1.

Corynebacterium Diphtheriae
a. Generality
i. 0.5–1 μm in diameter and several micrometers long.
ii. Characteristically, they possess irregular swellings at one end that give
them the “club-shaped” appearance
iii. Individual corynebacteria in stained smears tend to lie parallel or at acute
angles to one another - “Chinese Characters”
iv. Irregularly distributed within the rod (often near the poles) are granules
staining deeply with aniline dyes (metachromatic granules) that give the
rod a beaded appearance
b. Culture
i. On Blood agar
1. Colonies are small, granular, and gray, with irregular edges
2. May have small zones of hemolysis.
ii. On agar containing potassium tellurite
1. Colonies are brown to black with a brown-black halo
2. Tellurite is reduced intracellularly
3. Staphylococci and streptococci can also produce black colonies
c. Biotypes of C. Diphtheriae
i. Four bio- types of C diphtheriae:
1. Gravis
2. Mitis
3. Intermedius
4. Belfanti
ii. These variants have been classified on the basis of growth characteristics
such as colony morphology, biochemical reactions, and severity of
disease produced by infection.
iii. Corynebacteria tend to undergo pleomorphism in microscopic and
colonial morphology – Role of Bacteriophage
1. Bacteriophage infection from certain toxigenic diphtheria bacilli
makes the offspring of the exposed bacteria lysogenic and
toxigenic
2. Acquisition of phage leads to toxigenicity (lysogenic conversion)
d. Pathogenesis
i. C diphtheriae occurs in the respiratory tract, in wounds, or on the skin of
infected persons or normal carriers.
ii. It is spread by droplets or by contact to susceptible individuals
iii. Diphtheria toxin is a heat-labile polypeptide (MW 62,000) that can be
lethal in a dose of 0.1 μg/kg.
iv. Fragment B
1. MW = 38,000
2. No independent activity
 3. Required for the transport of fragment A into the cell.
v. Fragment A
1. Inhibits polypeptide chain elongation
2. Provided nicotinamide adenine dinucleotide (NAD) is present
3. Inactivating the elongation factor EF-2.
4. It is assumed that the abrupt arrest of protein synthesis is
responsible for the necrotizing and neurotoxic effects of diphtheria
toxin
e. Pseudomembrane formation
i. Diphtheria toxin
1. Absorbed into the mucous membranes
2. Causes destruction of epithelium and a superficial inflammatory
response.
ii. Necrotic epithelium
1. Becomes embedded in exuding fibrin and red and white cells
2. Grayish “pseudomembrane” is formed
3. Commonly over the tonsils, pharynx, or larynx
f. Clinical Findings
i. Var gravis tends to produce more severe disease than var mitis,
ii. IP: 2 – 4 days
iii. Order of symptoms
1. Sore throat and fever
2. Prostration and dyspnea
3. Irregularities in cardiac rhythm
4. Difficulties with vision, speech, swallowing or movement of arms
and legs
5. Subside spontaneously
g. Diagnostic Laboratory Tests
i. Swabs should be collected from beneath any visible membrane.
ii. The swab should then be placed in semisolid transport media such as
Amies TM.
iii. Smears stained with alkaline methylene blue or Gram stain show beaded
rods in typical arrangement.
iv. Inoculate a blood agar plate (to rule out hemolytic streptococci), a Loeffler
slant, and a tellurite plate and incubate all at 37 °C.
v. In 12–18 hours, the Loeffler slant may yield organisms of typical
“diphtheria-like” morphology.
vi. In 36–48 hours, the colonies on tellurite medium are sufficiently definite
for recognition of C diphtheriae
h. Resistance, Immunity and Treatment
i. Review of documented diphtheria toxoid immunizations and primary or
booster immunization if needed.
ii. Diphtheria antitoxin
 1. Produced in various animals (horses, sheep, goats, and rabbits)
by the repeated injection of purified and concentrated toxoid.
2. Treatment with antitoxin is mandatory when there is strong clinical
suspicion of diphtheria.
iii. Antimicrobial drugs (penicillin, erythromycin) inhibit the growth of
diphtheria bacilli
i. Epidemiology, Prevention, & Control
i. By age 6–8 years, approximately 75% of children in developing countries
where skin infections with C diphtheriae are common have protective
serum antitoxin levels.
ii. DPT Vaccine
1. Toxoids are commonly combined with tetanus toxoid (Td) and
sometimes with pertussis vaccine (DPT or DaPT) as a single
injection to be used in initial immunization of children.
2. For booster injection of adults, only Td toxoids are used
2. Actinomycetes
a. Large, diverse group of gram-positive bacilli with a tendency to form chains or
filaments.
b. As the bacilli grow, the cells remain together after division to form elongated
chains of bacteria (1 μm in width) with occasional branches.
c. Members of the aerobic Actinomycetes can be categorized on the basis of the
acid fast stain.
3. Nocardia sp
a. General Characteristics
i. Causative agent of Nocardiosis
ii. Nocardia asteroides complex (most common) and Nocardia brasiliensis
or Nocardia otitidiscaviarum
iii. Found world- wide in soil and water.
iv. Mode of Transportation
1. Nocardiosis is initiated by inhalation of these bacteria.
2. The usual presentation is as a sub- acute to chronic pulmonary
infection that may disseminate to other organs
3. Usually the brain or skin.
4. Nocardiae are not transmitted from person to person
b. Aerobic
i. Over the course of several days to a week or more, they develop heaped,
irregular, waxy colonies.
ii. Strains vary in their pigmentation from white to orange to red.
iii. These bacteria are gram-positive, catalase-positive, and partially acid-fast
bacilli.
iv. They produce urease and can digest paraffin.
v. The cell walls contain mycolic acids that are shorter-chained than those of
Mycobacteria.
vi. They are considered to be weakly acid- fast
 vii. Nocardiae form extensive branching substrates and aerial filaments that
fragment after formation, breaking into coccobacillary cells
c. Pathogenesis
i. Nocardiosis is an opportunistic infection associated with several risk
factors, most of which impair the cell-mediated immune responses.
ii. Nocardiosis begins as chronic lobar pneumonia, and a variety of
symptoms may occur, including fever, weight loss, and chest pain.
iii. The clinical manifestations are not distinctive and mimic tuberculosis and
other infections.
iv. Pulmonary consolidations may develop, but granuloma formation and
caseation are rare.
v. The usual pathologic process is abscess formation
d. Diagnostic Laboratory Tests and Treatment
i. Specimens consist of sputum, pus, spinal fluid, and biopsy material.
ii. Gram-stained smears reveal gram-positive bacilli, coccobacillary cells,
and branching filaments.
iii. With the modified acid-fast stain, most isolates will be acid fast.
iv. Nocardia species grow on most laboratory media.
v. Serologic tests are unreliable at present.
vi. The treatment of choice is trimethoprim-sulfamethoxazole
4. Actinomycosis
a. Generalities
i. Actinomycosis is a chronic suppurative and granulomatous infection that
produces pyogenic lesions with interconnecting sinus tracts that contain
granules composed of microcolonies of the bacteria embedded in tissue
elements.
ii. Causative Agent
1. Actinomyces israelii
2. Actinomyces naeslundii
3. Related anaerobic or facultative bacteria.
iii. Three common forms
1. Cervicofacial
2. Thoracic
3. Abdominal
iv. Infection is initiated by trauma that introduces these endogenous bacteria
into the mucosa
b. Culture Characteristics
i. Facultative anaerobes that grow best in an atmosphere with increased
carbon dioxide.
ii. On enriched mediums, such as brain-heart infusion agar, young colonies
produce gram-positive substrate filaments that fragment into short chains,
diphtheroids, and coccobacilli.
iii. After a week, these “spider” colonies develop into white, heaped-up
“molar tooth” colonies.
 iv. In thioglycolate broth, A israelii grows below the surface in compact
colonies.
v. Species are identified based on cell wall chemotype and biochemical
reactions.
vi. The sulfur granules found in tissue are yellowish in appearance, up to 1
mm in size, and are composed of macrophages, other tissue cells, fibrin,
and the bacteria
vii. Eosinophilic club-shaped enlargements of the bacterial cells often project
from the periphery of the granule
c. Clinical Findings
i. Cervicofacial disease presents as a swollen, erythematous process in the
jaw area.
ii. With progression, the mass becomes fluctuant, producing draining
fistulas.
iii. The disease will extend to contiguous tissue, bone, and lymph nodes of
the head and neck.
iv. Thoracic actinomycosis resembles those of a subacute pulmonary
infection: mild fever, cough, and purulent sputum.
v. Genital actinomycosis is a rare occurrence in women that results from
colonization of an intrauterine device with subsequent invasion
d. Diagnostic Laboratory Tests and Treatment
i. Pus from draining sinuses, sputum, or specimens of tissue are examined
for the presence of sulfur granules
ii. The granules are hard, lobulated, and composed of tissue and bacterial
filaments, which are club-shaped at the periphery
iii. Specimens are cultured in thioglycolate broth and on brain-heart infusion
blood agar plates, which are incubated anaerobically or under elevated
carbon dioxide conditions.
iv. Prolonged administration (6–12 months) of a penicillin is effective in many
cases
v. Clindamycin or erythromycin is effective in penicillin allergic patients