Streptococcus

Corynebacterium diphtheriae
Borrelia burgdorferi
G-ve
Anaerobic
Spirochetes
Ixodes ticks (nymph
stage)
IP : ? Early
stages:
- amoxicillin
- doxycycline
- cefuroxime

Late stages (IV):
- ceftriaxone
- penicilin

1. Microscopy,
Stain

Giemsa or Wright
stain
Darkfield
microscopy

2. Molecular

PCR
Serology (main)
ELISA Western
blot
Streptococcus - description
Gram positive oval or spherical cocci
pairs or chains
0.5 to 1.0mm
blood agar - haemolysis
colonies small (0.5-2.0mm), grey to greyish white
catalase negative
streptococcus
classification
based on presence or absence of haemolysis
around colonies growing on blood agar

haemolysis
beta (complete)
alpha (incomplete)
gamma (non-haemolytic)
appearance
distinct clear zone
greenish discoloration
no change
Lancefield classification (1933)
beta-haemolytic streptococci
group-specific carbohydrate of cell wall
20 Lancefield groups (A-H and K-V)
latex agglutination
Streptococci of importance in human infection
Lancefield group Type of haemolysis
S. pyogenes A b
S. agalactiae B b
S. pneumoniae none a
S. sanguis none a
S. mitior none a
Streptococcus pyogenes
Description
Gram-positive cocci in chains
facultative anaerobes
blood agar
small grey/greyish white colonies
complete/beta haemolysis

Habitat
nasopharynx
children 15-20% carriage rate (adults lower rate)

S. pyogenes - virulence

i. M protein
major surface protein and virulence factor
two polypeptide chains complexed in
alpha-helical coiled coil configuration
anchored in cell membrane
more than 80 serotypes
antiphagocytic
binding to factor H and fibrinogen impede
binding of C3b to bacterial surface
adhesin (skin keratinocyte)
type-specific opsonic antibodies against M protein
provide protective immunity
S. pyogenes - virulence

ii. Lipoteichoic acid (LTA)
Protein F1(PrtF1) aka streptococcal
fibronectin binding proteins (sfbI)
cell surface proteins
adheres to fibronectin on respiratory
epithelial cells

other proteins
Protein F2, SbfII, FBP54, vitronectin-binding protein,
collagen-binding protein,
S. pyogenes - virulence

iii. Capsule
composed of hyaluronic acid
chemically similar to human connective tissue
antiphagocytic
degree of encapsulation variable
mucoid colonies and more virulent
if exuberant encapsulation

adherence factor in pharynx as binds to CD44
on epithelial cells



S. pyogenes - virulence

iv. Streptolysin O (SLO)
Streptolysin S (SLS)
pore-forming cytolysins
haemolytic and cytotoxic
both responsible for haemolysis on blood agar

SLO is antigenic
antibodies to SLO (ASOT) used in serodiagnosis

S. pyogenes - virulence
v. Streptococcal pyrogenic exotoxins (SPE)
family of superantigens
SpeA, SpeC, SpeG, SpeH, SpeJ, SpeK, SpeL, SpeM,
Streptococcal superantigen (SSA)
Streptococcal mitogenic exotoxin Z (SMEZ, SMEZ-2)

streptococcal toxic shock syndrome
scarlet fever

S. pyogenes - virulence
vi. Spreading factors
Hyaluronidase - degrades hyaluronic acid
Deoxyribonucleases - hydrolyse nucleic acid and
nucleoproteins
Streptokinase - converts plasminogen to plasmin
- breaks down fibrin
vii. C5a peptidase
degrades complement component C5a
destroy C5a ability to act as chemo-attractant
of polymorphonuclear leucocytes


S. pyogenes - infections
Acute pharyngitis / tonsillitis
Scarlet fever
Impetigo, erysipelas, cellulitis, sepsis in burns,
necrotizing fasciitis
Toxic Shock Syndrome
Puerpural sepsis, endocarditis, pneumonia-post viral
Non-suppurative post-streptococcal sequelae:
rheumatic fever, acute glomerulonephritis

S. pyogenes - laboratory diagnosis
Specimens
throat swab
pus swab
blood culture
Direct examination by gram stain
Culture on blood agar at 37C
Bacitracin sensitivity test (rapid presumptive diagnosis)
Lancefield grouping by latex agglutination
S. pyogenes - laboratory diagnosis
Serological diagnosis
antibodies to streptolysin O, DNase B, hyaluronidase,
NADase and streptokinase

diagnosis of ARF and APSGN to confirm antecedent
streptococcal infection
ASOT
peak 2-4 weeks after acute infection
tonsillar-associated diseases
Anti-DNase B in pyoderma-associated diseases

Streptococcus pneumoniae
Pneumococcus

Description
Gram-positive ovoid or lanceolate cocci
pairs (diplococci)
grow well on blood agar
colonies
small (1mm), circular, raised, smooth
a haemolysis
Optochin sensitive
older cultures : draughtsman appearance
mucoid due to excessive capsular production

S. pneumoniae - virulence
Capsule
most significant virulence factor
polysaccharide
>90 capsular / serotypes
antigenic differences in polysaccharides
90% due to 23 serotypes
antiphagocytic
anticapsular antibodies protective


S. pneumoniae - virulence
Choline-binding proteins
pneumococcal surface adhesin A and choline-binding
protein C binds to epithelial cell receptors

Pneumococcal surface proteins A (PspA)
binds to complement factor B and prevents
deposition of C3b

Pneumococcal surface proteins C (PspC)
binds to complement factor H and prevents
deposition of C3b
S. pneumoniae - virulence
Pneumolysin
transmembrane pore-forming toxin
cytotoxic for phagocytic and respiratory epithelial cells
activate classical complement pathway

Autolysin
causes bacterial disintegration and release of cell wall
components (peptidoglycan and teichoic acid)

Neuraminidase
cleave sialic acid on mucous membrane surfaces
contribute to adherence




S. pneumoniae - pathogenic mechanisms
adherence
colonization
infection if carried into cavities and not readily cleared by
clearance mechanisms (ciliary action)
coexisting viral infection causing oedema
damage to ciliated bronchial cells
increased mucus production
invasion across mucosal barriers into bloodstream
escape from phagocytosis
activation of complement and inflammatory cytokines



S. pneumoniae - epidemiology
human only known reservoir
nasopharynx
20 - 40% children; 5 -10% adults
transmission by droplets or contact with respiratory
secretions
infections throughout life but most common in <2 year
olds and elderly
predisposed by defects in antibody, complement and
splenic function
also at risk are patients with chronic diseases
cirrhosis, renal failure, diabetes, congestive heart failure



S. pneumoniae - infections
Infection of middle ear, sinuses, trachea, bronchi and lungs
by direct spread from nasopharynx (Non-invasive diseases)

Infection of CNS, heart valves, bones, joints and peritoneal
cavity by haematogenous spread (Invasive diseases)

Infection of CNS, pleura or peritoneal cavity may occur by
direct extension or haematogenous spread




S. pneumoniae - infections
lobar pneumonia (commonest bacterial cause)
acute exacerbation of COPD
acute otitis media
sinusitis
meningitis
septicaemia (*splenectomised patients)

empyema
septic arthritis
osteomyelitis
endocarditis
S. pneumoniae - treatment
Was susceptible to penicillin but increasing
resistance to penicillin and other antibiotics
mutations in penicillin-binding proteins (PBPs)

Definitive therapy guided by antibiotic
susceptibility testing results
S. pneumoniae - prevention
Vaccination
Pneumococcal capsular polysaccharide vaccines
incorporates 23 of most common capsular types
recommended for older than 2 year olds at
increased risk of developing pneumococcal
infection or a serious complication

Conjugate pneumococcal vaccine
heptavalent polysaccharide vaccine
serotypes responsible for 70% invasive diseases
2, 4, 6 months and booster at 12-15 months


Corynebacteria
Corynebacteria
Greek: korynee = club
bacterion = little rod

Corynebacterium diphtheriae
major human pathogen

non-diphtheria corynebacteria
(coryneforms / diphtheroids)
diverse
increasing pathogenic role
C. diphtheriae - description
pleomorphic Gram positive slender bacilli

pleomorphism
often club-shaped
long and slender with rounded
or swollen ends
some coccoid
some globular




Description - characteristic features
1. Metachromatic (volutin) granules
intracellular long chain polymerised phosphate
2-3 granules per cell
polar
Neisser or Albert stain
beaded appearance

Description - characteristic features
2. Chinese lettering
on Gram stain
snapping fission
incomplete separation at moment of division and
daughter cells remain attached at one point
adjacent cells lie at various angles to one another and
appear as angled pairs or parallel rows (palisades)
V, L, W forms
C. diphtheriae - culture
1. Loefflers serum slopes
rapid growth at 12 to 18 hours

2. Culture media containing potassium tellurite
e.g. chocolate tellurite agar
selective medium
characteristic grey-black colonies


C. diphtheriae - epidemiology
humans only known natural host and reservoir
transmission primarily by
i. airborne respiratory droplets
ii. direct contact with respiratory secretions
primarily affects < 15 year olds
maximal 2
nd
to 5
th
year

incidence decreased steadily and now rare in
developed countries
major impact due to immunisation


Diphtheria - definition
a localised inflammation of the throat with greyish white
adherent exudate (pseudomembrane) and a generalised
toxaemia due to secretion and dissemination of a highly
potent toxin

C. diphtheriae - virulence
Diphtheria toxin
potent exotoxin
tox
+
gene
only strains lysogenic for bacteriophage
fragment B
attachment to host cell membrane and
transport of fragment A into cell
fragment A
inhibits polypeptide chain elongation
C. diphtheriae - Diphtheria toxin
primary effects
within first few days, toxin elaborated locally
induces a dense necrotic coagulum
pseudomembrane
fibrin, WBC, RBC, dead epithelial cells and bacteria
cardiac muscle structural and functional damage
demyelination in both peripheral and cranial
nerves
Agar gel precipitation (Elek) test
a wide filter paper strip impregnated with antitoxin is
implanted in a serum agar plate while medium is still fluid
when agar has set, the organism is streaked at right
angles to strip
precipitate / precipitin reaction in the form of double
arrow-headed lines after incubation