Bacterial Meningitis and Respiratory Infections

Understand the pathogenesis and clinical symptoms of respiratory pathogens

including Corynebacterium diphtheria, Bordetella pertussis, Haemophilus
influenza

• Describe clinical features of diphtheria

• Describe the function of diphtheria toxin and its role in myocarditis

• Know Elek test and the media used for C. diphtheria

• Describe the disease mechanism of whooping cough

• Describe the difference between H. Influenzae type b and nontypable H.

Influenzae

• Describe the clinical features of epiglottitis

• Describe the media used to grow Haemophilus

• Understand the composition of the vaccines for these pathogens

 Corynebacteria
diphtheria Bordetella pertussis Haemophilus influenzae

Type B Non-typable

Whooping Meningitis Epiglottitis

Diphtheria Bronchitis Otitis
cough media

Neisseria Sinusitis

meningiditis gonorrheae

Meningitis Gonorrhea
The nasal cavity, the
upper part of the
pharynx (throat), the
trachea, and the bronchi
are lined with
pseudostratified ciliated
columnar epithelium
 Corynebacterium diphtheriae

• G(+) club-shaped rods

• Facultative anaerobe
• Catalase positive
• Have metachromatic granules
• Have a phage-encoded toxin
• Can be carried asymptomatically
Corynebacterium diphtheriae

Virulence factor:

• A bacteriophage-encoded A-B toxin is responsible for the

pathogenicity of this organism.

• Function: interrupts peptide formation during translation

• The B subunit of the toxin can bind receptors on a variety of cells
including heart and nerve cells. It also helps in translocation.
• The A subunit terminates host cell protein synthesis by adding
ADP-ribose to the EF-2.

• The toxin is distributed by the circulation

Pathogenesis:

Respiratory disease is called diphtheria

• Transmitted by respiratory droplets
• Local multiplication in the in the pharynx and adjacent areas
causes initial damage.
• Symptoms:
• Low grade fever
• Sore throat
• Swollen neck “bull neck”
• Hoarseness, barking cough “diphtheritic croup”
• Exudative pharyngitis with a thick pseudomembrane

• The pseudomembrane is composed of:

• Bacteria
• Necrotic epithelium
• Macrophages
• Fibrin

• The pseudomembrane covers tongue, uvula, and can be

extended into the nasopharynx and the larynx.

• Fluid from the dying cells coagulates to form grayish green bull neck
membrane, purpose of membrane: protect bacteria
• The membrane firmly adheres to tissue
and is difficult to dislodge without causing
bleeding.

• Spreading of the membrane down the

bronchial tree can occur, causing
respiratory tract obstruction and dyspnea

• If the patient recovers, the membrane

eventually dislodges.

• Toxin may contribute to the initial adhesion

of bacteria.

• Bacteria does not invade the blood stream

Complications
Toxin spreads distally and leads to severe
complications including nerve damage and
myocarditis

• Myocarditis (20% of cases)

• Peripheral neuropathy (10% of

cases)
• Typical targets are nerves to the throat,
where poor nerve conduction may cause
difficulty swallowing.
• Nerves to the arms and legs also may
become inflamed, causing muscle
weakness.
• If C. diphtheria toxin damages the nerves
that help control muscles used in breathing,
these muscles may become paralyzed.

• Coma and death result from these

complications
VACCINE:

DTaP – (ages 2, 4, 5, 15 months and 5-6 years)

• D is for diphtheria toxoid

• T is for tetanus toxoid
• The acellular pertussis contains: pertussis toxoid,
hemagglutinin, fimbriae.
Diagnosis:

• Usually clinical diagnosis is used to give initial treatment

(as it takes 1 week or more to get definitive lab results)

• Direct examination of clinical material is unreliable as

several normal flora inhabitants resemble this organism

• Culture of the nasopharynx or throat specimen is done on

special medium: Cysteine-tellurite agar

• Selective: Tellurite inhibits growth of most upper respiratory tract

bacteria and gram-negative rods, and is reduced by C. diphtheriae to
tellurium to produce a gray color.
• Differential: H2S production from cysteine and its interaction with
tellurite salt produces a brown halo around the colonies.
Blood agar Tellurite - blood agar
• Cysteine-tellurite agar
Elek test
A toxigenicity test called Elek test is done on bacterial cultures:

• Anti-toxin filter is placed on an agar plate containing C.

diphtheriae
• Isolates of C. diphtheriae are streaked across the plate at an
angle of 90° to the antitoxin strip
• Toxigenic C. diphtheriae is detected because secreted toxin
diffuses from the area of growth and reacts with antitoxin to
form lines of precipitin
Anti-toxin soaked filter

Non-Toxigenic
C. diphtheriae

Toxigenic
C. diphtheriae
Diphtheria - First example where there was evidence of intoxication as means
of disease

1. In cases with diphtheria, bacteria could not be found anywhere except throat,
although symptoms were systemic and neurological.
2. Inoculating mice with cell-free supernatant from the growing bacteria gave them
neurological diphtheria disease.
3. Combining this supernatant with serum from an infected and recovered host,
before administration to a susceptible host, prevented disease
4. Combining the supernatant with serum of someone unaffected by diphtheria, did
not prevent disease.
5. The “anti-toxin” found in the serum, given post exposure to diphtheria could also
prevent disease in some cases

In February, 1902, the

first shipment of
diphtheria antitoxin
was sent to the Willard
State Psychiatric
Hospital, where the
disease had been
present for years.
Two cases of diphtheria in Ireland after almost 50 years
Both patients survived, but disease can kill one in 20 people who
contract it
Tue, Jun 20, 2017, 01:00

Almost 50 years after it was last reported,

diphtheria has made a comeback in Ireland
with two recent cases.

One case of the potentially fatal disease

was reported last year and one this year,
the HSE confirmed.

Both patients were adults aged between 45

and 55 years and survived after treatment
with antibiotics; one was male and one
female.
Bordetella pertussis
• Gram-negative coccobacilli
• Strict aerobes
• Oxidase positive
• Catalase positive
• Highly communicable and infectious
• Person-to-person spread via inhalation of infectious droplet
nuclei in aerosol
• Man is the only natural host for peryussis (in dogs, kennel cough is caused by
a different Bordetella specie)
B. pertussis on chocolate agar
Virulence factors

• Bacterial attachment and destruction of ciliated respiratory

epithelial cells via:
• Hemagglutinin
• Adhesive pili
• Outer membrane protein pertactin

• Massive proliferation of bacteria

Production of localized tissue damage by several toxins

Virulence factors Biological function

Adhesins
Filamentous hemagglutinin Binds to sulfated glycoproteins on ciliated cell
membranes. Binds to C3 on surface of PMN and
initiates phagocytosis
Toxins
Pertussis toxin Inactivates G1a , the membrane surface protein that
(inactivates Gi) controls adenylate cyclase activity. Causes
increased cAMP levels.
Adenylate Increases cellular level of adenylate cyclase and
cyclase/hemolysin toxin inhibits phagocytic killing and monocyte migration
(activates Gs)
Tracheal cytotoxin A peptidoglycan fragment that kills ciliated
respiratory epithelial cells and stimulated the
release of IL-1
Dermonecrotic toxin Causes dose-dependent skin lesions
Pathogenies – whooping cough:
Stage 0 1 2 3

Most ciliated
cells
destroyed
Pathogenies – whooping cough:

Strictly human disease. Disease divided in stages:

1st stage- catarrhal stage- common cold-like. Most bacteria made at this
stage and therefore the person is very contagious.

2nd stage- paroxysmal stage –ciliated epithelial cells are excruded from
the respiratory tract and the clearance of mucus is impaired. At this stage
whooping cough develops (series of repetitive coughs followed by a deep
noise inspiration – taking a breath). Mucus production can restrict airways.
Often vomiting and exhaustion follows these coughs. In adults – chronic
cough which can be contagious to children.

3rd stage: convalescent stage- paroxysms diminish in number and

severity. However secondary complications may occur. In vaccinated
people, organism can colonize but not cause disease - a “bad cold” is often
due to B. pertussis outgrowth in immunized people (Possibly due to the
acellular nature of vaccine).

Unvaccinated infants: high mortality rate.

When mucociliary clearance fails,
cough with high expiratory airflow Normal ciliated cells
becomes the secondary mechanism
for clearance of mucus.

Pertussis infection

Paroxysms of numerous, rapid

coughs due to difficulty
Normal function expelling thick mucus from the
tracheobronchial tree.
Vaccine: DTaP

• (D)iphtheria toxoid
• (T)etanus toxoid
• The acellular pertussis (aP) contains:
pertussis toxoid, hemagglutinin,
fimbriae
Diagnosis:
Culture:

• Regan-Lowe blood agar

• Media supplemented with charcoal and starch

• Media is also supplemented with NAD (Factor V) and incubated at 35oC in

humidified incubator.

• Organism is very sensitive to drying

• Bacteria is slow growing

• Does not grow on MacConkey agar or regular blood agar

Antigen-Antibody tests and PCR tests:

• Specific latex agglutination assay (using anti-pertussis specific Ab) and IF tests
can be done directly on the specimen
• PCR test can also be done
 BREAKING NEWS
COMMUNITY NEWS
Whooping cough hits Palo Alto schools Dec 2016

Students at Jordan Middle School and Gunn and Paly high schools are
among the cases of suspected and confirmed whooping cough recently
reported to county health officials.

Countywide, 17 confirmed cases of pertussis, a communicable disease, were

reported to the Santa Clara County Health Department between Oct. 1 and
Tuesday, according to agency spokeswoman Joy Alexiou.

It’s unclear whether the outbreak has peaked because numerous cases in
which students had a cough and underwent testing are awaiting confirmation,
Alexiou said.

Whooping cough cycles and peaks every two to five years. In 2014, California
experienced the worst whooping cough outbreak the state had seen in seven
decades despite public health campaigns to stem the illness after a 2010
outbreak.
Haemophilus influenzae

• Gram-negative rods (or pleomorphic)

• Facultative anaerobe
• Require hemin (factor X) and NAD (factor V)
for growth
• Catalase positive
• Oxidase positive

Chocolate agar:
moist, smooth colonies
Haemophilus influenzae virulence factors:

Encapsulated strains

• Hib - Type b strain is most invasive

• Polyribitol phopshate (PRP) is a polysaccharide
capsule
• Main virulence factor in Hib
• Hib conjugated vaccine protects against the capsule
• Encapsulated H. influenza are not found in the
normal flora of the upper respiratory tract
• Encapsulated bacteria can cross epithelial and
endothelial cells and enter blood causing high grade
bacteremia
• After the Hib vaccine encapsulated H. influenzae
type c and f and non-encapsulated strains are
responsible for most invasive diseases.
Non-encapsulated

• Non-typeable, NTHi
• H. influenzae colonize upper respiratory tract early in
life, and can spread locally to cause otitis media,
sinusitis, and bronchitis, but disseminated disease is
relatively uncommon.
• Pili and adhesins impair the function of the
ciliated cells in the oropharynx leading to damage
of the respiratory epithelia.
• Over time, colonization rates decline, dropping to
below 1% by adulthood.
Pathogenesis:
• Mainly pediatric
• Most of the time infections are caused by patient’s
endogenous bacterial flora
• Capsule resists phagocytosis and invades blood

Meningitis: often follows an upper respiratory infection or

pneumonia caused by another pathogen

• H. Infuenzae type b is the most common cause of

pediatric meningitis in places with no vaccine
• Person-to-person spread in common
• Up to 10% mortality rate in patients that receive
treatment
Initial manifestations of meningitis, seen in most
patients with Hib meningitis are

 Altered cry
 Lethargy Meningeal signs include:
 Nausea or vomiting
 Fever • Kernig’s Sign – if positive, then a
 Severe headache supine patient experiences pain after
his/her hips and knees are flexed at
 Neck stiffness 90% and a physician extends his/her
 Photophobia knees further beyond 135 degrees.
 Irritability • Brudzinski’s Sign – If positive then
flexing the patient’s neck causes flexion
 Anorexia
of the patient’s hips and knees.
 Seizures
 Epiglottitis:

• Epiglottis is a flap of tissue that sits at the

base of the tongue that keeps food from
going into the trachea, or windpipe, during
swallowing.

• Without an epiglottis, food could enter the airways, and

you would cough or choke after swallowing.

• When it gets infected and inflamed, it can

Thumb sign
obstruct, or close off, the windpipe, which
may be fatal unless promptly treated.
Epiglottitis:

Symptoms:
• Fever
• Epiglottis swells, turns bright red and protrudes into the airway.
• Stridor (high pitched sound heard on inspiration that is indicative of
airway obstruction).
• Patients can’t swallow saliva:
• Present with drooling
• Head held forward with tongue protruding, insisting on sitting up
in bed, “hot-potato cough”
• Babies don’t have enough air to cry
• Intubation often necessary
• Since vaccine, fewer cases.
Cellulitis (Hib):
• An inflammation of the
connective tissue underlying
the skin, that can be caused
by a bacterial infection
cdc.gov
• Often presents as reddish-
blue patches on cheeks and
periorbital (of the tissues
surrounding the eye) areas.
• Buccal cellulitis
Otitis, sinusitis, lower respiratory tract disease:

Usually due to nonencapsulated H. influenzae

Pneumonia

Indistinguishable from other pneumonias

Vaccine:
Hib:
A conjugate PRP capsular vaccine
(for type b)
Diagnosis:

Stain:

• For meningitis: stain blood or CSF specimen

• For localized infection take specimen by needle
aspiration from affected areas.
• Blood specimen can also be collected for
cellulitis and epiglottitis.
• Detecting of H. influenzae (gram-negative rods)
is useful in preliminary diagnosis.

Culture:

Chocolate agar (heat blood agar) to release

Factor V and Factor X
Diagnosis:

Culture:

• Bacteria can also be detected as small satellite

colonies in regular blood culture inoculated with
S. auerus, because Staph can lyse rbc allow the
release of factor X (hemin) and V (NAD).
Regular Blood agar plate
culture showing
Haemophilus influenzae
satelliting around
Staphylococcus aureus.
 Specific antigen tests – Latex agglutination test:

PRP capsule antigen can be detected in CSF and urine

(where some of the antigen is eliminated intact)
.
• PRP is detected via particle agglutination
• Can detect less than 1 ng/ml of PRP in a clinical
specimen

Specific Ab bound to particles Specific antigen (from patient) Co-agglutination

HEALTHY LIVING 07/07/2016 01:04 pm ET | Updated Jul 07, 2016
What Is Epiglottitis? Sarah Silverman’s Scary Illness, Explained
It’s rare, but it’s out there

Comedian Sarah Silverman says she is “lucky to be alive” after a life-

threatening case of epiglottitis last week. After visiting the doctor for a
sore throat, Silverman said she ended up in the ICU for at least five days,
drugged and restrained.

The most common cause of epiglottitis is infection with Haemophilus

influenzae type b, known as Hib. This bacteria can also cause pneumonia
and meningitis. Hib can be contracted by inhaling germs when infected
individuals cough, sneeze or blow their nose. Thankfully, most infants receive
Hib vaccinations, which has made epiglottitis rare. Various bacterial
infections like Streptococcus A, B or C ― the same bacteria that cause strep
throat ― and the viruses that cause shingles and chicken pox can also lead
to epiglottitis, along with throat injuries or burns.
Relation of the age incidence of bacterial meningitis
caused by Haemophilus influenzae to bactericidal
antibody titers in the blood
 Growth on Growth on Gram stain
CAP BAP
N. meningitidis + + Gram-
negative
diplococci
S. pneumoniae + + Gram-
positive
diplococci
H. influenzae + - Gram-
negative
coccobacilli