Aerobic Non–Spore-Forming

Gram-Positive Bacilli:
Corynebacterium, Listeria,
Erysipelothrix, Nocardia, and
Related Pathogens
 Listeria monocytogenes
• Distinguishing Features

• Small gram-positive rods (+),

• Beta hemolytic, nonspore-forming
rod on blood agar, CAMP positive
• Tumbling motility in broth; actin jet
motility in cells
• Facultative intracellular parasite
• Cold growth
 Reservoir

• Widespread: animals (GI and genital tracts), unpasteurized milk products,

plants, and soil

• Cold growth: contaminated food, soft cheese, deli meat, cabbage

(coleslaw), hot dogs, fruit, ice cream

• Transmission: foodborne or vertical (Transplacental—granulomatosis

infantiseptica)
Pathogenesis

• Listeriolysin O, a β-hemolysin, facilitates rapid egress from

phagosome into cytoplasm, thus evading killing when lysosomal
contents are dumped into phagosome; “jets” directly (by actin filament
formation) from cytoplasm to another cell

• • Immunocompromised status predisposes to serious infection

 Disease(s)
• Listeriosis (human, peaks in summer)
–– Healthy adults and children: generally asymptomatic or diarrhea with
low % carriage
–– Pregnant women: symptomatic carriage, septicemia characterized by
fever and chills; can cross the placenta in septicemia.

• In immunocompromised patients
–– Septicemia and meningitis (most common clinical presentation)
–– Listeria meningitis most common cause of meningitis in renal transplant
patients and adults with cancer
• Neonatal disease
–– Early-onset: (granulomatosis infantisepticum) in utero transmission;
sepsis with high mortality; disseminated granulomas with central necrosis
–– Late-onset: 2–3 weeks after birth from fecal exposure; meningitis with
septicemia
• Diagnosis: blood or CSF culture at 4˚C; CSF or Gram stain (>25%
lymphocytes + PMNs)

• Treatment: ampicillin with gentamicin added for

immunocompromised patients
• Prevention: pregnant and immunocompromised patients should
avoid cold deli food
 CORYNEBACTERIUM

Corynebacterium diphtheria

Distinguishing Features
• Gray-to-black colonies of club-shaped gram-positive rods arranged in V or
L shapes on Gram stain
• • Toxin-producing strains have β-prophage carrying genes for the toxin
(lysogeny, β-corynephage). The phage from one person with diphtheria can
infect the normal nontoxigenic diphtheroid of another, and thus cause
diphtheria.
• Reservoir: throat and nasopharynx

• Transmission: bacterium or phage via respiratory droplets

 Pathogenesis

• Organism not invasive; colonizes epithelium of oropharynx or skin in

cutaneous diphtheria
• Diphtheria toxin (A-B component)—inhibits protein synthesis by adding
ADP-ribose to eEF-2
• Effect on oropharynx: Dirty gray pseudomembrane (made up of dead
cells and fibrin exudate, bacterial pigment)
• Extension into larynx/trachea → obstruction
• Effect of systemic circulation → heart and nerve damage
 Virulent factor: diphtheria toxin
• The toxin encoding gene (tox) is carried byβ-
corynebacteriophage
• only the bacillus infected by the phage and
committed lysogenic conversion produce
diphtheria toxin
• The regulation of tox gene expression is
mediated by an iron-activated inhibitor (DtxR)
which is chromosomally encoded by C.
diphtheria

EM of ß-corynebacteriophage carrying tox gene

abed elkader elottol 13
• Diphtheria (sore throat
with pseudomembrane,
• bull neck,
• potential respiratory
obstruction, myocarditis,
• cardiac dysfunction,
• recurrent laryngeal nerve
palsy,
• lower limb polyneuritis),
renal failure
 Diagnosis
• Elek test to document toxin production (ELISA for toxin is now gold
standard) Toxin produced by Elek test toxin-producing strains diffuses away
from growth
• Antitoxin diffuses away from strip of filter paper
• Precipitin lines form at zone of equivalence
 Morphology
•Another characteristic is the presence of metachromatic granules
(RNA and polymetaphosphate) in bacterial cells. The granules are
bluish-purple with methylene blue, and dark purple by Albert
staining method.

Albert stain methylene blue stain

metachromatic granules
 Culture
•Aerobic and facultative anaerobic, growing well at 37C on
blood- or serum-containing medium.
•Loeffler’s serum slant: not a selective medium but gives
abundant growth and typical morphology of the bacillus.
•Blood tellurite agar: a selective medium because tellurite can
suppress the growth of normal flora in throat, and the colonies
are black-colored.
•Granules (volutin) produced on Loeffler coagulated serum medium stain
metachromatically
• Treatment
• Erythromycin and antitoxin
• For endocarditis, intravenous penicillin and aminoglycosides for 4–6
Weeks

• Prevention: toxoid vaccine (formaldehyde-modified toxin is still

immunogenic
• but with reduced toxicity), part of DTaP, DTP, or Td, boosters 10-year
intervals
 GENUS: ACTINOMYCES

Disease: actinomycosis
• Generally not painful but very invasive, penetrating all tissues including
bone
• Only in tissues with low oxygenation (Eh)
–– Cervicofacial (lumpy jaw): dental trauma or poor oral hygiene
–– Pelvic: from thoracic or sometimes IUDs
–– Abdominal: surgery or bowel trauma
–– Thoracic: aspiration with contiguous spread
–– CNS: solitary brain abscess (Nocardia will produce multiple foci)
 Actinomyces israelii
Distinguishing Features • Diagnosis: identify gram-positive
• Anaerobic branching bacilli in “sulfur
• Branching rods granules”; colonies resemble
molar tooth
• Non−acid fast
• Treatment: penicillin V and
• Reservoir: human; normal flora of surgical drainage; metronidazole
gingival crevices and female genital not effective
tract
• Transmission: endogenous
• Pathogenesis: invasive growth in
tissues with compromised oxygen
supply
• Tissue swelling can lead to
draining abscesses (sinus tracts)
with “sulfur” granules (hard
yellow microcolonies) in exudate
that can be used for microscopy
or culture
Gram Stain and Macroscopic Colonies of Actinomyces

• NOTE: Molar tooth appearance of colonies on agar

can help remind us that the oral cavity is a common
niche for Actinomyces.
 GENUS: NOCARDIA
• Nocardia asteroides and Nocardia brasiliensis

Distinguishing Features: aerobic; Gram-positive branching rods (some

areas of smear will be blue and some red; partially acid fast)
• Reservoir: soil and dust
• Transmission: airborne or traumatic transplantation
• Pathogenesis: no known toxins or virulence factors;
• immunosuppression and cancer predispose to pulmonary infection
 Disease(s)

• Nocardiosis
–– Cavitary bronchopulmonary nocardiosis
–– Mostly N. asteroides
–– Can be acute, subacute, chronic
–– Symptoms: cough, fever, dyspnea, localized or diffuse pneumonia with cavitation
–– May spread hematogenously to brain (brain abscesses)
• Cutaneous/subcutaneous nocardiosis
–– Mostly N. brasiliensis
–– Starts with traumatic implantation
–– Symptoms: cellulitis with swelling can lead to draining subcutaneous abscesses with
granules (mycetoma)
• Diagnosis: culture of sputum or pus from cutaneous lesion
• Treatment: sulfonamides (high dose) or trimethoprim/sulfamethoxazole (TMP-SMX)
mycetoma