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SPIROCHETES I: TREPONEMA
December 04, 2020 | Topic 19
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Overview Ø In whole blood or plasma stored at 4 C à
remain viable for at least 24 hours
I. Treponema species Ø Non-pathogenic or saprophytic strains (Reiter
II. Treponema pallidum strain)
III. Treponema pallidum endemicum • Anaerobic culture in vitro à 30 hours
IV. Treponema pallidum pertenue doubling time
V. Treponema carateum • Defined medium containing amino acids,
vitamins, minerals, salts, and serum
albumin
TREPONEMA SPECIES
GROWTH
Ø Treponema pallidum
• T. pallidum subspecies pallidum Ø Slow replication à 30-33 hours doubling time
(Syphilis) Ø In presence of reducing substances à remain
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• T. pallidum subspecies endemicum motile for 3-6 days at 25 C
(Bejel)
OTHER CHARACTERISTICS
• T. pallidum subspecies pertenue (Yaws)
Ø Treponema carateum (Pinta)
Ø Rapidly killed or immobilized by
GENERAL CHARACTERISTICS • Drying
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• High temperature (42 C)
Ø Gram-negative, actively motile • Trivalent arsenical, mercury and bismuth
• Slender spirals regularly spaced at a Ø Metabolic inactivity and slow multiplication rate
distance of 1 um from one another à of organism à slow rate of killing using penicillin
seen only with immunofluorescent or
darkfield microscope VIRULENCE FACTORS
Ø With pointed tapering ends
Ø Stain with difficulty except with Giemsa’s or
silver stain Ø Outer membrane proteins covalently bound
Ø No tricarboxylic acid cycle in the bacteria à to lipids
failure to grow in vitro • Lipids: keep the proteins inaccessible to
• No dependent on host cells for all antibodies
purines, pyrimidines, and amino acids • Proteins: promote adherence to host
cell
Ø Hyaluronidase: facilitates perivascular
STRUCTURE
infiltration; enhance invasiveness
Ø Coating of fibronectin: protect against
Ø Outer sheath: glycosaminoglycan coating phagocytosis
(mucoid layer) Ø Species-specific antigen on cell surface:
Ø Outer membrane: inside the sheath; contains evasion of immune system
peptidoglycan; maintain structural integrity
Ø Endoflagella or axial filaments: within PATHOGENESIS
periplasmic space; encased by outer membrane
Ø Inner or cytoplasmic membrane: within endo- 1) Adherence to skin or mucosal membranes à
flagella; osmotic stability; cover protoplasmic produce hyaluronidase à promote tissue
cylinder invasion
Ø Cytoplasmic tubules (body fibrils): near inner 2) Organism becomes coated with host fibronectin
membrane à protect against phagocytosis and immune
recognition
CULTURE
• Treponemes spread to other skin tests
and to other organs hematogenously
Ø Pathogenic T. pallidum never been cultured soon after infection
continuously on artificial • Skin lesions of primary syphilis à
• Usually cultured in testes of rabbits represent the primary site of initial
Ø Microaerophilic (1-4% oxygen) replication
SECONDARY STAGE
Ø Clinical evidence of disseminated disease
Ø “Flu-like” syndrome + lymphadenopathy
Ø Some with alopecia areata
Ø Lesions: highly infectious
1) Generalized mucocutaneous rash
• Red maculopapular rash anywhere in
the body including the hands and feet
2) Condylomata lata
• Moist pale papules in anogenital region,
axillas, and mouth
IMMUNITY Ø Other manifestations
• Syphilic meningitis
Ø Tissue destruction primarily due to host’s • Chorioenteritis
immune response to infection • Hepatitis
• Nephritis (immune complex type)
MODE OF TRANSMISSION • Periotitis
Ø Lesions also rich in spirochetes à highly
1) Sexual contact during primary stage infectious
2) Skin contact with disseminated rash during Ø Rash and symptoms gradually resolve
secondary stage spontaneously within 6-8 months of infection
3) Transfusion or contaminated blood • 30% complete cure without treatment
4) In utero from infected mother • Others become dormant in liver and
spleen
Ø Local multiplication at initial site of entry
a) Infectious lesions on the skin mucous LATENT STAGE
membranes of genitalia Ø Clinically inactive stage but with (+) serologic
b) 10-20%: initial lesion intra-rectal, perianal, or tests
oral Ø 30% of untreated infection
IMMUNOFLUORESCENCE
Ø Fluorescent spirochetes: more useful
REFERENCE
th
• Jawetz’ Medical Microbiology 28
Edition
• Proctor’s PowerPoint presentation
• 2021 Transcript
• Beshywap Transcript
Treponema pallidum
● T. pallidum subspecies pallidum (Syphilis)/ Great Pox From Jawetz:
● T. pallidum subspecies endemicum (Bejel)
● T. pallidum subspecies pertenue (Yaws) In proper suspending fluids and in the presence of reducing
Treponema carateum (Pinta) substances, T. pallidum may remain motile for 3-6 days at
25C. In whole blood or plasma stored at 4C, organisms
TREPONEMA PALLIDUM remain viable for at least 24 hours, which is of potential
importance in blood transfusions.
GENERAL CHARACTERISTICS
● Gram negative, actively motile
● Slender spirals regularly spaced at a distance of 1 μm from OTHER CHARACTERISTICS
one another
● Rapidly killed or immobilized by
▪ Seen only with immunofluorescent stain or darkfield
o Drying
microscope
o High temperature (42°C)
● With pointed tapering ends with regular intervals
o Trivalent arsenical, mercury & bismuth
● Stain with difficulty except with Giemsa’s or silver stain
● Metabolic inactivity + slow multiplication rate of organism
● No tricarboxylic acid cycle in the bacteria failure to grow
slow rate of killing using penicillin
in vitro
▪ Dependent on host cells for all purines, pyrimidines and
VIRULENCE FACTORS:
most amino acids
STRUCTURE
● Outer sheath: glycosaminoglycan coating (mucoid layer),
encloses with axial fibrils (originates from insertion pores at
both poles of cell)
● Outer membrane – inside the sheath; contains
peptidoglycan; maintain structural integrity
● Endoflagella or axial filaments – within periplasmic space;
encased by outer membrane, for rotation and flexion
● Inner or cytoplasmic membrane – within endo-flagella;
PATHOGENESIS
provide osmotic stability; cover protoplasmic cylinder
● Cytoplasmic tubules (body fibrils) – near inner membrane 1. Adherence to skin or mucosal membranes produce
● Absence of TCA hyaluronidase promote tissue invasion
2. Organism becomes coated with host fibronectin protect
CULTURE: against phagocytosis and immune recognition
● Pathogenic T. pallidum never been cultured continuously ● Treponemes spread to other skin sites & to other organs
on artificial media hematogenously soon after infection
▪ Usually cultured in testes of rabbits ● Skin lesions of primary syphilis represent the primary
▪ inoculation in anterior chamber of the eye site of initial replication
● Microaerophilic (1% - 4% oxygen) ● Most frequent inoculation body site: external genitalia
● In whole blood or plasma stored at 40°C ● Most prominent histopathologic findings: Arteritis and
→ remain viable for at least 24 hours periarteritis
● Non-pathogenic or saprophytic strains (Reiter strain)
▪ Anaerobic culture in vitro PHASES OF DISEASE
→ 30 hours doubling time 1. Primary phase (Acquired syphilis)
▪ Defined medium containing amino acids, vitamins, ● Chancres at site of penetration primary site of initial
minerals, salts and serum albumin replication, painless
● Endarteritis and periarteritis; PMNs & macrophages
GROWTH 2. Secondary Phase
● Slow replication ● (+) clinical signs of disseminated disease
SECONDARY STAGE
● Clinical evidence of disseminated disease
● “Flu-like” syndrome + lymphadenopathy
● Some with alopecia areata
● Lesions: highly infectious
1. Generalized mucocutaneous rash
o Red maculopapular rash anywhere in the body
including the hands & feet
2. Condylomata lata
o Moist, pale papules in anogenital region, axillas, and
mouth
IMMUNITY ● Other manifestations:
o Syphilitic meningitis
● Tissue destruction primarily due to host’s immune
o Chorioretinitis
response to infection
o Hepatitis
o Nephritis (immune complex type)
From Jawetz: o Periostitis
● Lesions also rich in spirochetes highly infectious
A person with active or latent syphilis appears to be resistant ● Rash & symptoms gradually resolve spontaneously within 6
to superinfection with T. pallidum. However, if early syphilis to 8 months of infection
is treated adequately and the infection is eradicated, the o 30% complete cure without Tx
individual again becomes fully susceptible. The various o Others become dormant in liver and spleen
immune responses usually fail to eradicate the infection or o resolve spontaneously but still highly infectious
arrest its progression.
LATENT STAGE
● Clinically inactive stage but with (+) serologic tests
CLINICAL MANIFESTATIONS ● 30% of untreated infection
● MOT: ● Patient is asymptomatic but in serologic test they are
1. Sexual contact during primary stage positive this occurs when the patient is untreated
2. Skin contact with disseminated rash during secondary ● There is activation of the dormancy: 2 consequences
stage o reverse back to secondary stager or
3. Transfusion of contaminated blood o progress to tertiary stage
4. In utero from infected mother
● Local multiplication at initial site of entry TERTIARY (LATE) STAGE
1. Infectious lesions on the skin or mucous membranes of ● 1/3 of untreated patients
genitalia ● Activation of dormant treponemes 3 – 30 years later in
2. 10% - 20%; initial lesion intra-rectal, perianal, or oral untreated cases
● Some spread to nearby LN blood ● Diffuse, chronic inflammation
● Characteristics:
ACQUIRED SYPHILIS 1. Granulomatous lesions (gummas) in skin, bones, and
PRIMARY STAGE liver
● Hard Chancre: painless, ulcerated skin lesion at the site of 2. Degenerative CNS changes (neurosyphilis) –
inoculation; 10-90 days after initial infection meningovascular SY, paresis, tabes dorsalis
● Painless LAD 1 – 2 weeks after appearance of chancre 3. CV lesions – aortitis, aortic aneurysm, aortic valve
● Spontaneous healing of the chancre within 3 to 6 weeks insufficiency
does not indicate a cure
● Highly infectious
DIAGNOSIS
TREPONEMAL TESTS
● Measure Ab’s vs. T. pallidum antigens
● Used to confirm if a (+) result from nontreponemal test is
truly (+) or falsely (+)
● Serial dilution of serum not done
● Report as reactive or non-reactive
● T. pallidum Particle Agglutination (TP-PA) – most widely
used in U.S.
● T. pallidum Hemagglutination (TPHA) & micro-
hemagglutination (MHA-TP) - based on the same
principles as the TP-PA but use sheep erythrocytes rather
than gelatin particles and may be more prone to
nonspecific agglutination.
● Fluorescent Treponemal Antibody Absorbed (FTA-ABS) –
most commonly used
● If (+) IgM FTA in blood of newborn (+) in utero infection
● Not helpful in diagnosis of neurosyphilis but if (-), exclude
neurosyphilis
TREATMENT
DOC: Penicillin
● Long-acting benzathine PEN for early stages
● Penicillin G for congenital and late syphilis (only PEN for
neurosyphilis & pregnant patients)
● Alternatives: tetracycline & doxycycline
● No available vaccine
REFERENCES
1. Lecture Notes
2. Recordings
3. Powerpoint
4. Medical Microbiology 28th Edition – Jawetz
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MICROBIOLOGY
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MICROBIOLOGY
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MICROBIOLOGY
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MICROBIOLOGY
LABORATORY TESTS
• Specimen: tissue fluid from early surface lesions;
blood serum for serology
• Dark-Field Examination
o Typical motile spirochetes
o Exudates from skin lesion; primary,
secondary and congenital syphilis
• Immunofluorescence
o Fluorescent spirochetes; more useful
❖ VDRL vs RPR
➢ VDRL form small aggregates – need a
microscope
➢ Antigen used in VDRL and RPR are the
same
• Indirect fluorescent antibody technique
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MICROBIOLOGY
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MICROBIOLOGY
• Treatment:
o Benzathine penicillin
▪ Children < 10 y/o: 600,000 U
benzathine penicillin IM
▪ > 10 y/o: 1.2 million U IM
o Single dose azithromycin 30 mg/kg not
to exceed 2 grams (WHO
recommendation)
Organisms Transmission
TREPONEMA PALLIDUM SUBSPECIES PERTENUE T. pallidum Sexually transmitted
(YAWS/FRAMBESIA/GRANULOMATOUS DISEASE) disease
• Endemic among children (<15 y/o) in humid, Vertical transmission from
hot tropical countries (like Philippines) mother to infant
• MOT: direct contact with infected skin lesions Blood transfusion (human
• Primary lesion: ulcerating papule, usu. on arms only)
or legs
T. pertenue Direct skin contact
• Late destructive lesions of the skin, LN, and
(human only)
bones → scar formation common → common in
T. carateum Direct skin contact
the legs
(human only)
• (+) cross-immunity with syphilis
T. endemicum Direct mucosal contact
o Diagnosis & treatment same as syphilis
(human contact)
o Dramatic improvement with PEN
Contaminated eating or
drinking vessels
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