You are on page 1of 72


Lecture 1

Prepared and presented by
Marc Imhotep Cray, M.D.

Scanning electron micrograph of Staphylococcus aureus bound to the surface of a human neutrophil. “Granulocytic Phagocytes,” by Frank R. DeLeo and William M. Nauseef.
Learning Objectives
By the end of this lecture you should be able to:
1. Describe the general mechanisms by which hosts resist colonization by
pathogenic microbes
2. Discuss the ways in which the normal flora contributes to the balance
between health and disease.
3. Explain the concept, components and mechanisms of bacterial virulence
and pathogenicity
Describe the stages in bacterial infection.
List and discuss the major features of the seven species of bacteria most
often involved in multiple systemic infectious diseases.

Marc Imhotep Cray, M.D.
Companion reading:
 Host Defense and Pathogenesis Notes

 Bacterial Diseases eNotes

 Bloch KC. Ch. 4 Infectious Diseases, Pgs. 61-69 In: Hammer GD and McPhee Eds. JS.
Pathophysiology of Disease: An Introduction to Clinical Medicine, 7th Ed. New York:
McGraw-Hill Education, 2014 (On Thumb drive.)

Marc Imhotep Cray, M.D.
Basic concepts
 Infectious diseases is one of the leading causes of death in both developed
and developing countries
 Worldwide, more persons succumb to microbial infections than to cancer
and heart disease combined
 Infections cause significant morbidity and mortality, especially in individuals
who are most vulnerable to illness:
 the very young,
 the elderly,
 the immunocompromised, and
 the disenfranchised
 Pathogenesis of infectious diseases reflects the relationship among
 the human host,
 the infectious agent, and
 the external environment
Marc Imhotep Cray, M.D.
Basic concepts (2)
Infectious agent can be either
 exogenous (i.e., not normally found on or in body) or
 endogenous (i.e., one that may be routinely cultured from a specific
anatomic site but that does not normally cause disease in host)

Infection results…
 …when an exogenous agent is introduced into a host from the
environment or
 …when an endogenous agent overcomes innate host immunity to
cause disease
o Host susceptibility plays an important role in either of these

Marc Imhotep Cray, M.D.
Human systems of defense
Two broad systems of defense against pathogens in the human
1. Innate or nonspecific immunity
 does not depend on previous exposure to the foreign substance
2. Adaptive or specific immunity

Major constituents of innate immunity:
 Physical barriers (skin and mucous membranes)
 Soluble factors (complement and cytokines),
 Physiologic factors (temperature, pH), and
 Cellular defenses (natural killer [NK] cells, neutrophils and
Marc Imhotep Cray, M.D.
Macrophage cytokines and functions
Macrophages release various cytokines in innate immunity

Function of cytokines:
 Tumor necrosis factor-α (TNF-α)
o Induces the inflammatory response
 lnterleukin-1 (IL-1)
o Induces fever, which enhances the immune response
 Interleukin-6 (IL-6)
o Induces the acute-phase response
 Interleukin-8 (IL-8)
o Chemotactic factor for neutrophils
 Interlukin-12 (IL-12)
o Activates NK and Th1 cells
Marc Imhotep Cray, M.D.
host-agent-environment interaction model
 Fundamental relationships involved in
the host-agent-environment interaction
 In the host, pathogenetic mechanisms
extend from level of populations
(eg, person-to-person transmission) to
level of cellular and molecular processes
(eg, genetic susceptibility)
 The environment includes vectors
(insects and other carriers that transmit
infectious agents) and zoonotic hosts or
reservoirs (animals that harbor Hammer GD and McPhee. Pathophysiology of Disease: An
infectious agents and often act to Introduction to Clinical Medicine, 2014

amplify the infectious agent)
Marc Imhotep Cray, M.D.
Host defense mechanisms
Humans are continuously exposed to microbes but it is
relatively rare for them to cause disease
 Testament to effectiveness of host defenses
o prevent invasion by normal flora
o defend against non-indigenous pathogens

• Defenses include:
 physical barriers
 mechanical processes
 specializes immune cells
 secretory immunity
 production of noxious compounds
 normal flora
Marc Imhotep Cray, M.D. 9
Physical barriers
Skin: physical barrier and other antimicrobial properties
 acidic pH (5-6)
 contains lactic acid, fatty acids (in sweat)
 normal skin flora (compete with pathogens)
Filtration of inhaled air: turbinate bones
Tears: lysozyme target peptidoglycan structure of gram-
positive cell walls
Commensal bacteria: skin, GI tract (compete with potential
Acidity: stomach, vagina
Marc Imhotep Cray, M.D. 10
Mechanical processes
Flushing: flow of fluid over mucosal surfaces removes bacteria
that are not specifically attached
 urine flow in urogenital tract
 gut contents in GI tract acid in stomach, pancreatic enzymes, bile,
Paneth cells (secrete defensins and lysozymes),peristalsis
 tears over cornea

Mucociliary action: in respiratory tract
 surface covered in layer of mucous prevents bacterial attachment
 ciliated epithelia push mucous upwards towards throat
o smokers, Kartagener’s syndrome Mucociliary paralysis
 Antimicrobial substances found in mucus: Lysozyme,
immunoglobulin A (IgA) antibodies, and iron-binding proteins
Marc Imhotep Cray, M.D. 11
Mechanical processes (2)
 Filtration of particles in upper airways (nose hairs and mucus)
 Mucociliary apparatus
 Cough reflex
 Mucus (lysozyme, sIgA antibodies, and iron-binding proteins)
 Alveolar macrophages (cytokines)
 Some bacteria that specifically target mucociliary apparatus:
 Bordetella pertussis
 Haemophilus influenzae
 Pseudomonas aeruginosa
 Mycoplasma pneumoniae

Marc Imhotep Cray, M.D.
Secretory immunity
Secretory immunoglobulin A (sIgA): Major role in mucosal
immunity, prevents colonization
 protection from proteolysis
 inhibits bacterial attachment to mucosal epithelia
 agglutinates bacteria
 binds (inactivates) toxins
 present in colostrum so protects suckling infants from infection

Does not activate complement or opsonize bacteria so relatively
unimportant in systemic infection

Marc Imhotep Cray, M.D. 13
Production of noxious compounds
Lysozyme (in saliva, tears, other mucosal fluids)
 cleaves peptidoglycans, disrupts bacterial walls

Lactoferrin, transferrin (in body secretions, serum)
 bind free iron so inaccessible for bacteria

HCl (in the stomach)
 sodium carbonate and achlorhydria neutralize

Bile salts and fatty acids (on skin)
 detergent effect disrupts bacterial cell walls

Marc Imhotep Cray, M.D. 14
Phases of the host response to infection

Hammer GD and McPhee. Pathophysiology of Disease: An Introduction to Clinical Medicine, 2014

 During earliest stage of initial infection, nonspecific mediators (complement, phagocytes)
 Adaptive immunity (production of antibody, stimulation of lymphocytes) requires clonal expansion
after recognition of specific antigens
 Once immunity toward a specific agent is induced, immune response remains primed so that
response to reinfection is much more rapid
Marc Imhotep Cray, M.D.
Normal flora
Commensal micro-organisms
 Human body normally harbors numerous species of bacteria, viruses,
fungi, and protozoa, referred to as the human microbiota
 The great majority of these are commensals, defined as organisms
that live symbiotically on (or) within the human host but rarely cause
Exclude colonization
 competing for ecological niches
 competing for essential nutrients
Produce anti-microbial compounds
 bacteriocins, volatile fatty acids

Contribute to immunity
 induce low levels of circulatory & secretory antibodies which cross react with
Marc Imhotep Cray, M.D. 16
Normal flora - examples
Skin: Staphylococcus epidermidis, micrococci, corynebacteria
Oral: streptococci, lactobacilli, staphylococci, corynebacteria,
Nasal cavity: S. epidermidis, S. aureus, corynebacteria
Urogenital: staphylococci, corynebacteria, E. coli, Lactobacillus
GI tract: E. coli, entercocci, bacteriodes, lactobacilli

Marc Imhotep Cray, M.D. 17
Commensal bacteria and toll-like receptor
(TLR) ligands
Commensal bacteria secrete toll-like receptor (TLR) ligands,
which bind to TLR on surface of normal intestinal tissue
 allows neutrophils and macrophages to recognize conserved bacterial
structures such as lipopolysaccharide (LPS)
This interaction stimulates basal signaling, which protects
against cellular injury

 Disruption of TLR signaling or antibiotic associated eradication
of commensal bacteria result in compromised ability of
intestinal epithelium to withstand injury and repair cell damage
(illust. next slide)
Marc Imhotep Cray, M.D.
Hammer GD and McPhee. Pathophysiology of Disease: An Introduction to Clinical Medicine, 2014

Marc Imhotep Cray, M.D.
Complement System
 Complement system is composed of a series of plasma protein and cell
membrane receptors that are important mediators of host defenses and
 Most of biologically significant effects of complement system are
mediated by third component (C3) and terminal components (C5–9)
o To carry out their host defense and inflammatory functions, C3 and
C5–9 must first be activated

 Two pathways of complement activation have been recognized and have
been termed classic and alternative pathways
 classic pathway is activated by antigen–antibody complexes or antibody-
coated particles, and
 alternative pathway is activated by mechanisms independent of
antibodies, usually by interaction with bacterial surface components
Marc Imhotep Cray, M.D.
Complement System (2)
 Inherited disorders of complement are associated with an increased risk
of bacterial infection

 Specific infections seen in complement-deficient patients relate to biologic
functions of missing component
 For example, patients with a deficiency of C3 or of a component in
either of two pathways necessary for activation of C3 typically have
increased susceptibility to infections with encapsulated bacteria such
as Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus
influenzae, and Klebsiella pneumoniae
 In contrast, patients with deficiencies of C5–9 have normal resistance
to encapsulated bacteria because C3b-mediated opsonization is intact
(illust. next slide)
Marc Imhotep Cray, M.D.
Complement reaction

Hammer GD and McPhee. Pathophysiology of Disease: An Introduction to Clinical Medicine, 2014
sequence and infections
associated with deficiency
 classic pathway is activated by
antigen–antibody complexes or
antibody-coated particles

 alternative pathway is activated by
mechanisms independent of
antibodies, usually by interaction
with bacterial surface components

Marc Imhotep Cray, M.D.
Concept of "Pathogenesis"
Pathogenesis - the course of the infectious process

"Virulence" factors or "pathogenicity" factors
 Microbes which can cause disease are thought to carry out
process by utilizing one or more properties called virulence
factors or pathogenicity factors



Marc Imhotep Cray, M.D. 23
Mechanisms of Pathogenesis
 Bacteria carry a variety of virulence
factors that facilitate pathogenesis:
These include:
 factors that help them evade the
immune system
 factors that facilitate adhesion
 factors that facilitate spread through
 invasion of host cells
 a variety of different toxins that are
toxic to host

Marc Imhotep Cray, M.D.
Bacterial virulence factors
fimbriae - adherence to host tissues
toxins - secreted or membrane-bound proteins, cause tissue
damage or inhibit tissue function
capsules - surface polysaccharides, protect against host immune
endotoxin - lipopolysaccharide (LPS), component of membranes
elicits immune/inflammatory responses
siderophores - scavenge iron and promote uptake into bacteria

Marc Imhotep Cray, M.D. 25
Bacterial virulence factors (2)
Factors that help bacteria evade the host immune system
 Structural components like capsules prevent phagocytosis
 A variety of proteins, such as listeriolysin O, facilitate intracellular
survival in phagosomes
 Enzymes involved in destruction of immune molecules include IgA
proteases and leukocidins
 Antigenic variation and phase variation result in a change of surface
antigens effectively allowing bacteria to hide from preformed antibody
 Intracellular invasion allows bacteria to evade humoral immune

Marc Imhotep Cray, M.D.
Bacterial virulence factors (3)
 Factors that facilitate adhesion, invasion, and spread include:
 flagella
 pili
 cell-wall associated proteins
 slime layers and
 enzymes including hyaluronidase, mucinase, and urease

Marc Imhotep Cray, M.D.
Bacterial virulence factors (4)
 Two general types of bacterial toxins are common
1. LPS, which is extremely toxic to animals, has been called the endotoxin of
gram-negative bacteria because it is an integral part of cell wall and is
released only when cells are lysed
 When LPS is split into lipid A and polysaccharide, all of toxicity is
associated with lipid A component
 Endotoxin stimulates inflammatory cytokines including tumor necrosis
factor alpha (TNF-α) and interleukin-1 (IL-1)
2. Many different exotoxins can be produced that affect a variety of cellular
processes including inhibition of protein synthesis; others have adenylate
cyclase activity or function as superantigens

 Some toxins are neurotoxins or cytotoxins
Marc Imhotep Cray, M.D.
 LPS found in outer membrane of gram-negative bacteria (both cocci
and rods)
Nitric oxide
Outer membrane
Le T and Bhushan V. Microbiology. In: First Aid for the USMLE Step 1 2015 O-antigen
eXtremely heat stable
Neutrophil chemotaxis

Marc Imhotep Cray, M.D.
Bacterial virulence factors - examples
These promote evasion of host immune response:
 Protein A
 Binds Fc region of IgG Prevents opsonization and phagocytosis expressed by
S. aureus
 IgA protease
 Enzyme that cleaves IgA Secreted by S. pneumoniae, H. influenzae type B, and
Neisseria (SHiN) in order to colonize respiratory mucosa
 M protein
 Helps prevent phagocytosis Expressed by group A streptococci Shares similar
epitopes to human cellular proteins (molecular mimicry) possibly underlies
autoimmune response seen in acute rheumatic fever
 Type III secretion system
 Also known as “injectisome”  Needle-like protein appendage facilitating direct
delivery of toxins from certain gram-negative bacteria (e.g., Pseudomonas,
Salmonella, Shigella, E. coli) to eukaryotic host cell

Marc Imhotep Cray, M.D.
Stages in bacterial infection
 Entry: skin is a major barrier but can be breached by bites or wounds, entry
usually via mucosal surfaces
 Colonization: attachment to mucosal surfaces
 Proliferation: acquisition of nutrients
 Invasion: entry into host tissue/cells; local, systemic
 Avoidance of immune system
o resistance to complement and antibody killing
o survival in phagocytes (resistance to enzyme degradation, reactive
oxygen species, escape)
 Overcoming iron limitation
 Transmission

Marc Imhotep Cray, M.D. 31
Organisms Comprising the Microbial World
Scope of the Problem:
 Viruses, bacteria, protozoa, fungi, and parasites
 Enormous diversity

Marc Imhotep Cray, M.D. 32
Hierarchy of Microbes: [Smallest  Largest]
Single-celled eukaryotes (animal-like cells):
 Parasitic protozoa
 Fungi/yeast
Higher eukaryotes:
 Parasitic intestinal worms
 Tissue worms

Marc Imhotep Cray, M.D. 33
Microbes are everywhere and in high numbers

1 gram of human feces contains about 1 trillion bacteria

Marc Imhotep Cray, M.D. 34
Common Clinical Ways of Categorizing Microbes
“Avirulent” or “nonpathogenic” - harmless
“Virulent” or “pathogenic” - capable of causing disease
Normal flora - microbes that colonize the body and usually do
not cause disease.
Opportunistic pathogens - microbes that normally do not
cause disease, but may under certain circumstances.
Frank pathogens - microbes that always cause disease.
Other - diseases caused mostly by ingestion of preformed
toxins or when toxins are produced from bacteria during
Marc Imhotep Cray, M.D. 35
Bacterial structures, Cell Wall

Le T and Bhushan V. Microbiology. In: First Aid for the USMLE Step 1 2015

Marc Imhotep Cray, M.D.
Clinical Bacteriology
Gram-positive lab algorithm

Marc Imhotep Cray, M.D. Le T and Bhushan V. Microbiology. In: First Aid for the USMLE Step 1 2015
A 54-year-old man develops a pyogenic infection along the suture line after
knee surgery. The laboratory gives a preliminary report of a beta-hemolytic,
catalase-positive, coagulase-positive, Gram-positive coccus. The most likely
causative agent is
(A) Moraxella catarrhalis
(B) Staphylococcus aureus
(C) Staphylococcus epidermidis
(D) Streptococcus agalactiae
(E) Streptococcus pyogenes

Marc Imhotep Cray, M.D.
Clinical Bacteriology
Gram-negative lab algorithm

Marc Imhotep Cray, M.D. Le T and Bhushan V. Microbiology. In: First Aid for the USMLE Step 1 2015
The World from the Microbe's Perspective
Microbes cannot think; SURVIVAL OF THE SPECIES.
they simply exploit the
human environment
solely for growth and

Marc Imhotep Cray, M.D. 40
Find Best Place for Troops to Invade
Concept of Site-Pathogen Combinations
 Staph infection: invasion through compromised skin

 Tuberculosis: inhalation into lung

 Strep infection: streptococci bind to throat epithelial cells

 Urinary tract infection: E. coli enter at urethral orifice

 Gastritis: stomach lining acceptable to Helicobacter pylori

Marc Imhotep Cray, M.D. 41
1) Initial Invasion (Infection)
Subtle Infiltration in quiet of night and often with camouflage
 Streptococcus pyogenes
 Streptococcus pneumoniae and Neisseria meningitidis

Massive invasion to overwhelm the opposition
 Some invaders can escape stomach acid (e.g., E. coli,

Marc Imhotep Cray, M.D. 42
2) Establishing a "Beach Head“ (Colonization)
Ensuring the availability of food and water (scavenging of
Establishing a good defense (armor; barriers) against an offensive
(immune) attack
3) Taking the Offensive (Invasion/Spread)
Moving out from initial site to more distant sites that offer more
territory and more opportunities for survival and expansion

4) Expand to Neighboring Environments
 Infect other individuals

Marc Imhotep Cray, M.D. 43
Examples of Microbial Pathogenesis
Strategies -Viruses
Viruses take over our cells and use them as "factories" to make
new virus particles:
 Budding - slow release; eventually stresses and kills the cell

 Lysis - rapid, complete destruction of cell by explosion

 Latent infection - more protracted, insidious infection that may
or may not lead to destruction of infected cell or may lead to

Marc Imhotep Cray, M.D. 44
This diagram illustrates
various types of viral
infections humans
commonly come into
contact with.

Marc Imhotep Cray, M.D. 45
 Bacteria exploit a wide spectrum of parasitic strategies

Marc Imhotep Cray, M.D. 46
Bacterial Diseases
Seven important species of bacteria are involved in so many different systems
they are presented your eNotes under the heading ‘‘Major Recurring Species’’
These species are:
1. Chlamydia trachomatis
2. Escherichia coli
3. Haemophilus influenzae
4. Pseudomonas aeruginosa
Note: To reinforce your pharmacology primary drugs for
5. Staphylococcus aureus treatment for specific organism are provided where there
is drug resistance, or where Tx involves something
6. Streptococcus pneumoniae besides or in addition to antibiotics, or is reasonably
straightforward, but are not recommended initial therapy
7. Streptococcus pyogenes for disease prior to identification of the bacterial agent.

Marc Imhotep Cray, M.D.
This diagram illustrates
various types of bacterial
infections that humans
commonly come into
contact with.

Marc Imhotep Cray, M.D.
1. Chlamydia trachomatis
1. Small, non–Gram-staining, obligate intracellular pathogen (OIP).
2. Found only in humans; transmitted as elementary bodies by direct contact
(birth, sex, or on feet of flies tracking from one eye to next).
1. Causes disease by intracellular replication that elicits (except in neonates) a
granulomatous response, which, if untreated, leads to symptoms depending on
the body locale, such as fallopian tube blockage, leading to infertility or ectopic

Marc Imhotep Cray, M.D.
Milner DA. Ed. Diagnostic pathology. Infectious Diseases. Philadelphia: Elsevier, 2015

Marc Imhotep Cray, M.D.
Chlamydia trachomatis cont.
2. The three major serovar groups each cause a different spectrum of disease;
multiple serotypes of each allow reinfection
a. Chl. trachomatis serovars D–K in the United States cause conjunctivitis,
genitourinary tract infection, and neonatal pneumonia
b. Chl. trachomatis serovars A–C cause trachoma
c. Chl. trachomatis serovars L1, L2, and L3 cause lymphogranuloma venereum
3. Lab ID (laboratory identification): cell culture required to grow so diagnosis is
commonly by immunofluorescence or genetic probes.
4. Treatment: commonly doxycycline, a macrolide, or fluoroquinolone (FQ)

Marc Imhotep Cray, M.D.
2. Escherichia coli
1. Motile, lactose-fermenting, member of the Enterobacteriaceae.
2. Colonic normal flora (nonpathogenic strains) of human and animals. May
colonize lower end of urethra and vagina Transmitted during birth or via
fecal–oral route.
1. E. coli causes urinary track infections (UTIs), neonatal sepsis and meningitis,
and diarrheal diseases.

Marc Imhotep Cray, M.D.
Escherichia coli cont.
2. Disease results when normal flora strains enter normally sterile sites or
when organism acquires virulence factors
a. All strains have endotoxin and constitutively produce common pili that
adhere to colon cells
b. Like other Enterobacteriaceae, E. coli easily receives (or donates) genetic
elements from other enterobacteria.
3. Lab ID
a. Grows on bile-containing media like Hektoen.
b. Ferments lactose and is identified by a panel of metabolic tests.
4. Treatment: treated (except for uncomplicated UTIs) according to drug
susceptibility results.

Marc Imhotep Cray, M.D.
3. Haemophilus influenzae
1. Gram-negative, fastidious, pleomorphic rod (short to almost filamentous
rods from cultures coccobacillary in cerebrospinal fluid [CSF])
2. Part of normal flora (NF) of upper respiratory tract  NF strains generally
do not have a capsule and are called nontypeable; encapsulated virulent
strains are stereotyped by lab
 all are transmitted via respiratory droplets by direct contact
1. Ottis media may be caused by any strain with or without capsule

Marc Imhotep Cray, M.D.
Haemophilus influenzae cont.
2. Virulent strains with type b capsule cause meningitis or epiglottitis in
unvaccinated children generally younger than 2 years of age.
H. influenzae type d causes exacerbations of chronic bronchitis in patients
with chronic obstructive pulmonary disease (COPD)

3. Lab ID: fastidious—does not grow on blood agar (BA) but grows on
chocolate agar (chocolate agar positive) or near Staph. aureus on BA (satellite
colonies); or with X (hematin) and V (nicotinamide adenine dinucleotide
[NAD]) factor supplementation on nutrient agar

4. Treatment: treated with cefpodoxime or ceftriaxone (for life-threatening
infections) or amoxicillin-clavulanate

Marc Imhotep Cray, M.D.
4. Pseudomonas aeruginosa
1. Gram-negative rod with polar flagella
2. Oxidase positive (not an Enterobacteriaceae) and obligate aerobe
3. Pigments: fluorescein, a fluorescent pigment, and pyocyanin, a blue-green
Bluegreen pus is a classic sign of Ps. aeruginosa cellulitis in burn patients
4. Ubiquitous and widely distributed in/on plants, soil, and water
Rapid growth even in distilled or tap water (i.e., sink drains, faucet aerators,
cut flowers)

Marc Imhotep Cray, M.D.
Pseudomonas aeruginosa cont.
1. Pseudomonas is a frequent cause of nosocomial infections, with
pneumonias in cystic fibrosis, burn, and neutropenic patients; cellulitis in
burn patients; eye and ear infections
2. Pathogenesis:
a. Exopolysaccharide layer (capsule) increases adherence to tracheal epithelium
and mucin. also inhibits phagocytic uptake
 Pili aid in adherence
b. In tissues or blood, endotoxin triggers inflammation or shock
c. Pseudomonas exotoxin A is an adenosine diphosphate (ADP)-ribosyl transferase (similar to
diphtheria toxin) that inactivates EF-2 (elongation factor) halting protein synthesis primarily
in liver and resulting in liver necrosis
d. Phospholipase-C damages all membranes, causing tissue necrosis; elastase and other
proteolytic enzymes damage elastin, immunoglobulin A and G (IgA, IgG), complement
components, and collagen
Marc Imhotep Cray, M.D.
Pseudomonas aeruginosa cont.
3. Lab ID: iridescent sheen on beta hemolysis around colonies grown on blood
agar; fruity odor
4. Treatment: drug resistance; do susceptibility tests.
a. Pseudomonas has a high inherent resistance and also acquires
resistance (e.g., beta-lactamases, decreased carbapenem entrance due
to porin loss, DNA gyrase mutations (FQ), and aminoglycoside-
inactivating enzymes
 Efflux pump rids it of antibiotics
b. Antipseudomonal penicillins, meropenem, imipenem, third-generation
and fourth-generation cephalosporins, or tobramycin is generally used;
combinations are often used in severe disease in immunocompromised
(IC) patients

Marc Imhotep Cray, M.D.
5. Staphylococcus aureus
1. Catalase-positive, coagulase-positive, beta-hemolytic, Gram-positive
coccus found in grapelike clusters
2. Colonizes mucosa (15% of adults are carriers)  Transmitted by direct
contact and fomites
1. Causes skin and surgical infections, endocarditis, toxic shock syndrome,
septicemias, scalded skin syndrome, food poisoning, infective arthritis,
osteomyelitis, postinfluenza pneumonia, and pneumonia in very young cystic
fibrosis (CF) patients

Marc Imhotep Cray, M.D.
Staphylococcus aureus cont.
2. Pathogenesis:
a. Hemolysins and other cytolytic toxins
b. Coagulase binds to prothrombin, triggering fibrin polymerization
around Staph. aureus, slowing clearance
c. Fibrinogen-binding clumping factor allows S. aureus to bind to normal
heart tissue to damage
d. Protein A on its surface binds the Fc portion of antibody, reducing
e. Teichoic acids (lipoteichoic and cell-wall–bound) play a role in
adherence and, when cell wall is breaking up, lipoteichoic acids with
peptidoglycan trigger shock via same pathways as endotoxin
3. Lab ID: positive catalase and coagulase tests; beta-hemolytic ferments
mannitol (mannitol agar positive)

Marc Imhotep Cray, M.D.
Staphylococcus aureus cont.
4. Treatment: drug resistance do susceptibility tests
a. In the 1950s, Staph. aureus acquired a plasmid conferring resistance to many early
antibiotics such as tetracyclines and penicillins
 A new group of penicillins (methicillin and nafcillin) were developed to target new
resistant strains These strains are known in the United States as methicillin-
sensitive Staph. aureus (MSSA)

b. In ] 1980s, some MSSA strains developed a new cell wall synthetic enzyme (PBP) made by
the mecA gene, which allows bacterium to build peptidoglycan in presence of methicillin or
nafcillin these strains are known as methicillin-resistant Staph. aureus (MRSA)

c. Now, there are vancomycin-intermediate Staph. aureus (VISA) with thick cell walls that bind
high levels of vancomycin and vancomycin-resistant Staph. aureus (VRSA) with even higher
resistance similar to vancomycin resistant enterococci (VRE)

Marc Imhotep Cray, M.D.
6. Streptococcus pneumoniae (Pneumococcus)
1. Gram-positive, alpha-hemolytic, lancet-shaped diplococcus
2. Oropharyngeal mucosal colonist/opportunist
1. Otitis, sinusitis, pinkeye; pneumonia or
meningitis in nonvaccinated young, old or alcoholics
2. Pathogenesis:
a. Colonizes with help of protein adhesins and an IgA protease; reduces
numbers of competing NF by production of large amounts of hydrogen
b. Thick polysaccharide capsule reduces effectiveness of complement and
antibodies, decreasing phagocytic uptake more than 80 different capsular
polysaccharide types.
c. Hemolyzes cells through pneumolysin and partially reduces hemoglobin to
green pigment (alpha-hemolysis)
Marc Imhotep Cray, M.D.
Streptococcus pneumoniae cont.
3. Lab ID Streptococcus pneumoniae
a. Alpha-hemolytic and lysed by bile and inhibited by optochin
b. Capsules are typed by quellung reaction (apparent capsular swelling when
mixed with the specific matching antibody)
4. Treatment: penicillin resistance due to decreased binding to penicillin-
binding proteins mandates testing
5. Prevention
a. A 7-valent polysaccharide-protein conjugate vaccine (T-cell dependent) for
b. A 23-valent polysaccharide vaccine for patients 65 years or older,
asplenics, diabetics, human immunodeficiency virus (HIV) positive, COPD, and
so forth

Marc Imhotep Cray, M.D.
7. Streptococcus pyogenes
(Group A strep [GAS])
1. GAS is beta-hemolytic, Gram positive, catalase negative, coccus in chains
2. Also known as GAS because it interacts with Lancefield antibodies for
Group A cell wall carbohydrates (the basis for the rapid antigen test)
3. Inhibited by bacitracin and produces L-pyrrolidone arylamidase (PYR test
4. Colonizes skin and upper respiratory tract mucosa Survives on hard
surfaces; spread by fomites, respiratory droplets, and direct contact
 Because GAS is not particularly invasive, it requires colonization and skin
trauma to infect

Marc Imhotep Cray, M.D.
Streptococcus pyogenes (Group A strep
[GAS]) cont.
1. GAS causes pharyngitis, impetigo, erysipelas, cellulitis, necrotizing fasciitis,
bacteremia, rheumatic heart disease, poststreptococcal acute
glomerulonephritis, and toxic shock syndrome
2. Tissue is damaged by enzymes, including streptolysins and streptokinase A
and B, which break down clots, DNase, and hyaluronidase (spreading factor in
necrotizing fasciitis)
a. Streptolysin S is a beta-hemolysin
b. Streptolysin O is an immunogenic, beta-hemolysin
 Antibody to Streptolysin O is a marker of recent mucosal infections and (or)
rheumatic heart disease (ASO titer) which is culture negative

Marc Imhotep Cray, M.D.
Streptococcus pyogenes [GAS] cont.
3. M proteins
a. Attach Strep. pyogenes to cytoplasmic membrane.
b. Class I M proteins extend through t cell wall to cell surface
c. Strains causing rheumatic heart disease have exposed class I M proteins, which are
responsible for cross-reactivity with human heart antigens
d. M-12 strains are associated with glomerulonephritis
4. Nonimmunogenic hyaluronic acid capsule—inhibits phagocytic uptake until
other surface components are opsonized
5. Strep. pyogenes erythrogenic (SPE) toxins
a. SPEs are produced only by strains of Strep. pyogenes carrying a lysogenic phage
b. All SPEs produce a fine, blanching, ‘‘sandpaper’’ rash on arms and upper trunk
c. SPE-A and -C are superantigens, nonspecifically activating large numbers of T cells and
triggering proinflammatory cytokines and ultimately producing shock and multisystem organ
6. Lab ID Pharyngitis: rapid antigen test with culture; all other infections:
Marc Imhotep Cray, M.D.
Malaria (several protozoan species of Plasmodium) - transmitted
to humans by bite of female Anopheles mosquitoes
 A major global health problem in tropical developing countries
 Plasmodium is a model intracellular parasite - carries out a key part of its
life cycle inside human red blood cell
 Produces enzymes that breakdown hemoglobin of red blood cell as a key
nutrient source
 Complex life cycle; partly in humans and partly in mosquitoes
 Phase in humans can be cyclic and thus give rise to relapses over several
 Treatment is difficult and resistance to drug therapy is highly problematic

Marc Imhotep Cray, M.D. 67
Hookworm- An Intestinal Roundworm
Life Cycle:
Penetrate skin

Immature worms Heart and lungs

Eggs mature Coughed up

Eggs in soil Swallowed

Eggs excreted Small intestine

Eggs in feces Larvae mature
Lay eggs

Marc Imhotep Cray, M.D. 68
Comparison of Viruses and Bacteria

Viruses Bacteria
 Size
10-100 times larger

 Replicate on their own? No Yes
 Structure Simple Complex cell
(Genetic material
+ protein coat only)
 Metabolic Functions No Yes
 Susceptible to classical antibiotics? No Yes
Marc Imhotep Cray, M.D. 69
1. “Microbial World”: viruses, bacteria, protozoa, fungi, and other parasites.
2. Microbes are everywhere in the environment; humans are heavily colonized!
3. In humans, there are “avirulent”: (e.g., normal flora which are beneficial)
microbes vs. those which are “opportunistic” or “pathogenic.”
4. Sole mission of microbes: Get by and multiply!
5. Viruses “take over” our cells and use them as “factories” to make new viruses
6. Bacteria and parasites have evolved highly ingenious strategies to evade our
immune responses and to exploit diverse environments within human body
7. Bacteria and parasites rely on traits (“virulence factors”) to make them
8. Studies of microbial “virulence factors” will provide novel insights for
developing new antibiotics and vaccines

Marc Imhotep Cray, M.D. 70

Sources and further study:
 Chen EM and Kasturi SS. Deja review, Microbiology and Immunology 2nd Ed. New York: McGraw-Hill,
 Kishiyama JL. Ch. 3 Disorders of the Immune System, Pgs. 31-59 and Bloch KC. Ch. 4 Infectious Diseases,
Pgs. 61-87 In: Hammer GD and McPhee Eds. JS. Pathophysiology of Disease : An Introduction to Clinical
Medicine, 7th Ed. New York: McGraw-Hill Education, 2014
 Johnson AG et al. Bacterial Diseases. In: Microbiology and immunology. 4th Ed. Baltimore: Lippincott
Williams & Wilkins, 2010
 Le T and Bhushan V. First Aid for the USMLE Step 1 2015, New York: McGraw-Hill, 2015
 Milner DA. Ed. Diagnostic pathology. Infectious Diseases. Philadelphia: Elsevier, 2015

eLearning (IVMS Cloud)
 Infectious Disease
 Microbial biology & Immune System
 Rural Medicine Global Health (Focus on Ethiopia)

 Ryan KJ and Ray CG Eds. Sherris Medical Microbiology, 5th Ed. New York: McGraw-Hill, 2010
 Carroll KC etal. Jawetz, Melnick, & Adelberg’s Medical Microbiology 27th Ed. New York: McGraw-Hill, 2016
Marc Imhotep Cray, M.D. 72