MYCOBACTERIA

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 I. TB Epidemiology
• 1/3 of the of the world population infected with TB
• Active disease in 9.1 mill people/yr
• Death in almost 2 mill people/yr
• 80% of cases in high-burden countries

Estimated new TB cases

(all forms) per 100 000 population

No estimate
0-24
25-49
50-99
100-299
300 or more

WHO data
Risk Factors for TB Transmission
Case:
Degree of infectiousness

Contact:
Length and intensity of exposure
- Household Contact
- Overcrowding and poor ventilation
- Occupational setting

Immune Defense
 MYCOBACTERIUM

• Aerobic bacilli –non spore forming

non motile
• Cell wall –rich in lipids
• Acid-fast bacilli
• Very slow growing

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Lipid-Rich Cell Wall of Mycobacterium
Mycolic acids

Unusual cell wall lipids (mycolic

acids,etc.)
(Purified
Protein
Derivative
)

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 Acid-Fast (Kinyoun) Stain of
Mycobacterium

NOTE: cord growth (serpentine arrangement) of

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 Eight Week Growth of Mycobacterium
tuberculosis on Lowenstein-Jensen Agar

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Important Human Pathogens
Mycobacterium tuberculosis
Mycobacterium leprae (uncommon)
Mycobacterium avium-intracellulaire Complex
(MAC) or (M. avium)

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Mycobacterium tuberculosis Infection
Introduction
Epidemiology
Pathophysiology
Clinical Manifestations
Diagnostic Testing
Treatment

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Tuberculosis is second only to HIV
infection in causing deaths from an
infectious agent.

Tuberculosis is more aggressive,

contagious, and lethal in people with
HIV-1–related immune dysfunction, and
HIV-1 progresses more rapidly in people
with active tuberculosis
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III. TB Pathogenesis: First Steps
Day 0-7 Droplet nuclei (< 5mm) containing 1-3 bacilli enter the alveoli
Bacilli are ingested by macrophages, dendritic cells

Day 7-14 Bacilli multiply in macrophages

Day 14-28 CD4 cells infiltrate, become activated, release cytokines and
activate macrophages

Week 4-6 Granuloma develop with activated macrophages, CD4 and CD8
cells; the center can become caseous

After 6 weeks Bacilli can multiply extracellularly in the caseous necrosis and a
cavity may form
 Epidemiology
In 2007, 13,293 tuberculosis cases were
reported in the United States.

Prevalence in foreign-born U.S. residents

is 9.7 times higher than that in U.S.-born
persons.

Approximately 1% of U.S. cases are

multidrug resistant (MDR), and of these,
only two cases in 2007 and four in 2006
were extensively drug resistant (XDR).
 Pathophysiology
Tuberculosis is caused by infection with
Mycobacterium tuberculosis, an acid-fast–
staining bacillus, which is inhaled into the
respiratory system by airborne droplets.

In the airways, alveolar macrophages

ingest the bacteria but are unable to arrest
multiplication of the organism, which
ultimately destroys macrophages.

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Infected macrophages are also carried to
lymph nodes, and in some patients, such
as those with immunosuppression, they are
carried to the bones, gastrointestinal tract,
and other locations.

These processes occur before immunity

develops, heralded by reactivity to the
tuberculin skin test (TST).

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Once immunity develops, a quiescent state
usually occurs in which infection is recognized
only by reactivity to tuberculin skin testing.

In some patients, a pulmonary Ghon complex

(localized parenchymal infection and lymph node
involvement) may reach significant size and
calcification status to be visible on radiographs.

Malnutrition, immunosuppressed states, and

stress are risk factors for primary progression or
reactivation of quiescent tuberculosis.

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 Clinical Manifestations

Patients with pulmonary tuberculosis

are often asymptomatic.

However, constitutional symptoms,

including anorexia, fatigue, weight
loss, chills, fever, night sweats, and
local symptoms such as cough, may
develop.

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 Clinical Manifestations

Hemoptysis and chest pain from pleural

involvement indicate advanced disease.
The pulmonary examination is often
minimally abnormal.

HIV-infected or other immunocompromised

patients often have no classic signs or
symptoms of tuberculosis and have a
greater likelihood of dissemination or
extrapulmonary infection.
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 Diagnostic Testing
Tuberculin Skin Testing
Interferon-γ Release Assays
Culture and Other Diagnosti
Methods
Radiographic Imaging

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 Tuberculin Skin Testing
The most common tuberculosis testing procedure is
the TST.

The procedure involves injecting purified protein

derivative (PPD) intradermally and assessing the
skin response to the antigen load.

The induration—not the erythema—resulting within

48 to 72 hours is then measured.

Various cutoff values are used, based on the

patient’s risk status, to increase the specificity of the
test results
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Interpretation of Tuberculin Skin Test Results
Criteria for Tuberculin Positivity by Risk Group

≥5 mm Induration
HIV-positive persons
Recent contacts of active TB case
Persons with fibrotic changes on chest
radiograph consistent with old TB

Patients with organ transplants and other

immunosuppressive conditions (receiving the
equivalent of ≥15 mg/d of prednisone for >4
weeks)
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Interpretation of Tuberculin Skin Test Results
Criteria for Tuberculin Positivity by Risk Group

≥10 mm Induration
Recent (<5 years) arrivals from high-prevalence countries
Injection drug users
Residents or employees of high-risk congregate settings:
prisons and jails, nursing homes and other long-term
facilities for the elderly, hospitals and other health care
facilities, residential facilities for patients with AIDS,
homeless shelters
Mycobacteriology lab personnel; persons with clinical
conditions that put them at high risk for active disease;
children age <4 years or exposed to adults in high-risk
categories
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Interpretation of Tuberculin Skin Test Results
Criteria for Tuberculin Positivity by Risk Group

≥15 mm Induration
All others with no risk factors for TB

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A booster effect whereby a negative TST result is
followed by a positive reaction a few weeks later
may occur and is caused by reactivation of immunity
that may be remote.

This phenomenon occurs more commonly in older

patients with a remote history of latent tuberculosis,
in those with nontuberculous mycobacterial
infection, and in those who have received bacillus
Calmette-Guérin (BCG) vaccination;

therefore, these populations are at lower risk for

tuberculosis reactivation than persons with initially
positive TST results, especially when the positive
TST result represents a recent conversion.
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However, caution should be exercised when
immunosuppressive therapy is planned.

False-positive and false-negative TST

results may occur, and approximately 20%
of patients with active tuberculosis may not
exhibit TST positivity.

A history of BCG vaccination should not

influence interpretation of the TST.

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 Interferon-γ Release Assays
The measurement of interferon-γ release by T
lymphocytes specific for M. tuberculosis is a new
test gaining popularity

Despite the Centers for Disease Control and

Prevention’s endorsing its use in all situations in
which the TST is done, the test’s lack of availability
and requirement of testing the patient’s blood within
12 hours of sample collection so that leukocytes are
still viable have limited its use.

Additionally, there are limited data on its use in

children, persons recently exposed to tuberculosis,
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immunocompromised hosts.
 Pathogenesis
• Inhaled aerosols
Engulfed by alveolar macrophages
Bacilli replicate
Macrophages die
• Infected macrophages migrate local lymph nodes
• Develop Ghon’s focus Primary complex
• Cell mediated immune response

stops cycle of destruction and spread

• Viable but non replicating bacilli present in macrophages

EVIDENCE OF INFECTION WITH M TUBERCULOSIS

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 Diagram
of a
Granuloma
NOTE: ultimately a
fibrin layer develops
around granuloma
(fibrosis), further
“walling off” the
lesion.
Typical progression
in pulmonary TB
involves caseation,
calcification and
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cavity formation.
 B or T lymphocyte

Macrophage

Apoptotic/necrotic infected
macrophage

Epitheloid macrophage

Apoptotic/necrotic infected epitheloid

macrophage

NK cell

Dendritic cell

Neutrophil

Giant cell

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 CLINICAL PRESENTATION

Pulmonary
Pulmonary tuberculosis
tuberculosis
Primary complex
Asymptomatic
HEALS

Acute pulmonary disease REACTIVATION

Systemic spread Post-primary
Aymptomatic /symptomatic tuberculosis

LATER DISEASE MILIARY TUBERCULOSIS

Renal / CNS etc Pulmonary
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meningitis
 DIAGNOSIS
Pulmonary
Pulmonary tuberculosis
tuberculosis

1 1 Primary complex
Asymptomatic
HEALS
2
3
Acute pulmonary disease REACTIVATION
Systemic spread Post-primary
Aymptomatic /symptomatic tuberculosis

LATER DISEASE MILIARY TUBERCULOSIS

3 Renal / CNS etc Pulmonary 3
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meningitis
 TREATMENT
• Anti-tuberculous drugs
– INAH
– Rifampicin
– Ethambutol
– Pyrazinamide
• DOT
• Multi-drug resistant tuberculosis

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 Treatment of TB: Drugs

• “Second line” TB drugs

• “First-line” TB drugs
• Quinolones (Levofloxacin, Moxifloxacin)
– Isoniazid (INH )
• Injectables (Capreomycin, Kanamycin,
– Rifampin (RIF)
Amikacin)
– Pyrazidamide (PZA)
• Cycloserine
– Ethambutol (ETH)
• Ethionamide
– Streptomycin
• P-aminosalicylic acid

• Others
 Treatment of TB: Principles
• Multi-drug therapy must be used to avoid resistance development
• Treatment may be begun if clinical suspicion is high

• Directly observed therapy is recommended (DOTS)

• Duration of treatment is 6 -12 months
• Intensive phase: 2 months

4 drug regimen: INH + RIF + PZA + ETH

• Continuation phase: 4 months (up to 10 months)

2 drug regimen : INH + RIF

 Side Effects and Monitoring
• Isoniazid: hepatitis, peripheral neuropathy
• Rifampin: hepatitis, orange body fluids
• PZA: GI, hepatitis
• ETH: optic neuritis, visual changes
• Streptomycin: renal, auditory and vestibular toxicity (aminoglycoside)
 PREVENTION
• Incidence declined before availability of anti-tuberculous
drugs
• Improved social conditions - housing /nutrition
• Case detection & treatment
• Contact tracing
• Evidence of infection / disease
• Treatment of infected / diseased contacts

ROLE
ROLE OF
OF IMMUNIZATION
IMMUNIZATION
BCG
BCG (bacillus
(bacillus Calmette
Calmette Guerin)
Guerin)
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 Mycobacterium leprae
• Acid fast bacilli
• Strict human pathogens
• Cannot be cultivated in-vitro
• Armadillo’s used for obtaining M leprae
• Transmission - ? Air borne
• Low infectivity - prolonged contact required
• Spectrum of clinical presentations
– dependent on host –parasite interactions
Borderline Borderline
Tuberculoid Lepromatous
Tuberculoid lepromatous
• Don’t grow in artificial medium or tissue culture
beyond.
• Doubling time 14 days in some animals (mice,
armadillos).
• Although lack of in vitro growth severely limits study
of the organism, the structure and cell wall
components appear to be similar to those of other
mycobacteria.
• One mycoside, (phenolic glycolipid I [PGL-1]), is
synthesized in large amounts and found only in M
leprae.

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 Pathogenesis
• In humans, the preferred cells are macrophages and
Schwann cells.

• PGL-1 and LAM have been implicated in the ability to

survive and multiply in these cells.

• The organism may invade peripheral sensory nerves,

resulting in patchy anesthesia.

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• The disease occurs in two major forms with a spectrum
of illness in between.
• In the tuberculoid form, few M leprae are seen in
lesions, which are granulomatous with extensive
epithelioid cells, giant cells, and lymphocytic infiltration.
• In lepromatous leprosy, the cellular response is
minimal, and growth of M leprae is thus relatively
unimpeded.
• Histologically, lesions show dense infiltration with
leprosy bacilli, and organisms may reach the
bloodstream.

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• Immunity to M leprae is T-cell–mediated.

• Tuberculoid cases have minimal disease and evidence of

TH1 immune responses including production of typical
cytokines IL-2, IFN-.

• Lepromatous cases have progressive disease and lack

TH1 mediators.

• Lepromin is no longer available, but tuberculoid cases

gave a vigorous DTH response whereas lepromatous
patients did not respond.

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 Tuberculoid Leprosy
• Tuberculoid leprosy involves the development of macules
or large, flattened plaques on the face, trunk, and limbs,
with raised, erythematous edges and dry, pale, hairless
centers.
• When the bacterium has invaded peripheral nerves, the
lesions are anesthetic.
• The disease is indolent, with simultaneous evidence of
slow progression and healing.
• Because of the small number of organisms present, this
form of the disease is usually noncontagious.

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 Lepromatous Leprosy
• In lepromatous leprosy, skin lesions are infiltrative,
extensive, symmetric, and diffuse, particularly on the
face, with thickening of the looser skin of the lips,
forehead, and ears.
• Damage may be severe, with loss of nasal bones and
septum, sometimes of digits, and testicular atrophy in
men.
• Peripheral neuropathies may produce deformities or
nonhealing painless ulcers.
• The organism spreads systemically, with involvement
of the reticuloendothelial system.
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 Treatment and Prevention
• Treatment has been revolutionized by the
development of sulfones, such as dapsone,
which blocks para-aminobenzoic acid
metabolism in M leprae.
• Combined with rifampin, dapsone usually
controls or cures tuberculoid leprosy when
given for 6 months.

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• In lepromatous leprosy and multibacillary intermediate
forms of the disease, a third agent (clofazimine) is
added to help prevent the selection of resistant
mutants, and treatment is continued at least 2 years.
• Prevention of leprosy involves recognition and
treatment of infectious patients and early diagnosis of
the disease in close contacts.
• Chemoprophylaxis with sulfones has been used for
children in close contact with lepromatous cases.

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Non tuberculous mycobacteria
M
M KANSASII
KANSASII

 Infection of respiratory compromised hosts

Present like pulmonary tuberculosis
Treatment – resistant to anti TB drugs

MM SCROFULACEUM
SCROFULACEUM

 Infection of cervical lymph nodes

Presents as cervical lymphadenopathy
Treatment – surgery
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Non tuberculous mycobacteria
M
M avium
avium intracellulare
intracellulare Immunocompetent
Immuno competenthost
host

Infection of cervical lymph nodes

Presents as cervical lymphadenopathy
Treatment – surgery

M
M avium
avium intracellulare
intracellulare Immunodeficient
Immuno deficienthost
host

 severe RTI
AIDS severe GI infection
septicaemia
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Non tuberculous mycobacteria
M
M ulcerans
ulcerans

 ‘Burundi’ ulcer
 Prolonged incubation required for growth

M fortuitum
M fortuitum // M
M chelonei
chelonei

 Injection related abscesses

Associated with sternal wound infections
following cardo-thoracic surgery
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