FINALS REVIEWER
 Predisposing factors: liver dysfunction, ↑ serum
CLINICAL
BACTERIOLOGY
NON-ENTERIC GI PATHOGENS
I. Vibrio
Characteristic:
 Faculatative anaerobic, Oxidase positive,
Susceptible to O/129
 Gastroenteritis (cholera-like)
 Infections from brackish or marine water
 Can be found in aquatic environments
 Consumption of raw seafood
 Curved, comma-shaped or straight gram negative
rods
 Polar/peritrichous, flagella
 Exhibit rapid darting or shooting star motility
Vibrio cholerae
 causative agent of cholera, also known as “Asiatic
cholera” or “epidemic cholera”
 Cholera toxin (Choleragen) result of enterotoxin
 profuse watery diarrhea
 “rice water stools” composed of fluids and mucous.
 Somatic antigens 01 and 0139 > Almost always
produce cholera toxin
 Have 3 serotypes: Ogawa, Inaba, Hikojima
Vibrio parahaemolyticus
 Gastroenteritis “summer diarrhea”
 Kanagawa toxin positive- association between
hemolysin production and virulence
 Kanagawa phenomenon – production of B-
hemolysis in a special high salt mannitol medium
(Wagatsuma agar)
Vibrio vulnificus
 can be found in marine environments on the
Atlantic, Gulf, and Pacific coasts of North America.
 Septicemia and wound infections
 Lactose Positive Vibrio
iron
 Infections can occur such as necrotizing fasciitis
and/or multiple organ system failure.
Vibrio alginolyticus
 A common inhabitant of marine environments and
is a strict halophile, requiring at least 1% NaCl
 Wound infections, strict halophile
LABORATORY DIAGNOSIS
i. Specimen Collection and Transport
 Body fluids, pus or Tissues, But swabs can be also
submitted
 Cary-Blair medium for Swabs
 Alkaline peptone water (pH 8.5) for stool culture.
ii. Culture Media
 Medium to large, smooth, opaque, iridescent with a
greenish hue in SBA (α or β hemolytic) or CHOC.
 NLF (Colorless) in MacConkey Agar
 TCBS > Thiosulfate Citrate Bile Salt Sucrose agar
II. Aeromonas
 Aeromonas hydrophila (“water loving”) is the most
common isolate
 Ubiquitous, oxidase (+), glucose-fermenter, gram
(-) rods
 Heat labile and heat stable cytotoxic enterotoxin
 Classified into one of two groups, the mesophilic
group (optimal growth around 37° C) or
psychrophilic group optimal growth around 22° C).
 Intestinal (five diarrheal syndromes) > Secretory
(w/ vomiting), dysenteric (w/blood & mucus),
chronic, cholera-like(rice-water), nebulous(similar
to ETEC’s “traveler’s diarrhea”)
 Extraintestinal Infection > Wound infections,
septicemia and meningitis
 appear as large, round, raised, opaque colonies with
an entire edge and a smooth, often mucoid, surface.
 Ferments lactose, pink-centered colonies in CIN
III. Plesiomonas shigelloides
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 Gastroenteritis, bacteremia and meningitis
 Straight gram (-) rods that occurs singly, in pairs, in
short chains and filamentous forms
 Shiny, opaque, smooth, γ-hemolytic in SBA
 White to pink in inositol brilliant green bile salt
agar
 LDC, ODC, ADH Positive “Positive Trio”
IV. Chromobacterium
 Slightly curved gram (-) rods with rounded ends
 Most colonies appear black or very dark purple
(violacein pigment)
 Smells like ammonium cyanide in SBA
 NLF in MacConkey
 Reduces nitrate, glucose fermente
 It is motile with polar flagella and, as its name
implies, produces a violet pigment about 91% of
the time.
 Osteomyelitis, wound abscess, Septicemia and
gastrointestinal infections (opportunistic)
 Violet pigment can interfere with oxidase tes
V. Laboratory Diagnosis
1. Thiosulfate Citrate Bile Salt Sucrose Agar
 Selective and differential media for Vibrio
 Contains sucrose, Na Citrate & ox gall (bile), and
pH indicator (bromthymol blue)
 Growth with fermentation (yellow): V. cholerae,
V. alginolyticus, V. fluvialis, V. furnissi
 Growth without fermentation (green/blue-
green): V. mimicus, V. parahaemolyticus, V.
vulnificus
 No growth: Aeromonas, Plesiomonas and
Chromobacterium
2. String Test
 Separate Vibrio spp. from Aeromonas and
Plesiomonas
 Reagent: 0.5% sodium deoxycholate
 Positive: Viscous stringing resulting to a long,
tenacious string Vibrio spp.
 Negative: No viscous stringing Aeromonas, P.
shigelloides, Chromobacterium
3. Vibriostatic Test
 Reagent: 0/129 (150 μg) impregnated disks
 Positive (susceptible): Vibrio cholerae,
Plesiomonas shigelloides
 Negative (resistant): Aeromonas spp., C.
violaceum and Other Vibrio spp.
CAMPYLOBACTER AND HELICOBACTER
 Oxidase Positive
 Most species are asaccharolytic
 Small, curved, motile, gram (-) bacilli
 Microaerophilic
Campylobacter jejuni
 Abortion in domestic animals such as cattle, sheep,
and swine
 Ingestion contaminated water and poultry
 Most common cause of bacterial gastroenteritis
 Guillain-Barre syndrome- autoimmune disorder
(cross-reactivity of Campylobacter Abs with the
nerve ganglia). Paralysis.
 Feces, Stuart medium, Cary-Blair and Campy Thio
Campylobacter fetus subsp. fetus
 Immunocompromised and elderly patient
 Bacteremia
 Has been isolated most frequently from blood
cultures
 Blood, Routine blood culture media
Helicobacter pylori
 Gastric ulcer patients
 Motility, Urease, Adhesine and Cytotoxins
 Gastric, peptic and duodenal ulcers
 Type B gastritis > a condition that associated
primarily with stress and chemical irritants
 GI carcinoma
 Tissue biopsy, Stuart’s, Cysteine-Brucella broth w/
20% Glycerol
Campylocabacter
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 Campy-BAP, Skirrow’s , Butzler and CCDA
 42 ̊C or 37 ̊C at 85% N2, 5% O2, and 10% CO2
 S-shaped resembling “wings of seagulls”
 Exhibit Darting Motility
 Moist “runny” looking and spreading (C. jejuni)
 Smooth, convex and tranluscent (C. fetus

Helicobacter
 Skirrow’s , CHOC agar or Brucella agar with 5%
Horse RBC
 42 º C at 5-10% O2, and 5-12% CO2
 Multiple flagella at one pole

HAEMOPHILUS AND
OTHER FASTIDIOUS
I. HAEMOPHILUS
 Non-motile and facultative anaerobic
 Ferment Carbohydrates (Except for H. ducreyi)
 Oxidase and Catalase Positive
 Reduce Nitrates to nitrite
 Obligate parasites
 Requires growth factors
 > Hemin/hematin (X Factor)
 > Nicotinamide adenine dinucleotide (NAD or V
Factor)

A. Haemophilus influenzae (Pfeiffer’s bacillus)

1. Capsule > antiphagocytic and anticomplementary
> a, b (most common), c, d, e, or f
2. IgA Protease > cleaves secretory IgA
3. Outer Membrane proteins and LPS
4. Adherence Mechanisms
a. Encapsulated > Lacks adherent capability; associated
with systemic and invasive infections.
b. Non encapsulated > Associated with localized
infections or may be carried asymptomatically
(nasopharynx).

ENCAPSULATED NON-
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 STRAINS ENCAPSULATED
STRAINS
iii. Colony morphology
Septicemia, Septic Otitis media
H. influenzae
arthritis
 Translucent, smooth and convex
Tracheitis Conjunctivitis
 “Mousy” or bleach like odor in CHOC agar
Meningitis Sinusitis
 Encapsulated strains are larger and mucoid
Osteomyelitis Bacteremia
H. ducreyi
Cellulitis, Pericarditis Pneumonia
 Small, flat, smooth, transparent to opaque
Pneumonia, Epiglottis
 Colonies can be pushed intact
 Clumpy in saline
B. Haemophilus aegyptius
“Koch-Weeks bacillus” Purulent conjuctivitis “pink eye”
iv. Laboratory Identification
H. influenzae Biogroup aegyptius
a. Neufeld Reaction
BPF (Brazilian Purpuric fever)- skin lesion, sepsis, fever
> Antisera is reacted with the antigens in the capsule
making the capsule more prominent
C. Haemophilus ducreyi b. Staphylococcus Streak (Satellitism or Satellite
▪ Chancroid (soft chancre venereal disease) phenomenon)
Haemophilus is streaked with S. aureus, S. pneumoniae
Neisseria and certain yeasts
Laboratory Diagnosis
Positive: Haemophilus appear as moist, small
i. Specimen Processing and Isolation “dewdrop” colonies surrounding S.areus colonies
a. Collected by pre-moisened swab, Stuart’s or c. X and V Factor Requirement and Hemolytic
Amie’s. Patterns
b. Culture Media d. Porphyrin Test
 Chocolate Agar  Test for the ability of the organism to convert:
 Chocolate agar with bacitracin  ALA (delta-aminolevulinic acid)→ porphobilinogen
or porphyrins
 Chocolate agar with 1 %IsoVitaleX for H. ducreyi
or H. aegyptius  Porphyrin → Hemin
c. Incubation  Porphobilinogen is detected using Kovac’s rgt.(red
color)
i. Most Haemophilus spp.
 Porphyrins (+) fluoresce reddish-orange at UV light
▪ 5% to 10% CO2 at 35°C to 37°C
(360 nm)
▪ 24 to 72 hours
ii. Haemophilus ducreyi
II. HACEK Group
▪ 5% to 10% CO2 at 33°C with high humidity
1. Aggregatibacter (formerly Haemophilus)
▪ Up to 7 days aphrophilus
 “foam loving” or needing high conc.of CO2

ii. Microscopic Morphology  With V factor dependent and independent Strains

1. Small. Gram (-) coccobacilli to long filaments. May  Gram Stain: Small Gram (-) coccobacilli
be encapsulated
 Convex, granular and yellow with an opaque zone
2. H. ducreyi - coccobacilli that appear as “school of near the center
fish”, “railroad tracks” or “finger prints” from genital
lesions.
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 Patients with infections present commonly with
clinical features of fever, heart murmur, congestive
heart failure, and embolism
2. Aggregatibacter (formerly Actinobacillus)
actinomycetemcomitans
 Short bacilli in pairs /chains
 Bipolar staining “Morse Code” appearance
 The isolates may require more than 24 hours for
visible growth; a distinctive “star shape with four to
six points” in the center of the colonies is often seen
at 48 hours
3. Cardiobacterium hominis
 It is pleomorphic, nonmotile, fastidious, gram-
negative bacilli, found as normal microbiota of the
nose, mouth, and throat and may be present in the
gastrointestinal tract.
 They grow slowly on SBA and CHOC agar and fail
to grow on MAC agar
 Fermenter (dysgonic); pits agar
4. Eikenella corrodens
 Infections from human bites or fights (clenched fist
wounds)
 A member of the normal biota of the oral and bowel
cavities.
 Non Fermenter; Pit agar; Chlorine bleachlike odor
 Non-motile, oxidase positive, asaccharolytic,
catalase negative; yellow pigment
5. Kingella spp
 Disease-major gram (-) bacteria in bone infections
in chidren below 3yrs. Old
 Fermenter (dysgonic); pits agar
 Nonhemolytic (K. denitrificans) or β-hemolytic
(K.kingae)
 It can grow on Neisseria selective agar and can
resemble Neisseria gonorrhoeae if the isolate does
not pit the agar as many strains do.
III. Capnocytophaga
 Periodontitis; Local infection to fulminant infection
(septicemia) esp. In neutropenic patients
 opaque, shiny; pale beige or yellowish
 May produce yellow pigment; can
 resemble colonies of E.corrodens
 They are fastidious, facultatively anaerobic, gram-
negative bacilli and require increased CO2 for
growth and isolation from blood cultures.
IV. Pasteurella
 Systemic, pneumonic and cutaneous infection from
animal (often cats) bites (zoonosis)
 Coccobacilli (ovoid, filamentous or bacilli); Bipolar
staining
 Grayish, non hemolytic, mucoid with narrow green
to brown halo around the colony
V. Brucella
 Brucellosis (Undulant/Malta fever)- zoonosis-
acquired through aerosol, percutaneous and oral
routes; Category B biological agents (high
morbidity, low mortality)
 Smooth, raised and translucent colonies
 Facultative intracellular pathogens
VI. Francisella tularensis
 Strictly aerobic; require cysteine, cystine or
thiosulfate (SBA, BCYE agar, CHOC)
 Gray-white, smooth, raised colonies
 zoonosis (ingestion, inhalation, arthropod bite),
highly infectious
 Tularemia (ulceroglandular, pneumonic, etc)- rabbit
fever, water rat trapper’s disease
VII. Legionella pneumophila
 Multiply at 20°C to 43°C and survive at 40°C to
60°C
 Capacity to adhere and persist in piped water
systems
 Legionnaire’s disease- fever w/ pneumonia
(sporadic, epidemic, nosocomial)
 Pontiac Fever- fever w/o pneumonia
VIII. Bordetella
1. Bordetella pertussis & B. parapertussis
a) FHA and Pertactin → facilitate attachment to
ciliated epithelial cells.
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b) Pertussis toxin → interferes to signal transduction.
c) Adenylate cyclase toxin → inhibits host epithelial
and immune effector cells.
d) Tracheal cytotoxin → causes ciliostasis and DNA
synthesis
 Incubate at moist chamber at 35°C for ≥7 days

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  Opportunistic (1-3% of all nosocomial infection,
NONFERMENTATING 2nd most commonly isolated non-fermenter);
GRAM NEGATIVE burns, trauma
 Ubiquitous; found in soil, water, foodstuffs
BACILLI
1. A. baumannii
General Characteristics
A. Grow in MacConkey as colorless colonies > Saccharolytic (glucose oxidizing), nonhemolytic
B. Fail to acidify O-F Media, overlaid with mineral strains.
oil
> Purplish hue due to lactose oxidation
C. Fail to acidify TSI
D. Most isolates in Oxidase Positive > appears blue-grey (cornflower blue) center in EMB
E. Resistance to a variety of classes of
antimicrobial agents 2. A. lwoffii

I. Pseudomonas aeruginosa > Asaccharolytic, nonhemolytic strains.

 Most commonly isolated species > 75% of 3. A. haemolyticus
nonfermenters in nosocomial bacteremias and
5% to 15% of nosocomial infections > β-hemolytic strains.
 Causes Otitis media and Jacuzzi/hot tub
syndrome
III. Stenotrophomonas
 Contaminants in blood drawing equipment
Virulence Factor (collection tubes, disinfectants, transducers,
venous catheters, etc.)
1. Exotoxins  Opportunistic (3rd most commonly isolated
Exotoxin A - most important exotoxin; blocks protein among nonfermenters
synthesis  lavender green pigment in BAP
 Ammonia-like smell
2. Endotoxin(LPS), motility, pili and capsule  Oxidase negative
 Catalase, Dnase, Lysine decarboxylase positive
3. Alginate > Polysaccharide polymer in mucoid strains
 Esculin and Gelatin hydrolysis (+)
4. Inherently resistance to a number antimicrobial  positive
agents

IV. Burkholderia spp.

Characteristics
B. cepacia
 Strict aerobic, Fruity, Grapelike or “corn  Pneumonia in patients with cystic fibrosis or
tortilla-like” Odor chronic granulomatous disease
 Growth at 42°C  Isolated from irrigation fluids, anesthetics,
 Grows in Cetrimide Agar nebulizers, detergents and disinfectants.
 Acetamide Positive  Onion bulb rot in plants and foot rot in humans
 Smooth, non-wrinkled and slightly raised; dirt-
like odor in BAP
Pigments  NLF; become dark pink to red after 4-7 days in
MacConkey Agar
Fluorescein (Pyoverdin) – green- P.fluorescens/P.  Most strains are ONPG positive
putida
Pyocyanin – blue B. pseudomallei
Pyorubin – red  “Melioidosis” (pulmonar disease) formation of
abscess
Pyomelanin – brown/black (P. stutzeri  Bipolar staining (safety pin) in Gram Stain
 Wrinkled and deep pink in Ashdown media
II. Acinetobacter
 “Earthy odor”
 Associated with ventilators, humidifiers,
catheters, etc.
B. gladioli
7|Page
  Associated with patients with CF (cystic
fibrosis) and CGD (chronic granulomatous
disease)

B. mallei
 Glanders- zoonosis affecting horses, mules,
donkeys.
 Formation of nodular lesions in lungs.
Coughing, fever and release of infectious nasal
discharge.
 Potential bioterrorist agent
 Nonmotile; non-pigmented colonies; no distinct
odor

LABORATORY DIAGNOSIS
Triple Sugar Iron Agar (TSI)
 K/K H2S-

Acetamide Utilization
 Determine the ability of an organism to use
acetamide as the sole source of carbon
 Indicator: Bromthymol blue (acetamide 
ammonia)

Growth at 42 degrees celcius

 Test the ability of an organism to grow at 42°C

8|Page

CELL WALL DEFICIENT
ORGANISMS
MYCOPLASMA AND UREAPLASMA
Mycoplasma
Two mycoplasma species are known human
pathogens.
 Mycoplasma pneumoniae > Respiratory disease
 Mycoplasma hominis > Urogenital tract disease
Mycoplasma species are the smallest self-
replicating organisms in nature.
General Characteristics of Mycoplasma
Do not possess cell walls
 Sometimes referred to as CWD (cell wall
deficient)
Resistant to cell wall active antibiotics
 Penicillins, cephalosporins
 Bonus is that antibiotics can help reduce normal
florae
Slow growing
Fastidious
 Require cholesterol and fatty acids for growth
Mycoplasma
 Sometimes known as pleuropneumonia-like
organism (PPLO)
o Eaton agent: from discoverer
 Colonies grow with center imbedded below agar
surface
o Thus appear as “fried eggs”
 Transmission
 Direct sexual contact, during delivery,
respiratory secretions, or fomites
o Very susceptible to heat and drying conditions
Location of infection
Epithelium of mucosal surfaces in respiratory
and urogenital tracts
Adhere tightly to epithelial cells
Oropharynx
 Relatively uncommon for M. hominis but
common for M. pneumoniae
Urogenital tract
 M. hominis (~10%-50%) women
Clinical Infections of M. pneumoniae
Diseases
 Bronchitis
 Pharyngitis
 Walking pneumonia (primary atypical
pneumonia)
Isolation always considered significant
 20% pneumonia in general populations
 50% in confined settings
 Prisoners, college students, and military
personnel
Mode of Transmission
Spread via close contact
 Aerosol droplets
Incubation
 2 to 3 weeks
 Headache, low-grade fever, malaise, anorexia,
sore throat, dry cough, earaches
 Extrapulmonary complications
Clinical Infections of Mycoplasma hominis
Infections of the lower urogenital tract
 Found in 50% of healthy patients
 Can cause infections of the upper urinary tract in
sexually active people
Salpingitis: inflammation of the fallopian tubes
Pyelonephritis: infection of kidney and ducts
Pelvic inflammatory disease (PID)
Postpartum fevers
Clinical Infections of Ureaplasma urealyticum
Infections of the urogenital tract
Normal florae of the lower urinary tract of
women
 Significant due to infection of fetus
 Chorioamnionitis (infection of placental
membrane)
 Congenital pneumonia
 Chronic lung disease in premature infants
 Meningitis of newborns with negative cultures
Other Mycoplasma Species
M. genitalium
Has been some association with NGU, cervicitis,
endometriosis, and PID
May lead to tubal sterility
Very difficult to culture, takes 2 to 3 months
Interferes with serology for other mycoplasma
M. fermentans (incognitus)
Likely an opportunistic respiratory pathogen
Adults with respiratory illness
9|Page
 Acute immunodeficiency syndrome (AIDS)– Tetracycline
related mycoplasma
M. hominis
Synovial fluid of patients with rheumatoid
arthritis Resistant to erythromycin; use clindamycin or
Lincomycin
U. urealyticum
Specimen Collection
Resistant to clindamycin or lincomycin; use
Extremely sensitive to drying due to lack of
erythromycin
cell wall
Swabs in transport medium
 Dacron polyester or calcium alginate
 Trypticase soy broth
If not plated immediately, freeze specimen at –
70°C

Identification of Mycoplasma and Ureaplasma

M. pneumoniae
Generally not cultured
 Takes too long, and sensitivity is low
Use serology
2 to 4 weeks apart for fourfold rise in titer
M. hominis and U. urealyticum
Culture
 Initially in liquid media, and watch for pH
change
 SP4, Shepard’s 10B, or 2SP broth
Plate enriched culture, and check for
characteristic colonies

M. hominis
Requires arginine
Turns pink
 Release of ammonium (NH4) from arginine
(phenol red indicator)
THE SPIROCHETES
Plate to agar Spirochetes
 A8 agar
 Look for characteristic fried egg colonies of a Helical-shaped, motile, unicellular bacteria
variety of shapes and sizes
 to 3.0-µm wide by 5- to 20-µm long
 Diene’s or methylene blue stain
 Exhibit various types of motion in liquid media
 Light blue “egg white”
 Free-living or survive in association with animal
 Dark blue “yolk”
or human hosts
Treponema pallidum subsp. pallidum
U. urealyticum
 Syphilis
Requires urea
T. pallidum other subspecies
Turns pink
 Release of NH4 from urea Borrelia
Plate to A8 agar plate
 Relapsing fever
 Lyme disease
Treatment Leptospira

M. pneumoniae  Leptospirosis

Erythromycin Spirillum minor

 Scattered reports of resistance
 Rat-bite fever
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Leptospires
Leptospira
Obligate aerobic helical rods 0.1-µm by 5- to 15-
µm long that are tightly coiled, thin, and
flexible.
Leptospirosis: L. interrogans
20 serovars
Most common
Icterohaemorrhagiae, Australis, and Canicola
Virulence factors
Unknown but may include
Reduced phagocytosis
Soluble hemolysin
Endotoxins
Infections Caused By Leptospires
 Organisms in mud or water enter through breaks
in the skin or intact mucosa.
Symptoms
Initial phase
 Fever, headache, malaise, and severe myalgia
 Renal lesions are interstitial nephritis with
glomerular swelling and hyperplasia.
 Illness lasts from less than 1 week to 3 weeks.
 Late manifestations caused by host immunologic
response to infection.
 Weil’s disease: severe systemic disease
 Jaundice, acute renal failure, hepatic failure,
intravascular disease Can be fatal
Epidemiology
Zoonotic disease
 Animal workers or in rat-infested surroundings
Dog, rats, and other rodents are principal hosts
 Excreted in urine
 Freshwater recreational exposure
 Water contaminated by urine
 Can survive for months in water
Infection
 Enters by contact with infected urine
Laboratory Diagnosis
Specimen collection
 Collect blood or cerebrospinal fluid (CSF)
during first week of illness
 Collect urine: yield higher after first week
 Direct microscopic detection is not
recommended.
Isolation and identification
 Culture: Fletcher’s, Stuart’s, or Ellinghausen-
McCullough-Johnson-Harris (EMJH) medium
 Use 1 to 2 drops of patient sample
 Serology: microscopic agglutination test (MAT)
for serotyping
 Immunoglobulin M (IgM) enzyme-linked
immunosorbent assay (ELISA) test
Antimicrobial Susceptibility
 Susceptible to
o Streptomycin
o Tetracycline
o Doxycycline
o Penicillin
Borreliae
 Helical bacteria 0.2 to 0.5 µm by 3 to 20 µm in
length
 Spirals vary between 3 to 10 per organism
 Less tightly coiled than leptospires
Relapsing fever
 B. recurrentis and B. duttonii
 Pediculus humanus louse-borne infection
Virulence Factors
 Evade complement by acquiring and displaying
suppressive complement regulators
o C4b-BP
o Factor H
 Relapses are caused by antigenic variation.
 Specific antibodies are rendered ineffective.
Symptoms
 Incubation period is 2 to 15 days.
 High fever (104°F) with shaking chills
 Periods of 3 to 7 days
 Delirium
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  Severe muscle aches and pain in bones and  Generally, only screen those with symptoms and
joints high-risk factors
 Generally, test by serology

Epidemic relapsing fever

Serologic Tests
 Transmission by crushing or scratching lice into
skin  ELISAs to demonstrate reactive antibody
 Detection of 2 of 3 IgM bands
 24 (OspC), 39, and 41 (flagellin) kDa
Endemic relapsing fever  Detection of 5 of 10 immunoglobulin G (IgG)
bands
 Transmitted by saliva during bite  18, 21, 28, 30, 39, 41, 45, 58, 66, 93 kDa

 Followed by remission and subsequent repeat of Clinical Manifestations

symptoms
 Sometimes hepatosplenomegaly and jaundice Stage 1
 Erythematous papule that rapidly expands
 Erythema chronicum migrans: classic “bulls-eye
Laboratory diagnosis rash” in 60% of patients
 Peripheral edema with central clearing
 Direct examination of spirochetes in blood
 Thick and thin films of Giemsa or Wright-
stained smears
Stage 2: acute
Symptoms
Culture
 Disseminated infection
 Kelly medium  Secondary skin lesions
 Animal inoculation (rarely)  Joint and bone pain
 Serology is difficult and impractical.  Neurologic and cardiac pathology
 Malaise and fatigue

Antimicrobial susceptibility
Stage 3: chronic
 Tetracyclines are the drugs of choice.
 Death of spirochetes can cause sudden endotoxin  Chronic cardiac symptoms
release (Jarisch-Herxheimer reaction).  Chronic neurologic symptoms
 Fever, chills, headache, myalgia  Chronic arthritis (most common symptom)

B. burgdorferi Lyme disease

Virulence Factors  First described in Lyme, Connecticut
 North America and Europe
 Binds plasminogen and urokinase-type
plasminogen activator to its surface
 Could act as a protease to promote tissue
B. garinii and B. afzelii
invasion
 Complement evasion  Asia and Europe
 Binds factor H 
Transmission
Treatment  Tick bites
 Protective clothing and repellent prevent
 Antibiotics: early stages doxycycline
infection.
 Late stages show no usefulness of antibiotics.

Detection Treponemes

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  Treponema pallidum subsp. pallidum
Syphilis
 Treponema pallidum subsp. pertenue
Yaws
 Treponema pallidum subsp. endemicum
Endemic syphilis
 Treponema pallidum subsp. carateum
Pinta
Syphilitic Infection
Transmission
 Infection caused by sexual contact (mucous
membranes)
 Can enter via cuts, abrasions, or directly through
intact mucous membranes
 Can enter other sites such as the lip or
transplacentally
Incubation period
 Disseminate throughout the body
 10 to 90 days (usually about 3 weeks)
Primary syphilis
 Chancre at infection site (usually one but
sometimes several in human immunodeficiency
virus (HIV)–positive patients)
Clean, smooth base, edge slightly raised and firm
Painless but may be tender
Heals in 3 to 6 weeks
 Base contains spirochetes that can be identified
by dark field microscopy or
immunofluorescence or serology.
Secondary syphilis
 Begins 2 to 12 weeks after chancre appearance
 Widespread macular rash (syphilitic roseola),
particularly palms and soles of feet
Systemic symptoms
 Lymphadenopathy, headache, lesions of the
mucous membranes and the skin, and rash
Latent syphilis
 Early latent phase: initial 4 years relapses occur;
patient is infectious
 Late latent phase: indefinite duration; sometimes
no complications ever appear
 Detected only through serology
Late syphilis (tertiary)
 Late complications of syphilis involving many
organs
Tertiary (Late) Syphilis
Complications
 Central nervous system (CNS) disease,
cardiovascular abnormalities, aortitis and valve
insufficiency, and granulomatous lesions
(gummas) in any organ
Asymptomatic CNS disease
 CSF abnormalities without symptoms
 Pleocytosis, elevated protein levels, depressed
glucose
Congenital syphilis
 Intrauterine infection
 Nonimmune hydrops: disease of placenta that
causes fetal death
 Hepatosplenomegaly, meningitis,
thrombocytopenia, anemia, and bone lesions
 Visible deformities
 Deformed tibias or teeth
Transmission
 Sexual contact, direct injection, direct contact
with lesions, transplacental transmission
Specimen collection
 Primary or secondary lesion is cleaned with
saline and gently abraded with dry, sterile gauze.
 Transfer serous fluid to slide with saline
 Coverslip and examine using darkfield
microscopy
Detection
 Nontreponemal tests (primary or secondary
stage only, later stages less than 1%)
o Venereal disease research laboratory
(VDRL)
o Cardiolipin antigen is mixed with patient
serum or CSF.
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 o If positive, flocculation occurs and can be
read microscopically.

 Rapid plasma reagin (RPR)

o Black carbon particles are bound to
cardiolipin and mixed with patient sera.
o Particles agglutinate, thus indicating a
positive test.

 Treponemal tests (all stages, although more

effective for secondary and late stages)
o Confirm nontreponemal tests
o Titers remain high despite treatment.

 Fluorescent treponemal antibody absorption test

(FTA-ABS)
o Patient sera is absorbed against nonpallidum
spirochetes.
o Absorbed serum is then placed with T.
pallidum organisms, and secondary
antihuman antibody conjugated to a
fluorescein is added.

 T. pallidum–particulate agglutination test (TP

PA)
o Antigens to T. pallidum are absorbed to
gelatin particles.
o Patient sera added, and gelatin agglutinates

 Enzyme immunoassay (EIA) test kits are not

comparable.

Treatment
 Penicillin
Long-acting is preferred
Benzathine penicillin

 Doxycycline and tetracycline > If penicillin

allergies

 Can develop Jarisch-Herxheimer reactions

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