Gram Negative Bacterial Infection

Benito K. Lim Hong III, M.D.

1. To know the various diseases caused by Gram (-)
Bacteria limited to Robbins Pathologic Basis of
Diseases & common in the local settings:
a. Neisserial Infection
b. Whooping Cough
c. Pseudomonas Infection
d. Chancroid
e. Granuloma Inguinale
2. To know the gross appearance of the common
disease cause by Gram (-) organisms as well as
histopathologic appearance of only commonly
biopsied lesion limited to Robbins Pathologic
Basis of Disease
3. To know the mechanism of action of the Gram (-)
infectious agents as to how they cause diseases
to humans limited to Robbins Pathologic Basis of
Disease
A 23 year old male came in to your clinic with
dysuria & discharges on his urethra. He claimed to
disclose in confidential that he had history of
sexual contact with 14 GROs from different night
clubs. Physical examination revealed a yellowish,
purulent discharges on his urethra.
A 14 year old boy came in to the ER due to high
grade fever, comatose, & a widespread
maculopapular skin rashes with petechiae in the
center. Patient had history of high grade fever
(T=42˚C), severe head-ache, irritability, & lost of
appetite. V/S: BP=Palpatory 50, HR=30 bpm,
RR=12 cpm, T=35˚C. Few minutes after delivering
to ER bed, patient went to respiratory arrest.
Resuscitation done but failed to revive the
patient.
Etiologic Agents:
1. Neisseria gonorrheae
2. Neisseria meningitides
 Gram (-) diplococci that are flattened on the
adjoining sides, give the pair the shape of a
coffee bean.
 Aerobic
 Stringent nutritional requirements
 Grows best in enriched medium such as
Chocolate Agar
Neisseria gonorrheae
Neisseria meningitidis
I. Neisseria gonorrheae
1. Sexually Transmitted Diseases
2. Eye Infections in Neonates passes through
infected birth canal of the mother
II. Neisseria meningitides
 Meningitis
General Principles:
Neisserial Infection is shown by high rates of
disease among people who are deficient in the
complements protein that forms the
membrane attack complex (C5 to C9).
I. Neisseria gonorrheae
Virulence Factors:
1. Single Complete Genes for Long Pili –
adherence of Neisseria gonorrheae to
epithelial cells & then binds to CD46, a
complement-regulatory protein expressed
by all human nucleated cells.
2. Expression Pili Loci – regulatory elements
for gene expression, as well as the entire
protein coding region.
Virulence Factors:
3. Silent Pili Genes in the Chromososmes –
encode antigenically variant pili proteins,
which lacks the regulatory elements
(promoter) as well as the DNA encoding the
N-terminal domain of the protein.
Homologous combination between the
silent loci & the expression loci for pili
shuttles variant gene into the complete loci,
resulting in expression of new pili protein.
N-terminal domain of the protein
Virulence Factors:
4. OPA Proteins – make the bacterial colonies
opaque, these proteins are located in the
outer membrane of the bacteria. They
increase binding of the organism to
epithelial cells & promote entry of bacteria
into cells. Due to shift in reading frame of
the gene, a single clone of the organism can
express none, 1 or several OPA genes at a
time, but only a 1 gene for pili protein.
Virulence Factors:
5. Antigenic variation – to escape the immune
response. A single clone of the organism
gives rise to multiple antigenic types,
allowing newly arisen antigenic variants to
escape the immune response.
II. Neisseria meninigitidis
Virulence Factors:
1. Capsule – prevent opsonization &
phagocytosis.
2. OPA Proteins
3. Antigenic variation
Neisserial Infection Virulence Factor
Difference Comparison

Neisseria gonorrheae Neisseria meninigitidis

Pili Capsule
 Neisserial Infection Virulence
Factor Similarities

1. OPA Proteins
2. Antigenic Variation
I. Neisseria gonorrheae
An important cause of sexually transmitted
disease.
2nd only to Chlamydia trachomatis as a
causative agents of sexually transmitted
infection.
I. Neisseria gonorrheae
In men, it causes urethritis.
In women, it is often asymptomatic & often go
untreated which could lead to pelvic
inflammatory disease & can lead to infertility or
ectopic pregnancy.
Gonococcal Urethritis (Gross)
Pelvic Inflammatory Disease (Gross)
Pelvic Inflammatory Disease (Histopathology)
I. Neisseria gonorrheae
Although Neisseria gonorrheae usually
manifest as a local infection in the genital or
cervical mucosa, pharynx, or anorectum,
disseminated infections may occur.
It may become disseminated in people who
lack the complements proteins that forms the
membrane attack complex.
I. Neisseria gonorrheae
Disseminated infection of adults & adolescents
usually causes septic arthritis accompanied by a
rash of hemorrhagic papules & pustules.
Neonatal with Neisseria gonorrheae infection
causes blindness & rarely, sepsis & the eye
infection of newborn (Ophthalmia
neonatorum) remains an important cause of
blindness in some developing nations.
I. Neisseria gonorrheae
The eye infection of newborn infected with
Neisseria gonorrheae is preventable by
instillation of Silver Nitrate or Antibiotics in the
newborn’s eye.
Gonococcal Septic Arthritis (Gross)
Ophthalmia Neonatorum (Gross)
II. Neisseria meningitides
A significant cause of bacterial meningitis
particularly among people between 5 & 19
years old.
The organism is a common colonizer of the
oropharynx & is spread by the respiratory
route.
II. Neisseria meningitides
Invasive disease mainly occurs when people
living in crowded quarters such as military
barracks or college dormitories, etc., encounter
new strains to which they have not previously
made an immune response.
An immune response leads to clearance of
colonization in most people, & this response is
protective against subsequent disease with the
same strains of bacteria.
II. Neisseria meningitides
Even in the absence of an immune response,
only a small fraction of those infected with
Neisseria meningitides gets meningitis.
The bacteria must invade respiratory epithelial
cells & travel to the basolateral sides of the
cells to enter the blood.
Once in the blood, the capsule of the bacteria
reduces opsonization & destruction of bacteria
by complement protein.
Fulminant Meningococcemia (Gross)
A 6 months old infant was brought by her mother
to the ER with violent coughing followed by loud
inspiratory whoop. History of vaccination revealed
inadequate vaccination of DPT Vaccine.
Etiologic Agents:
Bordetella pertussis
 Gram (-) coccobacilli.
Bordetella pertussis
An acute, highly communicable illness
characterized by paroxysms of violent coughing
followed by a loud inspiratory “whoop”.
DPT vaccination has been effective in preventing
whooping cough.
There is reported increased incidence of this
disease in other countries despite continued high
rate of vaccination.
The cause is unknown, but antigenic divergence of
clinical strains from vaccine strains & waning
immunity in young adults may play a role.
Pathogenesis:
Bordetella pertussis colonizes the brush border
of the bronchial epithelium & also invades
macrophages.
Virulence Factors:
1. Bordetella virulence gene locus (bvg) – a
transmembrane protein that “senses” signals
that induce expression of virulence factors. On
activation, it phosphorylates the protein
BVGA, which regulates the transcription of
mRNA for adhesins & toxins.
Virulence Factors:
2. Filamentous hemagglutinins adhesin – bind to
carbohydrates on the surface of respiratory
epithelial cells, as well as to CR3 (Mac-1)
integrins on macrophages.
Virulence Factors:
3. Pertussis Toxin – an exotoxin composed of 5
distinct peptides, including a catalytic peptide
S1 that shows homology with catalytic
peptide of cholera toxin & Escherichia coli
labile toxins.
Virulence Factors:
3. Pertussis Toxin – Like cholera toxin, it ADP
ribosylates & inactivates guanine nucleotide-
binding protein, so these G-proteins no longer
transduce signals from host plasma
membrane receptors paralyzes the cilia of
the pulmonary tract, impairing an important
pulmonary defenses.
Morphology:
Bordetella bacteria causes a laryngotracheo-
bronchitis that is in severe cases features
bronchial mucosal erosions, hyperemia, &
copious mucopurulent exudates.
Unless superinfected, the lung alveoli remain
open & intact
Morphology:
In parallel with a striking peripheral
lymphocytosis (up to 90%), there is
hypercellularity & enlargement of the mucosal
lymph follicles & peribronchial lymph nodes.
A 59 year old male, diabetic came in to the ER
with severe dyspnea, tachypnea, & change in
sensorium. V/S: BP=60/40, HR=160 bpm, RR=56
cpm, T=35.2˚C. Intubation was attempted
however, with difficulty due to copious, mucoid,
non-blood streaked secretions from the buccal
mucosa. Suctioning of the secretion was done &
intubation was attempted. Unfortunately, patient
went into respiratory arrest. Resuscitative
measures were done however, patient expired.
Etiologic Agents:
Pseudomonas aeruginosa
 Gram (-) coccobacilli.
 Aerobic.
 Opportunistic.
Pseudomonas aeruginosa
Susceptible Hosts:
1. Cystic Fibrosis Patients
2. Severe Burn Patients
3. Immunocompromised Patients
 Most cystic fibrosis patient die of pulmonary
failure secondary to chronic infection with
Pseudomonas aeruginosa
In addition, species in the Burkholderia cepacia
complex, which are transmitted between cystic
fibrosis patients, opportunistically infect people
with cystic fibrosis & often cause fatal infection.
Both Pseudomonas aeruginosa & Burkholderia
cepacia complex are very resistant to antibiotics,
making these infections difficult to treat.
1. Sepsis
2. Hospital-acquired Infections
3. Corneal Keratitis in wearer of contact lens
4. Endocarditis
5. Osteomyelitis in IV Drug Abuser
6. External Otitis Media (Swimmer’s Ear) in Healthy
People
7. Severe Otitis Media in Diabetics
Virulence Factor:
1. Pili & Adherence Proteins – bind to epithelial
cells & lung mucin
2. Endotoxin – causes signs & symptoms of Gram
(-) Sepsis
3. Alginate – mucoid exopolysaccharides forming
a slimy biofilm in which bacteria are protected
from antibodies, complement, phagocytes, &
antibiotics.
Virulence Factor:
4. Exotoxins A – similar in structure with
Diphtheria Toxin, inhibits protein synthesis by
ADP ribosylating EF-2, a ribosomal guanine
nucleotide-binding protein (G-protein).
5. Exoenzyme S – ADP-ribosylates G-proteins
including p21 RAS & may interfere with host
cell growth.
Virulence Factor:
6. Phospholipase C – lyses RBC & degrades
pulmonary surfactant.
7. Elastase – degrades IgGs & extracellular
matrix proteins.
Exoenzyme S, Phospholipase C, & Elastase
are important in tissue invasion &
destruction of the cornea in keratitis.
Virulence Factor:
8. Iron-containing compounds – extremely toxic
to endothelial cells & may cause the vascular
lesion that are characteristic to this infection
Morphology:
1. Pseudomonas pneumonia – is the prototype
of Necrotizing Inflammation, distributing
through the terminal airways in a fleur-de-lis
pattern with striking whitish, necrotic centers
& red, hemorrhagic peripheral areas.
Morphology:
1. Pseudomonas pneumonia – On microscopic
examination, masses of organisms cloud the
tissue with bluish haze, concentrating in the
wall of the vessels, where host cells undergo
coagulation necrosis & nuclei fade away.
Morphology:
1. Pseudomonas pneumonia – This picture of
Gram (-) vasculitis accompanied by
thrombosis & hemorrhage, although not
pathognomonic, is highly suggestive of
Pseudomonas aeruginosa infection.
Pseudomonas pneumonia
Morphology:
1. Pseudomonas pneumonia – Bronchial
obstruction caused by mucous plugging &
subsequent Pseudomonas aeruginosa
infection are frequent complications of cystic
fibrosis.
Morphology:
1. Pseudomonas pneumonia – Despite
antibiotics treatment & the host immune
response against the bacteria, chronic
Pseudomonas aeruginosa infection may
result in bronchiectasis & pulmonary fibrosis.
Morphology:
2. Ecthyma gangrenosum – well-demarcated
necrotic & hemorrhagic skin lesions of oval
shape often arise during these bacteremias.
This is seen in skin burn patient where the
organisms proliferate widely, penetrating
deeply into the veins & spreading to cause
massive bacteremias. Disseminated
Intravascular Coagulation is a frequent
complication of bacteremia.
Ecthyma gangrenosum
A 29 year old male came in to your clinic
complaining of a painful ulcerated lesion on his
penis. Patient disclosed that he had sexual contact
with several GROs in a motel. Upon physical
examination, the ulcerated lesion was tender with
a shaggy, yellow gray exudate and tender inguinal
lymphadenopathy
Etiologic Agent:
Haemophilus ducreyi
An acute, sexually transmitted, ulcerative
infection most common in the tropical &
subtropical areas & is more prevalent in lower
socioeconomic groups & among men who have
regular contact with prostitutes.
One of the most common cause of genital ulcers
in Africa & Southeast Asia, where it probably
serves as an important cofactor in the
transmission of HIV-1 infection.
Gross Morphology:
4 to 7 days after inoculation, the patient
develops a tender, erythematous papule
involving the external genitalia.
Males: Penis
Female: Vagina or Periurethral Area
Gross Morphology:
Over the course of several days, the surface of
the primary lesion erodes to produce an
irregular ulcer, which is apt to be more painful
in males than females.
In contrast to the primary chancre of syphilis,
the ulcer of chancroid is not indurated, &
multiple lesions may be present.
Gross Morphology:
The base of the ulcer is covered by shaggy,
yellow-gray exudate.
The regional lymph node, particularly the
inguinal region, become enlarged & tender in
about 50% of cases within 1 to 2 weeks of the
primary inoculation.
Gross Morphology:
In untreated cases, the inflamed & enlarged
nodes (buboes) may erode the overlying skin to
produce chronic draining ulcers.
 Penile Ulcer
Chancroid Chancre (Syphilis)
Microscopic Morphology:
The ulcer contains a superficial zone of
neutrophilic debris & fibrin, with an underlying
zone of granulation tissue containing areas of
necrosis & thrombosed vessels.
A dense lymphoplasmacytic inflammatory
infiltrate is present beneath the layer of
granulation tissue.
Microscopic Morphology:
Coccobacillary organisms are sometimes
demonstrable on Gram or Silver Stain, but they
are often obscured by the mixed bacterial
growth that is frequently present at the ulcer
base.
Chancroid (Histopathology)
A 24 year old male came in to your clinic
complaining of soft, protruberant lesion on his
penis which are raised & indurated. Patient
disclosed that he had sexual contact with several
GROs in a motel.
Etiologic Agent:
Calymmatobacterium donovani
Minute, encapsulated, coccobacillus
A chronic inflammatory disease which is sexually
transmitted.
Endemic in rural areas in certain tropical &
subtropical regions.
Untreated cases are characterized by the
development of extensive scarring , often
associated with lymphedema of the external
genitalia.
Culture of the organism is difficult & PCR assays
are still in development, so the diagnosis is made
by morphologic examination of smear or biopsies
of the ulcer.
Gross Morphology:
Begins as a raised, papular lesion involving the
moist stratified squamous epithelium of the
genitalia or rarely extragenital sites.
The lesion eventually undergoes ulceration,
accompanied by the development of abundant
granulation tissue, which is manifested grossly
as a protruberant, soft, painless mass.
Gross Morphology:
As the lesion enlarges, its borders become
raised & indurated.
Disfiguring scars may develop in untreated
cases.
Regional lymph nodes are spared or show only
non-specific reactive changes, in contrast to
chancroid.
Microscopic Morphology:
Marked epithelial hyperplasia at the borders of
the ulcer, sometimes mimicking carcinoma
(Pseudoepitheliomatous Hyperplasia).
A mixture of neutrophils & mononuclear
inflammatory cells are present at the base of
the ulcer & beneath the surrounding
epithelium.
Granuloma inguinale (Histopathology)
Microscopic Morphology:
Smear used to demonstrates the organisms:
1. Giemsa-stained smears of the exudate as
minute encapsulated coccobacilli
(Donovan Bodies) in macrophages.
2. Silver Stain (Warthin-Starry Stain)
Donovan Bodies