MYCOBACTERIUM

The mycobacterium is aerobic acid fast bacilli, non-motile and non-spore forming rod.
There are more than 50 mycobacterium species, which can be grouped into:-
1- Pathogenic species:-
a- M. tuberculosis (Pulmonary tuberculosis)
b- M. bovis (Gastrointestinal tuberculosis)
c- M. leprae (Leprosy)

M. tuberculosis
It cannot be stained by gram stain due to high lipid content of its cell wall (Mycolic acid).
By Ziehl-Neelsen stain Acid fast bacilli, they resist decolourization by sulphuric acid 20%
and they are also alcohol fast. The bacilli appear red rods and a blue background.
3- Pathogenesis:
M.tuberculosis is transmitted by inhalation of droplets or Of dust particles contaminated with
tubercle bacilli.
Formation of tubercle:
The tubercle is the basic lesion of tuberculosis
* Innate immunity:
1- Neutrophils: are attracted within few hours to the polysaccharide fraction of the bacilli.
They engulf the bacilli but can not digest them. Since the bacilli are protected by their lipid
capsules, while neutrophils lack the enzyme lipase. Neutrophil die rapidly.
2- Macrophages: are attracted by the lipid part of the bacilli. They engulf the bacteria,
macrophages contain lipase and after ingestion of the bacilli they become altered and appear
swollen that resembling epithelial cells, therefore termed epithelioid cells (In macrophage,
bacterial sulfolipids inhibit the fusion of the phagosome with lysosome)
* Acquired immunity (cell mediated immunity)
1- Presentation:
Macrophages present the bacterial antigen (tuberculoprotein) to T helper cell (TH1 cell).
These TH1 cells become sensitized and accumulate around the epithelioid cells after 10-14
days from the onset of infection.
2- Sensitized T-H1 cell secrete cytokines (Il-2, γINF and TNF-β& others) some of these
cytokines have beneficial effects (acquired immunity) and some lymphokines have harmful
effects (hypersensitivity)

Type of tuberculosis
I- Primary tuberculosis: (Latent) or (Ghon's complex)
Ghon's complex (lesion on infected organ, draining lymphatics and draining lymph
nodes) the bacilli are carried by macrophages and tissue fluids to the draining lymphatics
and draining lymph nodes.

In most people who breathe in TB bacteria and become infected, the body is able to fight the
bacteria to stop them from growing. The bacteria become inactive, but they remain alive in
the body and can become active later. This is called latent TB infection.

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 Difference Between Latent TB Infection and TB Disease
Latent TB Infection (85-95%) TB Disease (5-15%)
 Have no symptoms  Symptoms include
 Do not feel sick o a bad cough that lasts longer than
 Cannot spread TB to others 2 weeks
 Usually have a positive skin test o pain in the chest
 Chest x-ray and sputum test normal o coughing up blood or sputum
o weakness or fatigue
o weight loss
o no appetite
o chills
o fever
o sweating at night
 May spread TB to others
 Usually have a positive skin test
 May have abnormal chest x-ray, and/or
positive sputum smear or culture.

II- Secondary tuberculosis (re-infection type)

This may be endogenous due to reactivation of tubercle bacilli that have survived in the
primary lesion or exogenous from the environment. Reactivation is apparently due to an
impairment in immune status, often associated with malnutrition, alcoholism, severe stress,
immunosuppressive medication or diseases such as diabetes and ADIS.

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 Diagnosis:-
1- specimen
Sputum from pulmonary tuberculosis
Urine from renal tuberculosis
C.S.F from meningeal T.B
Stool from intestinal T.B
2- Direct smear
Stained with Ziehl Neelsen stain to detect acid fast bacilli.
3- Concentration methods (Petroff,s method)
The specimen is mixed with an equal volume of 2% NaoH and incubate at 37c
for 30 min. Then centrifuge, after that the deposite is neutralized by HCL
The concentration technique has the following advantage
a- It liquefies the specimen, thus releasing the tubercle bacilli
b- It destroys all bacteria other than tubercle bacilli
c- By centrifugation, the tubercle bacilli deposited in small volume.
Concentrated specimens are processed as follows:-
 Smears are made and stained by Ziehl Neelsen stain
 Culture on Lowenstein Jensen Medium, incubate at 37c, the growth start after 3
weeks as irregular, dry and yellowish in color. Culture should not be discarded
before 8 weeks.

4-Tuberculin test(MONTOUX) TEST

It is a delayed hypersensitivity skin test, used to detect cell mediated immunity to
tuberculosis.
The test is done by intradermal injection of 0.1ml of the purified protein derivative
(PPD) of the tubercle bacilli.
In positive test a local area of induration (10mm due to aggregation of lymphocyte) develop
48-72 hours after injection
In negative test, no reaction or induration occur.
Interpretation
1- A positive tuberculin test in adults indicates there is previously exposed to the tubercle
bacilli. It does not differentiate between active infection and immunity.
2- A positive test can be value in the diagnosis of the disease in children below 5 years
with no history of previous vaccination.
3- In endemic area a positive tuberculin test in adult should not have much significant,
since over 80% of the adult population are tuberculin test positive.
4- A negative tuberculin test is of value as it excludes infection in suspected case.
The test may be negative in the presence of tuberculosis infection in certain condition as:
 Miliary tuberculosis
 Measels
 Immunosuppression (HIV patient)
5- QuantiFERON-TB test: This laboratory test uses an ELISA to measure the
production of interferon-gamma by whole blood leukocytes incubated overnight with
PPD solution. After incubation of the blood with antigens for 16 to 24 hours, the
amount of interferon-gamma (IFN-gamma) is measured.
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 Treatment:-
1- Prolonged course: Treatment should be continued for 6 – 12 months as there is a slow
response for treatment. This is due to:
a- Most bacilli are intracellular.
b- The caseous material interferes with the drug.
2- Combination of drugs: 2-3 or more drugs are given at the same time and the
combination is changed every few months:
a- to reduce the drug toxicity
b- to prevent emergence of drug resistant strains
The first line of treatment drugs are; isoniazed (INH), rifampicin, thambutol and
pyrazinamide.
In infections with multiple drug resistant strains; second line drugs should be used. These
include streptomycin, ethionamide, cycloserine, amikacin and ciprofloxacin

Prevention: BCG vaccine (bacillus, Calmette-Guerin)