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Mycobacteria
Dr.SriMulyaningsih

ImportantHumanPathogens
M cobacteri mt Mycobacterium tuberculosis berc losis Mycobacteriumleprae (uncommon)

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LipidRichCellWallofMycobacterium
Mycolicacids

CMNGroup:
Unusualcellwall lipids(mycolic acids,etc.)
(PurifiedProteinDerivative) ( )

Mycobacteriumtuberculosis
M.tuberculosis complexincludesseveralspecies: 1.Mycobacteriumtuberculosis 2.Mycobacteriumbovis unpasteurizedmilk;recent rashofcasesinUS 3.MycobacteriumbovisBCG 4 Mycobacteriumafricanum andMycobacterium 4. canetti=rarecausesoftuberculosisinAfrica 5.Mycobacteriummicroti=pathogenforrodents

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Organismcharacteristics
1.Aerobic,nonmotile,nonsporeformingbacillus 2.Highcellwallcontentofhighmolecularweight lipids mycolic acid 3.SLOWGROWTHRATE a.generationtimeof20hoursvs E.coli generationtimeof g f20minutes
b.38weeksbeforegrowthonsolidmedia; c.implicationsforlengthoftreatmentforcomplete sterilizationcomparedwithmostbacterialpathogens

PathogenesisofTuberculosis
Inhalationofsmall(15m)dropletnuclei containing t i i M.tuberculosis t b l i expelled ll dby b coughing,sneezing,ortalkingofanother individualwithcavitary tuberculosis PrimaryinfectionbyM.tuberculosis ofnon immunealveolarmacrophages p g with unrestrainedproliferationwithintheinfected macrophages

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LungsaretheportalofentryexceptM.bovis inunpasteurized dairyproductsfromothercountries Inhalationofdropletnuclei(bacillus5microns):frominfectious personwithactivepulmonarytuberculosis, tuberculosis NOTjustpositive PPD a.cough:mostefficientat3000infectiousdropletnucleiper cough b.talking:similarquantityover5minutes c.sneezingmoreefficientthancoughing;singingintermediate b between talking lk and dcoughing. h d.Bacillusremainsaliveandinfectiousinairforlongperiod; ventilationkeyinpreventingtransmission;isolationofpatient andmandatednumberofairexchangesinhospitalrooms

PathogenesisofTuberculosis
Disseminationofinfectedmacrophages th through hthe th draining d i i lymphatics l h ti into i t th the circulation Developmentwithin38weeksofaCD4+T celldependentcellmediatedimmune response p withg granuloma formationand macrophageactivationatsitesofinfection

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PathogenesisofTuberculosis
Activeinfectionusuallytransformedinto l t ti latent infection f ti ( (exceptions: ti i infants, f t AIDS) WithdecrementinTcelldependentcell mediatedimmunity(yearslater)infection reactivatedwithdevelopmentoftuberculosis (HIVinfection, ( ,diabetesmellitus, ,renal disease,cancer,advancedage)

PathogenesisofTuberculosis
ReactivationofM.tuberculosis infectionwith partial ti li immunity it produces d hi high hti tissue concentrationsofmycobacterial antigens thatprovokeanintensemononuclearcell response(type4hyper sensitivityreaction)

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PathogenesisofTuberculosis
Densemononuclearcellinfiltratesdamage ti tissue d duet torelease l of factive ti oxygenradicals di l andlysosomal neutralproteases Tissuedamageoccursascaseation necrosis thatprogressestoliquefactionnecrosisinthe absenceoftuberculosisdrug gtreatment

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ClinicalFeaturesofTuberculosis
Apicalcavitary lesionsinupperlobesoflung b Xrayfilm by fil of fthe th chest h t PositivetuberculinskintestwithPPD (purifiedproteinderivative)

ChestXRayofPatientwithActive PulmonaryTuberculosis

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TuberculosisandtheDisadvantaged
Homelesspersons Intravenousdrugabusers Prisoninmates(Russiaandotherprevious statesoftheSovietUnion) RecentimmigrantstotheUnitedStates(Asia, LatinAmerica) HIV1infection/AIDS

Epidemiology
Worldwide:WHOMaps:Estimatedincidencevs.case notifications 1.M.tuberculosisinfectsonethirdworldspopulation causes8millionnewcasesactivediseaseannually 2.Causes2milliondeaths=2ndonlytoHIVascauseof deathfrominfectiousagentworldwideamongadults 3.HIV/TBrelationshiphasexacerbatedproblemwithTB i increasing i i inareaswith ithhi high hAIDSincidence i id Especially E i ll subSaharanAfrica 4.AbsolutenumbersofcasesofTBhighestinAsia

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Epidemiology
Downwardtrendinincidenceevenbeforeadventof antibiotics Annualdecreaseinmortalityandmorbidityof4%6%in developedcountries between1900andWW2: Betterlivingconditionslessconducivetoairborne spread. d Adventofantibioticslate1940s(Streptomycin)andINH in1952:Tuberculosisiscurable

Diagnosticprocedures:SPUTUM: staining,culturesandmolecular diagnostics

1.Acidfaststain: ZiehlNeelsen stain=fixedsmearcoveredwith carbolfuchsin,heated,rinsed,decolorized withacidalcohol;Kinyoun stainissimilarbut h ti unnecessary heating SMEARPOSITIVITYMEANSATLEAST10,000 ORGANISMS/mL SPUTUM

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Diagnosticprocedures
2.Culture: a. Solid S lidmedia= di L Lowenstein t i J Jensen( (eggb based) d) b. Middlebrook 7H11(agarbased):candetect colonymorphology,mixedinfections;can detect10100organisms/mL;38weeks incubationtodetectorganisms CULTURENECESSARYTODETERMINEDRUG SUSCEPTIBILITIES

LowensteinJensenEggBaseMedium
Coagulatedwholeeggs Potatoflour Glycerol Definedsalts MalachiteGreen(0.025g/100mL) (Petragnani 0.052g/100mL) (ATS0.020g/100mL)

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Middlebrook AgarBase7H10Medium
Definedsalts Vit i and Vitamins dC Cofactors f t Oleicacid Albumin Catalase Glycerol Dextrose MalachiteGreen(0.0025g/100mL)

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Diagnosticprocedures
3.Nucleicacidamplification candetectM.tuberculosiscomplexinfreshsputum: developedworldtechnology toocostlyforresourcepoorcountries 4.DNAfingerprinting:Molecularepidemiologictool: RFLP(Restrictionfragmentlengthpolymorphism);also developedworldtechnology producesDNAfragments; g ; Restrictionendonuclease p separatefragmentsbyelectrophoresis;probeto repetitiveDNAsequence=Insertionsequence(IS)6110 numerouscopiesofIS6110presentinM.tuberculosis chromosomeathighlyvariablelocations

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Treatment
1. Alwaysuseatleast2drugs; usually ll begin b i with ith3or4pending di sensitivities iti iti 2. Prolongedlengthnecessary: 69monthsif organismpansensitive 3. DirectlyObservedTherapyforallpatients a Nooneis100%compliantage, a. age sex, sex race, race education b.Dailytreatmentforfirst2months;

Treatment
Drugs:ALLGIVENONCEDAILYTOGETHER:NEVERDIVIDE DOSES 1.Isoniazid=INH;bactericidalagainstdividingorganisms 2.Rifampin=RMP=bactericidal;Enablesshortcourse treatment drugdruginteractions:RMPispotentinducerofhepatic microsomal enzymes:cytochrome p450 3.Pyrazinamide=PZA;Enablesshorteningofregimenfrom9 monthsto6months 4.Ethambutol=EMB:Usedindrugresistanceandsituations whereINHorRMPcannotbeused (INHhepatotoxicity;RMPdrugdruginteractions)

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Prevention:BCG
Mostwidelyusedandmostcontroversialvaccineinthe world A.Whatisit? M.bovis strainattenuatedthroughserialpassage B.Doesitwork?
1.Largeststudy:India=noprotectionfromTBinfection 2.Otherstudies:England=protectionfromTBinfection 3.Prevalenceofnontuberculous mycobacteria ingivenregionmay interfere 4.Backgroundprevalenceoftuberculosisdeterminesutility

C.Whousesit? Newbornsvaccinatedinallhighprevalenceareasofworld shownonfirstmap

Mycobacteriumleprae

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MycobacteriumlepraeInfections

MycobacteriumlepraeInfections(cont.)

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Tuberculoidvs.LepromatousLeprosy
ClinicalManifestationsandImmunogenicity

Lepromatousvs.TuberculoidLeprosy

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LepromatousLeprosy(Early/LateStages)

LepromatousLeprosyPre and PostTreatment

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