Pathology: ID & Micro

Pathology of Bacterial Infections ............................................................................................................................................ 2 Streptococci (I & II) ................................................................................................................................................................. 5 Enterococci.............................................................................................................................................................................. 9 Listeria & Other Gram-Positive Rods .................................................................................................................................... 10 Introduction to Gram-negative Bacilli................................................................................................................................... 14 Fastidious Gram Negative Rods ............................................................................................................................................ 17 Non-fermentative Gram Negative Bacteria .......................................................................................................................... 20 Neisseria Species ................................................................................................................................................................... 23 Anaerobic Gram Positive Bacteria ........................................................................................................................................ 25 Emerging and Re-emerging Bacterial Zoonoses ................................................................................................................... 28 Pathology of Mycobacteria Infection.................................................................................................................................... 31 Vector-Borne Zoonoses ........................................................................................................................................................ 34

Pathology of Bacterial Infections

Final outcome determined by host & bacterial pathogen: can direct Tx towards both Examples: think about what bacteria has to overcome to get in! Respiratory entry: eyes (blinking, tears, lysozyme, secreted IgA, lactoferrin sequesters iron); nasopharynx (microflora, secretions); lungs (resident macrophages) GI tract entry: mouth (sloughing cells, flow of saliva, lysozyme, sIgA, microflora, lactoferrin); stomach (low pH, proteolytic enzymes), small intestine (fast flow, mucous, sloughing cells); colon (slow flow, sloughing cells, mucus, lots of resident microflora) Pathologic & histopathologic correlates of bacterial infection Acute inflammation: PMNs (purulent): marginate & extravasate, eventually followed by mononuclear cells (48h: M & plasma cells) Can have necrosis (suppuration) Chronic inflammation: Key: Lymphocytes & Macrophages (= histiocytes) 1. Granulomas: aggregates of lymphocytes & histiocytes; often with fibroblasts & giant cells 2. Granulomatas: poorly aggregated infiltrates of lymphocytes / histiocytes 3. Chronic nonspecific inflammation: mostly infiltrates of lymphocytes, fewer histiocytes Major types of histopathologic inflammatory responses to bacterial pathogen infections 1. Exudative +/- necrosis o Usually localized o Vascular permeability ; recruitment of PMN & other WBC o Non-necrotizing: examples S. pyogenes Pharyngitis (strep throat): pus on tonsils; swollen (edema) lots of PMNs S. pneumonia Pneumonia: lobar, generally resolves well (not necrosis, just fill up alveoli with exudate & PMNs. Turn firm because filled up = consolidation) Meningitis: meninges / septae too wide (inflammatory cells); inflammation can cause bystander damage (neurological sequelae). Gross pathology: meninges cloudy (filled with leukocytes) o Necrotizing Exudative with necrosis = suppuration Host damage: can be from bacterial virulence factors P. aeruginosa o Pneumonia: consolidation with infiltrate; makes lots of toxins (cell damage & death); lots of hemorrhage and necrosis Clostridium perfringens Myonecrosis (gas gangrene): big gas bubbles produced; inflammation & necrosis 2. Chronic inflammation +/- granulomas o Granulomas & granulomatous inflammation activated epitheliod M, lymphocytes, etc. Response to bacteria that withstand PMN phagocytosis o Granulomas: M. tuberculosis: granulomas (nodular) with giant cells; caseous necrosis in center Little red bacilli with acid fast stain within or outside cells 2

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Granulomatous inflammation (more diffuse; same cells but less organized) M. leprae: foamy M; more diffuse organization; acid-fast rods inside cells Interstitial Inflammation Nonspecific morphology (chronic, nonspecific inflammation) Virus, Mycoplasma, Rickettsia, spirochete infections (if in infectious clinical setting) Mycoplasma pneumonia: Interstitial pneumonitis Thickening of alveolar spaces, lots of cells & fluid in interstitium (hurts O2 exchange) When do granulomas form and when does general chronic inflammation happen? Cytokines IL-1B, IFN-, CXCL, CCL granuloma forms Different cytokines IL-4, IL-10 chronic inflammation Each type of cytokine suppresses the other response

3. Cytopathic o Most typical of viral infections o Can be seen with intracellular bacterial infections Chlaymydia trachomatis U/G infections Cervix red, swollen; purulent mucoid exudates Chlamydia grows within vacuoles intracellularly 4. Cytoproliferative inflammation o Bartonella spp. (henslae) angioproliferative responses (cause blood vessels to overgrow) Esp. in HIV patients, causes dermis to be replaced by vascular structures From cats (also causes cat scratch fever) 5. Null reaction o Absence of inflammatory, necrotizing, or cytopathic responses o Rare in bacterial infections o Can occur with neutropenia, immune compromise (HIV, cancer chemo, genetic defects) or by rapid, unrestricted bacterial growth o Vibrio vulinficus with neutropenia: tons of Gram (-) bacteria but just a few inflammatory cells o Bacillus anthracis (anthrax): skin, meninges, inhalational. Bacteria grows faster than immune response is mounted (also suppress immune response) Extracellular vs Intracellular bacteria: differences in response Extracellular: Acute inflammation (PMNs) +/- necrosis (depends on virulence factors) 1. Acute inflammation with edema 2. Necrosis pus formation (suppuration) or abscess formation Eventually gives way to mixed acute & chronic inflammation Examples: S. pneumonia, S. aureus, P. aeruginosa, most other bacteria Intracellular: both facultative & obligate Chronic nonspecific or granulomatous inflammation 1. Granulomas (e.g. M. tuberculosis) 2. Chronic nonspecific or lymphohistiocitic inflammation (e.g. mycoplasma, rickettsiae, chlamydiae, spirochetes) Initially chronic inflammation +/- acute inflammation (chronic or mixed) Can cause necrosis 1. Caseous (e.g. granulomas) 2. Microabscesses (granulomatous inflammation) 3. Host-cell-specific necrosis or apoptosis Examples: M. tuberculosis, R. rickettsii (Rocky Mountain Spotted Fever), C. trachomatis (U/G infections) 3

Effects of alterations in host defense, inflammation, immunity 1. Physiologic defects Cystic fibrosis (no appropriate mucous production = lung infiltrates) Achlorhydria (cant generate acid in stomach = lower GI infections) 2. Host cant make inflammatory cells: no inflammatory infiltrates (congenital neutropenia, etc.) 3. Host inflammatory cells cant accumulate: no inflammatory infiltrates Leukocyte adhesion molecule deficiency (dont see WBC at site of infection) 4. Host immune suppressed (HIV, Rxs): modified inflammatory response Chronic granulomatous disease ( superoxide radicals in phagocytes: see bacteria ingested but not destroyed) Complement deficiency, asplenia = susceptibility to encapsulated bacteria (need C to opsonize) Hypogammaglobulinemia = opsonization HIV, cancer therapy, corticosteroid, immune suppressive therapy = T-cell responses Interferon- receptor deficiencies = recurrent Mycobacteria and Salmonella infections Hosts that lack inflammatory response = not well protected against effects of infection Laboratory tests to identify bacterial infections I. During active infection: Finding Organism 1. Nonspecific morphological PMNs in gastric mucosa H. pylori identification (Gram stains, tissue Abscesses with sulfur granules Actinomyces spp sections) Caseating granulomas M. tuberculosis o Initial inflammatory response Lymphocytic vasculitis R. rickettsii usually stereotypical and (Rocky Mountain Spotted Fever) nonspecific o Can use inflammation type, special stains, anatomic location, other clues H. pylori: seagull-shaped; on surface of mucosal epithelium; can use silver stain. PMNs in pits of gastric epithelium Actinomycosis: huge GPR collecting in abscesses with fibrous appearance; sulfur granules M. tuberculosis: acid-fast stain, or can use fluorochrome R. rickettsii: petichae, lymphocytic vasculitis (lots of lymphocytes around / in vessels & walls; R. rickettsii in endothelial cells 2. Culture 3. Direct detection in clinical samples (fluorescent Ab, in situ hybridization, PCR) II. Examining host immune response Serological (Ab detection): antibody present, seroconversion looking at humoral immunity o Ab titer increase: usually want to look @ onset of illness & follow titer level. Compare acute phase (low titer) to chronic phase (higher titer) to confirm Dx. o Fluorescence tests for Abs too (indirect) o Agglutination (mix serum with antigen & look for agglutination) o Western blots (HIV, Lyme disease) Cellular immunity tests (e.g. PPD) Lymphocyte proliferation test IFN production test

Streptococci (I & II)

General Features of Streptococci: Structure Streptococci: Major Pathogens Gram (+) cocci (GPC) in very nice Str. pyogenes Group A Most frequent cause of bacterial chains and pairs (division in 1 plane). infection globally Remain attached via thin cell wall Str. agalactiae Group B Peri-natal & opportunistic bridges Str. pneumoniae Primary cause of pneumonia & Non-motile, non-spore bearing meningitis globally Gram (+) cell wall +/- capsule (major Viridans group Relative wimps pathogens do have capsule) Physiology Organism Normal flora in Fastidious: enriched media, narrow pH/temp ranges Viridans #1 aerobic colonizer of upper Aerobic & facultative anaerobes resp tract (#2 aerobic on skin) Fermentative metabolism (glucose lactic acid, not Group A Small #s of individuals Krebs cycle) Group B Normal below the belt Catalase NEGATIVE Str. pneumoniae Depends on country & season o No cytochrome oxidative system (Gram negatives, S. aureus, etc. do have) Classification Hemolytic reaction Hemolysis Examples Blood agar Beta (produce H2O2, lyse RBC) Groups A & B (also C,D,F,G) Clear Alpha (degrade Hb to met-Hb) Viridans group Green Str. pneumoniae Non-hemolytic (gamma) Red Immunologic o Grouping: based on C-polysaccharide antigen on cell wall o Typing (for Group A): based on M-protein Genetic: 45+ strains known

Str. pyogenes
Group A strep virulence factors: Cytolysis and spreading factors Cell-associated: Hyaluronic acid capsule (unusual most just complex polysaccharide) INHIBITS PHAGOCYTOSIS M-protein (typing) 1. Inhibits C fixation 2. Major adherence factor: binds with LTA so cells can adhere to pharynx, skin & not be washed away Protein F: binds to fibronectin, adherence factor Lipoteichoic acid (LTA): binds with M-protein; adherence factor Cell-bound peptidase: inhibits C Peptidoglycan layer Has fimbrae (M-protein + LTA) to help adhere Extracellular: Hemolysins O (oxygen labile) and S (oxygen stable) 5

o Large zone of beta-hemolysis; most strains have both but if theyve only got one, its O o O: very antigenic (make Ab) Endonucleases: digest nucleic acids, nuclei of leukocytes. o Fewer WBC around than Staph infections, etc. because of endonucleases Streptokinase: liquefies material around cells; dissolves clots Pyrogenic exotoxins (A, B, C) Toxic shock toxin (like S. aureus toxin) Many others (so organism can diffuse throughout body)

Clinical features: Local manifestations: edema, heat, erythema, pain, spreads with extreme rapidity, few PMN-rich abscesses, systemic manifestations too Toxigenic strains: toxic shock, scarlet fever Disease presentations: Pharyngitis (also other URI: otitis, sinusitis). Pus; grayish-white discharge; edematous tonsils. Complications: clotting / obstruction / jugular vv infections. Common in children, closed populations (college, military). 3-5 days: transmissibility decreases Skin / soft tissue: erythema, edema, pain o Impetigo: frequently staph/strep mix; painful, swelling, little clear fluid-filled vesicles if strep only. Different M-protein types than pharyngitis types o Celulitis: superficial skin infection. rapid spread, advances up lympathics (reddish streaks). Huge vesicles with clear fluid later o Necrotizing fasciitis / myositis (killing skin / muscle cells). Abx dont reverse damage need surgical intervention. Path: dead mm cells, no PMNs Puerperal (post-delivery) sepsis more historically no. Scarlet fever o Str. pyogenes strain producing pyrogenic toxin (plasmid-mediated). Usually pharyngitis-associated o Scarlatiniform sandpaper rash (upper chest to trunk, extremities); strawberry tongue o Desquamation follows Toxic shock syndrome: strep TSS parallels S. aureus Post-streptococcal diseases (immunologic cross-reactions between strep antigens & heart or kidney) o Rheumatic fever (9-10d post-infection) Any M-protein type; reinfection has same latency Heart (myocarditis, valves); joints (arthraligias, arthritis), skin (erythema marginatum), CNS (Sydenhams chorea) o Glomerulonephritis (few days post-infection) Specific M-types implicated Proliferative disorder of renal glomerulus Edema, hypertension, hematuria, proteinuria Can have no sequellae or progress to end-stage renal disease More likely to transmit if high amount, in nose/throat; less likely if youve been a carrier for a while.

Str. agalactiae
Regular polysaccharide capsule (inhibits phagocytosis & C) 9 serotypes (M-proteins) with different capsule composition CAMP factor (hemolysin) Small zone of B-hemolysis Found in normal GI flora; vaginal tract of 5-30% sexually active women 6

Can be primary or co-pathogen in immunocompromised Clinical presentation: causes neonatal sepsis and meningitis (early & late forms) Associated with prolonged rupture of membranes in colonized mother Early onset: 1st 6 days. Septicemia (60%), also pneumonia (30%), meningitis (10%). 10% mortality Late onset: 7d-3mo. Majority due to type III; may be fulminant with septic shock & severe meningitis Neurologic sequellae: 25-50% children Prevention: Maternal screening Prophylactic antibiotics (if colonized mother or any mother with prolonged membrane rupture)

Str. viridians Group

General characteristics: Alpha-hemolytic (green pigment) Relatively non-virulent Normal flora of respiratory tract, vaginal tract, skin, other Pathogenicity Endocarditis: relatively indolent, really needs damaged setting (e.g. IV drugs, then lands on already damaged heart valve) Abcesses(most common cause of liver abscesses. Complications: rupture hemorrhage, high mortality rate.) o Str. anginosis, Str. intermedius, Str. constillatus Dental caries: Str. mutans (part of gingival flora, clings to enamel) o To get caries: need right microflora, diet, and host/teeth situation. o Str. viridians is most common aerobe in oral flora o Virulence: from high acid production Septicimia in immunocompromised patients Co-pathogens in mixed flora infections (e.g. Gram + and together) Non-infectious events: chronic gingivitis atherosclerotic plaques?

Str. pneumonia (the pneumococcus)

Gram positive, in pairs & chains like others (prominent pairs) Physiology: fastidious, narrow pH/temp ranges, fermentative metabolism, catalase negative (like other strep), prefer 5% CO2 Lab diagnosis: GPC in pairs (& chains) Alpha hemolytic inhibited by optochin Bile soluble Quellung reaction (add antipneumococcal Ab, see swelling)

Polysaccharide capsule: high MW, complex polysaccharides Types defined by capsule antigens Different types have different virulence, C and cytokine reactivity, Abx resistance, and preferred sites of pathogenicity Lots of cross-reactions (other microbial capsules, blood group antigens, other foreign polysaccharides) o Can get antibodies very early in life via cross-reactivity o Capsule very antigenic; repeat infection with same type is rare

Genetic features Transfer of DNA via transformation, phages, conjugation o Transformation ability varies with capsule type, inflammation (cytokine activation), other types of stress, antibiotics, starvation, chemical exposure. E.g. Abx can induce ability to acquire resistance! Virulence factors: major one is the capsule (blocks phagocytosis if specific antibody not present). Need capsule for virulence (capsule + rest of pneumococcus too) 7

Cell-surface-associated: o pili (adherence) o cell wall polysaccharides (induce inflammation, activate C) o surface protein A: inhibits activation of C, o autolysin (how pneumococci commit suicide when they dont like where they are) Cytoplasmic (release of these as cells lyse are primary cause of death within 48 hours despite abx): o Autolysin: releases pnemolysin & cell wall products o Pneumolysin: cytotoxin, activates C/cytokines o Neurominidase: exposes host cell receptor sites o Peptide permeases: enhance adhesion o Others (hemolysin, hydrogen peroxide, etc.)

Pathogenicity:#1 cause worldwide of pneumonia, meningitis, otitis, sinusitis Normal flora in 20-100% individuals (colonization: normally host makes protective Ab preventing blood-based spread, from this normal exposure) o Direct infections (otitis, sinusitis) can still occur Facultative pathogen; produces intense inflammatory response without necrosis Major cause of death at age extremes

Pneumonia Occurs with newly acquired type that patient doesnt have Ab to Typical case: respiratory viral infection, fever recurs 4-7d post viral infection, pneumonia sets in o Virus damages ability to clear tracheobronchitic tree, destroys ciliary epithelial cells, produces excess mucus & fluid, blocking normal clearance Often begins with aspiration of oropharyngeal contents (alcoholism, neurologic impairment, etc.) Purulent nasal discharge, lobar pneumonia, intact alveolar structure, inside of alveoli jammed with inflammatory cells. Radiology: alveolar infiltrate Little residual morbidity can resolve well (not destroying alveoli) Meningitis: Meninges jammed with PMNs, not in brain tissue 3x mortality of N. meningitis; more frequent, more sequelae (CNS, deafness) Pneumococcal septicemia: especially common in sickle cell children (give PCN prophy until vaccination possible) Management: 1. Antibiotics (Penicillins, others). a. Rapidly emerging resistance i. PBP mutations: intermediate resistance, can overcome with dose sometimes. Increasing doses doesnt help for endocarditis or meningitis (just cant get *drug+ high enough in there) ii. B-lactamase development b. Less active: cephalosporins (used to be 2nd line, now resistance emerging too) c. Varies with location 2. Prevention (vaccines) a. 23-component vaccines (23 different types / polysaccharides) b. Different kinds: peds vs adults c. Vaccine works less well in older patients (although mandated to offer to all pts > 55yo on discharge from hospital & document reasons for refusal)

Enterococci
General features: Look like strep (GPC in chains); metabolism like strep (facultative anaerobes, fermentative metabolism) Catalase negative (but can make a little bit if they receive DNA from other spp) Not fastidious (permissive pH range, no enriched media required, etc.). o Survive heating, dessication, resistant to disinfectant products (good at health care spread) o Not damaged by gastric pH Part of normal gut flora (E. faecalis & E. faecium are most prevelant) Mostly non-hemolytic (some spp alpha-hemolytic; very rare strains beta-hemolytic) Grow as small grayish colonies on blood agar Structure: normal gram+ cell wall, no flagellae, +/- capsule Infectivity: Commensals (below diaphragm colonic flora, vaginal flora, external genitalia) Facultative pathogens Virulence factors (importance unknown): adherence factors, cytolysins, permeability factor, gelatinase, aggregation factor (clumping), superoxide production LTA: can exhibit endotoxin-like features of septic toxicity (incl. hypotensive shock) in large amounts Biofilm formation (especially hearty) Diseases: E. faecalis (60-70%) & E. faecium (10-20%) Most commonly: mixed infections (e.g. abscesses below the diaphragm) o Intra-abdominal abscesses, colonic diverticulitis, urinary tract, gall bladder Enterococcal endocarditis o Classic presentation: elderly male with obstructive uropathy o Unlike S. aureus, symptoms commonly indolent; low grade fever often ignored o (especially big abx diffusion problem) Septicemia (predominantly in debilitated / immunocompromised; mortality 42-68%) Resistance: VRE: vancomycin-resistant enterococci (esp. E. faecium). Hospitals, nursing homes (where abx are used commonly); hand-spread; 50%+ mortality o Some strains have developed resistance to all new alternatives no effective antimicrobial choices Can transmit resistance genes to S. aureus: MAJOR CONCERN

Listeria & Other Gram-Positive Rods

Listeria Monocytogenes
Characteristics: Short, gram-positive rods, can live intracellularly Survives & grows at low temp (fridge), low pH (stomach acid), high [salt]: overcomes food prep barriers Colonizes: animals, humans, soil, vegetative matter Food-borne illness (listeriosis): contaminated meat, dairy, fruits, vegetables (rinse!) Pathogenesis: GI tract blood meninges Invades, survives in variety of cell types

Intestine: provokes active endocytosis (internalins) to cross mucosal barrier; survives intracellularly o Escapes death in lysozome: formes pores to get out of phagolysosomes o Replicates in cytoplasm (molecular mimicry: proteins look like host proteins) o Promotes actin polymerization, makes comets tail that pushes organism out into adjacent cell o Covered by host cell membrane (more molecular mimicry) in next cell Lab diagnosis of Listeria: Spread hematogenously Culture: grows well (30-37 C best) Virulence factors: many; survival & invasion. Internalin helps Blood agar: internalize, listeriolysin O (LLO) helps organism escape from o small white colonies phagocytic vacuoles (inserts pore), Act A induces actin polymerization o beta-hemolytic Catalase positive Characteristic tumbling motility

Epidemiology: major cause of bacteremia & meningitis Immunocompromised (especially cell-mediated immunity) and elderly patients Colonized mothers (can be asymptomatic) can pass to fetus High mortality (500-600 deaths; 2500 cases in US/yr)

Clinical presentation: Febrile gastroenteritis (6-48h incubation) in healthy persons. Self-limited. Many asymptomatic. o Fever/chills, abdominal pain, diarrhea, nausea/vomiting, myalgias Bactermia: (pregnancy or immunocompromise) o bactermia without an obvious source o Fever/arthalgias, headache, GI symptoms, backache: or asymptomatic. Meningitis: 2nd most common cause of bactermia in adults > 50 yo; 5th overall o Usual presentation of meningitis (stiff neck, headache) but: CSF glucose not low Mononuclear cells can predominate (intracellular; others = PMNs) Pregnancy: somewhat immunocompromised (predisposition) o Can be infected in last 2nd trimester & 3rd trimester 10

o Listeria can proliferate in placenta (infect child in utero) o Stillborn / neonatal death: up to 20% Neonatal infection o Disseminated form of disease: granulomatosis infantisepticum o Late onset up to 2 wks post-partum; meningitis o Hepatomegaly

Treatment: Ampicillin; TMP+SMX for PCN allergic (but watch out for kernicterus!?)

Bacillius spp.
General Characteristics: Aerobic, Gram positive rod Spore forming; ubiquitous Major pathogens: B. anthracis (anthrax), B. cereus (bacteremia, wound / eye infections, food poisoning)

Bacillus anthracis
Acquisition: Soilherbivoreshumans acquire via inoculation with spores: Inhalation*, ingestion*, or trauma (*=more lethal) Mostly in agrarian societies Category A biological terrorism agent (easy dissemination, high mortality, social disruption) Pathogenesis Spores skin, GI tract, lung germinate in M to regional lymph nodes local production of toxinsedema, necrosis bacteremia, toxemia Virulence factors: o Capsule: inhibit phagocytosis o Protective antigen: binds to cell membranes (better binding/transport of edema factor & lethal factor) o Edema factor: cellular cAMP; membrane permeability (edema) PMN function, cytokine pathways ( proliferation, bacteremia, systemic infection) o Lethal factor: Zn-dependent protease. Cleaves MAP kinases, oxygen radicals released Leads to M lysis and cell death Clinical presentations: Cutaneous anthrax: o Pruritic papule enlarges (round ulcer) painless, black eschar (dries, falls off); regional lymphadenitis Inhalational anthrax: mortality close to 100% o 1-6d incubation; initial Sx flu-like (non-specific: malaise, fever, non-productive cough, chest discomfort) o Rapid progression: dyspnea, cyanosis, shock o Hemorrhagic mediastinitis o Meningitis can occur o Radiography: mediastinal enlargement (hilar, mediastinal lymphadenopathy hemorrhage) o Pathology: tons / sheets of purple anthrax bacilli, tons of hemorrhage Gastrointestinal anthrax: 25-60% mortality
Pruritic: itchy Eschar: scab Papule: circumscribed, solid elevation of skin with no visible fluid, varying in size from a pinhead to 1 cm FYI: Anthracis = coal (black eschar)

Anthrax Dx: Hx of exposure; appropriate presentation Gram stain o Large, gram(+) rods in chains Culture: o Blood, CSF, pleural fluid o 6-24h growth on 5% sheeps blood o Medium gray irregular colonies, swirling projections o Non-hemolytic & non-motile o PCN susceptible 11

Ingestion of vegetative bacteria (not spores) from poorly cooked, contaminated meat ulcers in all areas of GI tract regional lymphadenopathy nausea, vomiting, bloody diarrhea, sepsis (excruciating pain) Pathology: intense submucosal hemorrhage

Treatment: EARLY administration of antibiotics is crucial Penicillin, doxycycline, ciprofloxacin Vaccine: military use only unless exposed to spores (lots of side effects; anthrax is rare)

Bacillus cereus
Soil organism; broad range of clinical syndromes Clinical presentations: Food-borne illness (especially rice that was left sitting out) o Diarrheal type: heat-labile enterotoxin; 8-16h post exposure o Emetic type: heat-stable enterotoxin; 1-5h post-exposure Ocular disease (penetrating trauma: bacteria in soil; almost always lose eye) & Wound infections (healthy persons): extensive damage, liquefactive necrosis Bacteremia, endocarditis, abscesses in immunocompromised pts & IV drug users Treatment: Food poisoning: usually self-limited Produces broad-spectrum -lactamase: resistant to PCNs & cephalosporins Vancomycin, clindamycin are active B. cereus Dx: Grams stain: GPR in chains Culture o Grows well on 5% sheeps blood o Large, feathery, spreading colonies o Beta-hemolytic (not anthrax) o Organisms are motile, lecthinase (+) (not anthrax)

Cornyebacterium diptheriae
General characteristics of Cornyebacterium spp. Aerobic bacteria, non-spore forming, Gram-positive bacilli Curved or club-shaped (corney = club) Catalase positive Normal flora of skin, mucous membranes of mammals; hard to distinguish colonization/contamination/infection Need to ID to species level when isolated from normally sterile sites, urine (if lots), clinical material Cornyebacterium diptheriae: most important pathogen Humans = only known reservoir; Asx carriers = important for epidemics Spread: airborne respiratory droplets, direct contact with resp. secretions or exudates from skin lesions, contaminated milk Most cases: colder months N. America: mostly disadvantaged groups (skin infections) Vaccine-preventable Pathogenesis Non-invasive Exotoxin: major virulence factor o 2-segment polypeptide B-segment (binding): bind to receptors on susceptible cells A-segment (active): inhibits protein synthesis in mammalian cells 12

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Can affect all cells in body (heart, nerves, kidney most common) Also contributes to pseudomembrane production

Clinical presentation: Respiratory tract disease: 2-4d incubation period; can have local inflammation at various sites o Pharyngeal (most common) 1. Abrupt onset (fever, malaise, sore throat) 2. Pseudomembrane forms & spreads one or both tonsils oropharynx, nasopharynx, soft palate white then dirty gray with black necrosis Can compromise & distort lower airway: bulls neck o Systemic complications from toxin: myocarditis, neurotoxicity (cranial neuropathies) Cutaneous: o Non-healing ulcers, dirty gray membranes, C. diptheriae Dx: superinfected with other bacteria Presumptive dx: clinical o Outbreaks among alcoholic homeless, impoverished Definitive dx: isolate, ID organism (no boosters, poor sanitation) Notify state lab (reportable) & send o Rarely associated with toxigenic illness material Others: can have invasive disease (e.g. endocarditis) with Lab dx: sheeps blood & selective medium non-toxigenic C. diptheriae Treatment & prevention Strict isolation Antibiotics: PCN or erythromycin for 14 days Supportive care Vaccine: part of childhood DTaP series (4 doses total); booster at school entry, every 10 years with tetanus

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Introduction to Gram-negative Bacilli

Gram negative bacilli: rods that stain red by Grams stain; large, diverse group Classification: growth requirements, phenotypic or genotypic characteristics, disease associations Major categories of GNRs: Enterobacteriaceae fermenters. Enteric pathogens & non-enteric infections Glucose non-fermenting GNRs Oxidase positive fermenters (cause diarrhea) Fastidious GNRs: require specialized media / growth conditions Anaerobic GNRs GNRs associated with zoonoses Can use selective material which is inhibitory to Gram (+), e.g. MacConkey agar, to isolate Gram (-) Red/pink: acid produced, lowers pH, lactose fermenter Clear: non-lactose fermenter; diarrheal pathogens No growth: not Gram (-)

Enterobacteriaceae (this lecture)

General characteristics: Tons of diversity, found in GI tracts of humans, animals, fish, etc. Some also in environment: soil, water, plants. Certain kinds (Salmonella, Shigella, Yersinia) shouldnt be in humans ever. Facultative anaerobes (rapid growth with or without O2) Grow readily on simple material (12-8h incubation). Diseases: all major categories except STDs Morphology: large, parallel sides, rounded ends Some strains: peritrichous flagella (go around whole circumference) Some: encapsulated Many: surface pili for adherence Do NOT form spores Antigenic structure (serotyping): O (somatic) antigen (= LPS = endotoxin): cell-wall LPS, heat-stable (IgM response) K or Vi (capsular) antigens: cell surface polysaccharide (Vi = virulence, for salmonella) H antigens: externally located flagellar proteins (IgG response) Remember the gram (-) cell wall: has porins in OM; antimicrobial resistance: mutate porin so drugs cant get in Enterobacteriaceae: Ferment glucose (often with gas production) Reduce nitrates to nitrites Catalase: positive Cytochrome oxidase: negative

Urinary tract infections

Community-acquired: 80% from uropathogenic E. coli, then Klebsiella and Proteus Predisposition: anatomy, density of mucosal receptors, sexual activity Hospital-acquired Frequently in patients with indwelling bladder catheters E. coli still main cause; also other resistant Gram (-)s Types of UTIs Urethritis (urethra) Cystitis (bladder) Pyelonephritis (kidney) Usually ascending; can be descending (from kidneys)

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E. coli: Need uropathogenic strains: low pH in urine, lots of antimicrobial compounds in urine Specific fimbriae (type 1, good for colon/vagina colonization), pili (P pili: E. coli: Lab Dx adherence to urinary tract) -hemolytic on sheeps blood Toxins: endotoxin and -hemolysin (pore forming cytotoxin; explains Lactose fermenter hemolysis, causes toxicity to uroepithelial cells too) Rapid indole positive Aerobactin siderophore (chelates iron) Proteus spp. Associated with UTIs, urolithiasis (stones) Proteus mirabilis, Proteus vulgaris Cycle: Proteus produces urease, hydrolyzes urea to CO2 + NH3 neutralize/alkalinize urine inorganic compounds fall out of solution & crystallize stones become embedded & reinfected Klebsiella pneumoniae UTIs, pneumonia; hospital-acquired infections with multidrug resistance Mucoid capsule (important for virulence) Get in lungs/urine; huge inflammatory response

Proteus: Lab Dx Non-lactose fermenter Very motile (swarming over agar plate)

Klebsiella pneumoniae: Lab Dx Non-lactose fermenter Non-motile Disgusting mucoid colonies

Gram-Negative Pneumonia
Predisposing factors: Gram (-) pneumonia
NON-HOSPITALIZED
Underlying cirrhosis ( encapsulated infections) Loss of consciousness, alcoholism, drug abuse Elderly, immunocompromised

HOSPITALIZED
Diminished cough reflex, anesthesia Mechanical ventilation Immunocompromised

Klebsiella pneumoniae Pneumonia: necrotizing, develop cavitation in areas of consolidation o If you survive: chronic lung disease (pulmonary fibrosis)

Pneumonia 1. Rapid growth 2. Inflammation (intense, PMNs) 3. Inefficient killing of organism (varies with host) 4. Obstruction, obliteration of lung tissue 5. Death (tissue / host)

Aerobic Gram-Negative Rod Meningitis

0-4 wks 4-12 wks 3mo 50 yrs > 50 yrs Grp B strep, E. coli, L. monocytogenes, Salmonella Grp B strep, E. coli, H. influenza, S. pneumoniae, N. meningitidis S. pneumoniae, N. meningitides (H. influenza in adolescents) S. pneumoniae, N. meningitides, L. monocytogenes, aerobic GNR

Predominantly neonates, elderly, neurosurgery pts Dont let your babies play with snakes & iguanas! (salmonella) Other factors: immunocompromise, head trauma/neurosurgery, CNS shunt ( aerobic GNR meningitis)

Aerobic GNR meningitis E. coli (75% capsular type K1) Klebsiella sp Salmonella sp Pseudomonas aeruginosa

Bacterial meningitis: Lab Dx: Neonatal meningitis: Exposure/colonization (Asx?) during birth + poor immune response bactermia meningitis LP: Other agents: : pressure, WBC, PMNs, protein, lactate Citrobacter koseri (sporadic cases, utilize citrate); : glucose Enterobacter sp (yellow pigmented, highly virulent, MDR) Gram stain & culture: GNRs & PMNs Gross path: cloudy, pus in meninges High mortality with GNR meningitis

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Intestinal infections
Salmonella (S. enterica = most pathogens; also S. bongori) Salmonella: Lab Dx Various virulence factors (Vi = salmonella typhi) Gram (-), non-motile Exposure: poultry or products (eggs) Produces H2S (black colonies) Stays in vacuoles inside cells; enters submucosa, basal membrane; goes to Use selective media to mesenteric lymphocytes blood stream recover from stool Clinical presentations: o Gastroenteritis (S. typhimurium mostly) 6-24h post-exposure: nausea, vomiting, abd. pain, diarrhea; 50% have fever o Bacteremia (non-typhoidal): much more frequently found in blood than Shigella o Typhoid fever (S. typhi, S. paratyphi) 1-4wk incubation; fever, multi-organ system infection, may or may not have diarrhea Multiplication in spleen, liver gall bladder during infection Shigella Four serotypes: S. sonnei (major in US), S. flexneri, S. boydii, S. dysenteriae (epidemic dysentery, produces Shiga toxin), Shigella: Lab Dx Presentation: fever, severe, cramping abd. pain, bloody diarrhea Gram (-), non-motile Virulence factors plasmid associated; LPS in all More severe pain than Salmonella, lower abd. (colon) Pathogenesis: o Through stomach acid & small bowel terminal ileum/colon o Engineers own phagocytosis o Escapes from vacuole! Stays in mucosa(fecal WBC confined to mucosal layer) o Non-motile; cause invasive infection by spreading cell-cell via actin polymerization. o Destroys colonic epithelial cells in process (blood, pus in stool); self-limiting 2-5d E. coli EnteroToxigenicEC (travelers diarrhea), EnteroInvasiveEC (uncommon, invasive) EnteroPathogenicEC (infantile, childhood diarrhea), EnteroAggregativeEC (travelers diarrhea): from previous lecture

ST E. coli: Lab Dx Gram (-) Hand-deliver quickly! Direct detection of SLT in STEC pts stool Culture: grows well on standard lab material; Shiga-toxin-producing E. coli: STEC selective material can be usd o Hemorrhagic Colitis PMNs + GNRs: think this family! o Hemolytic-Uremic Syndrome (thrombocytopenia, renal failure, hemolytic uremia) associated with production of Stx-2 (Stx-1 only: EPEC)

Yersinia can cause diarrhea too

Antibiotics & GNRs

Order susceptibility testing on organisms from clinical material (disk diffusion / microbroth dilution) o Look for MIC MDR control: hand hygiene, contact precautions, antimicrobial stewardship Klebsiella can be especially bad (resistant to almost everything!) 16

Fastidious Gram Negative Rods

Haemophilus sp
Characteristics: normal resp flora of humans & animals Pleomorphic, GNRs Invasive strains = encapsulated Requires special growth factors in vitro: X factor, V factor. Optimal growth on chocolate agar Lots of different kinds. No capsule = not invasive (H. influenza non-typeable for instance) H. influenzae type b (a-f are other types). o Type b causes epiglottitis, sinusitis, meningitis, pneumonia, septic arthritis, etc. H. influenzae non-typeable (unencapsulated): now #1 cause pediatric acute otitis media; sinusitis too o Replaced S. pneumoniae H. influenzae type B (HiB) Fallen 99% post-vaccine area (22 cases 2007, unvaccinated/incompletely vaccinated children)

Haemophilus: Lab Dx Epidemiology/pathogenesis Gram Stain (pleomorphic GNR) Nasopharynx of 3-5% healthy people colonized with Hib Culture (chocolate agar) Pathogenesis: penetrates submucosa of nasopharynx o Look for X, V factor requirements bloodstream CNS meningitis o Hemolysis? Virulence factors: capsular polysaccharide, fimbriae, IgA protease, OM proteins, ciliostatic glycopeptides (paralyzes cilia to make colonization easier) Treatment/prevention: 33% produce plasmid-mediated beta-lactamase (PCN resistant) Invasive disease: 3rd gen cephalosporin Non-invasive disease: amoxicillin + clavulanate HiB Vaccine x 4: 2,4,6,12-15 mo of age

Bordetella pertussis
Gram (-) coccobacilli (single or pairs; faintly-staining); strict aerobe; needs special media (have to ask for it) B. pertussis: Lab Dx Gram Stain (single/pairs, Gram (-) coccobacillus) Strict aerobe Best specimens: NP aspirates/swabs *Culture (special media) o Can require up to 10d to recover (way too long for Dx) *Nucleic acid detection: faster & most sensitive Serology = only retrospective * = recommended by CDC Epidemiology: Cant survive in environment: requires direct, person-person spread via airborne droplets Adults can be reservoir for infection o (unexplained cough = avoid babies!) Children < 1yo: most severe disease (immune system not at peak) Vaccine preventable! Pathogenesis: Non-invasive (secretes toxins) 1. Adheres to non-ciliated resp. epithelium (fimbrae) 2. Produces local damage; disrupts host defenses 3. Systemic disease Key virulence factor: pertussis toxin (all stages)

Clinical presentation: Pertussis syndrome (more atypical presentation in adult) 0. Incubation period (1-3 weeks) 1. Catarrhal stage (1-2 weeks): Most contagious; rhinorrhea, malaise, sneezing, low-grade fever 17

2. Paroxysmal stage (2-4 weeks): paroxysmal coughing with inspiratory whoops; post-cough vomiting, air hunger / apnea / cyanosis, peripheral lymphocytosis (hallmark: tens of thousands!) a. Basically cant get air! Whooping = trying to inspire against closed glottis. Really sucks to have. b. Radiography: Peri-hilar infiltrates, distal airways spared, 3. Complications: secondary bacterial pneumonia (damaged resp. epithelium), pulmonary hemorrhage (exertion of coughing), encephalopathy (toxin to brain), seizures (hypoxemia), coma/sudden infant death Treatment / Prevention Supportive care (vent, ICU, fluids, etc.) Erythromycin: doesnt alter course but decreases bacterial load (less infective) Vaccine: o used to use whole cell (DTP); high reactogenicity, 50-90% efficacy, wanes in adolescents/adults o Discontinued in some countries pertussis outbreaks o Acellular vaccine now in use: DTaP (diphtheria, tetanus, aceullular pertussis) Immunogens of B. pertussis, no endotoxins (less side effects) with equal efficacy 5 doses (2mo-5yr); one-time booster for adults (Tdap)

Legionella
General characteristics: thin, poorly-staining GNRs Require L-cysteine for growth; use AA for growth (non-fermenters) Biochemically inert (weak oxidase rxn; catalse positive, liquefy gelatin) Motility: polar flagella Epidemiology: tons of species; L. pneumophila is responsible for >90% disease (rest named by where theyre from) Ubiquitous, widely distributed in environment (aquatic settings: natural or man-made) Wide temperature range (0-63C) Parasitize & survive in free-living amoebae! Form biofilms in water systems Transmission: inhalation of droplets; aspiration of water; wound infection (more rare) by contaminated water Pathogenesis: 1. Adhere to resp epithelium 2. Phagocytosed 3. Intracellular survival / multiplication a. Inhibits acidification of lysosome b. No fusion of lysosome with phagosome c. Lysosome associates with rER (molecular mimicry; lined with ribosomes); bacteria replicates here 4. Cell rupture & release 24 kD protein macrophage infectivity potentiator (mip): target of many molecular tests Clinical presentations: Legionella pneumonia: 2-15% cases of CAP Legionnaires disease: systemic illness with pulmonary and extrapulmonary manifestations (rare to have extrapulmonary alone) o Radiologically indistinguishable from other pneumonias unilateral, lower-lobe alveolar infiltrates; some Risk factors for Legionella infections Cigarette smoking, chronic lung disease, alcoholism Immunosuppresion (corticosteroids, malignancies, HIV, transplantations) Diabetes, end-stage renal dz, CV dz, advanced age Legionella: Lab Dx Culture: need special medium (request!) to inhibit normal flora (abx, etc). Can take up to 7 days (slow growing) Legionella urinary antigen: only serotype 1, but that causes most dz Nucleic acid amplification (no FDA but some in-house depending on lab) Direct fluorescent antibody 18

pleural effusion cavities/abscesses can occur if immunocompromised o Slight, non-productive cough (no PMNs because intracellular) o GI: watery diarrhea; abd. pain o CNS: mental confusion, headache o Bradycardia; hyponatremia, hypophosphatemia, elevated CK, increased transaminases o Doesnt respond to beta-lactams Getting a sample: no special transport, room temp OK, refrigeration if delayed. Send sputum, aspirates, BAL fluids, pleural, lung tissue. Legionella urinary antigen detection Detects LPS of cell wall Serotype 1 only (80% of dz though) Antigen shows up day 1-3 of Sx; can persist for weeks/months Treatment: 10-14d Newer macrolides (azithromycin, clarithromycin); quinolones (levofloxacin) Can also use tetracyclines or TMP+SMX Prevention: Routine culture surveillance of hospital water distribution systems Treat If pathogenic legionella found (hard to get biofilm out). Chemicals, heating, etc.

19

Non-fermentative Gram Negative Bacteria

General features: White on MacConkey agar = non-fermenter (pink=fermenter) Complex mix (opportunistic pathogens of plants, animals, humans) 75% in clinical specimens are one of these four 1. Psudomonas aeruginosa 2. Acinetobacter baumanii 3. Burkholderi cepecia 4. Stenotrophomonas maltophilia Opportunistic pathogens: most often hospital-acquired (most) Non-Fermentive Gram (-)s: Aerobic, Non-spore forming, Bacilli Cytochrome oxidase positive Catalase positive Dont ferment CHOs; may oxidatively metabolize some sugars Motile, nutritionally versatile Grown on MacConkey Aga

Pseudomonas spp
Ubiquitious (soil, water, decaying organic matter, vegetation) Found throughout hospital environment (moist reservoirs, incl. dialysis equipment, mops, toilets, etc.) Simple growth requirements: wide temp range; can use lots of nutrients for C&N source o Can even grow in distilled water and disinfectant solutions! Lab classification: fluorescent (make pyoverdin green under UV) & non-fluorescent o Fluorescent group includes P. aeruginosa and P. fluorescens, most important for clinical o P. aeruginosa also makes pyocyanin Important for invasiveness & characteristic of aeruginosa on plate

Pseudomonas aeruginosa Aerobic, straight/slightly curved, non-spore forming, Gram(-) rod Motile (1+ polar flagella) Pseudomonas aeruginosa: definitive Lab Dx Grows well on SBA, chocolate, MacConkey; wide temp range; Gram (-) rod Catalase positive Oxidase positive (rapid oxidase test) Makes both pyoverdin & pyocyanin Grape-like or corn-tortilla odor Recognizable colony morphology Virulence: multifactorial (structural components, toxins, enzymes)

Structural: o LPS (endotoxin), Pili (adhesion; neuraminidase to remove sialic acid from pili receptor); capsule (adhesion &
suppression of phagocytosis / immune response); pyocyanin (tissue damage: hydroxyl radical products; IL-8 stimulus)

o SBA/chocolate: large colonies, metallic sheen, mucoid/rough/pigmented o MacConkey: lactose negative; green pigmentation or metallic sheen

Toxins/enzymes: o Exotoxin A & S(inhibits protein synthesis); cytotoxin (leukocydin) (cytotoxic for eukaryotic membranes; microvascular injury); Elastase (disrupts elastin-containing tissues, collagen)

Clinical presentation: Bacteremia, pneumonia top 2 Others: pretty much all sites of body but particularly adapted to respiratory tract o CF patients; chronic colonizer of pts with chronic lung P. aeruginosa: Predisposing factors disease Chronic debilitating illness (lots of hosp) o #1-2 cause of Ventilator-Associated Pneumonia (VAP) Prior therapy with broad-spectrum abx Can produce disease far away from initial site of tropism Breach of airway (tracheostomy, Intact host defenses: not at much risk (opportunist) endotracheal tube) Pulmonary infections in CF patients: colonization tracheobronchitis
Imparied host immunity (primary disease or iatrogenic)

20

 necrotizing bronchopneumonia Tropism for CF epithelial cells; actually switches to a CF phenotype (rough LPS, mucoid, less motility) o Increased Abx resistance because of prior broad-spectrum abx in CF pts Skin infections from P. aeruginosa: Ecthyma gangrenosum secondary to P. aeruginosa bacteremia (pretty classic for P.aerug) Folliculitis (e.g. after hot-tub) Burn wounds: P. aeruginosa very important! o Colonization local vascular damage / necrosis bacteremia o Risk correlates to extent of burned surface o Commonly <1wk from burn injury Community-acquired P. aeruginosa infections: can happen in outpatient setting Corneal ulcers, keratitis (extended wear contact lenses / abrasions / scratches) Endopthalmitis (deeper eye infection; after eye trauma or surgery) Exposure to moist environment (hot tub, whirlpool, swimming pool) Otitis externa : swimmers ear; malignant external otitis can extend to cartilage & bones (pts with diabetes, elderly, etc.) Puncture wounds (through tennis shoes, etc.) osteochondritis Endocarditis (IV drug users) Treatment, prevention, control: recognize high level antimicrobial resistance worldwide; carbapenems may be driving emerging resistance; lots of MDR Pseudomonas. Might be able to use old drug (colistin) despite bad side effect profile Cant eliminate from hospital environment: need infection control (safeguard patients) o Keep equipment sterile; prevent health care worker pt transfer; responsible ABx use

Acinetobacter spp
Widely distributed (nature & hospital) 2nd most common non-fermenter found in humans after P. aeruginosa Can survive on moist & dry surfaces; present in food & on skin Increased frequency: immunocompromised, debilitated pts Acinetobacter spp Gram(-) coccobacillary rods Strictly aerobic Grow on MacConkey (colorless) Non-motile, non-fermentative >> Oxidase negative << (key) Usually nitrate negative Risk factors: Acinetobacter Stay in ICU Abx treatment Surgery Mechanical ventilation

Acinteobacter baumanii: Most frequently isolated from human specimens Most often responsible: hospital-acquired infections

Clinical presentations: Hospital acquired: o Respiratory tract infection o UTI, Wound infection, Bacteremia o Nosocomial pneumonia / VAP o Digestive tract of ICU patients can be reservoir for MDR strains Community-acquired: o CA-Pneumonia with fatal outcome (initially misdiagnosed; wrong Tx) o Wound infections & osteomyelitis (e.g. battlefield infections)

Tx & prevention: Need Abx susceptibility testing for every clinically significant isolate! Intrinsic resistance to cephalosporins; carbapenem resistance ~ 20%; high frequency of MDR Ampicillin-sulbactim, ticarillin-clavulanate or imipenem are most effective Also: TMP-SMX, quinolones, doxycycline. Can add aminoglycoside if severe infection; colistin possible if MDR 21

Stenotrophomonas maltophilia
Similar profile to Burkholderia cepacia Widely distributed: nature & hospital Can colonize resp tract in pts. with prolonged hospitalization (e.g. immunocompromised) Virulence factors unknown, opportunistic human pathogen S. maltophilia Gram(-) rod Motile, non-fermentative Grows well on MacConkey Oxidase negative

Clinical presentation: Nosocomial; high morbidity/mortality o Bacteremia, pneumonia, UTI, wound infctions o Increasing incidence: resp tract infections in CF patients Treatment: Intrinsic resistance to almost every antimicrobial commonly used (B-lactams, AGs, others) TMP+SMX is primary choice for treatment

Burkholderia cepacia complex

B. cepacia: most commonly isolated Burkholderia sp. in clinical specimens; consists of 9 complex genovars Plants, soil, water as reservoir NOT part of normal human flora; can colonize resp tract Nosocomial: associated with contaminated hosp equipment, medications, and disinfectants o (even iodine & chloride solutions! Albuterol! Sterile blood culture systems!) Clinical presentation: opportunistic pathogen, variety of infections Bacteremia, UTI, septic arthritis, peritonitis, pneumonia Risk factor: chronic granulomatous disease or CF pts B. cepacia and cystic fibrosis Emerged in 1980s; require special infection control practices Approx 3% CF pts in US infected with B. cepacia, 6-7% adults Most strains inherently resistant (broad spectrum abx) May be absolute contraindication for lung transplant 20% develop cepacia syndrome: bacteremia, fatal outcome Treatment: resistant to most antimicrobials (B-lactams, AGs, others) Susceptible: TMP+SMX, ceftazime, imipenem, meropenem, some fluroquinolones

Burkholderia pseudomalli
Found in soil, water, vegetation: SE Asia, Northern Australia (watch out for travelers) Wrinkled colonies on plate Acquisition: inhalation or inoculation (trauma/wounds); Potential bioterrorism agent

Clinical presentation:Causes melioidosis Can be acute, subacute, or chronic (chronic can mimic TB) Pneumonia = most common clinical presentation (abscess formation, cavitation) Protean manifestation (assumes many forms) o Asx, cutaneous, pulmonary dz o High propensity for bacteremia o Diabetes, renal dz, cirrhosis, thalassemia, alcoholism (& immunocompromise) predispose Treatment: TMP+SMX and broad-spectrum cephalosporin 22

Neisseria Species
General characteristics: Gram (-) diplococci, inhabit mucous membrane surfaces Group contains: o Non-pathogens (upper resp tract dwellers) o Strict pathogens: N. gonorrhoeae (STI: gonorrhea); N. meningitidis (epidemic/endemic meningitis) Features of Neisseria Aerobic Non-motile, non-spore forming Oxidase, catalse positive Chocolate agar (best) Use CHO oxidatively

Neisseria gonorrhoeae
Same characteristics as other Neisseria Nutritionally: more fastidious Requires cysteine for growth; other requirements too Epidemiology: STI except in newborns humans are only host; huge incidence (355,000/yr), mostly in sexually active teens & young adults Women (men too) can be asymptomatic and transmit infection Risk factors: o Social: lower SES, urban, lack of education, unmarried, STD history) o Behavioral: unprotected intercourse, multiple / high risk partners, drug use, MSM Pathogenesis: adherence cell entry/transport evade stimulate PMN host response (pyogenic) Special features of surface structure: o Oligosaccharide endotoxin (smaller than LPS) o Pili (attachment), peptidoglycan (toxic to fallopian tubes), membrane proteins (survival & invasion) Adheres to non-ciliated cells (e.g. fallopian tubes); adjacent ciliated cells damaged, slough off, more can attach o Loss of ciliated cells obstruction, infertility, ectopic pregnancy, etc. Clinical presentation Women: Mucopurulent cervicitis is typical, also urethral syndrome (distal urethra), pelvic inflammatory disease (ascending disease; scarring, etc.). Neonates: perinatal transmission; Ophthalmia neonatorum (purulent conjunctivitis); also gonococcal scalp abscesses or systemic infections. Men: Urethritis, epididymitis, rectal infections (if MSM) Common features: purulent exudates, inflammation, erythema (penis/os). Burning on urination (men)
o

N. gonorrhoeae: Lab Dx Gram stain (better in male urethral samples) Culture-based: sexual abuse, treatment failures, test of cure o Multiple methods (need 2nd to confirm:
important to be right, esp. child abuse)

Nucleic acid amplification (PCR) very sensitive (cant use for test of cure)

Unusual adult manifestations: conjunctivitis, disseminated gonococcal infection (vesicle purulent papule, erythema, central necrosis)

Culture: selective media; supplemented with growth factors; 72h, small, glistening, raised. Glucose metabolizer(not maltose or sucrose) Treatment: Uncomplicated: Ceftriaxone IM or Cefixime PO o Treat for CHLAMYDIA TRACHOMATIS (lots of coinfection): AZI PO x1 dose or doxycycline PO bid x 7d) Report & contact-trace infected persons Prevention: sex ed, abstinence, condoms, no vaccine use 1% silver nitrate or macrolide antibiotic prophylax for newborns 23

Neisseria meningitidis (meningococcus)

All age groups, both individual (sporadic) & epidemic Multiple serotypes: B,C,Y most severe in US Immunization possible (esp. closed populations) Epidemiology All age groups, both individual (sporadic) & epidemic Multiple serotypes: B,C,Y most severe in US Asymptomatic nasopharyngeal carriage (8-25%), precedes infection o Colonization in closed populations (college, military) need vaccination Terminal C deficiency (C5-9): recurrent, severe infections Worldwide: Epidemics in some countries (at end of rainy season) USA: Vast majority sporadic with localized outbreaks o Case fatality: 10-14% !! Pathogenesis Virulence factors: Pili, engulfment, transport in host cells; Polysaccharide capsule ( phagocytosis, C); Lipooligosaccharide endotoxin (very toxic!) Process: HAPPENS REALLY FAST 1. Pili adhere to non-ciliated resp epithelium invades submucosa 2. Capsule prevents phagocytosis 3. Replicates in submucosa; evades 4. Spreads into bloodstream 5. Endotoxin in blood: cytokine & alternative C activation Clinical presentations: 1. Bacteremia without sepsis (rare) 2. meningitis with neurologic sequelae 3. meningococcemia (overwhelming sepsis & DIC) a. with adrenal insufficiency: Waterhouse-Frederichsen Syndrome N. meningitidis Lab Dx: Direct exam of CSF (presumptive, quick) Culture: CSF, blood, other o Chocolate agar Definitive ID: glucose & maltose use

Meningitis Meningococcemia Like other meningitis but faster. Sudden onset: Fever, chills, myalgias, arthralgias, headache, confusion, nuchal rigidity CSF: 1200 WBC/mL, Glc, protein Meningococcemia o Rash: palpable purpura (infection of endothelial cells DIC, small hemorrhages) o Can get peripheral gangrene; lose digits Adrenal hemorrhage can cause insufficiency (W-F syndrome) Treatment: Meningitis/meningococcemia: Penicillin (alternatives: ceftriaxone, chloramphenicol in other countries) o Not PCN resistant! Prophylaxis (close contacts) trace! Rifampin, cipro, ceftriaxone Vaccines: Old: polysaccharide tetravalent (poor immunogenicity, not long-lasting, no reduction in NP carriage) New: tetravalent conjugate vaccine (Menactra) for 2-55yo (give 11-12 or entry to HS; should have for college) o Capsular polysaccharide conjugated to diphtheria toxin; induces T-cell dep response (good for infants) o Reduces Asx carriage o Indications: asplenia, C deficient, traveling to endemic areas, closed pops, prevention, lab workers 24

Anaerobic Gram Positive Bacteria

General characteristics: Dont grow in presence of oxygen Anaerobic infections (Clinical Dx) Two groups: Foul-smelling discharge o Obligate anaerobes (strict or moderate) Proximity to mucosal surface o Aerotolerant anaerobes Gas in tissues Tons of different kinds (many part of normal microflora, protective) Negative aerobic cultures Classification (pathogenic): shape, gram, spore formation, toxin production Widespread: environment (soil, sewage, foods, etc.) o animals & humans: oral cavity around teeth, GI tract, skin (some), G/U tract o habitats with low oxygen tension & reduced oxidation reduction potential Pathogenesis: Disruption of normal mucosal barriers Anaerobic infections often mixed (synergy with aerobes, other anaerobes) Virulence factors: capsules, adhesions, enzyme production, toxin production (some very potent toxins) Presentations: brain abscess (usually anaerobes or microaerophilic strep) bacteremia (need virulence factors to get into bloodstream) lots of others (mixed) e.g. empyema (pus in pleural cavity) Lab Dx: Get a good specimen (not anything where anaerobes would be in normal flora; Exception: C. diff & feces) o gastric washings, urine, vagina/cervix, feces, upper resp. secretions, etc. are bad Swabs are bad specimens, aspirates & tissue biopsies are best (transport immediately) o Inject into anaerobe transport media Semi-solid, 5% CO2, reducing agent shows anaerobiosis o Culture in complex media: supplemented; chopped meat glucose; use anaerobe chamber The following are GRAM POSITIVE ANAEROBES

Peptostreptococcus
Anaerobic, Gram (+) cocci; variable shape & size Found on skin, mucous membranes Importance: Causes bacteremia & mixed infections

Propionibacterium spp
(Major metabolic product = propionic acid) Anaerobic, Gram (+) rods, highly pleomorphic (curved, clubbed, pointed ends) Normal flora of skin, mucous membranes; major contaminant of blood cultures Non-spore forming Importance: acne, also opportunist with medical devices(shunts, caths, prosthetic valves)

Actinomyces
Anaerobic, Gram (+) rods, pleomorphic (short/club shaped, long/thin/beaded rods, branching) Slow-growing makes a molar tooth colony. Reason why labs hold AnO2 cultures for up to 1 wk

25

Actinomycosis Indolent, progressive infection that progresses across tissue boundaries Purulent foci with dense fibrotic tissue around Can look like neoplasia/tumor (mass) Later: sinus tract; drainage with sulfur granules (yellowish) E.g. cervical actinomycosis (cervicofacial is most common)

Clostridium species: overview

Obligate anaerobes, Gram (+) bacilli spore-forming, pleomorphic, most motile Large group; ubiquitous in nature (GI tract of humans/animals; soil)

Clostridium perfringens
Clostridial myonecrosis (gas gangrene) Pathogenesis: production of phospholipase C (very potent alpha toxin)tissue destruction Diagnosis: clinical: septic appearance, gas in tissues (palpable bubbles), o Necrosis with gas & no inflammatory cells: phospholipase C kills them too quickly! Treatment: need extensive surgical debridement! (cant contain with abx & host immune system) o Supportive care o Abx: penicillin G + clindamycin o Hyperbaric oxygen for some locations Food poisoning: toxin made after food ingested Necrotizing enterocolitis: beta-toxin production after poorly cooked pork, rare in US

Clostridium difficile
Pseudomembranous colitis & antibiotic associated diarrhea; Pathogenesis: Toxin A (enterotoxin), Toxin B (cytotoxin) o Extra toxins: epidemic strain Clinical presentation: bloody diarrhea; can include toxic megacolon (distended) Diagnosis: DIRECT DETECTION OF TOXIN IN STOOL is major way to diagnose Treatment: o Withdraw offending antibiotic o Metronidazole PO or vancomycin o Surgery if toxic megacolon, intestinal perforation, severe illness

Clostridium botulinum
Botulinum toxin: most potent neurotoxin known; bioterrorism agent Botulism: three types 1. Foodborne: typically adults; from ingestion of preformed toxin in contaminated food (poorly-made jams, etc) 2. Infant: organism in GI tract; toxin produced in vivo, most common form of disease 3. (Wound) rare Pathogenesis: toxin production; potent neurotoxin that blocks Ach release at neuromuscular junctions Clinical presentation: 1. Incubation: 18-36h, dose dependent 2. Afebrile, alert, oriented, normal sensory exam; early nausea/vomiting, diarrhea 3. Cranial nerve symptoms (ptosis, blurry/double vision, trouble swallowing/talking, salivation) 4. Progressive motor symptoms: BILATERAL DESCENDING FLACCID PARALYSIS resp paralysis 26

5. Death in 60% (untreated; 5% with Tx) Lab Dx: toxin in serum, gastric fluid, stool Treatment: 1. Supportive care (airway support) 2. Administer antitoxin (equine serum for adults 9-20% hypersensitivity or human botulism Ig for infants) 3. (if wound: debride too)

Clostridium tetani
VACCINE PREVENTABLE! Widespread distribution of spores in soil & aquatic environments Pathogenesis: 1. Spores contaminate puncture wounds, etc. 2. Spores germinate (low oxidation-reduction from poor vascular flow) 3. Vegetative cells multiply; release tetanospasmin (attaches to peripheral nerve endings; travels up to CNS) 4. Toxin: binds gangliosides in CNS and blocks inhibitory impulses (PROLONGED MUSCLE SPASMS) Clinical presentation Spastic muscle contractions Difficulty opening the jaw (lock-jaw) Characteristic smile (risus sardonicus) Contractions of back muscles can result in arching can actually snap spine! Treatment: 1. Supportive care (airway maintenance, antispasmodics) 2. Antitoxins: human tetanus Ig, tetanus toxoid 3. Antibiotics: metronidazole Prevention: vaccine!

Clostridium septicum
Bacteremia associated with malignancy Pathogenesis: high dose chemo damages GI; organisms translocate at site of mucosal damage Blood cultures positive Treatment: Penicillin G, supportive care, sometimes surgery

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Emerging and Re-emerging Bacterial Zoonoses

Zoonosis: any infectious disease that may be transmitted from other animals (wild & domestic) to humans or from humans to animals Vector: any animal that transmits an agent of human disease or plays an essential role in the agents life cycle o E.g. mosquitos / malaria; snail hosts / schistosomiasis; rodents / leishmaniasis o Typically arthropod vectors (mosquitos, ticks, flies, lice, fleas) Emerging infections: diseases that have recently appeared or are growing in incidence. Lots! o Zoonotic, vector-borne, bacterial high RR for disease to emerge

Transmission of bacterial zoonoses Direct contact: animals/infected materials Animal bites / scratches Arthropod vectors Contaminated food

Leptospirosis (Leptospira); Brucellosis (Brucella) Cat scratch disease / bacillary angiomatosis (Bartonella henselae) Plague (Yersinia pestis) Lyme disease (Borrelia burgdorferi), Rocky Mountain Spotted Fever (Rickettsia rickettsi)

Leptospirosis
Leptospira: spirochete (spiral-shaped); Enormous taxonomic group Leptospirosis: Estimated >10M cases worldwide, uncommon in US (Hawaii, Wisconsin?), more common in tropics Acquisition: contaminated animal or rodent urine: lives in bladder, urinary tract of asymptomatic animals o Water/soil o Skin abrasions; conjunctivae o Domestic pets (dogs) / livestock too Clinical presentation: Fever, headache, myalgia, abdominal pain, conjunctival suffusion (inflammation / red eyes) 5-10%: Icteric form (Weils disease) o Can precede worse outcomes: renal failure, pulmonary hemorrhage, cardiac arryhmias Uveitis (late manifestation, can lead to blindness) Death in 5-15% (esp old age) Histopathology: Cholestasis: brown pigment in liver (jaundice too) Pulmonary hemorrhage(mechanism not known) Interstitial nephritis: chronic inflammatory cells in interstitial around tubules Pathogenesis: urine contaminated water mucous membrane / skin abrasion liver, CNS, kidney, all organs localized in kidneys patient sheds Leptospira in urine Virulence factors: motility, hemolysins, adhesions / invasions (bind & localize), hemostasis & coagulation genes Immunologic pathogenesis: o Proinflammatory response to LPS (via TLR2); activates host inflammation o Multi organ-system failure due to DIC o Pulmonary hemorrhage (Ig, C fixation on host cells; more common with high Ab titers) o Ocular disease: uveitis during immune phase Ig & C? uvea = iris, choroid, ciliary body Dx: can culture during acute phase (1st week); IHC / microscopy / PCR not great. 28

Microagglutination test (MAT): detect Abs as early as 5-7d post-onset; o single high titer acceptable; seroconversion preffered Tx: doxycycline, penicillin, cefotaxime.
Jarisch-Herxheimer reaction (proinflammatory cytokine cascade; like sepsis, should anticipate possibility)

Brucellosis (Brucella spp)

-2 proteobacteria Gram (-) coccobacillus; facultative intracellular B. melitensis is key organism. Not sure if 1 or 3 species Epidemiology: worldwide distribution (Eurasia, Africa, S. America most) ; domestic wild populations coexisting Human transmission: o Oral contamination (domestic farm animals) o Consumption of unpasteurized dairy products o Inhalation of aerosolized contaminated animal products Pathogenesis: 1. Enters via mucosa, endocytosed by phagocytes 2. Survives in acidified phagolysosome; enters into ER (abx resistant), delays apoptosis 3. Regulates TNF by translocating a protein into cells cytoplasm Granulomas everywhere = characteristic of intracellulars like brucella Clinical presentations Classic febrile brucellosis: acute infection insidious onset (fever, sweating, malaise, headache, weight loss; aches/pains frank arthritis) Relapsing / undulant brucellosis (Malta fever) > 2mo after classical febrile brucellosis if un/der treated Liver involvement, arthritis, uveitis, orchiepididymitis Can be chronic; > 1 yr Complications: Osteoarticular disease o Peripheral arthritis (acute infection, non-erosive, knees, hips, ankles, wrists) o Sacroilitis (acute infection) o Spondylitis (lumbar spine; often irreparable damage) Epididymoorchitis (granulomatous inflammation with lots of lymphocytes in epididymis; enlarged testicles) Abortion in pregnant females, liver, CNS (meningitis, etc grave prognosis) ENDOCARDITIS: main cause of mortality, usually aortic valve, generally requires surgery Relapse: inadequate treatment; usually 1st year Diagnosis: Blood or bone marrow culture: need Biosafety level 3 (easily aerosolized) Detect Abs (serum agglutination test: draw pt serum, add antigens for Brucella). Safer, for presumptive Dx Treatment: Doxycycline + rifampin (or streptomycin/netilomycin) for 4-6 weeks 29

Bartonella spp
Small, Gram (-) rods; facultative intracellular bacterium; -2 proteobacteria, related to Brucella Mammalian, arthropod reservoirs (rodents, felids, lice, fleas, ticks) Infects erythrocytes & endothelial cells Bartonella henselae: Cat-scratch disease Epidemiology: risk: kitten exposure, ownership, bites/scratches Cats: often seropositive; persistently infected with B. henselae (normal blood flora-ish) Fleas: vector between cats, not humans (except maybe immunocompromised?) Clinical diagnosis: Regional lymphadeopathy with or without fever Cat/kitten scratch/bite Papule at inoculation site (small, red, elevated lesion) Characteristic histopathological features o Stellate microabscess in granuloma (in lymph nodes) Apoptotic cells, macrophages, PMNs, epitheliod histiocytes, etc. o Clusters of bartonella inside lesions Pathogenesis: Fleas on infected cats defecate; cats clean, flea feces under claws Inoculation of bacteria in cat scratch Spread: draining lymph nodes infection Occasional: systemic spread but resolves spontaneously in most cases Clinical manifestations: Cat-scratch episcleritis (Parinauds oculoglandular syndrome) o Inoculation in/around eye; drains to post-auricular node o Neuroretinitis: CNS involved; fluffy infiltrates (bacteria in retina) Usually in immunocompromised pts: o Bacillary angiomatosis / peliosis Proliferation of blood vessels & capillaries in skin (angiomatosis) or liver/spleen (peliosis) Inflammatory cells in interstitium; bacteria cluster there o Endocarditis very important Thrombus-like material forms; most of necrotic lesion filled with Bartonella

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Pathology of Mycobacteria Infection

M. leprae: Leprosy
Caused by M. leprae (acid-fast; obligate aerobe) Prefers cooler parts of body (lesions on skin prominences, nose, URT, peripheral nerves, testes) o Neuropathy secondary damage to fingers, etc secondary infection; loss of digits. 2 types: tuberculoid (nothing to do with TB) & lepromatous LEPROMATOUS TUBERCULOID Weak host immune response Strong host immune response Numerous bacilli (MB: multibacillary) Few bacilli (PB: paucibacillary) Sheets of macrophages, not granulomas Granulomatous reaction Non-reactive lepromin (skin) test Reactive lepromin (skin) test o Note how immune reaction is responsible for other differences Extremely rare in USA; more common in other countries (esp. Africa, Nepal) usually travelers if in US

M. tuberculosis: TB
Epidemic waves of morbidity/mortality: sharp rise; peak, gradual decline over 100s of years Worldwide: #2 ID killer (HIV, 2.7M; TB: 2.2M; Malaria: 1.1M) o 2 billion infected with M. tb; 8M new cases/yr, 1 death every 10 seconds; 500k infected with HIV too o One untreated pt infects 10-15 new pts / yr Epidemiology: poverty, overcrowded housing, undernourishment (airborne) o Slums of US, etc. where poor, elderly together

Mycobacterium tuberculosis: Acid-fast bacteria (high lipid content of cell walls; Ziehl-Neelsen stain) o Red dye, washed away from other cells by acid alcohol, counterstain blue Obligate aerobes, hard to detect in tissue, slow to grow in culture Can survive intracellularly Transmission: Person-person (small airborne droplet nuclei) o Have to be small to avoid mucociliary apparatus o Produced when coughing/sneezing/speaking/singing o Remain airborne; disperse uniformly throughout enclosed space (cant use regular surgical mask) Expt: guinea pigs in cages on roof infected via aerosolization; distance didnt matter MDR-TB is more easily spread!

Primary TB:
Initial spread & development of Ghon focus / complex 1. Goes to middle, lower lung fields (in periphery) greatest volume of air goes there 2. Nuclei implant on respiratory bronchioles/ alveoli (past mucociliary system, way out into lungs) 3. Initially: non-specific PMN response (usually not observed) 4. Alveolar M engulf mycobacteria multiply within M 5. Some mycobacteria are killed by M process/present antigen to T-helper lymphocytes release lymphokines to attract more M & activate monocytes infiltrate; activated histiocytes granuloma forms o Caseous center, etc. If you hear caseous or AFB, think TB! 31

6. Some M with M. TB transported to regional lymph nodes, then throughout body o Ghon focus: initial site of implantation o Ghon complex: Ghon focus + lymph node (classic for primary TB) Simon foci: some bacteria lung apacies (higher oxygenation, lower blood flow so lymphostasis) Apical scars: common in tuberculin + pts; harbor more bacilli (dormant) than other areas of lung 1st part driven by anatomy/physiology; this is driven by metabolic character of the organism Outcomes of this part: >90% heal; have positive PPD; viable bacilli remain! (calcified granule in lung can harbor dormant M. TB) 5% go on to develop progressive primary TB

Progressive Primary TB
5-10% of patients (especially lowered immunity, kids, elderly) progress to primary progressive TB If granulomata erode, can discharge into different spaces 1. Miliary TB: erode into vessel Characteristics: tons of evenly-sized, tiny foci throughout lung (bacteria well mixed in blood) larger foci towards apex (better oxygenation) Worst prognosis Pulmonary vein: left heart; to rest of body: new lesions in both lungs Pulmonary artery: back into that lung; new lesions in one lung 2. TB Bronchopneumonia: erode into airway Characteristics: larger pieces of granuloma breaking off unevenly sized, clustered nodules 3. TB empyema: erode into pleural space Characteristics: can see granulomatous change, caseation in former pleural space

Post-primary TB
Infections which develop in individuals with immunity to bacillus. 1. Reactivation of previously healed TB (Simon foci) a. Begins in posterior segment of upper lobe b. About 1-2% untreated PPD + pts will reactivate < 5yrs 2. Reinfection of previously infected individual (with different strain) a. Not totally prevented; suggests BCG vaccine not effective CAVITATION IS HALLMARK OF POST-PRIMARY TB: Granulomata eroding, eventually leave cavitation where they were before (especially near apex) Can manifest as TB bronchopneumonia (airway), Miliary TB (vein), TB empyema (pleura) like before or o Massive hemorrhage (erode into artery) specific for post-primary TB o Leads to hemoptysis Cavity can also heal (risk of aspergilloma fungal - infection) Preventing post-primary TB: treat PPD+ even if asymptomatic! Cuts risk of developing active disease; can treat while still healthy!

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Non-Tuberculous Mycobacteria
A.k.a. atypical mycobacteria, anonymous mycobacteria, pseudotubercule bacilli Classified into 4 groups, dont produce disease in guinea pigs Acquired from ENVIRONMENT (soil, water) not person-person like M. tb Opportunists: usually infect people with underlying lung dz or decreased immunity

HIV & Mycobacterium tuberculosis

HIV: depletes CD4+ cells; decreases monocyte/macrophage function HIV+ & +PPD: very high active disease rate Highest AIDS demographic groups: blacks/Hispanics 22-44 = greatest increase in TB Reversal of downward TB trend (1985-6: AIDS)

HIV patients & TB: TB usually diagnosed 6mo before opportunistic infections (more virulent); now an AIDS-defining dz More often extrapulmonary TB TB in lungs often non-apical, non-cavitary; poorly-developed granuloma (no good immune response) Drug-resistance higher; PPDs more often negative Complications: crushing spine (Potts disease); ocular involvement Rest of world: TB is leading cause of death in HIV+ individuals Worrisome: TB form in Africa resistant all known drugs; usually fatal.

HIV & NTM

NTM (e.g. mycobacterium avium complex) common in pts with AIDS (need low CD4 count) Enter via GI tract; occur late (less virulent), no person-person transmission No granulomas, histiocytes packed with bacilli (look pale blue & striated)

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Vector-Borne Zoonoses
Vector: any animal that transmits an agent of human disease or plays an essential role in the agents life cycle typically refers to arthropod vectors (mosquitos, ticks, fleas, flies, lice, etc.) Vector transmission only: Lyme disease, RMSF Direct-contact and vector transmission: plague

Yersinia pestis (Plague)

Gram-negative coccobacillus; stains in a bipolar pattern; facultative intracellular bacterium Ecology: endemic foci maintained; persistant rodent hosts; flea vector active year round Epizootic hosts; low resistance to infection (squirrels / chipmunks), high mortality/population density Rural rats fleas urban rats fleas humans(bubonic) humans(pneumonic) Potential bioterrorism agent (pneumonic) Transmission: Flea bite: bubonic plague 1. Rat flea bites patient 2. Inoculate flea material into wound drain to local lymph nodes bubo (hyperplasia & necrosis of LN) 3. Fever, headache, chills, malaise, painful lymphadenopathy (2-6d later) 4. With Tx: cure in 3-5 days Aerosol: pneumonic plague Pulmonary infection rapid spread & septicemia Either: septicemic plague Invade blood without buboes; high frequency of death Endotoxin / cytokine release / Gram (-) sepsis; resp. distress syndrome (ARDS); SIRS Complications: endophthalmitis, mmeningitis, tissue abscesses Epidemiology: endemic in Africa, Asia, N/S America; >2,000 cases / yr in world, high case fatality rate Human transmission: depends on environment, host mammals, arthropods Pathophysiology: rapid spread & growth in tissue & blood PMN: engulf & kill Yersinia M: just get infected; Yersinia propogates inside, kills M Bacteria suppresses leukocyte function o Yops: suppress inflammation o LcrV: stimulates TLR-CD14 on MIL-10(anti-inflammatory ) LPS activates systemic inflammatory responses, coagulation, fibrinolytic pathways (SEPSIS) Pla protease (plasmid) tissue destruction & Cdegradation (required for bubo) Pathology: Extensive tissue necrosis without extensive inflammation Diagnosis: clinical suspicion, blood culture, bipolar staining Treatment: streptomycin, doxycycline, sulfonamides

Borrelia burgdorferi (Lyme Disease)

Borrelia burgdorferi: Spiral-shaped (corkscrew / twisting motility); small, obligate parasite found with mammals, birds, ticks Transmitted exclusively through tick bites Maintained in small mammal via Ixodes species tick cycle (mammal reservoir, tick vector varies with location) o Tick: larvae nymph adult; nymphs do most of the biting (small tick = immature) o Larvae needs to acquire borrellia from mammal reservoir (last seasons nymphs did the infecting!) 34

Tick-bite (ixodes scapularis, deer tick) transmitted Tick life cycle: Tick bite: inserts through epidermis into dermis; both insert/secrete saliva & aspirate tissue (infects & can be infected); spirochete to tick midgut o Mild inflammatory lesion where bite occurs Epidemiology: N. America (northeast, Wisconsin/Michigan area, etc.), Europe, Asia Seasonality: bimodal distribution (most May-July: nymphal deer ticks; secondary peak in late fall: adult ticks) Incidence increasing Clinical presentation: Early localized infection: erythema migrans (bulls eye) o EM +/- draining lymphadenopathy; usually 1st week post-tick bite. EM not always present! o Nonspecific inflammation; perivascular lymphocytes: looks like chronic inflammation Early disseminated infection: systemic manifestation (disseminates to lymphatics, blood vessels, capillaries) o Fever (infrequent in early-localized) o Multiple erythema migrans o CN VII palsy, Carditis (arrhythmias), Oligoarticular arthritis, Meningitis Late infection: oligoarticular, chronic arthritis, encephalopathy (very rare), chronic pain/memory loss/etc. Post-Lyme disease syndrome: no response to antibiotics, not present in vaccine placebo group from trial, independent of serological results, no resistance to Abx: NO EVIDENCE FOR LONG TERM ABX and this cluster of symptoms really seems unrelated to Borrelia! Pathogenesis: inflammatory response to spirochetal lipoproteins in specific anatomical sites OpsA (adhesion for borreliae in tick midgut) OpsC (transmission from tick salivary gland; infection in mammal) Dissemination: spirochetes blind plaminogen; converted to plasmin, helps in interstitial / cell invasion o Host plasmin + spirochete: better movement through ECM (degrade); activate matrix metalloproteases to cleave ECM more Lots of lipoproteins (interact with TLRs host proinflammatory cytokine & chemokine production) o Joints: arthritis; heart: carditis; neural structures: neuritis Diagnosis: Clinical (Hx exposure; endemic region, erythema migrans), culture, SEROLOGY Serology: enyzme immunoassay (sensitive, not specific) first, then western blot to confirm Treatment: amoxicillin, doxycycline, ceftriaxone (CNS infections) Prevention: Vaccine no longer available Prophylatic doxycycline for tick bites in highly endemic areas (85-90% effective < 24 hrs) Remove attached ticks, avoid areas, etc.

Rickettsia rickettsii (Rocky Mountain Spotted Fever)

Gram (-), Obligate intracellular bacteria (Rickettsia = intracytoplasmic; Erlichia & Anaplasma = intravacuolar) True bacteria (debated at first: DNA, RNA, ribosomes, binary fission) Close relative to mitochondria (ATP transporter to steal ATP from cell: opposite of mito, etc.) Tick-bite transmitted Epidemiology: SE USA, emerging in Southwest. North, Central, South America Case-fatality rate: up to 8% overall, higher in children & elderly. Lyme disease: non-fatal; RSMF: can be deadly! 35

Pathogenesis: attach & enter endothelial cells escape from phagosome & inhibit phagolysosome fusion escape, cell dies Causes lymphocytic vasculitis Rash progression in RSMF Clinical presentation: SUDDEN ONSET Macular: flat, pink-red High fever, severe headache, severe myalgias Maculopapular: raised; blanches Maculopapular-petechial rash after 3-5d Petichiae: blood extravasated Normal WBC with left shift; thrombocytopenia (wont blanch) Lymphocytic vasculitis loss of intravascular fluid o Hypotension; shock, end-organ ischemic injury GI system, renal system (acute tubular necrosis secondary to hypotension) o Cerebral edema; meningoencephalitis E.g. herniated brainstem through foramen magnum, crush respiratory centers o Non-cardiogenic pulmonary edema Pathology: inflammation, damage to endothelium, damage to dermis, not epidermis (around endothelial cells) Diagnosis: clinical (h/o tick bite, fever, headache); SEROLOGY 5x risk death after 5d of illness Most not treated until after 5d: hallmark rash comes in late! o Presentation during non-peak tick activity, early presentation (1st 3 days) higher risk for missed Dx Culture not advocated: VERY HAZARDOUS (use PCR or skin biopsy with antigen) o Serology not useful in first 7-14 days Treatment: doxycycline (or tetracycline; doxy has better outcome than chloramphenicol; tooth-staining uncommon with these doses in kids)

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