MycobacteriaNocardia

Actinomyces

Prof. Károly NAGY

Institute of Medical Microbiology Semmelweis University

NAGY KÁROLY

� aerobic, rod shape(0.4x3 µm), no spores or cilias

� Can not be stained by Gram , once stained, reisist decoloration by acid or alcohol

Acid-fast bacteria

�

� high level resistance towards chemicals

MYCOBACTERIA (> 50 species, saprophitic)

Pathogenicity Species Reservoire Disease

Pathogenic M.tuberculosis human tbc

M.leprae human lepra

M.bovis bovine, human intestinal-,miliary tb c

Potentially M.avium- soil, birds, water disseminated and lung tbc

Pathogenic intracellulare bovine (frequent in AIDS )

M.kansasii water, bovine lung tbc

M.marinum fish, water sc.nodules, skin ulcers

M.scrofulaceum soil, water granuloma, cervical ly.ad

M.ulcerans human, environment sc.nodules, skin ulcers

M.fortuitum-chelonei soil, water, animals sc.abscess,disseminated

Stained by Ziehl-Neelsen acid-fast dye

lipid bilayerplasma memrane

peptidoglycan

Lipid+LPS

Mycolic acid(mycolyltrehalose:„cord-factor”)

porins

D-arabinoseD-galactose

acyl lipids

Gram negatíve Gram positive Complex (acid-fast )

Ziehl-Neelsen stain

„Cord-formation”

M. tbc

Mycobacterium tuberculosis

Culture: aerobic, slow growth : cell division 18 h

� Solid mediumLöwenstein-Jensen (egg,potato extract

Malachit-green, antibiotics)3-8 weeks

� Broth media

Sula (semisynthetic, Malachit-green)

Growth: clamps, bigger volumes

Mycobacterium tuberculosisPathogenesis

alveolsgranulomalympnodescaverna

Source of infection:Sick humananimal

InfectionAerosol dropletsdustper os (milk)contacts

Tbc develops in < 5% of those infected

Lung granuloma

Mycobacterium tuberculosisPathogenesis

2-4 weeks post infection:�CD4 T-cell cytokins activate macrophages

����Granuloma and caverna formation:cytokine toxycity, complement activation,ischemia, macrophag enzym activity,etc.

High number of bacteria in sputum:primer and secunder infection,high resistance towards drying and chemicals !

Surviving in phagolysosomes

alveolar macrophag

Mycobacterium tuberculosis: Pathogenesis

Focal,cheesy necrosis:Caverna formation

Mycobacterium tuberculosis (tbc): Clinical picture

Pulmonal: lung (middle/lower lobes), lymphnodes, pleura

tünetek: weakness, fatigue,weight loss, caughing, spitting: yellow/green mucus, blood in the sputum, short breath, night sweating, pain in chest, back

• clinical diagnosis• x - ray• microscopy• culture

In those infected disease develops <2years: 5%, > 2 years : additional 5-10%

Extrapulmonal : haematogen or urogen dissemination, contact infectio

• gastrointestional (infected milk)• genito-urinary system (kidney tbc)• bone (deformity)• skin tbc (erythema multiforme, aquarium disease)• scrofula (neck swelling, ulcer)

Mycobacterium tuberculosis (tbc): Clinical picture

IMMUNITY

PRIMER

SECUNDER

Source ofinfection

Gate ofentrance

M. tuberculosis: surviving strategies in macrophag es

- high resistency of lipid/wax cell wall- neutralisation of free radicals- ammonia formation, which inhibits

* formation of phagolysosomes* activity of lysosomal enzymes

„dormant” state

I. type II.type III. type IV.typehypersensitivity

anaphylaxias cytotoxikus immunkomplex delayed, tuber-culin type

IgE IgG IgG -- Complement Complement -- - - T lymphocyte

pollen,animal Rh, bact.,virus, intracellularfur, penicillin gyógyszer fungi, etc, microbeanimal sera animal sera

local,gene- self cell Co activation granulomaralised, ADCC formationodema, his- lysis trombocytetamin activationskinprobe - - skinprobe

M. tuberculosis INDUCED IMMUNE DESTRUCTION

Tuberculin test: Mantoux - probe

Suitable to detect tbc infection or validation of the effect of BCG vaccination

Purified,standardised tuberculoprotein : M.tbc PPD (Purified Protein Derivate)

5 TU intracutan inoculation, < 10 mm induration: negatívread after 48 h 10-20 mm induration: BCG-hypersensistivity

> 20 mm induration: infekctious hypersensitivityNot M. tbc specifcConversion (pozitív): M.tbc infection, BCG vaccination

Reversion (negatív): early infection, miliary tbc, meningitis, AIDS, immunosuppression,

morbilli,varicella, wooping cough , influenza, helmintiosis, old age

THE HISTORY OF TUBERCULOSIS

•Kr.e. 1000 egyptian mummies – bone destrucion, abscess•Hyppokrates: aerosol, droplets infection•Middle ages: „phtysis”, the disease of the lung•Franz de la Boë (1614 – 1672) : „tuberculum”•London, XIX.c.:every 3. death due to tbc•Johan Lukas Schönlein (1793 – 1864): the clinical

definition of tuberculosis (1832)•1882: Robert Koch: a ‘Koch-bacillus” the etiological factor

1890 – tuberculin, 1930- diagnostical meaning•1906: Albert Calmette és Camille Guerin : a „BCG”,

the possibility of active immunization (1921)•1930: a Lübeck catastrophy: the significance of virulent/

avirulens strains, not interchangeable•1930: introduction of tbc screening programs,epidemy decr ease•1945: WW II: epidemy increase•1950-1980: significant decreasing•1992: WHO Tbc: global problem•2000: WHO AIDS – Malaria – TBC GLOBAL EMERGENCY

Famous people who have had tuberculosis :Calvin

Anton ChehovBranwell Bronté

Emily BrontéFrédéric Chopin

DescartesJohn Keats

D.H. LawrenceVivien Leigh

Nelson MandelaMoliere

George OrwellPaganini

Edgar Allan PoeRichelieu cardinal

SchillerJean J. RousseauSir Walter Scott

P.B.ShellySpinoza

R.L. StevensonDesmond Tutu

Simonetta VespucciMargaret Gardner (a former Ms. World)

EPIDEMIOLOGY : TB Incidence 2001

25 - 49

50 - 99

100 - 299

< 10

10 - 24

per 100 000 pop

> 300

Tbc prevalencia - Hungary

Tbc split by gender and age

MALES FEMALS

RISK FACTORS

HOMLESS

DIRCT CONTACT

IMMIGRANT

LONELY

„Frigyes Korányi” National TBC and Pulmonological Institute

INCIDENCE OF TUBERCULOSIS• TB is responsible for 25% of adult deaths in the developing world- more than those caused

by diarrhea, malaria and AIDS combined • South Africa has one of the highest incidences: >200/100 000 • 35 people die of TB every day in South Africa • The incidence in the 'first world' is less than 10/100 000

THE GLOBAL EMERGENCY1. 8-12 million new infections with M. tuberculosis per year 2. 2-3 million people die from TB per year 3. If present trends continue, deaths will exceed 4 million by 2004 4. There is also the emergence of multi-drug resistant M. tuberculosis5. These trends, and the association of TB with HIV infection, has led to TB being declared

A GLOBAL EMERGENCYby the World Health Organization(1993)

Laboratory diagnosis

The basics of the effective treatment of tbc: early, rapid and accurate diagnosis

Microscopy od stained smear Isolation, culture

sensitivity104 bacterium/ml 102 bacterium/ml

low sensitivity long culture time: 4-8 hétCytocentrifuge (Sauton – and Dubos media )

Laboratory diagnosis

BacTec automats : radioactive palmitinic acid/CO2fluorescent detectionturbidityother color reaction

Rapid growth detection4-14 nap

Biosensors:

Molecular detection : PCR, LCRRFPL, DNA typing, DNS-chipDrug sensitivity/ resistancedetermination( hours, 1-2 days)

< 1 h

Atypical and apathogenic mycobacteria

M. avium-intracellulare, M. kansasi , M. scrofulaceu mM. smegmatis, M. phlei, stb

induce mycobacteriosises

characteristics : occurrence in the naturefaster growthpigment formationniacin negativitydifferent drug resistancymember of the normal flora

disease: local (skin, lung, lymphnodes, etc.) processesno transmission from human to human,nozokomial infectionsgeneralized in AIDS

THERAPY

• Stop infectivity• Inhibit drug resistance• Prevent remission of infection• Goal : complete recovery

Combination treatment, long time (6 -12 month) treatmentInitial, intense phase:

3 -4 anti tuberculotics against extracellular bacteriaStabilisation phase:

fewer drugs against intracellular, slow growing bacteria

INH (isonikotinic acid hidrazid ) - Rifampicin - PirazinamidEthambutol (AIDS, extrapulmonal tbc, meningitis)Ciprofloxacin,ethionamid,cycloserin (Multiresistant M.tbc)Clarithromycin,rifampicin,etambutol,clofazimin (M. avium-intracellulare)Doxicyclin ( M. fortuitum-chelonei)

Multiresistant strains !TBC – AIDS coinfections

PREVENTION

2. Vaccina : BCG inoculationM.bovis live, attenuated strain BCG (Bacillus Calmette-Guerin)2 - 42 day after birth, partial resistency

3. Chemoprofilaxis:

INH monotherapy , Rifampicin (min. 6 month)

1. Prevention of infection:General hygienic rulesEffective treatment of those infectedEradication of infected cattles

Induces lepra (Hansen disease) , does not grow in media or cell culture, Only in mouse sole and in armadillo. Aerob, pálcika alakú, saválló baktérium : Ziehl – Neelsen festésLaboratory diagnosis : from skin disorders, nose mucosaSyphilis serological reactions are fals posistive in lepra

The bacteria grow intracellularly in skin histiocytes, endothel cells and superficialnerves (Schwann-cells) . Optimal temperature: 30 C°

Tuberculoid lepra: normal cellular immunity,

few bacteria growing,

giant cells in granulomas

Lepromin skin tests: positive

Lepromatic lepra: immune response towards M.leprae is weak

skin, mucosa : large number of bacteria (histiocyt es)

Lepromin skin test: negative

Immune response to only M.leprae is defective,

cellular and humoral immune response towards other

microorganisms are intact

Antibodies are not protective

Macular skin disorders:Insensibility ulcer

Long incubation time: 10-15 year ! Gradual disease formation

Nodular skin disorders: „ lion face” (facies leontina)

Fingers, extremitiesexposed to amputation

because trophicalDisorders,

resorption of bonesresulting in

loss of nose cartilagsor digits

Boswelia carteri (Tömjénfa)„Salai guggul”

Dapson (sulfonamid residue)Rifampin (inhibitor of bacterial RNS synthesisClofazimin

Nocardia genusNocardia genusObligate aerob, Gram positive, moderate acid fast , filamental bacteria

Occurrence : widespread, soil, water

Domestic animals, dogs, cows (natural hosts)

In Humans: N.asteroides N. braziliensis

Nocardiosis: chronic, lobular pneumonia, miliary tbc-like

fever, weigh loss, chest pain. Lung abscess, haematogen

dissemination:central nerve system abscesses

Mycetoma: abscess in hand, leg, s.cutan connecting tissues

Laboratory diagnosis : sputum, pus, liquor smearsGram- and acid fast staining

Treatment: Surgical removaltrimetoprimsulfonamids

ActinomycesActinomycesAnaerobic, no spores, Gram positive, irregular shape rods

Actinomyces israelii: non obligate anaerobic, slow growth (7-10 days)

ActinomycosisActinomycosis

Gram positive

Gram negative

Actinomyces mycelium

Pathogenesis : 2 -3 mm, yellow granules (mycelia) consisting of the bacterial bodies

ActinomycosisActinomycosisPathogenesis : typical endogenous infection. Caries teeth, pharyngeal lavage, intestines, Vaginal floraPathogenic process is initiated by: trauma, pyogenic infections, i.u. contraceptive devices

ABSCESS FISTULA DRAINING OF PUS

Lung actinomycosis

Pelvic inflammation

SKINactinomycosis

Therapy:• Surgical removal• Penicillin• sulfonamids