MYCOBACTERIA • The granuloma is an organization of
lymphocytes, macrophages,
MYCOBACTERIA
• slender, slightly curved or straight,
rod-shaped organisms
• nonmotile and do not form spores
• The cell wall has extremely high lipid
content; thus, mycobacterial cells
resist staining with commonly used
basic aniline dyes, such as those
used in the Gram stain, at room
temperature.
• take up dye with increased staining
time or application of heat but resist
decolorization with acid-ethanol
• This characteristic is referred to as
acid fastness—hence, the term AFB
Extrapulmonary Tuberculosis
—and is
• Mycobacteria are strictly aerobic,
but increased carbon dioxide (CO2)
will enhance the growth of some
species
Mycobacterium tuberculosis Complex
• consists of M. tuberculosis, M. bovis
• (including the vaccination strain
bacillus Calmette-Guérin), M.
africanum, M. canettii, and M.
microti. M. africanum
Mycobacterium tuberculosis
• TB is usually a disease of the
respiratory tract.
• Tubercle bacilli are acquired from
persons with active disease who are
excreting viable bacilli by sneezing
or talking.
• hard tubercle or granuloma may be
formed
fibroblasts, and capillaries.
• With granuloma formation, healing
occurs, as well as fibrosis,
encapsulation, and calcification, with
scar formation as a reminder of the
past infection.
• In infected individuals, there is a
potential for reactivation of TB.
• Clinical diagnosis of primary TB:
positive PPD skin test.
• diagnosis is confirmed by stained
smear and culture of sputum, gastric
aspirates, or bronchoscopy
specimens.
• Miliary TB refers to the seeding of
many organs outside the pulmonary
tree with AFB through
hematogenous spread.
• Almost any organ of the body can be
infected by M. tuberculosis
• Pleurisy, an unexplained pleural
effusion with mononuclear
pleurocytosis, manifests as cough,
fever, and chest pain, resembling
the presentation of bacterial
pneumonia.
• Lymphadenitis
• Genitourinary TB
• Skeletal TB of the spine is referred to
as Pott disease.
• Meningitis
• Cerebrospinal fluid (CSF)
examination usually reveals an
elevated protein level, decreased
glucose level, and a predominance
of lymphocytes.
• Colonies are typically raised, with a
dry, rough ppearance.
• The colonies are nonpigmented and
classically described as being buff-
colored
• Elaboration of cord factor can result
in characteristic cord formation.
• Optimal growth occurs at 35° C to
37° C.
• Positive for niacin accumulation
• reduction of nitrate to nitrite
• Production of catalase
• Grows on thiophene-2-carboxylic
acid hydrazide (T2H)
• Treatment
• For pulmonary TB, treatment
typically involves a 9-month course
of therapy with isoniazid and
rifampin, usually once per day the
first month and twice a week
thereafter.
• regimens also include a 2- to 8-week
initial course of streptomycin or
ethambutol
• Pyrazinamide (PZA) may be added to
the regimen if there is a suspicion of
lowered cellular immunity and a
need to obtain bactericidal levels of
antimycobacterial activity
intracellularly in macrophages.
• MDR-TB is defined as resistance to
at least isoniazid and
• rifampin
• Extensively drug-resistant TB (XDR-
TB) is defined as resistance to
isoniazid and rifampin plus
resistance to any fluoroquinolone
and at least one of three injectable
second-line anti-TB drugs—the
aminoglycosides amikacin,
kanamycin, or capreomycin.
Mycobacterium bovis
• TB primarily in cattle but also in
other ruminants, as well as in dogs,
cats, swine, parrots, and humans.
• The disease in humans closely
resembles that caused by M.
tuberculosis and is treated similarly.
• 21 days of incubation at 37° C.
• niacin-negative
• do not reduce nitrate
• do not grow in the presence of (T2H)
thiophene-2-carboxylic acid
hydrazide
Nontuberculous Mycobacteria
• Slowly Growing Species
Mycobacterium avium Complex
• Mycobacterium avium and M.
intracellulare are part of the
Mycobacterium avium complex
(MAC).
• environmental saprophytes and
have been recovered from soil,
 water, house dust, and other
environmental sources
• M. avium is a cause of disease in
poultry and swine
• Zoonotic
• the cells are short, coccobacillary,
and uniformly stained, without
beading or banding
• production of a heatstable catalase
and the ability to grow on media
containing 2 μg/ mL of T2H
Mycobacterium avium subsp.
paratuberculosis
• Causative agent of Johne disease, an
intestinal infection occurring as a
Mycobacterium kansasii
chronic diarrhea in cattle, sheep,
goats, and other ruminants.
• very slow growth rate (3 to 4
months)
• Needs mycobactin-supplemented
medium for primary isolation.
Mycobacterium genavense
• cause of disseminated infections in
patients with AIDS
• enteritis and genital and soft tissue
infections
• Middlebrook 7H11 agar
supplemented with mycobactin.
• heat-stable catalase,
pyrazinamidase, and urease
Mycobacterium haemophilum.
• Submandibular lymphadenitis,
subcutaneous nodules, painful
swellings, ulcers progressing to
abscesses, and draining fistulas are
often the clinical manifestations.
• A unique characteristic of this
organism is its requirement for
hemoglobin or hemin for growth.
• chocolate (CHOC) agar, Mueller-
Hinton agar with 5% Fildes
enrichment, and Löwenstein-Jensen
(LJ) medium containing 2% ferric
ammonium citrate.
• Optimal growth temperature is 28° C
to 32° C; little or no growth occurs at
37° C.
• cells are strongly acid-fast, short,
occasionally curved bacilli without
banding or beading, and arranged in
tight clusters or cords
• M. kansasii strains have been
isolated from water
• infections are not normally
considered contagious from person
to person
• susceptible to rifampin and
ethambutol, partially resistant to
isoniazid and streptomycin, and
resistant to pyrazinamide
• a multidrug regimen of isoniazid,
rifampin, and ethambutol is
currently recommended
• long rods with distinct crossbanding
• colonies appear smooth to rough,
with characteristic wavy edges and
dark centers when grown on
Middlebrook 7H10 agar
• Colonies are photochromogenic
• With prolonged exposure to light,
most strains form dark red crystals
of β-carotene on the surface of and
inside the colony.
• strongly catalase-positive
• hydrolyze Tween 80 in 3 days
 • strong nitrate reduction • contact with salt water or
• Pyrazinamidase production inadequately chlorinated fresh
water containing the organism.
Mycobacterium malmoense
• tender red or blue-red subcutaneous
• chronic pulmonary disease and nodule, or swimming pool
cervical lymphadenitis granuloma, usually occurs on the
• resistant to isoniazid, streptomycin, elbow, knee, toe, or finger
p-aminosalicylic acid, and rifampin • susceptible to rifampin and
and susceptible to ethambutol and ethambutol, resistant to isoniazid
cycloserine. and pyrazinamide, and partially
• short coccobacillus without cross resistant or intermediate to
bands on acid-fast–stained smears. streptomycin
• Colonies are smooth glistening, and • Cells of M. marinum are moderately
opaque, with dense centers long to long rods with
• cross barring.
Mycobacterium scrofulaceum
• M. marinum is photochromogenic,
• cervical lymphadenitis in children young colonies
• Colonies grown in or exposed to
Mycobacterium simiae
light develop a deep yellow color.
• isolated from the lymph nodes of • Growth is optimum at incubation
monkeys temperatures of 28° C to 32° C.
• Colonies on Middlebrook 7H10 agar • none reduces nitrate or produces
are thin, transparent or tiny, and heat-stable catalase
filamentous • The organisms hydrolyze Tween 80
and produce urease and
Mycobacterium ulcerans
pyrazinamidase.
• Mycobacterium ulcerans is a rare
Mycobacterium xenopi
cause of mycobacteriosis, also
referred to as Buruli ulcer • recovered from hot and cold water
• acid-fast cells are long, without taps (including water storage tanks
beading or crossbanding of hospitals) and
• birds
Mycobacterium marinum
• susceptible to the quinolones
• Mycobacterium marinum has been (ciprofloxacin, ofloxacin); some
implicated in diseases of fish and isolates are susceptible to
isolated from aquariums. vancomycin, erythromycin, or
• Cutaneous infections in humans cefuroxime
occur when traumatized skin comes • Colonies on Middlebrook 7H10 agar
into are small, with dense centers and
filamentous edges.
 • cornmeal-glycerol agar reveals • pleomorphic, ranging from long and
distinctive round colonies with tapered to short, thick rods partially
branching and filamentous acid-fast
extensions; aerial hyphae are usually • positive 3-day arylsulfatase test and
seen in rough colonies. reduction of nitrate
• Young colonies grown on cornmeal
Mycobacterium smegmatis Group
agar have a bird’s nest appearance,
with characteristic sticklike • The M. smegmatis group contains
projections. two species, M. smegmatis and M.
goodie.
• M. smegmatis has been implicated
Rapidly Growing Species in rare cases of pulmonary, skin, soft
tissue, and bone infections.
• Mycobacterium chelonae–
• cells are long and tapered or short
Mycobacterium abscessus Group
rods with irregular acid fastness.
• M. abscessus subsp. abscessus
Occasionally rods are curved with
(formerly M. abscessus), M.
branching or Y-shaped forms;
chelonae, and M. fortuitum.
swollen, with deeper staining,
• M. chelonae have been associated
beaded, or ovoid forms are
with a variety of infections of the
sometimes seen.
skin, lungs, bone, central nervous
• Colonies appearing on egg medium
system, and prosthetic heart valves.
after 2 to 4 days are usually rough,
• M. abscessus seen in patients with
wrinkled, or coarsely folded;
cystic fibrosis (CF)
smooth, glistening, butyrous
• tap water is an important reservoir
colonies may also be seen.
• positive 3-day arylsulfatase test, no
• negative arylsulfatase reaction,
reduction of nitrate, and growth on
positive iron uptake, ability to
MacConkey agar without crystal
reduce nitrate, and growth in the
violet
presence of 5% NaCl and on
Mycobacterium fortuitum Group MacConkey agar without crystal
violet
• M. fortuitum, M. peregrinum, and
an unnamed third species. Mycobacterium leprae
• isolated from water, soil, and dust
• causative agent of Hansen disease
• associated with localized cutaneous
(leprosy), an infection of the skin,
infections
mucous membranes, and peripheral
• Middlebrook 7H11 agars after 1 to 2
nerves
days of incubation colonies with
• The two major forms of the disease
branching filamentous extensions
are tuberculoid leprosy and
and rough colonies with short aerial
lepromatous leprosy.
hyphae.
 • Symptoms of tuberculoid leprosy nonchromogenicum
include skin lesions and nerve M shimoidei
involvement that can produce areas M terrae
with loss of sensation. M trivale
• patients with lepromatous leprosy if M ulcerans
untreated, life-threatening M xenopi
• It is characterized by skin lesions and Rapid Growers M abscessus
M fortuitum group
progressive, symmetric nerve
M chelonae group M
damage.
phlei
• Lesions of the mucous membranes M smegmatis
of the nose may lead to destruction M vaccae
of the cartilaginous septum,
resulting in nasal and facial
deformities. SPECIES ALWAYS CONSIDERED
• combination of PATHOGENS
diaminodiphenylsulfone (dapsone), M Humans Pulmonary
clofazimine, and rifampin tuberculosi and
• M. leprae has not been grown on s disseminated
artificial media. tuberculosis;
• mouse footpad millions of
• the length of the bacillus is at least cases
five times the width of the bacillus annually in
the world
CLASSIFICATION ORGANISM M leprae Humans Leprosy
TB Complex M tuberculosis M bovis Humans,Cattle Tuberculosis-
M africanum like disease;
M bovis rare in North
Photochromogens M asiaticum America;
M kansasii Mbovis is
M marinum dosely related
M simiae to
Scotochromogens M flavescens Mtuberculosis
M gordonae
M scrofulaceum
M szulgai SPECIES POTENTIALLY PATHOGENIC IN
Nonchromogens M avium complex HUMANS
M celatum
Moderat
M haemophilum
ely
M gastri
common
M genavense
causes of
M malmoense
disease
M Soil, Disseminated,
 M avium water, pulmonary, very mycobacteria grow best at temperatures ≤
Complex birds, common in AIDS 33 °C. There are many other saprophytic
fowl, patients; occurs Mycobacterium species not listed here that
swine, in other seldom if ever appear in cultures of
cattle, immunosuppres patients' specimens.
environme sed pa tients,
nt uncommon in UNCOMMON TO VERY RARE CAUSES OF
patients with DISEASE
normal immune
systems M Humans, Pulmonary
M Water, Pulmonary, africanum monkeys cultures,
kansasii cattle other sites resembles M
tuberculosis
Rapid
rare
growers
M Humans? Blood in
M Soil, Cutaneous genavense pet birds? AIDS
fortuitum water, lesions most patients,
and M animals, common, grows in
chelonae marine life subcutaneous liquid
abscesses, medium
disseminated (BACTEC)
infections, grow and on solid
in 7 days M medium
fortuitum is supplemente
more d with
susceptible to mycobactin
antibiotics j; grows in 2-
8 weeks
M Unknown Subcutaneou
SAPROPHYTIC SPECIES THAT RARELY haemophilu s nodules
CAUSE DISEASE IN HUMANS m and ulcers
primarily in
M gordonae Water
AIDS
M flavescens Soil, water
patients,
M fallax Soil, water
requires
M gastri Gastric washing hemoglobin
or heming
These saprophytic Mycobacterium species grows at 28-
are very uncommon causes of disease in 32°C rare
humans. Positive cultures for these M Unknown, Pulmonary,
malmoense environme tuberculosis-
mycobacteria usually represent
nt like (adults),
environmental contamination of specimens
lymph nodes
and not disease. Many of the saprophytic (children);
 most related to M
reported maninum,
cases are takes 6 12
from weeks to
grow optimal
Sweden, but
growth at 33
organism
°C suggests
may be environmenta
much more l source, rare
widespread; M xenopi Water, Pulmonary,
M birds tuberculosis-
malmoense like with
is closely preexisting
related to M lung disease,
avium- rare
intracellular
takes 8-12
weeks to
grow
M marinum Fish, water Subcutaneou
s nodules
and
abscesses,
skin ulcers
M Soil, water, Cervical
scrofulaceum moist foods lymphadenitis
; usually
cured by
incision,
drainage, and
removal of
involved
lymph nodes
M simiae Monkeys, Pulmonary,
water disseminated
in AIDS
patients; rare
M szulgai Unknown Pulmonary,
tuberculosis-
like, rare
M ulcerans Humans, Subcutaneous
environmen nodules and
t ulcers may be
severe, M
ulcerans is
closely