Medical Microbiology

Microbiology of the Cardiovascular &

Lymphatic System

Programme title: Medicine Doctor (MD)

Module title: CV & L S
Haftom H. Duration:
Academic year: Year I, 2010 E.C.

Medical microbiology, College of health Science, Aksum University

2010 E.C.
Outline
1. Learning objectives
2. Introduction to CVS & LS
infections
3. Common bacteria
4. Common viruses
5. Fungi
6. References
Learning objectives

 Upon completion of this topic, you will be

able to:

 List important microorganisms involved in disease

causation of the CVS & LF
 Describe the classification, characteristics and
infections of important microorganisms involved
in CVS & LF infections
Introduction
Normal flora

─ Cardiovascular system is normally free of

microbial organisms

─ Isolation of bacteria or fungi from the blood

usually indicates a serious infection that may
result in death
 Predisposing conditions

1. Localized infections

─ Mouth infections (dental caries, abscess)

─ During tooth extraction (dental
procedures)
─ Sore throat (pharyngitis)
─ Tonsilitis
─ Other localized infections: UTI, Skin, bone, lung
2. Abnormal heart valve
─ Increased chance of colonization during
transient bacteremia
─ For example, infective endocarditis occurs in
patients with altered & abnormal heart, due to
exposure to bacteria (even during transient
bacteraemia)
3. Contaminated intravenous infusions
4. Low immunity level
─ Newborns
─ Compromised host defenses
5. Bioprosthetic & other devises

─ Prosthetic heart valve

• Provide site of colonization for foreign agent
or for transient bacteremias
─ Intravenous catheter
• Direct access of skin flora to circulatory
system
─ Infected intravenous needles
 Cardiovascular infections

 Endocarditis
 Other intravascular infections
─ Pericarditis
─ Myocarditis
─ Aortitis
─ Mycotic aneurysm
─ Septic thrombophlebitis
─ Indwelling device infections
 Septic Shock

─ Some terms
• Septicemia is presense of persistent & proliferating
pathogens/or their toxins in blood
› This septicemia may lead to sepsis
• Sepsis is a systemic inflammatory response caused by
spread of bacteria/or their toxins from a focus of
infection
• Septic shock: sepsis + uncontrollable decreased arterial
blood pressure
─ Sepsis with persistent hypotension despite fluid
recovery and resulting tissue hypoperfusion
─ Gram-negative bacterias are the most common
causes of septic shock (̴ 40% of patients), but
Gram +ve too (5% of patients)
• Although gram-positive bacteria do not contain LPS,
their cell wall peptidoglycan can elicit a shock syndrome
similar to that caused by LPS, but usually not as severe.
• Septic shock may also occur with viral & fungal
infections
─ Septic shock in Gram-negative infection is due to the toxic
effect of lipopolysaccharides (endotoxin) found in
their cell wall
• Endotoxin within the circulatory system has multiple effects
on blood cells (neutrophils & platelets), complement, clotting
factors, & inflammatory mediators in the blood
• Release of inflammatory mediators cause local circulatory
failure & multiorgan failure
• Damage to the vascular endothelium plays a major role
in both the hypotension & DIC seen in septic shock
• Damage to the endothelium allows the leakage of plasma & red
cells into the tissue, resulting in the loss of blood volume &
consequent hypotension
• Also, damaged endothelium serves as a site of platelet
aggregation & activation that leads to the thousands of
endovascular clots manifesting as DIC
DIC
─ Microbiological diagnosis of septic shock is made by:
• Culturing local infections thought to be the source
of microbemia &
• Culturing the blood

─ Survival depends on rapid treatment consists of:

• High-dose IV broad-spectrum antimicrobial agents
• Intravenous fluids
• Supplemental oxygen therapy
• Mechanical ventilation,
• Transfusions of blood products & clotting factors, as
needed
 Infective Endocarditis

─ Infection of the heart chambers or valves

─ Generally, classified as:

a.Acute endocarditis
b.Subacute endocarditis
c.Prosthetic valve endocarditis
› May present either acute or subacute in onset
─ Pathogenesis

• Microbes that enter the blood lodge on heart valves

› Damaged heart valves are more susceptible
• Growth & colony formation
• Colonies become covered with fibrin & platelets
(vegetation), which protect the organisms from
phagocytes
− The vegetation is mass of fibrin & platelets, plentiful causative
agents, & inflammatory cells
• Clots may dislodge as infected emboli & may
metastasize
Fig. Bacterial Endocarditis
─ Microbiologic diagnosis
• Infective endocarditis is microbiologically
diagnosed through blood cultures

─ Therapy consists of prolonged IV Rx with

bactericidal antibiotics to eradicate bacteria
within the protective clot
• But, prosthetic valve infections frequently require
surgical removal of the infected valve
• Therapy should be guided by susceptibility studies
─ Antimicrobial prophylaxis should be
administered to patients with defective heart
valves who are undergoing dental & other
procedures known to produce bacteremia
 Infective myocarditis

─ May be due to:

a. Infections
• Bacteria
• Virus
• Fungi
b. Immune-mediated reactions
• Post-viral
• Post-streptococcal (rheumatic heart disease)
Fig. Arrow shows a collection of lymphocytes infiltrating the cardiac muscle in
response to a viral infection (from Cooper LT. New Engl J Med 2009;360:1526-38)
 Pericarditis

─ Bacterial infection leads to purulent

pericarditis, in which the pericardial
exudate resembles pus & contains many
neutrophilis
 Infectious vasculitis

─ Causes are:
• Direct Infection
• Immunologic (Immune complex-mediated)
› Bacterial & Viral antigens may cause vasculitis

─ It includes:
1. Infections of arteries
2. Infections of veins
1. Infections of arteries

─ Arteries may become infected:

• During endocarditis (mycotic aneurysms) or
• After other bacteremias in patient with
atherosclerosis (aortitis)
a. Infective aortitis

─ Rare infection following bacteremia in older

persons with extensive atherosclerotic disease of
the aorta

• The bacteria cause aortitis by infecting the

aorta at sites of atherosclerotic plaque
• Bacterial proteases lead to degradation of
collagen in the aortic wall
b. Mycotic aneurysm (a.k.a., bacterial aneurysm)

─ A localized dilation of the wall of blood vessel

caused by the growth of a fungus, usually
occurring as a complication of bacterial
endocarditis
─ Bacterial proteases lead to degradation of
collagen, and the resulting destruction of the
aortic wall leads to formation mycotic
aneurysm
─ May rupture in spite of antibiotic treatment
─ Blood cultures are positive in the majority
of patients with infective aortitis

─ Treatment includes:
• Antibiotic therapy &
• Surgical removal of the affected part of the aorta
2. Infections of veins

─ Eg. Septic thrombophlebitis:

• Occurs in several different veins

• Treatment involves high-dose antibiotics
+/- heparin
Table: Examples of Infections of veins in d/t locales

Syndrome Veins Predisposition Microbiology Treatment

Lemierre’s Internal Prior exudative Fusobacterium IV Penicillin G
syndrome jugular v. pharyngitis necrophorum

Pylephlebitis Portal v. Diverticulitis; other B. fragilis, other Broad-spectrum

intraabdominal intestinal bacteria IV therapy;
infections heparin
Septic pelvic Ovarian v. Post-partum Intestinal flora Broad-spectrum
thrombophlebitis and others IV therapy;
heparin
Line-related septic Any small Infection usually Staph. IV anti-staph
phlebitis or great indwelling IV antibiotics;
vein catheters excision of
purulent small
veins
 Lymphatic system infections

 Lymphadenitis
 Lymphangitis
 Lymphadenopathy (buboes)
 Bacteriology of
Cardiovascular System
1. Staphylococcus spp

 Distinctive characteristics

Gram-positive cocci,
arranged in grape-like irregular
clusters
Facultative anaerobes
Catalase positive
 Members of normal flora of skin &
the mucous member
 Cont…

Important spp:

a. S. aureus

─ Virulence factors
• Protein A: binds to the Fc portion of IgG
• Capsule
• Coagulase: retard migration of phagocytes to
the site by converting fibrinogen to fibrin (clot)
• Hyaluronidase: hydrolyzes hyaluronic acids,
promoting the spread of staphylococci in tissue
 Cont…

b. S. epidermidis

─ Slime production:
• It produces an extracellular polysaccharide
material called slime
• Facilitates adherence to bioprosthetic
material, & acts as a barrier to antimicrobial
agents
─ Therefore, it is involved in prosthetic
materials, shunts, surgery
 Cont…

 Clinical significance

 Infective pericarditis/myocarditis/endocarditis

─ Staphylococcus spp cause 20–35% of endocarditis

• S. aureus cause by injection of contaminated
preparations or needle contamination with S. aureus
› S. aureus colonizes the skin, and if the skin is not
sterilized before injection, the bacteria can be
introduced into bloodstream
• S. epidermidis is a common cause of prosthetic
heart valve endocarditis
 Cont…

Infective aortitis
─ May result from direct invasion of the aortic wall

One of the infectious causes of aortic aneurysms

─ This may develop as a result of staphylococcal infections
of the aorta, usually at atherosclerotic plaque

Cutaneous vasculitis
 Cont…

 Laboratory diagnosis

 Microscopy & culture from punctate

─ Gram stain smears: Gram positive cocci in
clusters
─ S. aureus colonies show β hemolytic
(complete haemolysis) on blood agar &
golden yellow to cream & occasionally white
colonies on nutrient agar
Fig. Gram staining of a pus preparation: Fig. Culture on blood agar: convex colonies
Gm+ cocci, some in grapelike clusters with yellowish pigment & porcelain/cream like
surface.
 Cont…

 Biochemical tests

─ Catalase test: All Staphylococci spp are catalase +ve

H2O2 + colony O2 bubble
─ Coagulase test:
• S. aureus is distinguished from the others primarily
by coagulase production
• Tested by adding few drops of a broth culture of the
organism to 0.5ml of human or rabbit plasma

 DNA test from punctate if required

 Cont…
 Treatment

 Treatment of S. aureus infections

For penicillin sensitive organisms: Penicillin G
For methicillin sensitive organisms: Nafcillin or
oxacillin
For those resistant to methicillin (MRSA): Vancomycin,
alternative drug: TMP-SMX (trimethoprim-
sulfamethoxazole)
 Acquired drug resistance by S. epidermidis is even more
frequent than by S. aureus
Vancomycin sensitivity remains the rule, but
vancomycin-resistant isolates have been reported
2. Streptococcus spp

 Distinctive characteristics

Gram positive cocci arranged in

chains
Non-motile, non-spore formers
Catalase-negative Fig. EM of Streptococcus
 Cont…

Important spp:

1. Streptococcus pyogenes

─ ß-hemolytic, Group-A streptococci

• Group A polysaccharide antigen present in their
cell wall
─ Virulence factors include:
a. Hyaluronic acid Capsule
 Cont…

b. Cell wall components

• Fimbriae
› It contains the major S. pyogenes virulence factor, the M
protein. [Note: The bacterium is not infectious in the
absence of M protein]
• Protein F (fibronectin-binding protein)
› Mediates attachment to fibronectin in the pharyngeal
epithelium

c. Extracellular products
• Secretes a wide range of exotoxins & enzymes
 Cont…

2. Streptococcus pneumoniae (Pneumococcus)

─ Non-groupable, α-haemolytic streptococci

• Do not have cell wall-defined group
antigens (grouped as viridans streptococci)
─ Inhabits the nasopharyngeal areas of healthy
individuals
─ They are surrounded by a polysaccharide capsule
• Capsule of S. pneumoniae is the most
important virulence factor
 Cont…

 Transmission

─ Colonization of the heart may follow

asymptomatic bacteremia, artificial or
damaged heart valves
• When individuals with known valvular heart
disease undergo dental work or other procedures,
this can produce asymptomatic bacteremias in
which colonization of the heart might follow
 Cont…

 Clinical significance

 Pericarditis/Myocarditis/endocarditis

─ Streptococcus spp cause 60-80% of

endocarditis

› Oral streptococci (most are viridans group) are

responsible for 50–70% of all cases of bacterial
endocarditis
 Cont…

─ The origins of endocarditis lie in:

• Invasion of the vascular system through lesions
in the oral mucosa
• A transitory bacteremia results
• The heart valves colonized and a biofilm is
formed by the organism
• Predisposing factors include:
› Congenital heart defects
› Acute rheumatic fever
› Cardiac surgery, &
› Scarred heart valves
 Cont…

 Rheumatic heart disease (RHD)

─ RHD is seen in Rheumatic fever (RF)

─ RF is principally a disease of childhood, although it can
occur in adults
─ Certain "rheumatogenic" strains of group A
streptococci appear to be associated with rheumatic fever
 Cont…

─ Up to 60% of patients with acute rheumatic fever

progress to rheumatic heart disease (RHD)
• RHD is a pancarditis, i.e., it involves all 3 layers of
the heart
• Valvular damage (chronic valvular deformities) is
the hallmark of rheumatic carditis

─ It is proposed that antibodies directed against

the M proteins of group A streptococci cross-
react with myosin in cardiac muscle & is
involved in the pathogenesis of rheumatic fever
 Cont…

– Rheumatic fever is a complication of almost always

streptococcal pharyngitis (i.e., strep throat)
• But, it occurs only in 3% patients with group A
streptococcal pharyngitis
• It rarely follows infections by streptococci at other sites

– Recurrent attacks of RF are associated with types

of group A ß-hemolytic Streptococcus to which the
patient has not been previously exposed and,
therefore, to which immunity has not developed
 Cont…

 Infective aortitis

─ May result from direct invasion of the aortic wall

 Cutaneous vasculitis

─ It is commonly related to such disparate

infections as streptococcal illnesses
 Cont…

 Laboratory diagnosis

Specimens: blood, throat swabs

Microscopy and culture from punctate/blood

─ Since the symptoms of RF occurs 2-3 weeks
after an infection with S. pyogenes, by this
time, throat cultures are usually negative
─ In this case SEROLOGY
Fig. Gram-positive cocci in chains Str. pyogenes
Fig. Str. pyogenes colonies: transparent, Fig. Str. Pneumoniae colonies: Smooth,
smooth, and well-defined zone of complete glistening, wet-looking, mucoid;
or β- haemolysis α-Hemolytic
 Cont…

Biochemical tests

─ Str. pyogenes
• Catalase: negative Fig. Group A streptococci is susceptible to
Bacitracin disk (left); The right shows resistance
• Bacitracin: susceptible

─ Str. Pneumoniae
• Catalase test: negative
• Optochin-susceptibility-
test: susceptible
 Cont…

 Serology
─ In (RF), increasing titers of serum antibodies to group
A streptococcal antigens (such as antistreptolysin O,
anti-DNAase & antihyaluronidase) provide concrete
evidence of a recent infection with group A
Streptococcus

 DNA test from punctate if required

 Cont…

 Treatment & prevention

 Infection of the heart valve (infective endocarditis)

is fatal if not treated
 Prompt treatment of streptococcal pharyngitis with
antibiotics prevents an initial attack of RF and, less
often, a recurrence of the disease
 There is no specific treatment for acute RF, but
corticosteroids and salicylates are helpful in
managing the symptoms
 Cont…

Individuals with known valvular heart disease

who undergo dental work or other procedures
(that may produce asymptomatic bacteremias)
are given antibiotics to prevent colonization of
the heart
 Cont…

3. Viridans Streptococci

 Distinctive characteristics

 Gram positive cocci

 They are members of the oral flora & upper GIT flora
 Collectively defined as those producing -hemolytic or
non-hemolytic colonies on blood agar
 Eg., S.mutans, S.sanguis, S.mitis
 Cont…

 They involved in endocarditis

• They form exopolysaccharides (glucan, frutan)

and this enable them to adhere to cardiac tissue
3. Enterococci

 Distinctive characteristics

Gram-positive cocci in chains

Facultative anaerobe
Catalase-negative
Members of the normal flora of the colon & are
noted for their ability to cause cardiovascular
infections
 Cont…

 The clinically most important species:

─ Enterococcus faecalis
• The majority of human clinical isolates
• α, ß, ϒ- hemolysis
─ Enterococcus faecium
• Associated with a remarkable capacity for
antibiotic resistance
• α- hemolysis
 Cont…

 Enterococci are not very virulent, but prominent

causatives of nosocomial infections as a result of
their antibiotic resistance

─ These organisms are highly resistant to

environmental and chemical agents, and can persist
on fomites
─ No exotoxins or virulence factors identified
 Cont…

 Disease

 Enterococci rarely cause disease in healthy

individuals

─ However, under conditions of lower immunity &

disrupted GIT or genitourinary tract integrity, can
spread to normally sterile sites
 Cont…

Endocarditis

─ Enterococci are among the most common

causes of hospital-acquired endocarditis
• The endocarditis is rare but life-threatening
─ May enter bloodstream during GIT or
genitourinary tract procedures; thus, infect the
endocardium & cause endocarditis
 Cont…

 Laboratory Diagnosis

 Gram-stained smear & culture

─ α-, ß-, or non-hemolytic colonies on blood agar
 Enterococci are distinguished from the non-Group D
streptococci by their ability to survive in the presence
of bile, & to hydrolyze the polysaccharide esculin
 E. faecalis can be distinguished from E. faecium by their
fermentation patterns
 Serologic tests not useful
 Cont…

 Treatment

 They frequently develop resistance to antibiotics

─ Strains manifesting multiple resistance are found
mainly in hospitals
─ They are not killed by penicillin G
─ Even, vancomycin-resistant enterococci (VRE)
have emerged
 As a result, a combination of penicillin +
aminoglycoside (such as gentamicin) is required
to be killed
 Cont…

 Prevention

Penicillin + gentamicin should be given to

patients with damaged heart valves prior to
intestinal or urinary tract procedures

No vaccine is available

4. Mycobacterium tuberculosis

 Distinctive characteristics

Acid-fast bacilli
Are obligate aerobic
Grow slowly
 Cont…

 Disease

 Tuberculous myocarditis/pericarditis

─ One of the extrapulmonary form of active TB

─ Usually associated with concurrent pulmonary
disease
─ Immunologically mediated injury
 Cont…

─ Tuberculous Pericardial Disease is a

common cause of chronic pericardial effusion,
especially in parts endemic areas

─ Tuberculous pericarditis may scar & cause

constrictive pericarditis
› Result impaired filling of the ventricles due
to limited expansion by the stiff pericardium
 Cont…

Atrioventricular block

Causes aortitis
─ Loss of aortic wall elasticity results from
granulomatous destruction of the medial
layer may result in aortic aneurysms

Cutaneous vasculitis
 Cont…

 Laboratory Diagnosis

Microscopy & culture from punctate

─ Acid fast staining
─ Blood cultures are often positive & reveal the
nature of the infecting agent
 Cont…

Pericardial biopsy
─ If the etiology of chronic pericardial effusion
remains unclear by detailed analysis of the
pericardial fluid, a pericardial biopsy (by
thoracotomy) should be performed
─ If definitive evidence is still lacking but the
specimen shows granulomata with caseation,
anti-tuberculous chemotherapy is indicated

DNA test from punctate if required

 Cont…

 Treatment

Treated as pulmonary TB with addition of

corticosteroids to prevent scarring
Multidrug therapy
─ In as much as Rx is quite effective, fail to notice a
tuberculous pericardial effusion may have
serious consequences
Tubercular cardiac constriction should be
treated surgically (pericardiectomy) while the
patient is receiving anti-TB chemotherapy
5. Treponema pallidum

 Distinctive characteristics

Gram-negative
Long, slender, spiral- shaped rods,
Organisms are highly motile
Does not grow in bacteriologic media or in cell
culture
 Cont…

Transmission

─ Almost always by sexual contact or

─ Transplacentally (congenital syphilis)
 Cont…

 Syphilitic vascular diseases

Heart involvement occurs in the tertiary stage

of syphilis, many years after acquisition
 Cont…

Pericarditis
─ Treponema pallidum is among the
etiologies of infectious pericarditis

Etiologies of Atrioventricular block

 Cont…

Syphilitic infective aortitis

─ Spirochetes invade the aortic root and induce destructive

granulomatous inflammation
─ Tertiary syphilis can cause aortic root dilation (aortic
aneurysm) & aortic insufficiency
• Destruction of collagen & elastic tissues leads to
dilation of the aorta, scar formation, and calcification
• Therefore, older adults with acquired aortic root
dilation and/or aortic insufficiency should have
syphilis serology test
Syphilis also cause infective vasculitis
Fig. Cardiovascular syphilis - narrowing of coronary ostia in aortus
 Cont…

 Laboratory diagnosis

Diagnosis is established by a positive

serologic test, i.e., rapid plasmin reagin
(RPR) or fluorescent treponemal antibody
 Cont…

 Treatment

 Any adult with aortic root dilation or aortic valve

insufficiency should have serologic testing for
syphilis and receive treatment for tertiary syphilis if
confirmed positive
─ Treatment includes surgical excision & repair
 The better control and treatment of syphilis in its
early stages has decreased the frequency of these CVS
complications
6. Rickettsia spp.

 Distinctive characteristics

Gram-negative, but stain poorly

Small, rod-like or coccobacillary in shape
Rickettsiae are obligate intracellular
parasites, because they are unable to produce
sufficient energy to replicate extracellularly
Produce various enzymes for metabolism
 Cont…

Not routinely cultured b/c of obligate

intracellularity & hazard to laboratory
personnel
But, grown in cell culture, embryonated eggs,
or experimental animals
 Cont…

Species
─ R. rickettsii
─ R. akari
─ R. prowazekii
─ R. typhi
─ R. tsutsugamushi (currently named, Orientia tsutsugamushi)
Virulence factors:
─ Rikettsial pathogenesis is primarily due to
destruction of endothelial cells by
replicating bacteria
 Cont…

 Pathogenesis & clinical manifestations

Rickettsia are transmitted to humans by

arthropods such as fleas, ticks, mites, or lice

Have an affinity for endothelial cells located

throughout the circulatory system
 Cont…

 Cause infective vasculitis,

myocarditis/pericarditis

─ Rickettsiae produce a characteristic widespread

vasculitis
─ The organism usually disseminate from the entry site
into the blood and invade endothelial cells, smooth
muscle cells of the media of small vessels and capillaries
─ Each different rickettsial disease affects different types of
small vessels and its extent and severity varies
─ Rickettsial diseases commonly cause vasculitis, which
affects small coronary blood vessels
 Cont…
1. Rocky Mountain spotted fever
─ A tick-borne disease caused by R. rickettsii
Rickettsialpox: other spotted fever caused by R.
akari; the vector is a mite
2. Typhus:
─ There are several forms of typhus, namely-

a. Louse-borne epidemic typhus: this is the most

important of the typhus group diseases & caused by R.
prowazekii
─ [Note: Epidemic typhus is a different disease from salmonella-
induced typhoid fever. When the two diseases were determined
to be caused by different organisms, the salmonella-induced
disease was named typhoid, meaning typhus-like]
 Cont…

b. Flea-borne endemic typhus (murine typhus):

caused by R. typhi

c. Chigger-borne scrub typhus: caused by R.

tsutsugamushi (currently named, Orientia
tsutsugamushi); vector is mite larvae

d. & several other quite rare forms

Table: Epidemiology of common Rickettsia and Orientia infections.
 Cont…
 Lab identification

Serological tests to diagnose typhus:

─ Indirect fluorescent antibody test
─ Complement fixation test
─ Weil –felix reaction: Some of the antigen
of Proteus strain (OX-19, OX-2,OX-K)
agglutinates with sera from patients with
rickettsial diseases
 Cont…

 Treatment, prevention & control

 Drug of choice: tetracycline & chloramphenicol

 Personal hygiene
 Delousing with insecticide
 Tick repellents
 Removing of vegetations in which rates & mites live
 7. Francisella tularensis

 Distinctive characteristics

 Gram-negative
 Small, pleomorphic coccobacilli
with a lipid-rich capsule (may be
a virulence factor)
 Strict aerobe & rarely cultured
 Facultative intracellular parasites
 Cont…

 Epidemiology

Primary pathogen of animals (includes wild &

domestic mammals, birds, & house pets), zoonotic

Infection of humans by contact with infected

animal tissues or bite arthropod (for example,
ticks, lice, & mites); inhalation or ingestion
also can result in infection
 Cont…

 Pathogenesis

After inoculation into the skin, it multiplies

locally
Spread to regional lymph nodes, producing
lymphadenopathy (buboes), and with
bacteremia, may spread to distant organs
─ It parasitizes the reticuloendothelial system
and lives intracellularly in macrophages,
inhibiting phagosome-lysosome fusion
Result in Tularemia
Fig., Patient with oculoglandular tularemia.
 Cont…
 Lab identification

Gram stain has little value- b/c weakly staining, gram-ve

Culture from lymph node biopsy, sputum & blood

─ Isolation of bacteria is not often attempted, because
of the high risk of laboratory infection
─ It is nutritionally fastidious & requires a sulfhydryl
source such as cysteine; the medium of choice is
cysteine-glucose-blood agar
─ Colonies are blue-gray, round, smooth, & slightly
mucoid
 Cont…

Agglutination test:
─ The diagnosis of tularemia is most frequently
confirmed by agglutination testing

Indirect fluorescent antibody test with

commercially available antisera can be useful

PCR is helpful
Fig., Gram stain of Francisella tularensis isolated in culture; note
that the extremely small coccobacilli look like fine sand.
 Cont…

 Treatment & Prevention

 The drug of choice is streptomycin

or gentamicin
 A live attenuated vaccine is available
for people with occupational risk
 Handling animals with gloves, particularly
when skinning or eviscerating, gives
protection, and contact with ticks should be
avoided
8. Burkholderia

A. Burkholderia mallei

 Gram-negative rod
 It is not an environmental organism and does
not persist outside its equine hosts
 Infection is from contact with horses
 The polysaccharide capsule is a critical
virulence determinant
 Cont…

Cause Malleus (glanders)

─ Inoculation into the skin, where it causes local
infection with nodules & regional lymphadenitis
─ Starting from these primary infection foci they can
move to other organs, either lymphogenously or
hematogenously, and cause secondary abscesses
there

 Microscopy & culture from nasal secretion, abscess or

blood
 Treatment: penicillins & cephalosporins
 Cont…

B. Burkholderia pseudomallei

 It is facultative intracellular organism

 Its natural reservoirs are soil & water
 Infection is acquired by direct inoculation
when soil contaminates skin abrasions,
inhalation, or ingestion
─ Only rarely is the organism transmitted from
person to person
 Cont…

 The pathogen invades the body

 Replicate in PMNs & macrophages aided by
its capsule for its intracellular survival
 Infection can disseminate & cause abscesses in a
number of d/t organs
 Cause Melioidosis, a disease of animals &
humans resembling malleus
 Cont…

 Diagnosis is made by Microscopy & culture

from sputum, abscess or blood
 Treatment: Tetracycline,
chloramphenicol, sulfonamides have been
effective in therapy

 The recognition of this bacterium as a potential

agent of biologic warfare has stimulated
interest in the development of a vaccine
9. Yersinia pestis

 Distinctive characteristics

N. meningitidis
Gram-negative
Small rod that stains bipolarly with special stains
N. meningitidis
Non-motile; encapsulated
Animals are natural hosts of yersinia, and humans
are accidental hosts of yersinia infection
 Cont…

Virulent factors

1. It produces V (protein) & W (lipoprotein)

surface antigens
─ Together confer on the cells the ability to resist
phagocytic digestion
2. Endotoxin: contribute to the toxaemia of plague
3. Capsule: helps to resist phagocytosis
4. Plasminogen activator & fibrinolysin,
which may play a critical stage of infection
 Cont…

 Epidemiology

 Yersinia pestis is predominantly a zoonotic with

worldwide distribution
 The organism can infect a variety of mammals
 Transmitted by fleas, the rat flea (Xeopsylla
cheopsis) carries infection from rat to rat and from
rat to human; or by ingestion of contaminated
animal tissue or via respiratory route
 Humans are generally accidental & dead-end hosts
 Cont…

 Pathogenesis & Clinical manifestations

 Organisms are carried by the lymphatic system

from the site of inoculation to regional lymphnodes,
where they are ingested by phagocytes
 Resistant to intracellular killing by phagocytes &
instead may multiply within these cells
The affected lymph nodes display hemorrhagic
necrosis:
– Buboes (are characterized by edema and congestion)
are typically located in the groin, but may also occur in
axillae or on the neck
 Cont…

 It is called Bubonic Plague

 Common complications are disseminated

intravascular coagulation (DIC)
 Cont…
 Lab diagnosis

Specimen: aspirate from a bubo, blood

1. Microscopy

─ Gram-stain, Wright’s stain, immunofluorescence

stain, methylene blue stains, basic fuchsin stain , and
Wayson’s stain to demonstrate bipolar granules
 Cont…

2. Culture
─ The organism grows on blood agar, MacConkey agar or
cefsulodin-irgasan-novobiocin agar (CIN, a medium
selective for Yersinia)
• NB: All cultures are highly infectious & must be handled with extreme
caution
─ Identification is based on biochemical screening

3. Biochemical tests
─ Y. pestis is catalase +ve, oxidase –ve
─ A microbiology specialist laboratory is required to identify Y. pestis
 Cont…

4. Serology

─ In the absence of a positive culture, serologic

tests for anti-Yersinia antibodies may assist in
diagnosis
• Fluorescent antibody technique using Y. pestis
antisera
READING ASSIGNMENT
 Chlamydia trachomatis
 Mycoplasma pneumoniae
 Corynebacterium (Diphtheria)
 Borrelia burgdorferi (Lyme disease)
 Enterobacteriaceae (e.g., Salmonella)
 Gram-negative anaerobes
 Neisseria
 Legionella
 Actinomyces spp.
 Nocardia spp
 HACEK group organisms (Haemophilus spp., Actinobacillus actinomycetemcomitans,
Cardiobacterium hominis, Eikenella corrodens, Kingella kingae)
Virology of Cardiovascular
System
1. Enterovirus

A member of the family Picornaviridae

─ Positive-strand, ssRNA
─ Non-enveloped, icosahedral

Clinically important spp

a. Coxsackievirus group A & B
b. Echovirus
 Cont…

a. Coxsackievirus A & B

 Coxsackievirus, group A, with 22 serotypes

 Coxsackievirus, group B, with 6 serotypes
 Cont…

 Pathogenesis & CV infections

 Heart infections are transmitted by fecal-oral route and

occasionally from pharyngeal secretions
─ Ingested coxsackieviruses spread from pharynx/gut to
lymphatics & then to blood
─ Invasion of heart takes place & results in acute
inflammation
 Result in acute myocarditis & pericarditis
─ The prognosis is good & complete recovery is the rule
 Cont…

 Microbiologic diagnosis

 Coxsackievirus may be isolated from throat swabs,

fecal specimens or occasionally pericardial fluid
 Serology, if necessary combined with isolation
and PCR of punctate

 Viral RNA detection methods may be used on

endomyocardial biopsy tissue
 Cont…

Transmission is either direct or in food & water

There are no specific vaccines

 Cont…

b. Echovirus

 Other member of the genus enterovirus

 Like other enteroviruses, transmitted per os and
replicate at first in the lymphoid tissue of the
pharyngeal space, later mainly in the intestinal wall
─ They then reach their “target organs” (e.g.,
heart), followed by organ infection,
(pericarditis & myocarditis)
─ However, only develops in a small percentage of
cases
2. Rubella virus

In the family togaviridae

Single-stranded, positive strand,
enveloped RNA virus
Icosahedral

It is the only member of the

Rubivirus genus
 Cont…

Respiratory secretions of an infected

person are the primary vehicles for
transmission
 Cont…

 Clinical significance

Rubella can cause myocarditis and

associated congenital lesions in the fetus

─ If a woman is infected during pregnancy, there

can be severe damage to the developing fetus,
es., in the first trimester
─ This damage can include congenital heart
disease
Fig. Pathology of rubella virus infection.
 Cont…

There is no treatment, but there is a vaccine

Fetal damage from rubella is preventable by

live attenuated rubella vaccine that is
included with the routine childhood vaccinations
3. Ebola virus

 Description

 Taxonomy
– Order: Mononegavirales
– Family: Filoviridae
– Genus: Ebolavirus
– Species: Ebola virus
– 4 strains:
• Ebola-Zaire, Ebola-Sudan, Ebola-Ivory Coast
– Cause disease in humans
• Ebola-Reston
– Disease in nonhuman primates
 Cont…

 Structure of Ebola genome &

proteins
– Long, filamentous, enveloped,
coiled rod
– (-) ssRNA viruses (800-1000 nm)
– Appears to have “spikes” due to
glycoprotein on outside
membrane
– The name “Ebola” originates from
the Ebola river in the Democratic
Republic of Congo (formerly Zaire,
b/c of the first recorded outbreak
there)
 Cont…

– Transcribed into 8 sub-genomic mRNA proteins:

7 structural & 1 nonstructural
o The 7 structural proteins are:
• Nucleoprotein (NP)
• 4 viral proteins (VP35, VP40, VP30, VP24)
• Glycoprotein (GP)
• RNA-dependent RNA polymerase (L protein)

‹ NP, VP35, VP30, L protein: required for transcription & replication

‹ VP40, GP, VP24: associated with the membrane

Fig. Genome
Fig. Proteins
 Cont…

 Replication

– Replication takes 8 hours; therefore, it spreads rapidly

– Its life cycle begins with attachment to specific cell-surface
receptors,
• Followed by fusion of virion envelope with cellular membranes
& the concomitant release of the virus nucleocapsid into cytosol
– The viral RNA polymerase (encoded by the L gene)
partially uncoats the nucleocapsid & transcribes the genes
into (+) mRNAs
– Then the mRNA translated into structural & nonstructural
proteins
– In addition, genomic replication occur
 Cont…

– Newly synthesized structural proteins & genomes self-

assemble & accumulate near the inside of the cell membrane
– Push through cell surface, gaining their envelopes from the
cellular membrane they bud from
– The mature progeny particles then infect other cells to repeat
the cycle

– Ebola genome capable of rapid mutation

• Very adaptable to evade host defenses & environmental
change
– Never normal flora in humans
 Cont…

 Epidemiology

 Its natural habitat is Africa

 First appeared in Africa in 1976 in two countries
– 2 species were identified in 1976 in Zaire (now called
Democratic Republic of Congo) & Sudan (in a town called N’zara)
with Case fatality rates of 83% & 54%, respectively
• Zaire ebolavirus (ZEBOV) &
• Sudan ebolavirus (SEBOV)
– A 3rd species, Reston ebolavirus (REBOV), was discovered in
November 1989 in a group of monkeys (Macaca fascicularis)
imported from the Philippines
– Ivory Coast ebolavirus – Only one human case recorded, that
was unlucky scientist & he survived
 Most Recent
– The largest outbreak to date is the 2014 West Africa Ebola virus
outbreak, which is affecting Guinea, Sierra Leone, Liberia & Nigeria.
 Cont…

 Natural reservoir
– Ebola virus evolved to occupy special niches in the wild
• Fruit bats, particularly species of the genera
Hypsignathus monstrosus, Epomops franqueti &
Myonycteris torquata, are considered possible natural
hosts for Ebola virus
‹ As a result, the geographic distribution of Ebolaviruses
may overlap with the range of the fruit bats
• Although non-human primates have been a source of
infection for humans, they are not thought to be the
reservoir but rather an accidental host like human
beings
• However, it demands more studies on what organism carries it
naturally without being infected
 Cont…

 Suspected to be a zoonotic (animal-borne) & the

suspected vectors include:
– Bats (considered as the most likely natural reservoir)
– Non-human primates, such as: monkeys,
gorillas,chimpanzees
• Outbreaks occurred in countries that house 80% of
the world’s remaining wild gorilla & chimpanzee
populations
• These outbreaks were preceded by abnormally large
death in wild Gorilla populations
• The same distinct viral strains were isolated in
animal carcasses & in bodies of those who handled
those carcasses
 There is no evidence that mosquitos or other insects
can transmit Ebola virus
 Cont…

– Transmission
• Direct contact with blood, body secretions of infected person/or
mammal
› The 3 strains are transmitted by contact fluids or skin; but,
Ebola-Reston has shown to be airborne
› It is transmitted to people from wild animals & spreads in
human population through human-to-human transmission
• Indirect transmission
› By contact with contaminated medical equipment, particularly
needles & syringes
› Improper sterilization of medical equipment
› Medical workers who do not wear appropriate protective
clothing may also contract the disease
# Nosocomial transmission (spread of a disease within a health-
care setting)
 Cont…

 Pathogenesis

 Enters bloodstream through skin,

membranes, open wounds
 Endothelial cells, mononuclear
phagocytes & hepatocytes are the main
targets of infection
 Target mainly small capillary
vessels
Copyright: Russell Kightley Media,
Australia
 Cont…

 The cytopathic effect on endothelial cells

results in a loss of vascular integrity,
– Causing permanent bleeding (internal &
external)
• Causes blood vessel “bursting”
• Systemic (all organs/tissues)
 In addition to the loss of vascular integrity,
the synthesis of GP:
– Reduces specific integrins (i.e., responsible
for cell adhesion to the intercellular structure) &
Cause damage to the liver, which leads to
coagulopathy
 Not much is known about the body’s response
– b/c of the dangers of handling samples from
infected patients & the short time span
available for investigation
 Cont…

 Clinical manifestations

 Ebola virus disease (a.k.a.,

Ebola hemorrhagic fever)
– Acute, mostly fatal disease
– Incubation Period: anywhere
from 2-21 days
– Early symptoms
• Muscle aches, vomiting, fever
(extremely high To)
• Skin rash, diarrhea, stomach
pain, Severe headache,
Weakness, Red eyes
(conjunctivitis)
 Cont…

– Acute symptoms

• Bleeding/hemorrhaging from
skin, orifices, internal organs
› External bleeding,
Extremely high body
temperature, Prostration

 Fatality rates:
– Ebola-Sudan – 60%
– Ebola-Zaire – 77-88%
– Ebola-Cote D’Ivoire: only one
Fig. Mass graves for Ebola victims
human case recorded, patient survived
 Cont…

 Laboratory Diagnosis

 Classified as Biosafety level 4 agents

– Greatest threat to humans, requiring biosafety level 4-equivalent
containment
– Samples of bodily fluids & tissues from people with the disease
should be handled with special caution
– Laboratory researchers must be properly trained in BSL-4
practices & wear proper personal protective equipment
 Early Diagnosis
• Very difficult
• Signs & symptoms very similar to other infections
 Cont…

 Laboratory tests

– ELISA- test for IgM & IgG anitbodies

• Detecting antibodies against the virus is effective
late in the disease & in those who recover
– Serum neutralization test
– Antigen detection tests
– Electron microscopy
– PCR
• A test to match the genome from the sample to
known Ebola genome
 Cont…

– Virus isolation
• Isolating the virus by cell culture, detecting the viral
RNA by PCR and detecting viral proteins by ELISA is
effective early and in those who have died from the
disease
• During an outbreak, virus isolation is often not feasible.
The most common diagnostic methods are therefore real
time PCR and ELISA detection of proteins, which can be
performed in field or mobile hospitals
• Filovirions can be seen and identified in cell culture by
electron microscopy due to their unique filamentous
shapes, but electron microscopy cannot tell the difference
b/n the various filoviruses despite there being some
length differences
 Cont…

 Treatment

 There is no cure for Ebola; however, new drug therapies are

being evaluated,
• Zmapp is one of them
• Doctors transmitted blood from survivors to sufferers, hoping
to transmit whatever antibodies helped them survive

 Severely ill patients require intensive supportive care

– Providing fluids & electrolytes
– Maintaining oxygen status & blood pressure
– Treating other infections if they occur
 Cont…

 It is unknown whether or not survivors gain immunity

from infection
– Believed it is possible, but because of the limited ability to test
this theory, it remains to be seen.

 It is category A bioterrorism agent by the CDC (Centers

for Disease Control & Prevention)
– It has the potential to be weaponized for use in biological
warfare (no uses)
 Cont…

 Prevention
 No licensed vaccine is available
– Several vaccines are being tested, but none are available for clinical
use
– The Ebola virus is now on the “A” list for hopeful vaccination
development
 Extensive precautions taken when dealing with suspected cases to limit
transmission
– Several layers of protective clothing covering entire body (up to four)
– Complete equipment sterilization
– Hand washing
– Quarantine (a.k.a., enforced isolation of Ebola HF patients)
 Once someone recovers from Ebola, they can no longer spread the
virus. However, Ebola virus has been found in semen for up to 3
months. People who recover from Ebola are advised to abstain from sex
 Cont…

 Since virus is contagious in fluids for days after death,

burial use extreme caution during handling, transport, &
cultural practices
• Have a protective clothing
• Body sealed in body bag & coffin
• Sanitation of all equipment before & after
• Incinerate all waste
 Decreasing the spread of disease from infected animals
to humans
– Checking animals for infection & killing and properly
disposing of the bodies if the disease is discovered
– Properly cooking meat and wearing protective clothing
when handling meat may also be helpful, as are wearing
protective clothing and washing hands when around a
person with the disease.
 Cont…

 If you are in or traveling to an area affected by the Ebola

outbreak, protect yourself by doing the following:
– Wash hands frequently.
– Avoid contact with blood and body fluids of any person, particularly
someone who is sick.
– Do not handle items that may have come in contact with an infected
person’s blood or body fluids.
– Do not touch the body of someone who has died from Ebola.
– Do not touch bats and nonhuman primates or their blood and fluids
and do not touch or eat raw meat prepared from these animals.
– Avoid hospitals where Ebola patients are being treated.
– Seek medical care immediately if you develop fever (temperature of
38.6oC and any of the other following symptoms: headache, muscle
pain, diarrhea, vomiting, stomach pain, or unexplained bruising or
bleeding.
– Limit your contact with other people until and when you go to the
doctor. Do not travel anywhere else besides a healthcare facility
4. Adenoviruses

 Non-enveloped, icosahedral, Double-stranded DNA

viruses; in the family adenoviridae
 Causes myocarditis/pericarditis
─ Adenovirus infection of heart muscle to be one
cause of left ventricular dysfunction
 Serology, if necessary combined with isolation &
PCR of punctate
 No antiviral agents are currently available for
treating adenovirus infections
 READING ASSIGNMENT
 Hepatitis viruses (Hepatitis B & C viruses)
 Herpes viruses (Herpes simplex virus, Varicella-zoster virus,
Epstein-Barr virus, & Cytomegalovirus)
 HIV
 Mumps
 Viral Hemorrhagic Fever
– Arenaviruses (Junin virus, Machupo virus, Lassa virus, Guanarito virus, & Sabia virus)
– Filoviruses (Ebola virus & Marburg virus)
– Bunyaviruses (Rift Valley fever virus, Hantavirus, & Crimean- Congo H.F.)
– Flaviviruses (Yellow Fever virus, Dengue virus, Kyasanur Forest Disease)
 Parvovirus B19
 Influenza viruses
 Parainfluenza viruses
 Mycology of
Cardiovascular System
1. Candida albicans

 Distinctive characteristics

A Yeast
Show pseudohyphae
Opportunistic pathogens
 Cont…

 CVS diseases

Pericarditis/myocarditis/endocarditis

─ Candida infection of the myocardium typically

occurs in immunocompromised patients,
although the heart is relatively resistant to
fungal infection
 Cont…

 Microbiologic diagnosis

 Microscopy: candida yeast cells can be detected in

unstained wet preparations, Gram stained
preparations or direct IF
o In stained smears, the yeasts can often be seen attached to
pseudohyphae

 Culture: C. albicans grows well on Sabouraud agar and

most routinely used bacteriological media
 Cont…

 Treatment

 Removal of the infected valve and long-term

antifungal therapy constitute appropriate treatment
for Candida endocarditis
─ Therapy for Candida endocarditis consists of
amphotericin B + flucytosine & early
surgery; long-term suppression with an oral azole
is advised’
2. Aspergillus spp

 Distinctive characteristics

Lightly colored or hyaline (moniliaceous) molds

Opportunistic fungi
 Cont…

 Aspergillus CVS Diseases

 Endocarditis (native or prosthetic endocarditis),

pericarditis, myocarditis
─ Most cases are prosthetic valve infections; Native
valve disease is reported, especially in persons using
illegal IV drugs
─ Culture-negative endocarditis with large vegetations
is the most common presentation, but embolectomy
reveals the diagnosis in a few cases

 Infective vasculitis as a result of direct infection

 Cont…

 Microbiologic diagnosis

Microscopy (direct IF)

Culture
PCR if required
 Cont…

 Treatment

Surgical treatment is important in heart

valve aspergillosis
Aspergillus endocarditis have very poor
outcomes
READING ASSIGNMENT

 Cryptococcusis
 Histoplasmosis
 Coccidioidomycosis
 Blastomycosis
 Mucormycosis
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Edition. The McGraw-Hill Companies, Inc.
 Harvey RA., Champe PC. and Fisher BD. (2007): Microbiology
Lippincott’s illustrated reviews.2nd edition. Lippincott Williams & Wilkins.
 Internet sources
 Jawetz, Melnick, & Adelberg (2007): Medical Microbiology, 24 th edition.
The McGraw-Hill Companies, Inc.
 Kayser FH., Bienz KA., Eckert J., Zinkernagel RM. (2005): Medical
Microbiology. Thieme Stuttgart. New York.
 Mims C., et al. (2004): Medical microbiology. 3rd edition. Elsevier ltd.
 Monica C. (2006): Part I: District laboratory practice in tropical countries.
2th edition. Cambridge university press.
 Monica C. (2006): Part II: District laboratory practice in tropical
countries. 2th edition. Cambridge university press.
 Rubin R. & Strayer DS. (2012). Pathology: clinicopathologic foundations
of medicine. 6th ed. Lippincott Williams & Wilkins.