control of meningococcal disease. Meningococcal
vaccines are given to small children, young people at risk including mili-
tary recruits and are used by travelers visiting countries with a high
incidence of meningococcal disease. However, widespread use of mono­
valent serogroup conjugate vaccines may become ineffective when the
capsule types switch due to genetic exchange or strains arise that show
reduced capsule expression.
Capsule polysaccharide vaccines for the pathogenic meningococcal
serogroups A, C, Y and W135 used before the era of conjugated vac-
cines reduced the incidence of infection among military recruits,
reduced the progress of epidemics of serogroup A disease and pro-
tected susceptible complement factor-deficient individuals.12 These
vaccines are safe, with mild local adverse events, and have good efficacy
(>85%) in older children and adults. However, due to lack of a
T-helper response, nonconjugated capsule vaccines are poorly immu-
nogenic below 2 years of age, fail to induce immunologic memory and
provide protection for only 3–5 years.
Outer Membrane Vesicle
OMV vaccines with a low LOS composition show efficacies of 50–80%
in clinical trials, but do not protect young children and are in general
too strain-specific, i.e. the vaccines can be used against clonal disease
outbreaks, but not for prevention of sporadic disease caused by diverse
strains.12 Multivalent vaccine strains based on common variants of
PorA (a major inducer and target of bactericidal antibodies) may
provide protection against multiple subtypes of N. meningitidis.
Diagnostic Microbiology
GONOCOCCAL INFECTION
Diagnosis of gonococcal infection is made at two levels: presumptive
and confirmed. Antimicrobial treatment must be started based on the
results of the presumptive tests, but additional tests must be performed
to yield a confirmatory diagnosis.
Collection of specimens for diagnosis depends on the clinical mani-
festations and the sites exposed. Male urethral exudates and female
cervical swabs should be taken from all cases of suspected gonococcal
infection for direct examination and culture. Neutrophils containing
gram-negative cocci in the Gram-stained smear are presumptive evi-
dence of gonococcal infection (Figure 179-7). Gram stain is highly
sensitive and specific for diagnosing genital gonorrhea in men. Gram-
stained smears from endocervix specimens of symptomatic women
have a sensitivity of only 40–60% relative to culture, but have a high
predictive value. In asymptomatic women, Gram stain has a low pre-
dictive value and is not useful. Direct detection (i.e. with or without
culture) of gonococci is performed by rapid and sensitive diagnostic
nucleic acid amplification tests (NAATs) that simultaneously detect
Figure 179-7  Gram stain of a urethral discharge from a male who has gonorrhea.
Note the intracellular gram-negative diplococci with neutrophils.

TABLE
179-3  Specimens and Culture Media for the Isolation of N. Gonorrhoeae and N. Meningitidis
Species Disease Specimen/Site
N. gonorrhoeae Cervicitis Endocervix, urethra (Bartholin’s glands, rectum, pharynx)
Pelvic inflammatory disease (PID) Endocervix, endometrium, fallopian tubes
Disseminated infection (DGI) Endocervix, urethra, skin lesions
Joint fluid
Blood
Ophthalmic Conjunctiva
N. meningitidis Meningitis/sepsis Cerebrospinal fluid
Blood
Nasopharynx
Skin lesions
N. gonorrhoeae and Chlamydia trachomatis.40 NAATs require only a
freshly voided urine sample. Limitations are cost, risk of carryover
contamination, inhibition and inability to provide antibiotic resistance
data.41 Frequent horizontal genetic exchange leading to commensal
Neisseria spp. acquiring N. gonorrhoeae genes may give false-positive
results. Furthermore, some N. gonorrhoeae subtypes may lack specific
sequences targeted by a particular NAAT due to sequence variation in
the dynamic gonococcal populations, leading to false-negative results.
Maximal culture recovery of gonococci by culture requires imme-
diate plating of the collected specimen.1,11 If this is not possible, swabs
can be transported in commercially available charcoal-containing
transport media. When appropriate, cultures should be obtained from
blood and biopsies from skin lesions and joint fluid aspirates. Com-
monly used culture media are Thayer–Martin and Martin–Lewis.
These media contain lysed or heated blood (chocolate agar) supple-
mented with growth factors and a variety of antimicrobials to suppress
the growth of other bacteria and yeast. Specimens taken from sites that
are normally sterile are cultured on antibiotic-free media to enable
growth of occasional strains that are susceptible to the antibiotics
added to the growth media. Growth is performed in an atmosphere
with 5–10% carbon dioxide at 95–98.6°F (35–37°C) for 48 hours.
Gram-negative diplococci with a positive oxidase and catalase test may
be N. gonorrhoeae.
Confirmatory culture identification includes mass spectrometry
(MALDI-TOF) analysis and carbohydrate utilization tests, which can
be supplemented by monoclonal antibody testing (PorB), chromo-
genic detection of specific enzyme activities and DNA-based culture
confirmation tests. Gonococci oxidize glucose, but not maltose,
sucrose or lactose.
MENINGOCOCCAL INFECTION
CSF, blood, nasopharyngeal swabs and aspirates are the most relevant
specimens for the diagnosis of meningococcal disease.1,11 Additionally,
skin biopsies, synovial fluid, sputum and conjunctival swabs may be
cultured if clinically indicated. Because meningococci, like gonococci,
are susceptible to desiccation and temperature extremes, specimens
should be cultured as soon as possible.
For presumptive diagnosis, specimens are examined by Gram stain.
Gram-stained smears are made directly from CSF, if the CSF is cloudy,
or after centrifugation if the CSF is clear. The majority of the smears
will show gram-negative diplococci inside and outside polymorpho-
nuclear leukocytes (PMNs) when the CSF bacterial count is >105/mL.
Smears from CSF containing <103 mL of bacteria will be positive in
only 25%; on average 60–90% of culture-positive CSF specimens are
positive in the Gram stain. Gram-stained smears from petechial skin
lesions due to meningococcemia may detect meningococci in more
than 70% of cases.
Direct detection of meningococci is performed by NAAT.40,41
NAATs are also useful in confirming the diagnosis in patients who had
Chapter 179  Neisseria 1561
Media for Cultivation
Selective
Selective, nonselective
Selective, nonselective
Nonselective, selective
Blood culture medium
Nonselective, selective
Nonselective, blood culture medium
Blood culture medium
Selective, nonselective
Nonselective
antibiotic treatment prior to collection of CSF and whose CSF Gram
stain, antigen test and culture are negative.
The proportion of PMNs in CSF from patients who have menin-
gitis ranges from 49% to 98% (mean of 86%). Other CSF abnormali-
ties include low glucose and an elevated protein concentration. In
patients partially treated with antibiotics, the CSF leukocyte count,
glucose and protein concentration, and the antigen tests remain
abnormal for several days, whereas bacteria might not be evident on
smear or by CSF culture. Blood cultures are positive in only 50% of
patients with meningococcal disease. A nasopharyngeal swab from
young children will provide valuable information in cases of suspected
meningococcal disease.
For isolation of N. meningitidis by culture, the clinical specimen
should be inoculated on selective and nonselective growth media
(Table 179-3).1 Appropriate nonselective media are 5% sheep blood
agar (in contrast to gonococci, meningococci grow well on this
medium) and chocolate agar.11 Selective media used to culture naso-
pharyngeal specimens are the same as those mentioned for gonococci.
Most blood-containing media support the growth of meningococci.
Meningococci are grown on agar media in a 5–10% carbon dioxide-
enriched atmosphere with rather high humidity at 95–98.6°F (35–
37°C). After 18–24 hours, flat, gray-brown, translucent, smooth,
1–3 mm in diameter colonies of N. meningitidis are present, which can
be analyzed by Gram stain.1 The finding of oxidase- and catalase-
positive gram-negative diplococci is sufficient to support a tentative
diagnosis of meningococcal disease, to be confirmed by MALDI-TOF
analysis. For conventional confirmatory identification, differentiation
characteristics are the production of acid from glucose and maltose.
Gonococci acidify only glucose and N. lactamica produces acid from
glucose, maltose and lactose, although a number of commensal Neis-
seria spp. may be misidentified as N. meningitidis on the basis of car-
bohydrate oxidation. Isolation of N. meningitidis can also be confirmed
by NAAT or 16S rRNA gene sequencing.40
MOLECULAR TYPING OF N. GONORRHOEAE
AND N. MENINGITIDIS
The current methods for monitoring transmission of N. gonorrhoeae
are multilocus sequence typing (MLST) and genome sequencing.42
Gonococcal serotyping is based on a panel of monoclonal antibodies
directed against variant epitopes on PorB-IA and PorB-IB. At least 55
serovars have been identified.
For larger studies on N. meningitidis genome evolution and surveil-
lance, MLST shows that epidemics are often caused by specific com-
plexes of related hypervirulent lineages.42,43 Targeted and complete
genome sequencing are the next generation of typing methods that are
being applied, along with MALDI-TOF.11
Phenotypic classification of N. meningitidis is based on antigenic
differences of the major surface antigens which provides information
about the serogroup (capsule, e.g. B), serotype (PorB porin, e.g. 15),
1562 SECTION 8  Clinical Microbiology: Bacteria

TABLE
179-4  Characteristics of the Most Common Human Neisseria spp. That Can Be Used in Species Differentiation
ACID FROM
Reduction
Species Colony morphology on chocolate agar Glucose Maltose Lactose Sucrose Fructose of Nitrate

N. gonorrhoeae Gray-brown, translucent, smooth (0.5–1 mm diameter) + − − − − −

N. meningitidis Gray-brown, translucent, smooth (1–3 mm diameter) + + − − − −

N. lactamica Gray-brown, translucent, smooth (1–2 mm diameter) + + + − − −

TABLE Examples of Nonpathogenic Neisserial TABLE Clinical Disease Caused by the Pathogenic
Species Rarely Isolated From Clinical Disease 179-6  Neisseria spp.
179-5 
in Humans
Neisseria spp. Clinical Diagnosis Reference
Neisserial Species Clinical Disease Observed When Isolated
N. gonorrhoeae Most common manifestations 11, 44, 45, 47
N. lactamica Meningitis or sepsis in adults and children Local urogenital:
Urethritis
N. cinerea, N. Native and prosthetic endocarditis, often in patients Cervicitis
polysaccharea, with heart abnormalities or intravenous drug use Salpingitis/PID
N. sicca, N. Proctitis
subflava
Less common manifestations 44, 45
N. sicca Native and prosthetic valve endocarditis Pharyngitis
Meningitis cases
Rarely pneumonia and osteomyelitis Uncommon manifestations 45, 46
Acute conjunctivitis
N. subflava Rarely endocarditis, meningitis and sepsis Acute keratitis

N. flavescens Once in an outbreak of meningitis Systemic dissemination, 44, 45

Occasionally in sepsis resembling chronic uncommon
meningococcemia Dermatitis–arthritis–
tenosynovitis syndrome
N. mucosa Occasional endocarditis, meningitis, ocular Monoarticular septic
infections, cellulitis, pneumonia and empyema arthritis/perihepatitis
Endocarditis
N. cinerea Conjunctivitis in newborns (ophthalmia neonatorum)
Meningitis
Proctitis and lymphadenitis
Meningitis in patients with facial trauma N. meningitidis Most common manifestations 11, 12, 13, 33,
Pneumonia in immunodeficient patients Systemic infections: 48, 49
Meningoencephalitis/
N. elongata Endocarditis or sepsis, wound infections,
meningitis
osteomyelitis after oral surgery
Sepsis with meningitis
N. weaveri Human wounds due to dog bites Sepsis without meningitis
Meningococcemia without
septic complications

Less common 11, 12

Persistent
meningococcemia
serosubtype (PorA porin, e.g. P1.7) and LOS immunotype (e.g. L3) of Low-grade fever, rash and
arthritis: arthritis–
a particular strain. This results in the classification: B, 15, P1.7, L3. dermatitis syndrome
Multiple epitopes may be recognized depending upon the presence of Pharyngitis
phase or antigen variants in the bacterial population. Antigen-based Community-acquired
typing, however, is relevant only for vaccine efficacy studies. pneumonia

IDENTIFICATION OF NONPATHOGENIC
NEISSERIA SPECIES
The commensal Neisseria spp. colonize the human nasopharynx
and oropharynx.1, 2 They can be isolated on nonselective rich media
and identified by MALDI-TOF. Strains of N. lactamica, N. gonorrhoeae
and N. meningitidis can be differentiated by their patterns of acid
production (see Table 179-4).1,2 N. lactamica produces acid from
lactose and can thus be differentiated from meningococci. This and
other nonpathogenic neisserial species are only occasionally associated
with disease, although N. lactamica has been isolated from cases of
meningitis or sepsis in both adults and children (Table 179-5).
In general, the commensal Neisseria spp. are susceptible to penicil-
lin, ampicillin and tetracyclines. Only N. mucosa is penicillin-resistant
and sensitive to chloramphenicol. Some strains of N. lactamica have
an altered penicillin-binding protein 2 as found in relatively penicillin-
resistant N. meningitidis. Rare strains of N. sicca, N. flavescens and N.
subflava are penicillin-resistant because of production of β-lactamase.
Such strains are a potential source of β-lactamase genes that are trans-
ferable to meningococci and gonococci.1
Clinical Manifestations
GONORRHEA
N. gonorrhoeae usually causes an infection of the urethra (urethritis)
and cervix (cervicitis). Ascending gonococcal infection in infected
women can result in pelvic inflammatory disease (PID) (Table 179-6)
(see also Chapters 53 and 54). Other frequently infected anatomic
niches are the rectum, oropharynx and conjunctiva.44 All N. gonor-
rhoeae strains are considered to be pathogenic. The infective dose for
the male urethra is as low as 250 gonococci; for the uterine cervix this
ranges from 102 to more than 107 gonococci. Certain gonococcal
strains may cause disseminated infection and/or arthritis.45 Dissemina-
tion to more distant sites occurs in about 0.5–3% of gonococcal
infection.44
Urogenital Gonococcal Infection
In men, acute anterior urethritis is the most common manifestation
of gonorrhea. Symptoms are a purulent urethral discharge and dysuria.
 Chapter 179  Neisseria 1563

Acute epididymitis is the most common local complication. In women,
the endocervix is the primary site of infection. This infection is char-
acterized by (muco)purulent discharge and intermenstrual bleeding,
but is often asymptomatic. Urethral infection is present in 70–90% of
women who have gonococcal cervicitis. Infection of the Bartholin’s
glands leads to abscess formation in about 35% of the patients. Gono-
coccal infection in women may ascend to cause endometritis, acute
salpingitis or PID in 10–20% of the cases.11
In males infection usually manifests after development of who has the infection. Gonococcal conjunctivitis is usually severe, with
inflammation caused by local induction of cytokines and influx of
PMNs. Examination of male biopsies and exudates shows gonococci
attached to and within the epithelial cells, development of (sub)
mucosal microabscesses and exudation of pus with gonococci inside
PMNs.11
In women gonococcal infection can ascend to the upper genital
tract and selectively adhere to nonciliated cells of the fallopian tubes.
Ciliated cells are lost through cytotoxic effects of released peptidogly-
can fragments and LOS. Tissue invasion and the inflammatory
responses generated may manifest as PID and can lead to infertility.
Gonorrhea in Children.  Historically gonococcal infection in chil-
dren included only ophthalmia neonatorum (acute gonococcal con-
junctivitis).46 However, children can acquire gonococcal infection by
sexual contact with an infected person.47 Such infection indicates
sexual abuse.
Localized Gonococcal Infection Outside
the Urogenital Tract
Proctitis.  Anorectal gonorrhea is only present in up to 5% of
women who have gonorrhea, while gonococci can be cultured from
the anorectal region of 40% of women and homosexual men with
gonorrhea.
Pharyngeal Gonorrhea.  Pharyngeal infection occurs in 10–20%
of women who have gonorrhea, in 10–25% of homosexual men who
have the infection and in 3–7% of heterosexual men with gonorrhea.
The infection is due to orogenital sexual exposure. Most cases are
asymptomatic and resolve spontaneously.
Acute Conjunctivitis.  Ophthalmia neonatorum is acquired during
passage through an infected birth canal.46 In adults ocular infection
usually results from autoinoculation of the conjunctiva in a person
an overt purulent exudate and corneal ulceration.
Disseminated Gonococcal Infection
Disseminated gonococcal infection is reported in 1–2% of patients
who have gonococcal infection and can occur as dermatitis–arthritis–
tenosynovitis syndrome, monoarticular septic arthritis, perihepatitis,
endocarditis or meningitis.44,45
MENINGOCOCCAL INFECTION
The clinical spectrum of meningococcal disease includes meningoen-
cephalitis, meningococcemia without meningitis, and bacteremia
without septic complications.12, 48 The disease usually begins abruptly
with headache, meningeal signs including stiffness of the neck and
fever (Figure 179-8a).49 Mortality approaches 100% in untreated cases,
but is around 10% when appropriate antibiotic therapy is instituted.
The incidence of reported neurologic sequelae is low, with hearing
deficits, epilepsy and arthritis most commonly noted.
Meningitis (see also Chapter 19)
The most frequent form of meningococcal infection is acute pyogenic
meningitis due to inflammation of the meninges, with or without
meningococcemia.48 Among patients who have meningococcal disease,
75% have meningitis; 40% of them also have bacteremia.

a b

c d

Figure 179-8  Typical symptoms of meningococcal infection. Stiffness of the neck may indicate meningitis. Fine erythematous macules, maculopapular petechial erup-
tions and purpuric/petechial or ecchymotic skin lesions that are hemorrhagic and necrotic may accompany meningococcal sepsis. (From Brandtzæg et al.49)
1564 SECTION 8  Clinical Microbiology: Bacteria

Meningococcemia
Meningococcemia may be transient, occult or result in severe sepsis.
TABLE The Most Prevalent Neisserial Antibiotic
179-7  Resistance Markers
Bacteremia without meningitis occurs in 7–10% of patients. Menin-
gococcemia can manifest as pink maculopapular petechial eruptions Drug
(Figure 179-8b).12,33 Rapidly progressive infections may result in pur- Resistance
puric petechial or ecchymotic skin lesions that are hemorrhagic and Antibiotic Gene Gene Product Reference
necrotic (Figure 179-8c,d). Fulminant shock may dominate the clinical Penicillin/ PbpA,B Penicillin-binding protein 51
picture of acute meningococcal sepsis.12,33 Sepsis may progress to dis- β-lactams mtr Efflux pump 11
seminated intravascular coagulation (DIC) characterized by increasing env Accessory outer membrane 11
petechiae or purpura fulminans, resulting in extensive areas of tissue protein
penA TEM-1 type β-lactamase, 8
destruction secondary to coagulopathy, rapid onset of hypotension PPNG
and adrenal hemorrhage (Waterhouse–Friderichsen syndrome).
In the blood N. meningitidis replicates to high levels and sheds Ciprofloxacin gyrA DNA gyrase 11
parC Topoisomerase IV
OMVs. The OMVs may subvert the complement system and high
levels of circulating LOS overactivate the innate immune system. Cir- Sulfonamide sul1 Dihydrofolatesynthase 12
culating levels of the proinflammatory mediators tumor necrosis factor Tetracycline tetM Soluble ribosomal protein 11
(TNF), interleukin (IL)-1 and interferon-gamma (IFN-γ) strongly cor-
relate with development of lethal septic shock.33,48 In patients with Rifampin rpoB RNA polymerase subunit B 11
complement deficiencies the clinical picture can be milder and they
may only present with fever, while the blood culture is positive.
Encapsulated meningococci enter the CSF likely by the hemato­
genous route via the veins in the subarachnoidal space (the blood–CSF protection against meningococcal disease as development of invasive
barrier) and the choroid plexi rather than through the brain paren- meningococcal disease correlates with the absence of bactericidal anti-
chyma (blood–brain barrier).33, 48 The absence of opsonophagocytosis bodies.43
in CSF enables uncontrolled bacterial growth and inflammation of the
leptomeninges and subarachnoid space. Attracted PMNs aggravate the Management
inflammatory response and release cytotoxic mediators.
GONORRHEA
Other Meningococcal Infections The treatment of gonorrhea is discussed in Chapter 65.
Due to hematogenous spread meningococci may cause a plethora of Drug resistance in gonococci is increasing, and the main drug resis-
infections (Table 179-6). Persistent meningococcal bacteremia is asso- tance markers are depicted in Table 179-7. Since 1976, gonococcal
ciated with low-grade fever, rash and arthritis (arthritis–dermatitis isolates with a decreased sensitivity for penicillin (minimum inhibitory
syndrome).11,12 Meningococci are implicated as the etiologic agent in concentration (MIC) >0.1 mg/L) have been emerging. Fluoroquino-
approximately 5–14% of patients who have community-acquired lones (i.e. ciprofloxacin, ofloxacin or levofloxacin) are also no longer
pneumonia. Pharyngitis is associated with recent contact with indi- recommended for treatment of gonococcal infections due to the sharp
viduals who are colonized by meningococci and is often a symptom increases in antibiotic resistance.10
prior to serious meningococcal disease. Treatment of hospitalized PID cases takes into account the impor-
tant role of both gonococci and C. trachomatis in addition to anaerobic
Meningococcal Carriage cover in PID patients, and is described in Chapter 54.
Infection due to N. meningitidis commonly results from asymptomatic
oronasopharyngeal mucosal carriage.43 At any time about 10% of the MENINGOCOCCAL DISEASE
general population is colonized with meningococci. In children under Patients with meningococcal disease are treated with benzylpenicillin
4 years of age the carriage rate is less than 1%, but this progressively when susceptible or a third-generation cephalosporin (e.g. cefotaxime
increases with age to peak at about 20–25% in late teenage and early or ceftriaxone).33,49 When the etiology is not known at admission,
adult life. During carriage, non-groupable meningococci are most ceftriaxone or cefotaxime is used for the first 24–48 hours to cover the
often isolated. Immunohistochemistry has also demonstrated menin- possibility of other bacterial pathogens.33,50 The management of men-
gococci within the tonsillar tissues in 45% of patients undergoing ingitis is discussed in detail in Chapter 19. There are N. meningitidis
tonsillectomy.49 strains that have decreased sensitivity to penicillin due to reduced
Meningococcal carriage induces bactericidal antibodies within 1–2 affinity of penicillin to PBPs 2 and 3, resulting from a penA gene altered
weeks after colonization. Antibodies may last for several months after by transformation.51 In addition, β-lactamase-producing strains have
carriage. N. lactamica carriage elicits bactericidal antibodies that cross- occasionally been recovered. Cefotaxime or ceftriaxone is used when
react with various meningococcal serogroups and serotypes. Carriage relatively penicillin-resistant strains are isolated.
of N. lactamica is approximately 4% by 3 months of age and peaks at
21% by 18–24 months of age.43 N. lactamica may contribute to References available online at expertconsult.com.

KEY REFERENCES
Bowler L.D., Zhang Q.Y., Riou J.Y., et al.: Interspecies
recombination between the penA genes of Neisseria men-
ingitidis and commensal Neisseria species during the
emergence of penicillin resistance in N. meningitidis:
natural events and laboratory simulation. J Bacteriol
1994; 176:333-337.
Elias J., Frosch M., Vogel U.: Neisseria. In: Jorgensen J.,
Pfaller M., Carroll K., et al., eds. Manual of clinical micro-
biology. 11th ed. Washington DC: ASM Press; 2015:
635-651.
Giuliani M.M., Adu-Bobie J., Comanducci M., et al.: A uni-
versal vaccine for serogroup B meningococcus. Proc Natl
Acad Sci USA 2006; 103:10834-10839.
Maiden M.C., Bygraves J.A., Feil E., et al.: Multilocus Vogel U., Claus H., Frosch M.: Rapid serogroup switching
sequence typing: a portable approach to the identification in Neisseria meningitidis. N Engl J Med 2000; 342:
of clones within populations of pathogenic microorgan- 219-220.
isms. Proc Natl Acad Sci USA 1998; 95:3140-3145. Yazdankhah S.P., Caugant D.A.: Neisseria meningitidis: an
Pizza M., Rappuoli R.: Neisseria meningitidis: pathogenesis overview of the carriage state. J Med Microbiol 2004;
and immunity. Curr Opin Microbiol 2015; 23:68-72. 53:821-832.
Stephens D.S., Greenwood B., Brandtzaeg P.: Epidemic
meningitis, meningococcaemia, and Neisseria meningiti-
dis. Lancet 2007; 369:2196-2210.
van Deuren M., Brandtzaeg P., van der Meer J.W.: Update
on meningococcal disease with emphasis on pathogenesis
and clinical management. Clin Microbiol Rev 2000;
13:144-166.

REFERENCES
1. Tønjum T.: Family Neisseriaceae and genus Neisseria.
In: Garrity G., ed. Bergey’s manual of systematic bacteri-
ology: the proteobacteria. New York: Springer Verlag;
2005:775-798.
2. Liu G., Tang C.M., Exley R.M.: Non-pathogenic Neis-
seria: members of an abundant, multi-habitat, diverse
genus. Microbiology 2015; 161:1297-1312.
3. Claus H., Vogel U., Swiderek H., et al.: Microarray
analyses of meningococcal genome composition and
gene regulation: a review of the recent literature. FEMS
Microbiol Rev 2007; 31:43-51.
4. Davidsen T., Tønjum T.: Meningococcal genome
dynamics. Nat Rev Microbiol 2006; 4:11-22.
5. Alfsnes K., Raynaud X., Tønjum T., et al.: Mathemati-
cal and live meningococcal models for simple sequence
repeat dynamics – coherent predictions and observa-
tions. PLoS ONE 2014; 9(7):e101637.
6. Snyder L.A., Davies J.K., Ryan C.S., et al.: Comparative
overview of the genomic and genetic differences
between the pathogenic Neisseria strains and species.
Plasmid 2005; 54:191-218.
7. Bille E., Zahar J.R., Perrin A., et al.: A chromosomally
integrated bacteriophage in invasive meningococci. 2005; 15:409-419.
J Exp Med 2005; 201:1905-1913.
8. Roberts M.C.: Plasmids of Neisseria gonorrhoeae and
other Neisseria species. Clin Microbiol Rev 1989;
2(Suppl.):S18-S23.
9. Schoen C., Blom J., Claus H., et al.: Whole-genome
comparison of disease and carriage strains provides
insights into virulence evolution in Neisseria meningiti-
dis. Proc Natl Acad Sci USA 2008; 105:3473-3478.
10. Centers for Disease Control and Prevention: Gonor-
rhoea treatment guidelines. Available: http://www.cdc Lancet 1992; 340:1379-1381.
.gov/std/tg2015/gonorrhea.htm.
11. Elias J., Frosch M., Vogel U.: Neisseria. In: Jorgensen J.,
Pfaller M., Carroll K., et al., eds. Manual of clinical
microbiology. 11th ed. Washington DC: ASM Press;
2015:635-651.
12. Stephens D.S., Greenwood B., Brandtzaeg P.: Epidemic
meningitis, meningococcaemia, and Neisseria menin-
gitidis. Lancet 2007; 369:2196-2210.
13. Rouphael N.G., Stephens D.S.: Neisseria meningitidis:
biology, microbiology, and epidemiology. Methods Mol
Biol 2012; 799:1-20.
14. Goldschneider I., Gotschlich E.C., Artenstein M.S.:
Human immunity to the meningococcus. I. The role 27723.
of humoral antibodies. J Exp Med 1969; 129:1307-
1326.
15. Achtman M.: Epidemic spread and antigenic variability
of Neisseria meningitidis. Trends Microbiol 1995; 3:186-
192.
16. Boisier P., Nicolas P., Djibo S., et al.: Meningococcal
meningitis: unprecedented incidence of serogroup
X-related cases in 2006 in Niger. Clin Infect Dis 2007;
4:657-663.
17. Rosenstein N.E., Perkins B.A., Stephens D.S., et al.:
Meningococcal disease. N Engl J Med 2001; 344:1378-
1388.
18. Schneider M.C., Exley R.M., Ram S., et al.: Interactions
between Neisseria meningitidis and the complement
system. Trends Microbiol 2007; 15:233-240.
19. Merz A.J., So M.: Interactions of pathogenic Neisseriae
with epithelial cell membranes. Annu Rev Cell Dev Biol
2000; 16:423-457.
20. Tønjum T., Koomey M.: The pilus colonization factor
of pathogenic neisserial species: organelle biogenesis
and structure/function relationships. Gene 1997;
192:155-163.
21. Howie H.L., Glogauer M., So M.: The N. gonorrhoeae
type IV pilus stimulates mechanosensitive pathways
and cytoprotection through a pilT-dependent mecha-
nism. PLoS Biol 2005; 3:e100.
22. Boulton I.C., Gray-Owen S.D.: Neisserial binding to
CEACAM1 arrests the activation and proliferation of
CD4+ T lymphocytes. Nat Immunol 2002; 3:229-236.
23. van Putten J.P.M., Duensing T.D., Carlson J.: Gonococ-
cal invasion of epithelial cells driven by P.IA, a bacterial
ion channel with GTP binding properties. J Exp Med
1998; 188:941-952.
24. Kahler C.M., Datta A., Tzeng Y.L., et al.: Inner core
assembly and structure of the lipooligosaccharide of
Neisseria meningitidis: capacity of strain NMB to
express all known immunotype epitopes. Glycobiology
25. Perkins-Balding D., Ratliff-Griffin M., Stojiljkovic I.:
Iron transport systems in Neisseria meningitidis. Micro-
biol Mol Biol Rev 2004; 68:154-171.
26. Davidsen T., Koomey M., Tønjum T.: Microbial
genome dynamics in CNS pathogenesis. Neuroscience
2007; 145:1375-1387.
27. Lehner P.J., Davies K.A., Walport M.J., et al.: Meningo-
coccal septicaemia in a C6-deficient patient and effects
of plasma transfusion on lipopolysaccharide release.
28. Vogel U., Claus H., Frosch M.: Rapid serogroup switch-
ing in Neisseria meningitidis. N Engl J Med 2000;
342:219-220.
29. Power P.M., Jennings M.P.: The genetics of glycosyl-
ation in Gram-negative bacteria. FEMS Microbiol Lett
2003; 218:211-222.
30. Aas F.E., Egge-Jacobsen W., Winther-Larsen H.C.,
et al.: Neisseria gonorrhoeae type IV pili undergo mul-
tisite, hierarchical modifications with phosphoethanol-
amine and phosphocholine requiring an enzyme
structurally related to lipopolysaccharide phosphoetha-
nolamine transferases. J Biol Chem 2006; 81:27712-
31. Plummer F.A., Chubb H., Simonsen J.N., et al.: Anti-
body to Rmp (outer membrane protein 3) increases
susceptibility to gonococcal infection. J Clin Invest
1993; 91:339-343.
32. Giuliani M.M., Adu-Bobie J., Comanducci M., et al.: A
universal vaccine for serogroup B meningococcus. Proc
Natl Acad Sci USA 2006; 103:10834-10839.
33. van Deuren M., Brandtzaeg P., van der Meer J.W.:
Update on meningococcal disease with emphasis on
pathogenesis and clinical management. Clin Microbiol
Rev 2000; 13:144-166.
34. Antignac A., Rousselle J.C., Namane A., et al.: Detailed
structural analysis of the peptidoglycan of the human
pathogen Neisseria meningitidis. J Biol Chem 2003;
278:31521-31528.
Chapter 179  Neisseria 1564.e1
35. van Ulsen P., Tommassen J.: Protein secretion and
secreted proteins in pathogenic Neisseriaceae. FEMS
Microbiol Rev 2006; 30:292-319.
36. Hamilton H.L., Dominguez N.M., Schwartz K.J., et al.:
Neisseria gonorrhoeae secretes chromosomal DNA via a
novel type IV secretion system. Mol Microbiol 2005;
55:1704-1721.
37. Bilukha O.O., Rosenstein N.: Prevention and control of
meningococcal disease. Recommendations of the Advi-
sory Committee on Immunization Practices (ACIP).
MMWR Recomm Rep 2005; 54:1-21.
38. Snape M.D., Pollard A.J.: Meningococcal
polysaccharide-protein conjugate vaccines. Lancet
Infect Dis 2005; 5:21-30.
39. Pizza M., Rappuoli R.: Neisseria meningitidis: pathogen-
esis and immunity. Curr Opin Microbiol 2015; 23:68-72.
40. Wu H.M., Cordeiro S.M., Harcourt B.H., et al.: Accu-
racy of real-time PCR, Gram stain and culture for Strep-
tococcus pneumoniae, Neisseria meningitidis and
Haemophilus influenzae meningitis diagnosis. BMC
Infect Dis 2013; 13:26.
41. Whiley D.M., Garland S.M., Harnett G., et al.: Explor-
ing ‘best practice’ for nucleic acid detection of Neisseria
gonorrhoeae. Sex Health 2008; 5:17-23.
42. Maiden M.C., Bygraves J.A., Feil E., et al.: Multilocus
sequence typing: a portable approach to the identifica-
tion of clones within populations of pathogenic micro-
organisms. Proc Natl Acad Sci USA 1998; 95:3140-3145.
43. Yazdankhah S.P., Caugant D.A.: Neisseria meningitidis:
an overview of the carriage state. J Med Microbiol 2004;
53:821-832.
44. Kerle K.K., Mascola J.R., Miller T.A.: Disseminated
gonococcal infection. Am Fam Physician 1992;
45(1):209-214.
45. Rice P.A.: Gonococcal arthritis (disseminated gonococ-
cal infection) [review]. Infect Dis Clin North Am 2005;
19:853-861.
46. Desenclos J.C., Garrity D., Scaggs M., et al.: Gonococcal
infection of the newborn in Florida, 1984–1989. Sex
Transm Dis 1992; 19:105-110.
47. Bilek N., Martin I.M., Bell G., et al.: Concordance
between Neisseria gonorrhoeae genotypes recovered
from known sexual contacts. J Clin Microbiol 2007;
45:3564-3567.
48. Tønjum T., Henriques-Normark B., Brandtzæg P.:
Meningitis. In: Rosenberg G., DeLong E.F., Thompson
F., et al., eds. The Prokaryotes. New York: Springer
Verlag; 2013:401-427.
49. Brandtzæg P., Dahle J.S., Høiby E.A.: The occurrence
and features of hemorrhagic skin lesions in 115 cases of
systemic meningococcal disease. NIPH Ann 1983;
6:183-190.
50. Sim R.J., Harrison M.M., Moxon E.R., et al.: Underes-
timation of meningococci in tonsillar tissue by naso-
pharyngeal swabbing. Lancet 2000; 356:1653-1654.
51. Bowler L.D., Zhang Q.Y., Riou J.Y., et al.: Interspecies
recombination between the penA genes of Neisseria
meningitidis and commensal Neisseria species during
the emergence of penicillin resistance in N. meningiti-
dis: natural events and laboratory simulation. J Bacteriol
1994; 176:333-337.