Microbiology of Respiratory

System
Mycobacteria
M. tuberculosis
 Slowgrowing bacteria (The generation time:
15 to 20 hours)
 Facultative intracellular pathogen.
 Can be cultured on bacteriological media
Lowenstein-Jensen medium
 Obligate aerobe (lung and the kidney)
 Canlive in macrophages / Previously
dormant (latent) bacteria can cause illness
months or years later
- Acid fast rods with a waxy cell (mycolic acids) wall (C78 – C90)
with high lipid content (neither Gram-positive nor Gram-negative).

- Wall makes mycobacteria highly resistant to:

- Desiccation
- Many chemicals (including NaOH)
- Sensitive to UV
Cord factor (trehalose
dimycolate) is correlated with
virulence of the organism.

- Virulent strains grow in a

characteristic “serpentine”
cordlike pattern, whereas
avirulent strains do not.
-In the United States,
tuberculosis is almost
exclusively a human
disease.

- In developing
countries,
Mycobacterium bovis
also causes
tuberculosis in
humans.
Each year
- 1.7 million people die of tuberculosis and that 9 million new cases occur.

- An estimated 500,000 people are infected with a multidrug-resistant strain of

M. tuberculosis.
Transmission & Epidemiology

 Person to person

 Lung is initial site of infection

 Humans are natural reservoir

Clinical findings
 Asymptomatic, Asymptomatic, ……
 Fever, fatigue, night sweets, weight loss
 Cough, , hemoptysis
 Scrofula (cervical lymphadenitis)
 Erythema nodosum
 Miliary TB
 Tuberculosis meningitis, Osteomyelitis
 GI TB
 Renal TB
Pathogenesis
- Facultative intracellular organism
- Inhibit phagosome-lysosome fusion, allowing intracellular survival.
- Cord factor (trehalose dimycolate), That causes serpentine growth in vitro
- Inhibits leukocyte migration.
-Tuberculin (surface protein) along with mycolic acid causes delayed
hypersensitivity and cell-mediated immunity (CMI)
-Granulomas and caseation mediated by CMI
- No exotoxins or endotoxin; damage done by immune system
- Primary pulmonary tuberculosis

- Organisms replicate in naive alveolar macrophages, killing the

macrophages until CMI is set up (Ghon focus) / organsisms in local lymph
nodes / healing without disease

- Organisms in Ghon complex remain viable unless treated

- Host inflammatory response to TB creates open lung lesions (pulmonary

cavities) that contain huge numbers of organisms. Coughing spreads.

- Damage is caused by chronic inflammation and survival of organisms

within macrophages.
Pathogenesis
 Twoimportant proteins: tuberculosis
necrotizing toxin / early secreted antigen - 6
 Exudative lesions: Acute inflammation
 Granulomatous lesions:
Central area of giant cell
Containing bacilli (surrounded by
epithelioid)
- Langhan`s giant cell
- Tubercle
- Ghon complex
latent infection. Of those exposed
to M. Tuberculosis:

Approximately 90% develop latent

infection and approximately 10%
develop disease.

- Of those who have latent

infection, approximately 10%
progress to active disease
(reactivation) at a later time,
whereas 90% remain latent.
Scrofula is mycobacterial cervical lymphadenitis that presents as swollen,
nontender lymph nodes. caused by hematogenous or lymphatic
dissemination of pulmonary TB or reactivation of latent TB

- Mycobacterium tuberculosis causes most cases of scrofula Lymphadenitis

Miliary tuberculosis is characterized by multiple disseminated lesions that resemble
millet seeds.

- Tuberculous meningitis and tuberculous osteomyelitis, are important disseminated

forms.
Endogenous Reactivation / (Secondary Tuberculosis)
- Usually occurs within 2 years after initial infection.

- The most common site of reactivation is the apex of the lung.

- Nearly all TB in previously infected patients is the result of
endogenous reactivation.

- Lesions slowly become necrotic, undergo caseous necrosis, and

eventually merge into larger lesions.

- The discharge of caseous material can lead to a rapidly progressive

tuberculous pneumonia.
Immune Response
- TB requires a cellular immune response / antibodies playing no apparent role.
- The pathologic features of TB are the result of hypersensitivity to
mycobacterial antigens leading to formation of granulomas (sometimes called
tubercles).
- Characteristic of the disease are tubercles found in many organs, including
the liver, spleen, kidneys, brain, and meninges.
- Healing with eventual fibrosis, encapsulation, and scar formation.
- Necrosis in TB tends to be incomplete, resulting in semisolid caseous material.
(unstable and providing conditions in which bacteria multiply to very high
numbers).
- Immunocompromised persons organisms may invade the bloodstream and
disseminate miliary tuberculosis. (tubercles similar to millet seeds (bird seed)).
Macrophages: Two cytokines produced: IL-
1 and TNF-a .
- Produce cytokines mediate fever, weight
loss, and night sweats.
Tuberculin Skin Test / Purified protein derivative: PPD skin
test (Mantoux):
Delayed-Type Hypersensitivity / 48–72 hours
- Intradermal injection of proteins, or tuberculin, a mixture
known as purified protein derivative (PPD).
- Positive skin test indicates only exposure but not
necessarily active disease
- Not used to test population are tuberculin positive: has
received the bacille Calmette-Guérin (BCG) vaccine).

- Tuberculin conversion: indicates recent tuberculous

infection .
- Immunocompromised persons with tuberculous infection have negative tuberculin
tests.

- So, a negative tuberculin skin test does not exclude active TB.

- A false-positive tuberculin test may be caused by exposure to atypical

mycobacteria (induration size is usually small).
 DIAGNOSIS
- Tuberculin skin test results.
- History, direct examination of sputum or exudates, and a chest radiograph.
- Acid-fast staining culture of sputum.
- Detection with auramine-rhodamine stain (fluorescent apple-green).
- The gold standard for diagnosis of TB is culture.
- Detection of colonies (takes 3 to 6 weeks).
- Radiometric culture techniques (Liquid BACTEC): detection of radioactive CO2
released by organisms metabolizing 14C-labeled palmitic acid, providing results
within 7 to 14 days.
- Nucleic acid amplification methods.
- Quantiferon-TB Gold Test: measures interferon-gamma production when
leukocytes exposed to TB antigens
Treatment & Prevention
 Initial phase: INH + RIF + PZM + ETHAMBUTOL)
 Continuation phase: INH + RIF
 DOT (directly observed therapy) / the failure of
patients to complete the full course of therapy
 MDR: bedaquilline +
 XDR: ????
 PPD (????)
 Quantiferon-TB Gold
 BCG
Treatment:
- Drug resistance is a worldwide problem:
- Strains of M. tuberculosis resistant to isoniazid (isonicotinic acid
hydrazide, INH),
- Strains resistant to multiple antibiotics (called multidrug-resistant or MDR
strains
- Multiple drugs critical to treat infection

- Standard observed short-term therapy for uncomplicated pulmonary TB /

- Intial stage: First 2 months: rifampin + isoniazid + pyrazinamide +

ethambutol (RIPE)

− Next 4 months: rifampin and isoniazid

Prevention:

-Isoniazid taken for 9 months can prevent TB in persons with infection but
no clinical symptoms.

-Bacille Calmette-Guérin (BCG) vaccine containing live.

- UV lights or HEPA filters used to treat potentially contaminated air.

Mycobacteria Other than Tuberculosis (MOTTS)

- Atypical mycobacteria
- Noncontagious
- Found in surface waters, soil, cigarettes
- Commonly found in southeastern U.S.
- Can cause tuberculosis-like disease but are less frequent pathogens.