General Bacteriology 23.04.2020
General Bacteriology 23.04.2020
General Bacteriology 23.04.2020
STAINING
Two basic methods provide foundations for differential staining and detection of bacteria: the Gram stain
and acid-fast stains.
Bacteria are generally studied when fixed and stained. Smears or films of bacterial cultures and clinical
specimens are usually fixed by heat, the slide being first throughly dried in air and then heated gently in a
flame. Vegetative bacteria are thereby killed, attached to the surface of the slide and preserve from
undergoing autolytic changes.
During staining, the coloured, positively charged cation of basic dyes such as methylene blue combines with
negatively changed groups in the cell protoplasm, specially with the phosphate groups in the abundant
nucleic acids. Acid dyes, having coloured anions, do not stain bacteria strongly except at very acid pH
values, and thus can be used for ―negative staining‖.
Negative or background staining is of value as a rapid method for the simple morphological study of bateria
and yeasts.
In the case of bacteria, Gram’s stain has the widest application, distinguisinhg them as ―Gram-positive‖ or
―Gram-negative‖, according to wether or not they resist decoloration with acetone, alcohol or aniline oil after
staining with a triphenyl methane dye, such as methyl violet, and subsequent treatment with iodine. The
Gram-positive bacteria resist decoloration and remain stained a dark purple colour. The Gram-negative
bacteria are decolorized, and are then ounterstained light pink by the subsequent application of safranin,
neutral red or dilute carbol fuschin.
Gram reactivity appears to reflect a fundamental aspect of cell structure and is correlated with many other
biological properties.
Gram-positive bacteria are more susceptible than Gram-negative bacteria to the antibacterial actions of
penicillin, acids, iodine, basic dyes, detergents and lysozyme, and less susceptible to alkalis, azide, tellurite,
proteolytic enzymes, lysis by antibody and complement, and plasmolysis in solutes of high osmotic pressure.
The probable mechanism of the Gram stain is attributed to differences in the permeability of the two
essential cell wall types. After staining with methyl violet and treatment with iodine, a dye-iodine complex is
formed within the cell; this is insoluble in water but moderately soluble and dissociable in the acetone or
alcohol use as the decolorizer. Under the action of the decolorizer, the dye and iodine diffuse freely out of
the Gram-negative cell, but not from the Gram-positive cell, presumably because the cell wall of the latter is
less permeable. Gram-positive bacteria become Gram-negative when their cell wall is ruptured or removed.
G+ G-
2. Gram stain 20 s
3. Lugol solution 20 s
4. Alcohol máx. 20 s
6. Safranin 1 min
8 Drying
2. Anatomy of the bacterial cell I – contents of cytoplasm, cytoplasmatic membrane
The cytoplasm, or main part of the protoplasm, is a predominantly aqueous environment packed with
ribosomes and numerous other protein and nucleotide - protein complexes.
Bacterial nucleoid
The genetic information of bacterial cell is mostly contain in a single, long molecule of double-stranded
deoxyribonucleic acid (DNA). The cell solves the problem of packaging this enormous macromolecule by
condensing and looping it into a supercoloid state.
The bacterial nucleoid lies within the cytoplasm. This means that as DNA-dependent RNA polymerase
makes RNA, ribosomes may attach and initiate protein synthesis on the still attached (nascent) messenger
RNA. Synthesis of mRNA and protein are therefore seen to be directly coupled in bacteria.
Cytoplasmic membrane
The bacterial protoplasm is limited externally by a thin, elastic cytoplasmic membrane which is 5-10nm
thick and consists mainly of phospholipids and proteins.
Integral, transmembrane and peripheral or anchored proteins occur in abundance and perform similar
functions to those described in eukaryotes (e.g. transport and signal transduction).
Prokaryotic cell membranes are relatively protein-rich, allowing relatively little space for phospholipids.
3. Anatomy of the bacterial cell II – cell wall, capsule, flagella, fimbriae, pili
Cell wall
The cell wall encases the protoplast and lies immediately external to the cytoplasmic membrane. It is 10-
25nm thick, strong and relatively rigid, tough with some elasticity, and openly porous, being freely
permeable to small molecules. It supports the weak cytoplasmic membrane against the high internal osmotic
pressure of the protoplasm and maintains the characteristic shape of the bacterium in its coccal, bacillar,
filamentous or spiral form.
Capsule
Many bacteria have been demonstrated to possess a more or less continuous but relatively amorphous layer
external to the Gram-negative and Gram-positive envelopes.
This layer is called a capsule. The capsular gel consists largely of water and has only a small content of
solids. In most species, the solid material is a complex polysaccharide, though in some species its main
constituent is polypeptide.
The capsule have some role in interactions with the external environment. In some cases capsules have been
shown to protect against phagocytosis, the lytic action of complement and bacteriophage invasion.
Capsules also appear to have a role in protecting cells against desiccation. The production of extracellular
polysaccharides in general provides a matrix within which biofilm formation can take place.
Flagella
Motile bacteria possess filamentous appendages known as flagella, which act as organs of locomotion. The
flagellum is a long, thin filament, twisted spirally in an open regular wave form. It originates in the bacterial
protoplasm and the structure projects throught the cell envelope. According to the species, there may be one,
or up to 20 flagella per cell.
The external portion of a flagellum is essentially a polymer of a single protein, flagellin, while the basal
region inserted into the cytoplasmic membrane comprises multiple subunits which anchor and power the
organ.
Motility is clearly important to many bacteria and probably serves mainly to place the cell in environments
favourable to growth and free from noxious influences.
In some cases possession of flagella is thought to contribute to the pathogenesis of disease.
Fimbriae and pili
Many bacteria possess filamentous appendages termed fimbriae or pili. These terms are often uses
interchangeably, although the latter was originally reserved for structures involved in genetic exchange
between bacteria (sex pili). Fimbriae are far more numerous than flagella and more much shorter and only
about half as thick.
In contrast, sex pili are structurally similar to other fimbriae but are longer and confer the ability to attach
specifically to other bacteria that lack these appendages. Sex pili initiate the process of conjugation; they also
act as receptor sites for certain bacteriophages.
- Lag - microbes are growing but not dividing. During this phase, bacterial growth cycle, synthesis of
RNA, enzymes and other molecules occurs.
- Log (exponential) - cells are dividing at a constant speed. The relation between the number of living
cells and time is exponential. There are more than enough nutrients to allow the cells to grow.
- Stationary - the number of cells is stable - the number of cells being produced - number of cells
dying. Here the growth rate slows down duw to the lack of nutrients and the accumulation of
metabolites.
- Death - number of cells dying > number of cells being produced. Here the bacteria have run out of
nutrients and die.
Growth conditions:
1) Temperature: most bacteria grow optimally at human body temperatures (37ºC). e.g. E.coli, which is
part of the normal human intestinal microflora. Some can survive at higher/lower temperatures than the
human body temperature.
2) pH: optimal conditions are between 6,7-7,5. However some other bacteria, like vibrio cholera can
survive in pH conditions as high as 9,0 and gastric helicobacter can survive in acidic pH.
3) NaCl concentration: should be about 0.9% (physiologic saline). Staphylococci can multiply on sweaty
skin, where the concentrations are about 10% (used on BA -> selective media).
4) Nutrients: need to be in the correct balance of carbon, nitrogen, hydrogen, sulphur, iron, etc, for
synthesis of specific bacterial compounds. Some bacteria also require ―growth factors‖ i.e. organic
compounds they are unable to synthesise themselves.
5) Osmotic pressure: bacteria are about 80-90% water; they require moisture to grow because they obtain
most of their nutrients from their aqueous environment.
6) Anaerobes/aerobes: oxygen may or may not be needed, depending on the species of bacteria and the
type of metabolism used to extract energy from food. In all cases, the initial breakdown of glucose to
pyruvic acid occurs during glycolysis, which produces a net gain of two molecules of ATP
6. Microbial metabolism
This is the way in which a microbe obtains energy and nutrients it requires; to survive and reproduce. The
processes can be anabolic (synthesis of compounds and the consumption of energy) or catabolic (break down
of substrates to gain energy). Although some bacteria are able to obtain their resources for growth in many
ways. The basic details of glycolysis, the tricarboxylic acid cycle, oxidative phophorylation, ATP
biosynthesis and amino acid metabolism are constant.
Human pathogenic bacteria are always chemosynthetic, organotrophic bacteria (or chemoorganotrophs).
Catabolic reactions:
- Digestion - bacterial exoenzymes split the nutrient substrates into smaller molecules outside the cell.
- Uptake - nutrients are taken up by passive diffusion, or more usually active transport through the
membrane.
- Preparation for oxidation - phosphorylation, etc
- Oxidation - removal of electrons and H+ ions. The H2 atoms are then transferred to the hydrogen
acceptor.
There are 3 types of catabolism:
1) Fermentation - breakdown of nutrients without the need for oxygen. Only small amounts of energy are
produced. Products are lactate, ethanol, etc.
2) Aerobic respiration - uses oxygen and a small amount of nutrient provides a large amount of energy.
Products are CO2 and H2O.
3) Anaerobic respiration - another electron acceptor
The type of catabolism is related to oxygen consumption:
- Facultative anaerobes: they oxidise nutrients by respiration and fermentation. They can grow in all
conditions.
- Obligate (strict) aerobes: they can only reproduce in the presence of oxygen.
- Obligate (strict) anaerobes: they die in the presence of oxygen. Their vital enzymes are inhibited by
oxygen.
- Micro-aerophilic bacteria - grow in conditions with traces of oxygen
- Aerotolerant anaerobes - they don’t utilise oxygen for growth but can survive in its presence.
- Capnophilic bacteria - they need higher amounts of CO2.
8. Sterilization
Sterilization means the foreign of an article from all living organisms, including viruses, bacteria and their
spores, and fungi and their spores. In practise, all processes of sterilization have a finite probability of
failure. An article may be regarded as sterile if it can be demonstrated that there is a probability of less than 1
in a miliion of there being viable microorganism on it.
Uses:
Sterilization is required for instruments and materials used in procedures that involve penetration into
normally sterile parts of the body, e.g. in surgical operations, intravenous infusions, hypodermic injections
and diagnostic aspirations. It is also required for media, reagents and equipment used in laboratory practice.
METHODS:
- Heat - the only method of sterilization that is both reliable and widely applicable is by heating under
carefully controlled conditions at temperatures above 100ºC to ensure that bacterial spores are killed.
- Ionizing irradiation - both β (electrons) irradiation and γ (photons) irradiation are employed
industrially for the sterilization of single-use disposable items such as needles and syringes, latex
catheters and surgical gloves, and in the food industry to reduce spoilage and remove pathogens.
- Filtration - filters are used to remove bacteria and all larger microorganisms from liquids that are
liable to be spoiled by heating, e.g. blood serum.
- Sterilant gases - ethylene oxide is used mainly by industry for the sterilization of plastics and other
thermolabile materials that cannot withstand heating. Formaldehyde in combination with
subatmospheric steam is more commonly used in hospitals for reprocessing thermolabile equipment.
- Sterilant liquids - use of liquids such as glutaraldehyde is generally the least effective and the most
unreliable method, only to be applied when no other sterilization method is available.
The method to use for sterilization depends on the resistance of the materials to various temperatures,
humidity, chemicals, etc. Also, the temperature and time has to be sufficient enough to kill the microbes.
To check how effect the sterilization was, indicators that change colour can be used at certain temperatures.
This is the chemical method. There is a biological one as well, which consists of using resistant strains of
Bacillus genus. Since they are resistant, their survival is assessed at the end of the sterilization cycle.
9. Disinfection
Desinfection, the freeing of an article from some or all of its burden of contaminating microorganisms, is a
relative term embracing a wide range of efficacy against particular viruses, vegetative bacteria and fungi, but
not usually including bacterial spores.
Uses:
Desinfection is applied in circunstances in which sterility is unnecessary or sterilizing procedures are
impracticable.
METHODS:
Desinfection is achieved by means of processes similar to, although less severe than, those used for
sterilization.
- Heat - various methods are available using steam or water; some incorporate a cleaning stage within
an automatic controlled process.
- Ultraviolet radiation - this has limited application for the desinfection of surfaces and some piped-
water supplies, but lacks penetrative power for more widespread application.
- Gases - formaldehyde is used as a fumigant in laboratory environments.
- Filtration - are supplied to operating theatres and other critical environments is filtered to removed
potentially hazardous microorganisms.
- Chemicals - various chemicals with antimicrobial properties are used as desinfectants. They are all
liable to be inactivated by excessive dilution and contact with organic materials. Nevertheless, they
may provide a convenient method for environmental desinfections and other specific applications.
- The effectivity of various desinfectants to various organisms, can be found in booklets where they
are divided into different groups, which are alphabetically arranged, e.g. A = effective to yeast and
bacteria, B = effective against viruses, C = bacterial endospores, T = TB mycobacterium, M =
atypical mycobacterium and V = filamentous fungi
Since most bacteria possess a rigid cell wall that is lacking in mammalian cells, this structure is a prime
target for agents that exhibit selective toxicity, the ability to inhibit or destroy the microbe without harming
the host. However, the bacterial cell wall can also prevent access of agents that would otherwise be effective.
Inhibitors of bacterial cell wall synthesis act on the formation of the peptidoglycan layer.
β-lactam agents
Penicillins, cephalosporins and other compounds that feature a β-lactam ring in their structure fall into this
group. All these compunds bind to proteins situated at the cell wall - cell membrane interface. These
penicillin-binding proteins are involved in cell wall construction.
Opening of the β-lactam ring by hydrolytic enzymes, collectively called β-lactamases, abolishes antibacterial
activity.
Penicillins: Benzylpenicillins (penicillin G) exhibits unrivalled activity against staphylococci, streptococci,
neisseriae, spirochetes and certain other organisms.
Benzylpenicillin revolutionized the treatment of infection caused by some of the most virulent bacterial
pathogens, but it also suffer from several shortcomings.
- breakdown by gastric acidity when given orally
- very rapid excretion by the kidney
- susceptibility to penicillinase (β-lactamase)
- a restricted spectrum of activity
Methicillin- resistant Staphylococcus aureus (MRSA) and other staphylococci that owe their resistance to
alterations in the target penicillin-binding proteins are resistant to all penicillins and to all other β-lactam
antibiotics.
Cephalosporins
Cephalosporins are generally stable to staphylococcal penicillase but they lack activity against enterococci.
They exhibit a broader spectrum than most penicillins and are less prone to cause hypersensitivity reactions.
Other β-lactam agents
Monobactams - are monocyclic compounds with a spectrum that is restricted to aerobic Gram-negative
bacteria.
Carbapenems - have an unusually broad spectrum of activity, embracing most Gram-positive and Gram-
negative aerobic and anaerobic bacteria.
Oxo-cephems - are broad-spectrum β-lactamase - stable compounds
The clavam, clavulanic acid, exhibits poor antibacterial activity, but has proved useful as a β-lactamase
inhibitor when used in combination with β-lactamase - susceptible compounds.
The sulphones also act as β-lactamase inhibitors and are marketed combined with ampicillin.
Glycopeptides
Vancomycin and teicoplanin are large molecules that are unable to penetrate the outer membrane of Gram-
negative bacteria, and the spectrum is consequently restricted to Gram-positive organisms. Their chief
importance resides in their action against Gram-positive cocci with multiple resistance the other drugs.
Triangle relationship
Antimicrobial agents
Pathogenicity: requires the attributes of transmissibility or communicability from one host or reservoir to a
fresh host, survival in the new host, infectivity or the ability to breach the new host’s defences, and
virulence, a variable that is multifactorial and denotes the capacity of a pathogen to harm the host. Virulence
is a sense of a parasite-host relationship in which the capacity of the organism to cause disease is considered
in relation to the resitanc e of the host.
Virulence determination: both opportunistic and primary pathogens possess virulence determinants or
aggressins that facilitate pathogenesis. Possession of a single virulence determinant is rarely sufficient to
allow the initiation and production of pathology. Many bacteria possess several virulence determinants, all of
which play some part of various stages of the disease process.
!!! Different strains or species of bacteria may produce different types of fimbriae which can be indentified
on the basis of antigenic composition, morphology and receptor specificity.
Adhesion induces structural and functional changes in mucosal cells -> contributes to disease. Cell invasion
confers tha ability to avoid humural host defence mechanisms and potentially provides a niche rich in
nutrients and devoid of competition from other bacteria.
Other kind of invasion is penetration through or between epithelial cells.
Uptake into host cells:
- bacteria inside membrane-bound vesicle. Haemolysin/listeriolysin destroy the membrane -> bacteria is
free in cell’s cytoplasm and inhibits the host protein synthesis
- bacteria inside membrane-bound vesicle. Several vesicles coalesce to form large intracellular vacuoles.
Avoidance of host defence mechanisms: Lysozyme is active primarily against G+ bacteria but potentiates the
activity of complement against G+ organisms. Transferrin and lactoferrin chelate iron in body fluids, and
reduce the amount of free iron to levels that necessary for bacterial growth.
CAPSULES:
1. the hydrophobic nature of the capsule may hinder uptake by phagocytes;
2. capsules prevent efficient opsonization
3. it makes more immunogenic surface components and reduce interactions with both complement and
antibody
IM protein:
binds fibrinogen and fibrin and covers the staph’s surface.
ANTIGENIC VARIATION: variation in surface antigen composition during the course of infection provides
a mechanism of avoidance of specific immune responses. Another interesting mechanism of antigen
variation is the genetic rearrangements demonstrated in the fimbriae.
IRON ACQUISITION: Some staphylococci produce extracellular called siderophores and receptors for
transferrin and lactoferrin.
Virulence: how many organisms are required to cause disease in 50% of those expose to the pathogen.
Virulence factor: characteristic of bacteria that enhances its pathogenicity.
1. entry in to host: microorganism can enter host by the respiratory tract, GIT, urogenital tract or skin that
has been burned, cut or punctured. Once entered the pathogen has to overcome host defences like
phagocytosis, acidic environment of stomach and urogenital tract, hydrolytics + proteolytics enzymes
formed in saliva, stomach and small intestine. Bacteria with outer polysaccharide capsule - more chance
of surviving
2. Adherence to host cell: can either be due to pilli (groups A strep, Neisseria) adhesion mollecules (
interactions between specific receptors on the mammalian cell membrane -usually carbohydrates, and
ligands - usually proteins, on the bacterial surface) or particularly hydrophobic cell walls, surface charge.
Adherence enhances virulence by preventing bacteria from being carried away by peristalsis, mucus,
saliva, urine... Flagella can act as adhesin.
3. Invasiveness: invasiveness is facilitated by several enzymes including collagenase, hyaluronidase...-
liquifies tissue and facilitates invasion after - inflammation. Toxins, other aggressins and induction of
intracellular signalling pathways mediated tissue damage at local or distant sites.
4. Bacterial toxins: exotoxins: proteins secreted by Gram+ and Gram- bacteria.
endotoxins: lipopolysaccharides and are integral part of Gram- cells.
Endotoxins cause septic shock (fever, shock, hypotension, thrombosis)
Primary pathogens: cause disease even in healthy poeple. Different strains of any bacterial species can vary
in their genetic make up and virulence. Conversely, people vary in their genetic make up and susceptibility
to invading bacteria.
Opportunistic pathogen: cause disease under certain condition (decresed immunity of individuals or when it
reaches other place in body) - normal members of flora. Rarely cause disease in individuals with intact
immunological and anatomical defences. Only when such defences are impaired or compromised are these
bacteria able to cause disease. Also, normal huan flora, when introduced into anatomical sites in which they
are not normally found may allow their localized multiplication and subsequent development of disease.
Adherence factors:
1) Fimbriae (pili) – their end reacts with a receptor on the epithelial surface.
2) Nonfimbrial adhesions – hemagglutinins of yersinae, bordetellae, F protein of streptococcus
pyogenes.
3) They can envelope projections (hemagglutinin) of influenza virus. Glycoprotein gp120 of HIV is
also an adherence factor.
4) Parasites – suck themselves to the mucosae.
5) Micromycetes – glucans and mannans of yeasts and keratophilia of dermatophytes (skin moulds).
Penetration factors:
· Direct penetration:
- Small cracks in skin
- Small cracks in mucosa
- Animal bite
- Arthropod bite
- Enzymes
· Forced penetration:
- Changing cellular framework (invasiveness)
- Ruffling (trouble) of epithelial surface (e.g. Salmonella)
- Unknown mechanisms.
Multiplication:
- Intracellular multiplication – better because of good nutrient supply, and defense against host
immunity. Examples of intracellular parasites are mycobacteria, rickettsiae, chlamydiae, usteriae,
salmonellae.
- Extracellular multiplication – stopped by antibacterial substances (e.g. complement, lysozyme,
antibodies) but mostly because of shortage of free iron (lactoferrin, transferring) and also high
temperature.
Invasion by transmission:
· The way of transmission – exit point of the body, and entry point of the host.
· Microbe tenacity – degree of resistance to the external environment. E.g. Clostridium tetani,
Giardia lamblia, and Helminthes eggs (Taenia saginata) are all spore forming, so, that they can
survive in the external environment.
· Minimum infectious dose – amount of microbes required to start infection. An immune person has
a high infectious dose Coxiella burnetii, which causes Q fever, has an extremely low infectious
dose.
· Behavior of the host - immune defense reflexes (cough, sneezing, diarrhea).
· Way of elimination - every biological substance is infectious.
· Amount of eliminated substance
· Portal of entry - better penetration through mucosa than skin. Some requires direct transmission
(sexual contact, e.g. streptococci, treponemae), biological vector (tick, mosquitos -> arboviruses,
borreliae), and transmission by water (leptospirae, shigellae).
Host defences: Bacteria are surrounded by a cytoplasmic membrane and a peptidoglycan cell wall.
Associated with these basic structures there can be a variety of other components such as proteins, capsules,
lipopolysaccharides or teichoic acids. There are also structures involved in motility or adherence to the cells
of the host. These are some of the components to which the immune system directs its response.
Specific antibodies can bind to flagella or fimbriae, affecting their ability to function properly and can
inactivate various bacterial enzymes and toxins.
Endotoxins: G- lipopolysaccharide, also called LPS is a component of the outer membrane of G- bacteria,
and is released from the bacterial surface via outer membrane vesicles. LPS is anchored into the bacterial
outer membrane through a unique molecule termed lipid A.
Endotoxin is a potent activator of macrophages, resulting in the induction of a range of cytokines which are
involved in the regulation of immune and inflammatory responses.
Exotoxins: are diffusible proteins secreted into the external medium by the pathogen. Most pathogens secrete
various proteins molecules that facilitate adhesion to, or invasion, of, the host. Many others cause damage to
host cells.
Exotoxins vary in their molecular structure, biological function, mechanism of secretion and immunological
properties.
- type I toxins bind surface receptors and stimulate transmembrane signals
- type II toxins act directly on membranes, forming pores or disrupting lipid bilayers
- type III toxins translocate an active enzymatic component into the cell which modifies an intracellular
target molecule.
Aggressins
Any substance produced in the body by a pathogenic bacteria that enhances virulence of bacteria by
paralyzing host defence mechanism (e.g. RRC, ureases, matalloprotease, mucinases, phospholipases,
hyaluronidases).
APC - it includes macrophages, B cells and dendritic cells. These cells are equiped with speciallized cell
membrane proteins called Major Histocompability Complex (MHC).
APCs first phagocytize and partially degrade foreign mollecules then display a frequent peptide antigen that
it is bound by MHC and triggers cytotoxic T cell response (presence of MHC reassures T cells that the
antigen is non self).
MHC in humans = HLA - human leucocyte antigen
MHC:
type I - presents peptide from proteins insidee cell (e.g. viral infection). All nucleated cells present them
type II - peptides from extracellular and intravesicular proteins that enter cell by phagocytosis . Presented by
macrophages, dendritic cells, B cells.
Antigen recognition: an antibody is a glycoprotein produced by plasma cells and circulates in the blood and
other body fluids. Antibody molecules will recognize free native antigen.
This contrasts dramatically with the situation in cell-mediated immunity; the T lymphocyte antigen receptor
will only bind the fragments of antigen that are associated with products of the major histocompability
complex (MHC). T cell recognition of antigen is said ti be MHC-restricted.
T cells express surface receptors that allow them to recognize unique, antigen derived peptide sequences
(generally composed of α/β polypeptide chains joined by dissulfide bond).
21. Immunoglobulins
Soluble, globular proteins that are important components of
acquired immunity. They are able to recognize a lot of
epitopes (1 Ab -> 1 epitope).
If the antigen is soluble then the size of the complex will determine its physical state. Small complexes will
remain soluble while large complexes will form precipitates).
2. Opsonization of bacteria
specific antibodies coat surface of bacteria making it a more recognizable target for ingestion by
macrophages -> a specific conformation on the Fc receptors on the surface of the phagocyte. The important
residues are in the CH2 domain near the hinge region.
3. Activation of complement
Bacterium in plasma is coated with Antibodies -> The Fc portion of certain isotypes once antigen has been
bound, will activate complement -> boun antibodies form a receptor for the 1st protein of the complement
system -> This requires that C1q, a subunit of the 1st complement component croos-links 2 antibody Fb
portions. ->complement can form a lethal pore in cell membrane of some bacteria releasing cell contents ->
complement binding also favours uptake and destruction of bacteria by phagocytes.
Humural Mechanism
One of the mechanisms by which the immune innate system defends body is by inflammatory reaction which
is accompanied by increased concentration of serum proteins called acute phase proteins (e.g. CRP is
produced by liver in response to tissue damage. It binds to cell walls of bacteria and fungi and activates the
complement system.
*Lysozyme - found high concentrations in most tissue fluids, functioning as a mucolytic enzyme, splitting
sugars of cell wall of many G+ bacteria causing their lysis.
1. Vasodilation: increased blood flow to injured area provides, increased delivery of plasma proteins,
neutrophils and phagocytes.
2. Increased permeability: protein rich exudate with Igs + complement moves to injured area
3. Emigration of leucocytes
4. Chemotaxis - for phagocytic cells to be effective they must be attracted to the site of infection. Once they
have passed through the capillary walls they move through the tissues in response to a concentration
gradient of molecules produced at the site of damage:
- products of injured tissue
- factors from the blood (C5a)
- leukotrienes, histamine (neutrophils and mast cells)
- bacterial products
Some of these cells destroy the invading microorganism by phagocytosis followed by intracellular digestion
(-> phagocytes whilst others limit the infection by releasing compunds toxic to microorganisms -> K, natural
killer cells).
Natural killer cells
They destroy abnormal host cells such as virus-infected cells or neoplastic by released of compounds that are
highly cytotoxic causing the formation of pores in the membrane of a target cell resulting in osmotic lysis or
triggering apoptosis.
They can also cause apoptosis by surface contact with the target cell. They are stimulated by IFN and IL-2.
Eosinophils are no effiecient phagocytic cells but their granules contain molecules that are toxic to parasites
(worms and others that cannot by phagocytosed). This release of molecules must be controlled so that tissue
damage is avoid.
MHC II - antigen are bound to T helper cell -> cloning of this helper T cell -> cytokines activate killing of
intracellular or organism ->(Th2 cells; IL-4,5,6) B cell division and differentiation -> differentiation to
plasma cells -> memory B cells
-> production of Abs (primarily IgM are produced
then switching to IgG might occur) -> complement activation
-> opsonization
-> neutralization of toxins
T cell dependent activation of B cells.
Multivalent antigens cross-link B cell surface receptors which results in B cell clones -> Plasma cells ->
Antibody production (no class switching + affinity mutations - no Th2)
Antibodies acquired by either immunization or previous infection or given passively as antiserum are able to
neutralize bacterial toxins.
Many bacterial exotoxins are enzymes, and protective antibody can prevent interaction of the enzyme with
its substrate.
Antibody may also act by stopping activation of a zymogen into an active enzyme.
The direct binding of antibody to a bacterium can interfere with its normal functioning in numerous ways.
Antibody can kill bacteria or its own or in conjunction with host factors and alls.
Antibodies that affect the activity of specific transport system will deprive that bacteria of their supply and
other essential chemicals.
Invasion can also be inhibited by antibody that attaches to the flagella of the microorganism in such a way as
to affect their motility. Antibodies can agglutinate bacteria, and formation of the aggregate will impede the
spread of the organism.
In certain circumstances, antibodies in conjunction with other bactericidal molecules lead to more efficient
bacterial destruction.
29. Immunodeficiency
Can be:
- primery - genetic, inborn disorders
- secondary - acquired, due to presence of another disease (e.g. malnutrition)
Causes:
- defects in B cells or antibody production
- defects in T cells with or without concurrent B cells defect (Severe Combined Immunodeficiency =
SCID)
- phagocyte and/or NK cell defect (chronic granulomatous disease)
- deficiencies in complement, cytokines or another mediator
This might lead to really severe infections.
The deficiency states seen are due either to defects in one of the components of the system itself, or are
secondary to some other diseases process affecting the normal functioning of some part of the lymphoid
tissues.
The compromised host is prone to infectious diseases that the normal individual would easily eradicate or not
succumb to in the first place.
- Defective innate defense mechanisms:
Defects in phagocyte function takes 2 forms:
1. Where there is a quantitative deficiency of neutrophils which may be congenital (e.g. infantile
agranulocytosis) or acquired as a result of replacement of bone marrow by tumor call or the toxic effects
of drugs or chemicals.
2. Where there is a qualitative deficiency in the functioning of neutrophils which, while ingesting bacteria
normally, fail, because of an enzymatic defect, to digest them.
Characteristic of these diseases is a susceptibility to bacterial and fungal, but not viral or protozoan
infections.
The complement system can also suffer from certain defects in function leading to increased susceptibility to
infection.
- Defective acquired immune defense mechanisms
■ Primary immunodeficiencies: arise through failure of any of the developmental processes from stem cell to
functional end cell.
There are several types of B cell defect that give rise to hypogammaglobulinaemias, i.e. low levels of γ-
globulins (antibodies) in the blood.
In patients with dysgammaglobulinaemia there is a deficiency in only one antibody class.
Individuals with T cell defects tend to have more severe and persistent infections than those with antibody
levels since TH cells are involved in the generation and control of humoral immunity.
■ Secondary immunodeficiency acquired deficiencies can occur secondarily to a number of disease states or
after exposure to drugs and chemicals.
Microorganism
↓
Attachment ← Innate defense mechanisms,
Antibody to adhesins
↓
Local proliferation ← Phagocytes
Complement lysis
Block metabolite transport
↓
- Invasion - Antibody to aggressins, antibody to organism, complement lysis,
phagocytes
- Toxin production (toxigenic bacteria) - Antibody to toxin
- Intracellular growth (chronic bacterial infections) - cell-mediated immunity
1.Staphilococcus aureus
Staph. aureus is a Gram-positive coccus. The cocci are mainly arranged in grape-like clusters, but some may
occur as a single cell or pairs of cells.
Pathogenesis: Staph. aureus is present in the nose of 30% of healthy people and may be found on the skin. It
causes infection most commonly at sites of lowered host resistance, e.g. damaged skin or mucous
membranes.
Virulence factors: there are plenty of virulence factors but only some of them are present in nearly 100% of
strains; others are produced just by one strain among one thousand. Examples: hemolysisn, coagulase,
hyaluronidase, protein A (antiphagocytic effect), fibronectin, cytolytic exotoxin, TSST-1.
Staphylococcal toxins:
- ENTEROTOXINS: enterotoxins, types A-E, G, H, I and J are commonly produced by up to 65% of strains
of Staph. aureus. When ingested as preformed toxins in contaminated food, microram amounts of toxin can
induce within a few hours the symptoms of staphylococcal food poisoning: nausea, vomiting and diarrhoea.
- TOXIC SHOCK SYNDROME TOXIN (TSST-1): a multisystem disease caused by staphylococcal TSST-1
or enterotoxin, or both -> established with the use of highly absorbent tampons. TSST-1 and the
enterotoxins are now recognized as superantigens, i.e. they are potent activators of T lymphocytes resulting
in the liberation of cytokines such as tumour necrosis factor.
- EPIDERMOLYTIC TOXINS: two kinds of epidermolytic toxins (A and B) -> cause blistering diseases.
Epidemiology: the sources of infection are infected lesions -> large numbers of staphylococci are
disseminated in pus and dried exudate discharged from large infected wounds, burns, secondarily infected
skin lesions, and in sputum coughed from the lung of a patient with bronchopneumonia. Direct contact is the
most important mode of spread.
Diseases:
- in skin - musculoskeletal
furuncle osteomyelitis
carbuncle arthritis
impertigo - genitourinary
cellulitis renal carbuncle
wound infection UTI of the lower part
superficial abcesses (folliculitis) - cardiovascular
endocarditis
Treatment
In staphylococci the drug of choice is Oxacilin.
- in UTI - cafalosporins of first generation
- allergic persons - macrolids
- locomotor system - lincosamids
- aminoglycosides in combination only
- glycopeptidic antibiotics (vankomycin and teikoplanin) are a reserve. USed in MRSA and MRSKN
In strains resistant even to glycopeptides, or in patients that have contraindications newer antibiotic linezolid
can be used.
MRSA -> methicilin resistant staphylococci are epidemiologically important starins, often causing serious
hospital infections. They are caused by change of so named membrane penicillin binding proteins (PBP).
Pathogenesis
Production of an exopolyssacharide, allowing adherence and subsequent formation of a multi-layered
biofilm, appears to be essential for the pathogenesis of device related Staph. epidermidis infection.
Attachment is enhanced by the presence of matrix proteins, such as fibronectin and fibrinogen. The
subsequent incorporation of teichoic acid appears to provide the biofilm with stability.
3. Strepatococcus pyogenes
This species, which consists of Lancefield group A streptococci, is among the most prevalent of human
bacterial pathogens. It causes a wide range of suppurative infections in the respiratory tract and skin, life-
threatening soft tissue infections, and certain types of toxin-associated reactions.
Pathogenesis
VIRULENCE FACTORS: strains of Str. pyogenes express a large arsenal of virulence factors and, hence,
their pathogenicity and the clinical signs that they induce are very diverse. The virulence factors are involved
in adherence, evasion of host immunity and tissue damage.
ADHESION: intercation with host fibroconectin, a matrix protein on eukoryotic cells, is considered the
principal mechanism by which Str. pyogenes binds to epithelial cells of the pharynx and skin.
M PROTEINS: the ability of Str. pyogenes to resist phagocytosis is to a high degree due to the cell surface-
exposed M protein.
CAPSULE: like other bacterial capsules it has an antiphagocytic effect.
C5a PEPTIDASE: it specifically cleaves, and thereby inactivates, human C5a, one of the principal
chemoattractants of phagocytic cells.
STREPTOLYSINS: Str. pyogenes produces two distinct haemolysins - streptolysins O (oxygene-labile) and
S (serum-soluble), both of which lyse erythrocytes, polymorphonuclear leucocytes and platelets.
PYROGENIC EXOTOXINS: most strains of Str. pyogenes exotoxins because of their ability to induce
fever.
HYALURONIDASE: streptococci use a secreted hyaluronidase to degrade hyaluronic the ground substance
of host connective tissue. This property may facilitate the spread of infection along fascial planes.
STREPTOKINASE: streptokinase, also known as fibrinolysin, is another spreading factor. Once host
plasminogen is bound to the bacterial surface, it is activated to plasmin by strptokinase. As a result, soft
tissue infections due to Str. pyogenesare more diffuse, and often rapidly spreading, in contrast to the well
localized abscesses that typify staphylococcal infections.
DEOXYRIBONUCLEASES (DNAases): the enzymes hydrolyse nucleic acids and may play a role as
apreading factors by liquefying viscous exudates.
Clinical features
The most common route of entry of Str. pyogenes is the upper respiratory tract. Spread from person to
person is by respiratory droplets or by direct contact with infected wounds or sores on the skin.
- Non-invasive streptococcal diseases: the most common infections caused by Str. pyogenes are
relatively mild and non-invasive infections of the upper respiratory tract (pharyngitis) and skin
(impertigo).
Pharyngitis: clinical signs such as abrupt onset of sore throat, fever, malaise and headache generally
develop 2-4 days after exposure to the pathogen. The posterior pharynx is usually diffusely reddned, with
enlarged tonsils that may show patches of gray-white exudate on their surface and, sometimes,
accumulations of pus in the crypts. The local inflammation results in swelling of cervical lymph nodes.
Scarlet fever: pharyngitis caused by certain pyrogenic exotoxin-producing strains of Str. pyogenes
may be associated with a diffuse erythematous rash of the skin and mucous membranes.
Skin infections: Str. pyogenes may cause several types of skin infection, sometimes in association
with Str. aureus. It primarily affects exposed areas on the face, arms or legs. The skin becomes colonized
after contact with an infected person and the bacteria enter the skin through small defects. Initially, clear
vesicles develop, which within a few days become pus-filled.
- Invasive soft tissue infections
Necrotizing fasciitis: this infection pregresses very rapidly, destroying fat and fascia. Systemic
shock and general deterioration occur very quickly.
Streptococcal toxic shock syndrome: patients with invasive and bacteraemic. Str. pyogenes
infections, and in particular necrotizing fasciitis, may develop streptococcal toxic shock syndrome. A
striking feature of this acute fulminating disease is severe pain at the site of initial infection, usually the soft
tissues. The additional clinical signs resemble those of staphylococcal toxic shock syndrome and include
fever, malaise, nausea, vomiting and diarrhoea, dizzines, confusion, and a flat rash over large parts of the
body.
Rheumatic fever: this manifest as an inflammation of the joints (arthritis), heart (carditis), central
nervous system (chorea), skin (erythema marginatum), and/or subcutaneous nodules. Polyarticular arthritis is
the most common manifestation, whereas carditis is the most serious as it leads to permanent damage,
particularly of the heart valves. The disease is autoimmune in nature and is believed to result from the
production of autoreactive antibodies and T-lymphocytes induced by cross-reactive components of the
bacteria and host tissue.
Acute post-streptococcal glomerulonephritis: the clicical manifestations include:
• coffee-coloured urine caused by haematuria
• oedema of the face and extremities
• circulatory congestion caused by renal impairment
Treatment
• penicillin (either G-penicillin for parenteral use or V-penicillin for oral use)
• macrolids - in penicillin allergic persons only
• vancomycin - is a reserve, 100% effective
• RESISTANT TO AMINOGLYCOSIDES (used as selective medium)
Treatment
G+ penicillin and ampicilin sensitive
5. Sreptococcus pneumonia
Str. pneumoniae, commonly called the pneumococcus, is a member of the oropharyngeal flora of 5-70% of
the population. They are G+, encapsulated cocci, viridating and facultative anaerobes. Str. pneumonia
generally occurs as characteristic diplococci. Str. pneumoniae is an important pathogen, which is largely
ascribed to its capsular polysaccharide. It primarily causes disease of the middle ear, paranasal sinuses,
mastoids and the lung paranchyma, but may spread to other sites, such as the joints, peritoneum,
endocardium and biliary tract and, in particularly, the meninges.
Pathogenesis
Virulence factors:
CAPSULE: the capsule is antiphagocytic, inhibiting complement deposition and phagocytosis, where type-
specific opsonic antibody is absent.
IgA1 PROTEASE: pneumococci produce an extracellular protease that specifically cleaves human AgA1 in
the hinge region. This protease enables these pathogens to evade the protective functions of the principal
immunoglobulin isotype of the upper respiratory tract.
PNEUMOLYSIN: pneumococci produce an intracellular membrane-damaging toxin known as pneumolysin,
which is released by autolysis. Pneumolysin inhibits:
• neutrophil chemotaxis
• phagocytosis and the respiratory burst
• lymphocyte proliferation and immunoglobulin synthesis
AUTOLYSIN: autolysis enables the release of pneumolysin and, in addition, large amounts of cell wall
fragments. The massive inflammatory response to these peptidoglycan fragments is an important component
of the pathogenesis of penumococcal pneumonia and meningitis.
Treatment
Penicillin. When resistance to penicillin is deveplod. vancomycin is used
Vaccines: PPV (pneumococcal polysaccharide vaccine): risk individuals > 2 years old
PCV (pneumococcal conjugated vaccine): babies and toddlers
Enterococcus species
Enterococcus have their natural habitat in the human intestines. The species most commonly associated with
human disease are E. faecalis and E. faecium. The diseases with which they are associated are:
• urinary tract infection
• infective endocarditis
• biliary tract infections
• suppurative abdominal lesions
• peritonitis
E. faecalis and E. faecium are important causes of wound and urinary tract infection in hospital.
Treatment
They are susceptible to penicillin in combination with aminoglycosides. They are resistant to vancomycin.
7. Corynebacterium
The term coryneform is used to describe aerobic, non-sporing and irregularly shaped Gram + rods.
CORYNEBACTERIUM DIPHTERIAE: the major disease caused by C. diphteriae is diphteria, an infection
of the local tissue of the upper respiratory tract with the production of a toxin that causes sustemic effects,
notably in the heart and peripheral nerves.
C. diphtheriae are non-motile, non-spore forming, straight or slightly curved rods with tapered ends.
Snapping division produces groups of cells in angular and palisade arrangements.
C. diphteriae is aerobic and facultative anaerobic.
To cause disease C. diphtheriae must:
• invade, colonize and proliferate in local tissues
• be lysogenized by a special β-phage, enabling it to produce toxin.
The diphtheria toxin possibly assists colonization of the throat or skin by killing epithelial cells or
neutrophils.
The exotoxin is produced locally and is spread by the bloodstream to distant organs, with a special affinity
for heart muscle, the peripheral nervous system and the adrenal glands.
The diphtheria toxin binds to a specific receptor on susceptible cells and enters by receptor-mediated
endocytosis.
Inhibition of protein synthesis is probably responsible for both necrotic and neurotoxic effects of the toxin.
Production of toxin is enhanced considerably when the bacteria are grown in low iron conditions.
Nontoxigenic strains of C. diphtheriae may cause pharyngitis and cutaneous abscesses.
Diphtheria antitoxin (hyperimmune horse serum) is given, since antibiotics have no effect on preformed
toxin which rapidly diffuses from the local lesions and soon becomes irreversibly bound to tissue cells.
Treatment
Treatment with parenteral penicillin or oral erythromycin eradicates the organism and terminated toxin
production.
8. Listeria monocytogenes
The are non-sporing Gram.positive bacilli, found usually in pairs or short chains. They have a positive
catalase test and can grow even in low temperatures and increased NaCl levels.
Listeria is phagocytosed by macrophages -> phagolysosome is not formed because of the action of
Lysteiolysin O -> Listeria escaps and multiplies -> bacteria on surface of macrophages -> pseudopod
extension -> listeria infects other macrophage
The disease chiefly affects pregnant women, unborn or newly delivered infants, the immunosuppressed and
elderly. It is predominantly transmitted by the consumption of contaminated food.
The bacilli are non-motile at 37ºC, but exhibit characteristic ―tumbling‖ motility when tested at 25ºC.
Most cases of human listeriosis are caused by serovars 4b, 1/2a and 1/2b.
It grows in a wide range of foods having relatively high water activities and over a wide range of
temperatures. Growth at refrigeration temperatures is relatively slow.
Pathogenesis
L. monocytogenes is an intracellular parasite, and it is in this environment that the pathogen gains protection
and evades some of the host’s defences.
Listerial surface protein, internalin is involved with the initial stages of invasion on all cell types. After
internalization, L.monocytogenes becomes encapsulated in a membrane-bound comportment.
The ability to polymerize actin by listeria all surface protein subverts the host cell’s cytoskeleton and confers
intracellular motility to the bacterium.
L. monocytogenes principally causes intra-uterine infection, meningitis and septicaemia.
Pregnant women often have very mild symptoms (chills, fever, back pain, sore throat and headache,
sometimes with conjunctivitis, diarrhoea or drowsiness) but may be asymptomatic until the delivery of an
infected infant.
Cultures from high vaginal swabs, stool and midstream urine samples, together with pre- or postnatal
antibody tests, are of little help in diagnosis.
While the outcome of infection for the mother is usually benign, the outcome for the infant is more variable.
Abortion, stillbirth and early-onset neonatal disease are common.
Early neonatal listeriosis is predominantly a septicaemic illness, contracted in utero.
Early-onset disease represents a spectrum of mild to severe infection which can be correlated with the
microbiological findings. The neonates who die of infection usually do so within a few days of birth and
have pneumonia, hepatosplenomegaly, petechiae, abscesses in the liver or brain, peritonitis and entercolitis.
Treatment
ampicillin + sulfometoxazole
9. Mycobacterium tuberculosis
M. tuberculosis are non-motile, non-sporing, non-capsulated, straight or slightly curved rods.
Tubercle bacilli are able to grow on a wide range of enriched culture media, but Lowenstein-Jensen (LJ)
medium is the most widely used in clinical practice.
All mycobacteria are obligate aerobes.
Tubercle bacilli survive in milk and in other organic materials and on pasture leand so long as they are not
exposed to ultraviolet light, to which they are very sensitive. They are also heat-sensitive, and are destroyed
by pasteurization. Mycobacteria are susceptible to alcohol, formaldehyde.
The tubercle bacillus owes its virulence to its ability to survive within the macrophage rather than to the
production of a toxic substance. The nature of the immune responses following infection changes with time
so that human tuberculosis is divisible into the primary and post-primary forms with quite different
pathological features.
-Primary tuberculosis
These bacilli are engulfed by alveolar macrophages. Some bacilli are carried to the hilar lymph nodes where
additional foci of infection develop.
Within about 10 days of infection, clones of antigen-specific T lymphocytes are produced. These released
cytokines, notably interferon-γ, which activate macrophages and cause them to form a compact cluster, or
granuloma, around the foci of infection.
Granuloma formation is usually sufficient to limit the primary infection: the lesions become quiescent and
surrounding fibroblasts produce dense scar tissue, which may become calcified. Not all bacilli are destroyed:
some remain in a poorly understood dormant form which, when reactivated, causes post-primary disease.
- Post-primary tuberculosis
Endogenous reactivation may occur spontaneously or after an intercurrent illness or other condition that
lowers the host’s immune responsiveness.
CD4+ -> IFN-γ -> activation of macrophages -> macrophages engulf M. tb but aren’t able to destroy it ->
epitheloid cells + Langerhans giant cells -> granulomas with central caseous necrosis are formed -> lesions
may arrest and become fibrotic and calcified
-> they may rupture leading to propagation of Tb to the rest of respiratory system + blood
Treatment
takes 6 months or more and uses a combination of drugs (ethambutol, streptomycin, pyrozinamide, isoniazid
= RESPI)
BCG (bacille Calmette Guérin) vaccine is used in individuals under heavy sustained risk of infection.
Treatment
Most environmental mycobacteria are resistant to many antituberculosis drugs in vitro although infections
often respond to various combinations of these drugs.
Rifampicin + Isoniazid + ethambutol -> given for up to 18 months
Lab ID
Sulphur granules in pus.
Treatment
Penicillin G for weeks or months - surgical debridment is done
If the patient is allergic - tetracyclines
Nocardia
Nocardia asteroides and Nocardia brasiliensis are oportunistic human infection, inhaled or acquired by
contamination of skin wounds. Cutaneous nocardiosis starts with traumatic implantation - cellulite with
swelling. In most cases there are multiple confluent abscesses with little or no surrounding fibrous reaction
and local spread may result in empyema.
They are strict aerobe, grow in BA.
They cause chronic pneumonia which is predisposed by lymphomas, drugs or immunocompromised patients.
Treatment
Sulfonamides with or without trimethoprim.
13. Bacillus
Are Gram+ rods which form endospores (central), are encapsulated, facultative or strictly aerobic.
Treatment
Penicillin, erythromycin, doxycylin and ciprofloxacin
Vaccine: cell free vaccine available for high risk occupations.
Treatment
Antitoxin (trivalent A, B, E) and inward botulism - penicillin
Treatment:
Penicillin or metronidazole + antitoxin + debridement of wound
Clostrisium Perfringens
They are G+ bacillus with blunt dnes capsulated and non-motile. They are part of the normal flora of vagina
and GIT.
Pathogenic factors:
- exotoxins (at lest 12) from which the most important α toxin, lecithinase which degrades mammalian
cell membranes causing lysis of endothelial cells, WBC, RBC and platelets – cytotoxic and necrotic
effect.
- enterotoxin: acts in loer portmon of small intestine by disrupting ion transport and leasing to loss of
fluid and intracellular proteins.
- degradative enzymes: proteases, DNAses, collagenases which liquefy tissue and promote spread of
infection
Diseases:
Gas gangrene: the disease is characterized by rapidly spreading oedema, myositis, necrosis of tissues, gas
production and profound toxaemia occurring as a complication of wound infection.
The main source of the organisms is animal and human excreta, and spores of the causative clostridia are
distributed widely.
It may be indirectly derived from dirty clothing, street dust, and even the air of an operating theatre if the
ventilating system is poorly designated or improperly maintained. The skin often bears spores of C.
perfringens, especially in areas of the body that may be contaminated with intestinal organisms.
Treatment: penicillin + metronidazole + aminoglycoside
Food poisoning:
The C. perfringens enterotoxin (CPE) mediating the disease is heat-labile (inactivated at 74ºC) and can be
detected in poor prepared meat and poultry.
Lab ID:
Neutrophils that contain diplococci
Treatment:
Penicilin, 3rd generation cephalosporins
Erythromycin also treste clamydia and is less toxic
Salmonella antigens:
- Long-chain lipopolysaccharide (LPS) comprises O antigens
- Salmonallae are usually highly motile when growing in laboratory media and flagellar protein
subunits contain the epitopes that form the basis of the flagella-based serotyping scheme generally
known as the H antigens.
Certain serotypes of S. enterica express a surface polysaccharide, of which the Vi (virulence) antigen
of S. Typhi is the most important example. Since the polysaccharide may encapsulate the entire bacterium,
antibodies designed to recognize the LPS antigens may be prevented from binding, which can occasionally
make detection of the O antigens difficult.
Diseases:
- Enteric fever: fever + abdominal symptoms (nonspecific symptoms: chills, sweats, headache,
anorexia, weakness, sore throat and diarrhoea/constipation) incubation 5-21 days.
Complications: intestinal, hemorrhages and focal infections and endocarditis
- Paratyphoid fever: transmitted by ingestion of focal or water contamined by human feces.
Treatment
β lactams and fluoroquinolones. Prevention is done by accomplishing proper sewage disposal, correct
handling of food and good personal hygiene.
vaccination: Typhi, Paratyphi A and Paratyphi B (TAB) - for endemic level.
21. Shigella
This is a G- rod, with Hajna +, oxidase - and lactose - on endo agar. They are non-motile and non-capsulated
pathogens.
It is spread from person to person with contaminated stools as major source of organisms (flies and
contaminated food also transmit the disease) - low infectious dose (because Shigella has innate tolerance to
low pH).
40 serotypes of Shigella organized into 4 groups (A, B, C and D). Group D is Shigella sonnei.
Shigella enters intestinal cells by endocytosis through Payer’s patches -> Shigella escapes from endocytic
vesicles and multiplies inside cell protected from macrophages -> Shigella invades neighboring cells (lamina
propria) -> mucosal abscess forms as cells die causing diarrhea with blood mucous and painful abdomen
(patches of necrotic epithelium are sloughed and ulcers form).
Shigella invades and destroys mucosa of large intestine -> infection rarely penetrates deeper layers and does
not lead to bacteriemia.
Pathogenic factor:
- exotoxin (Shigatoxin) - enterotoxin and cytotoxic effect (secondary role development of intestinal
lesions)
- LPS - causes localized cytokine release and the resultant inflammatory response and cellular
disruption enables bacteria to enter
Disease:
- bacillary disentery (diarrhoea with blood, mucous and painful abdominal cramping)
Treatment:
Antibiotics like ciprofloxacin and ampicillin might be used to diminish duration of disease and period of
shedding organism but use controversal.
Protection of water and flood supply and personal hygiene crucial!
Maintenance of hydration!
Klabsiella
They are facultative anaerobic, non-motile but express fimbriae. They also possess K and O antigens and a
large luxurious capsule (-> mucoid appearance).
Klebsiella pneumonia and Klebsiella oxytoca cause necrotizing lobar pnuemonia in individuals
compromised by alcholism, diabetes or COPD. Klebsiella penumonia might also cause UTIs and bacteriemia
particularly in hospitalized patients.
They grow through enterobactin-mediated iron-sequestring
Treatment
ampicillin, amoxacillin + β-lactamase inhibition
Serratia
Is a motile pathogen.
Serratia marcescens might infect humans and might cause lower respiratory infection, urinary tract
infections, meningitis, sepcticaemia, endocarditis.
Proteus
HAS RAUS PHENOMENON IN AGAR. They are motile pathogens and they cause nosocomial UTIs,
wound infections, pneumonias and septicemias in compromised patients.
Urea is splitted (by urease) into ammonia and the resulting alkaline environment promotes precipitation of
struvite stones.
Pseudomonas pseudomallei
It is a normal inhabitant of soil and water. The transmission is done through wounds in skin, ingestion, and
inhalation.
It causes melioidosis with varied presentations like P. mallei
26. Campylobacter
They are G- rod, not growing on endo agar, curved or spiral S shaped with a single polar flagellum grows in
microaerophilic conditions. They grow on BA with antibiotics (to inhibit growth other fecal flora). It has O,
H and K antigens.
They adapted to colonize mucous membranes and are able to penetrate mucous with facility.
They are transmitted via oral-fecal route or direct contact with contaminated water
Campylobacter jejunii:
- acute enteritis appears after 7 days incubation in healthy people and it is self-limiting. Symptoms
may be either systemic (fever, headache and myalgia) and intestinal (cramps and diarrhea with or
without blood)
- causes also travelers’ diarrhea and pseudoappendicitis
- bacteremia may occur in children and elderly people
The jejunum and ileum are the 1st to become colonized, but the infection extends distally to affect the
terminal ileum and usually the colon and rectum.
They are invasive, similar to Salmonella, Shigella or Yersinia infections.
Diarrhea should be treated with fluid and electrolyte replacement unless for patients with severe symptoms (-
>erythromycin)
Complications:
- reactive arthritis
- Guillain-Barre
Treatment
2 or more antibiotics are applied due to rapid resistance of H. pylori, generally tetracyclin + metranidazole +
bismuth salts.
28. Vibrio
They are G- which grow on endo agar with Hajna red +, oxidase +. They are motile by meansof single
flagellum, has O and H antigens but only O is important distinguishing strains that cause epidemics,
facultative anaerobe, which the growth is stimulated by NaCl.
Vibrio cholerae is transmitted by contaminated food or water, there are 2 biotypes of other species: Classic
and El Tor (hemolysin, higher carriage rates and the ability to survive in water for long time).
Vibrio cholerae infects the small intestine. The organism is non invasive and causes disease through the
action of an enterotoxin.
Cholera toxin binds to a ganglioside receptor -> A subunit enters the cell membrane, activates Gs which will
activate adenylate cyclase -> Adenylate cyclase produces elevated cAMP -> cAMP causes active secretion
of ions and water. Inhibition of uptake of Na+ and Cl- and hypersecretion of Cl- and HCO3-.
Diseases:
-Cholera: characterized by massive loss of fluid and electrolytes (vomiting and watery diarrhoea) from body
incubation of hours to days is followed by a profuse watery diarrhoea. If untreated -> death from severe
dehydratation followed by hepovolemic shock will ensue.
Replacement of fluids and electrolytes is crucial in preventing shock.
Treatment
Doxyxyxlin
Vibrio parahemolyticum will not grow in the absence of NaCl. Outbreaks of GIT disease (explosive
diarrhoea, abdominal pain, nausea and vomiting) that results from ingestion of inadequately cooked seafood
disease is self limiting and antibiotics don’t alter cause of infection.
29. Haemophilus
They are G- rod, not growing on endo agar (Pasteurellacae grows on chocolate agar).
H. ducrey: sexually transmitted disease, chancroid (painful penile ilcers). X factor only in BA (H.
parainfluenza: V factor).
H. influenza: may be encapsulated (6 capsular types) or uncapsulated. Satellite phenomena is visible in BA
with Staph. aureus. When cultured on ChA with factor V and X, if growing on both.
It has an important virulence factor -> serious invasive H. influenzae disease is associated with capsular type
b.
Hib is particularly important in young children. Noncapsulated strains can also cause pneumonia among
elderly people and people with chronic lung disease..
Normal component of upper respiratory tract flora, may colonize conjunctiva and genital tracts - humans
only natural hosts.
Pathogenic factors:
- IgA protease - degrades secretory IgA, facilitating colonization of upper respiratory tract mucosa -> H.
influenza enters the blood stream and disseminates to distant sites.
- Fimbriae which assists the attachment to epithelial cells - outer membrane components.
Diseases:
- Otitis media, sinusistis, epiglottitis, bronchopneumonia (contagious spread from its site of colonization in
respiratory tracts).
- Meningitis, septic arthritis, cellulitis (invasion of blood stream)
Treatment
- vaccine against Hemophilus influenza type b, administrated to infants has helped decrease the frequency
of bacterial meningitis (appeared with otitis media)
- 3rd generation cephalosporins - ceftriaxone, for meningitis and epiglottitis
- amoxicillin for sinusitis, otitis media and upper RTIs
30. Bordetella
They are G- rods which grows on BG (Bordet-Gengou) media, are encapsulated that grows singly or in pairs.
They are aerobic pathogens, transmitted by droplets via coughing but the organism survives only briefly
outside RTI.
Bordatella pertussis
pathogenic factors:
- pertussis toxin: lymphocytosis, sensitization to histamine, activation of insulin production -
hypoglycemia.
- agglutinogens: promote attachment of bacteria to host cells
- dermonecrotic toxin: vasoconstriction and ischemic necrosis
- tracheal cytoxin: inhibits cilia movement and regeneration of damaged cells.
- adenylate cyclase: decreases chemotaxis and phagocytosis of bacteria
Treatment
- Erythromycin
- DPT vaccine
Bordatella parapertussis
Grows on nutrient agar.
Pertussis incubation period is 2-3 weeks divided into 2 phases:
- catarrhal: rhinorrhea, mild conjunctival infection, malaise -> dry non productive cough
- paroxysomal: paroxysms of coughing followed by a whoop as patient inspired rapidly, causes
leucocytosis
Convalescence requires at least 2-3 weeks where 2nd infections might occur.
31. Legionella
They are G- rods which grow on BCYE (Buffered Charcoal Yeast Extract), aerobic, facultative intracellular
bacteria that causes respiratory tract infection.
Their natural habitat is soil and water (including cooling towers and water distribution system).
Legionella Pneumophila most important subtype, may be acquired by inhalation of aerosolized organisms
but may also be due to swimming in contaminated water. It is not transmitted from person to person. They
are chlorine resistant.
Organism enters upper RT by aspiration of water or inhalation of aerosol - failure to clear organism permits
them to reach lungs alveolar macrophages in lung bed are an important line of defense - phagocytize L.
pneumophila but phagosome doesn’t fuse with lysosome - organism multiplies in phagosome until cell
ruptures - new crop of bacteria.
Diseases:
- RTI
- Laegionaires disease: incubation 2-10 days. Atypical acute lobar pneumonia that develop in 1-5% of
people exposed to common source. Many LD patients have symptoms: fever, malaise, confusion,
hallucinations, myalgia, respiratory distress.
- Pontiac fever: inflenza like that infects healthy people generally 90% of people exposed to same source
are infected. 1 week - healed people, no therapy needed.
Treatment
macrolides, erythromcin, azythromycin
32. Brucella
B. abortus - cattle B. mellitensis - goat + sheep B. suis - suine B. canis - dog
All of them may cause disease in humans. Infections arise through direct contact with infected animals.
They are G- rods, aerobic, intracellular parasites that can survive and multiply within host phagocytes.
Caused by contact with cow, pig or goat or by consumption of dairy products. Brucella typically enters body
by cuts and abrasions in skin ot through GIT and eventually inhalation of aerosols among abbatoir workers.
Once organisms enter; ther are transported via lymphatic system to reticulo-endothelial system and lymph
nodes, spleen, bone marrow, liver, kidneys.
Disease
Brucellosis: incbation varies from 5 days to several months. Symptoms are nonspecific and flu like - malaise,
sweats, fever anorexia, GI symptoms , headache.
Treatment:
Doxycyclin + gentamycin (6 weeks treatment necessary)
33. Yersinia
They belong to Enterobacteriaceae and are non-sporing, no-motile, facultative anaerobe, G- rods which grow
on endo agar, lactose -, Hajna red +, oxidase -.
Yersinia pestis
Squirrel <-> flea <-> rat
sylvatic plague ↓ urban plague
bubonic plague - Y. pestis produces a coagulase that causes blood to
↓ clot in the animals foregut - when animal next feeds,
↓ it regurgitates bacteria from foregut to peoples skin
bubonic plague
Treatment
Limiting potential contamination of meat.
Antibiotic therapy (ciprofloxacin) is essential for systemic diseases but questionable for endocarditis.
Prevotella meraninogenicus
It is an anaerobe. Normal gingival flora, respiratory and alimentary up tract. They provoke oral abscessi,
dental and sinus infection, pulmonary tract infecion and abscess. brain abscess.
Heparinase leads to clotting in brain.
Treatment
Penicillin
Fusobacterium
They are G- rods, spindle shaped growing in mouth, female genital tract and colon. They cause peritonitis,
abdominal abscesses, pelvic inflammatory disease, emphysema, necrotizing aspiration pneumonia,
peridontal disease and Vincent’s angina.
Congenital syphilis: after 10-15 weeks of pregnancy, the fetus might be infected and might die or be aborted.
Those who live have secondary syphilis.
Lab ID
Screening tests Confirmation
Treatment
Penicillin single treatment for primary + secondary syphilis
37. Borrelia
They have a linear rather then circular plasmid and chromosomal DNA.
Transmitted by Ixodes tick - becomes infected while feeding on infected animals and then bittes man.
Borrelia Burgdoferi
Lyme disease is transmitted by a bite a Ixodes tick that needs to be attached at least for 24 hours before
infecting reason. Primary reservoirs are deers and rodents.
1) stage: 3-32 days after bite, a characteristic red circular lesion with clear centre appears (erythema
migrans appears). Flu like symptoms accompany this erythema. The organism spreads via lymph or
blood to musculoskeletal sites, skin or heart.
2) stage: arthritis, arthralgia, cardiac and neurologic complications
weeks to months later
3) chronic arthritis and CNS disease
Rarely fatal but might cause poor level of life if untreated.
Lab ID:
IgG and IgM determination using ELISA and confirmation by W. blotting and PCR.
Treatment:
Tetracyclines, cephalosporines, penicillin
Borrelia Recurrentis
Responsible for disease relapsing fever which is characterized by several cycles of recovery (development of
specific anti-spirochetes Ab) followed by relapse. The natural hosts for these organisms include rodents and
other small mammals on which the ticks normally feed.
B. recurrentis is able to change its surface protein antigens (with each relapse a new antigenic variant
appears).
Transmitted from human to human by body lice.
Lab ID
Diagnosis is made by appearance in Giemsa stain.
Treatment
tetracyclins, erythromycin and penicillin
38. Leptospira
They have an envelope composed of 3-5 layers of protein, polysaccharide and lipid covers the bacteria and is
the main target for the host immune response.
Leptospira interrogans: Sensitive to drying and a broad range of desinfectants. Leptospirosis is primarily an
animal disease that is transmitted to humans primarily by water or food contaminated with animal urine. The
leptospira can also enter the body via small skin abrasions or the conjunctiva, mucous membrane.
1-2 weeks after infection fever occurs at which time spirochets appear in blood. After 1 week symptoms
decrease. However in cases of biphasic diseases: spirochets reappear accompanied by invasion of liver,
kidneys and CNS (results in jaundice, hemorrhage, tissue necrosis and or asseptic meningitis).
Vasculitis resulting in damage to the endothelial cells of small blood vessels is probably the main underlying
pathology.
Lab ID
Diagnosis based on serologic agglutination test.
Penicillin + doxycyclin at first stage (24-48h) but later uneffective
39. Chlamydia
They are non-motile, small bacteria, which are obligate intracellular parasite depending on host cell for
energy (ATP). They grow in cytoplasmic vacuoles. The genus is divided into: Chlamydia Trachomatis
(genitourinary tract and eye diseases), Chlamydia passitaci and C. pneumonia cause infection in various
levels of RT.
Treatment
Macrolide and tetracyclin sensitive
Extracellular infections form - elementary body (is the only infectious stage of the chlamydil developmental
cycle), can survive extracellular cell to cell passage and initiate infection.
Growth cycle: elementary body taken up by phagocytosis into susceptible host cells (facilitated by proteins
in chlamydial cell envelope that funcion as adhesins) -> elementary body prevents fusion of phagosome with
lysosome - particle reorganizes in the next 8h into larger non infectious reticulate body - metabolically
active non-infectious and will divide repeatedly by binary fission within cytoplasm of host cell -> inclusion
body -> after 48h multiplication ceases and reticulate body condenses to become new elementary body ->
elementary bodies are released from cells by cytoplasmic ending in host cell death.
Chlamydia trachomatis
Major casual agent of non gonococcal urethritis and can also cause eye infections with symptoms ranging
from irritation to blindness, ectopic pregnancy or infertility in pelvic inflammatory disease.
NGU (non gonococcal urethritis) serotypes D-K - young sexually active individuals, in males the urethra is
the principal site of infections while in females, cervicitis and urethritis are more common.
Cervicitis - fallopian tubes infection - pelvic inflammatory disease
Same symptoms as gonorrhea but longer incubation, more mucoid and less purulent reaction. This
progresses to epididymitis or prostatitis.
LGV (lymphagranuloma venereum) - more invasive sexually transmitted disease transient papules in
external genitalia -> (1-2 months) painful swelling of inguinal and perirectal lymph nodes -> affected lymph
nodes suppurate and chronic inflammation and fibrosis lead to ulceration and blockage of lymph drainage -
peroscrotal elephantiasis
Trachoma
Chronic keratoconjunctivitis that often results in blindness. It is trnasmitted by personal contact.
Neonatal conjunctivitis: acquired while passing through birth canal.
Lab ID:
direct test by microscopic examination using direct fluorescent Ab that reveal cellular cytoplasmic
inclusions.
Treatment
azythromycin and tetracyclin
Ehrlichia
They are G- bacilli which parasitize leucocytes and grow in cytoplasmic vacuoles, creating morulae
(inclusions).
2 of its tick born forms are known:
- human monocytic ehrliosis (HME) caused by E. chaffeensis
- human granulocytic anaplasmosis (HGA) caused by E. equi
They cause acute fever, myalgia, moderate to severe leucopeniaand thrombocytopenia.
Treatment
Doxycyclin
Coxiella
They are obligatory intracellular, G- bacilli
Coxiella burretii - causes Q fever
1) it can resist hot degradative enzymes within cytoplasmic vacuoles
2) they are resistant to heat and drying and also can persist outside the host for a long time
3) human infection is caused by inhalation of infected dust in barnyards, slaughterhouse
4) It reproduces in respiratory tract
Treatment
Doxycyclin
Treatment
Doxycylin or azythromycin - may persist in covalescence upper RT for week
1. Composition of viruses
Viruses are complexes consisting of only proteins and nucleic acids (DNA or RNA).
They lack cellular structures and independent metabolic processes - therefore they have no metabolic system
and so depend on synthetic mechanism of a living cell.
Viruses deliver their nucleic acid into a host cell and proceed to produce components of new viruses in
accordance with the genetic information they contains. They can infect bacteria (so called bacteriophages)
plants, animals and humans.
Many viruses have an envelope composed of a protein containing lipid bilayer, whose presence or abscence
further distinguishes on virus group from another.
A mature virus particle is also known as a virion.
It consists of:
- Genome of DNA or RNA
- Capsid - virus coded proteins enclosing the nucleic acid of the virus, determining its antigenicity.
The capsid can have a cubic (rotational), helical or complex symmetry and is made of subunits
called capsomers. In some cases an envelope surrounds the capsid, and it is always delivered from
cellular membrane.
- Enzymes - e.g. neurominidase, required for invasion and release of myxoviruses; DNA polymerase
in small pox virus.
There are NA and DNA viruses. The nucleic acid of DNA virus is usually double-stranded and linear or
circular depending on the fmily. The nucleic acid of RNA viruses is usually single stranded with the
exception of reoviruses.
Viruses with ssRNA are divided into 2 groups:
1. Sense/ positive strand virus: if genome RNA has same polarity as viral mRNA and can thus function
directly as mRNA then it is called positive strand or sense stran.
2. Antisense/negative strand virus: if genome RNA has polarity opposite to that of mRNA they have first to
be transcribed into a complementary strand, before it is translated into proteins.
3. The primary characteristic of virus is that replication is obligatorily intracellular
2. Virus-cell interactions
A virus-cell interaction is a very quick process involving fusion of the viral envelope with cell membranes.
Productive interactions: viruses that infect and replicate within cells causing cells to lyse when the progeny
virions are released (this is known as the cytolitic cycle).
Non-productive interactions: viruses that infect cells but do not complete the replication cycle.
The host cell is termed permissive or non-permissive depending on the outcome of the virus-cell interaction.
Interaction of viruses with cells can result in:
- production of new virus particles with or without lysis of host cells
- abortive infection (a non-productive infection)
- latency, where the virus exists with limited expression of viral genes
Cytolitic growth cycle - when virus particles come into contact with the host cells, part of the capsid binds to
a specific receptor to initiate entry into the host cell. The virion then enters or penetrates into the host cell
and is partially uncoated to reveal the viral genome, and so macromolecular synthesis of virus components
can take place.
Early mRNA is first transcribed and translated into proteins. The newly formed virus particles are assembled
and released during cell lysis.
3. Antiviral Agents
Inhibitors of neuraminidase
Sanguinavir, blocks action of influenza virus neuraminidase
4. Interferons
Type I: IFN α, IFN β : produced by the virus infected cells (fibroblasts, macrophages). In the target cells
they inhibit viral replication by blocking translation of viral protein.
Type II „Immune―: IFN γ: produced by activated T 1 cells in response to a specific antigenic signal, causes
H
activation of macrophages.
IFN-α and IFN-β are produced in response to the presence of viruses and certain intracellular bacteria.
Double-stranded RNA may be the important inducer.
To exert their biological effects these molecules must interact with cell surface receptors. IFN-α and IFN-β
share a common receptor while IFN-γ binds to its own specific receptor. After binding to the cell surface
receptors, interferons act by rapidly and transiently inducing or up-regulating some cellular genes and
down-regulating others. The overall effect is to inhibit viral replication and activate host defence
mechanisms.
They can inhibit many stages of the virus life cycle - attachment and uncoating, early viral transcription,
viral translation, protein synthesis and budding.
Some viral proteins can inhibit the interferon response
5. Humoral immunity to viral infections
Antibodies cannot enter cells, and therefore are ineffective against latent viruses and those that
spread directly from cell to cell. They will, however, bind to ectracellular viral epitopes. These epitopes can
be on intact virions or on the surface of infected cells. The binding of antibody to free virus can inhibit a
number of processes essential to virus replication. Antibodies can block binding to the host cell membrane,
and thus stop attachment and penetration.
Antibody can also work at stages after penetration. Uncoating, with the release of viral nucleic
acid into the cytoplasm, can be inhibited if the virion is covered by antibody.
Antibody can also cause aggregation of virus particles, thus limiting the spread of the infectious particles and
forming a complex that is readily phaocytosed.
In some infections, viral proteins remain on the surface of the cell after entry or become associated
with the cell membrane during replication. Antibodies against these molecules can cause cell lysis by the
classical pathway but an intact alternative pathway is necessary to amplify the initial triggering by the
antibody-dependent pathway.
In many situations, viruses seem to be able to escape the humoral defence mechanisms. Some
viruses become latent, e.g. herpesviruses, and are reactivated despite the presence of circulating antibody, as
they can pass directly from cell to cell. Other escape mechanisms include antigenic variation in which the
antigenic structure of the virus (e.g. influenza type A) changes so that antibodies formed to the previous
strain are no longer effective.
In viral infections the efficiency of antibody depends largely on whether the virus passes through
the blood-stream outside host cells to reach its target organ.
In comparison, in viral diseases such as influenza and the common cold, the viruses do not pass
through the bloodstream. In this type of infections a high level of antibody in the blood will be relatively
ineffective in comparison with its effect on blood-borne viruses. In this case the antibody must be present in
the mucous secretions at the time of infection.
Humoralimmunity does play a major protective role in polio and a number of other viral
infections, and is probably he predominant form of immunity responsible for protection from reinfection.
A virus will remain relatively safe from immune destruction if it remains within the cell and allows only
very low or no viral antigen expression on the infected cell membrane.
Viruses that move from cell to cell without entering the extracellular fluids will also escape the action of
antibodies, as will those passed from to cell by cell division.
A number of infections continually shed virus into external secretions, such as saliva, milk or urine. As
long as the infected cell only forms virus on the luminal surface of the mucosa then cells of the immune
system and antibody will be unable to destroy the infected cell. IgA present in the secretions may neutralize
the virus, but this class of antibody does not activated complement efficiently so the cell will not be lysed.
Susceptibility to infection is generally greater in very young and very old people because of a weaker
immune response. However, the immunopathology tends to be less severe.
Physical and physiological differences may also contribute to age-related disease susceptibility. Certain
viral infections produce a milder disease in children than in adults e.g. varicella.
Antigenic variation
A micro-organism can avoid the acquired immune response by periodically changing the structure of
molecules that are recognized by the host immune system. The micro-organism will only be able to change a
component in a way that does not alter the functioning of the molecule.
Antigenic variation is likely to be an important viral adaptation for overcoming host immunity in long-
lived species such as humans where there is a need for multiple re-infection of the same individual if the
virus is to survive and the virus is unable to become latent.
Persistence of virus
Certain viruses give rise to a persistent infection, which is held in check as long as the immune system
remains intact. In other persistent infections, the immune system contributes to the pathology of the disease.
8. Adenoviruses
Are non-enveloped DNA viruseses, with icosahedral nucleocapsid and a single piece of double-stranded
DNA. They belong to the Adenoviridae family, which consists of:
· Mastadenovirus – infects mammalians
· Aviadenovirus – infects avian species
Epedemiology:
- The site of clinical syndrome is generally related to the mode of virus transmission Most
adenoviruses are primary agents of respiratory diseases and assymptomatical diseases of the
intestine and can be isolated from stool of both healthy and people after they had a respiratory
problem. Two adenoviruses subtypes are associated with GI disease and are transmitted by fecal-
oral route.
- Ocular infections are transmitted by direct incoulation of the eye by virus contaminated hands,
ophtalmic instruments.
Replication:
1. Virus attaches to host cell receptors via knobs on the tips of viral fibres -> entry into cell by cell
mediated endocytosis -> viral genome is uncoated whilst being transported to nucleus -> in
nucleus there is transcription of viral genes, genome replication and assembly occurs. The
adenovirus encodes for early proteins such as:
- DNA polymerase and others that affect transcription and replication of viral genome.
- The ones that inactivate p53 and pRb that prevents progression towards the cell cycle
2. In the end of the productive cycle, the virus kills the host cell as cellular DNA, RNA and protein
synthesis are all shut off during infection.
GI diseases
- Infantile gastroenteritis -> viral diarroheal disease (serotypes 40 and 41)
UT disease
- Hemorrhagic cystitis -> hematuria and virus can usually be identified in urine
Lab ID
- Not done generally but may be done in epidemics or nosocomial outbreaks
- GIT type: ELISA direct test of stool specimen
- Serotype can be identified by agglutination inhibition using type specific antisera
Treatment
- Live attenuated adenovirus vaccine is used for protection of military population
- No antibiotics
Latent infection - a type of persistent infection in which the viral genome is present but infectious virus is not
produced except during intermittent episodes of reactivation.
Reactivation – reactivation from the latent state may be restricted to asymptomatic virus shedding.
Recurrence or recrudescence – when reactivated virus produces clinically obvious disease.
Outside the capsid in mature particles is an amorphous proteinaceous layer, the tegument, surrounded by a
lipid envelope derived from cell membranes.
The genome of herpes virions is linear double-stranded DNA.
The family Herpesviridae comprises three broad groups:
· Alphaherpesviruses, e.g, HSV, VZV; rapid growth, latency in sensory ganglia
· Betaherpesviruses – CMV; slow growth, restricted host range
· Gammaherpesviruses, e.g. EBV; growth in lymphoblastoid cells
Replication
After attachment to receptors, the envelope of herpes virions fuses with the cell membrane. The
nucleocapsids cross the cytoplasm to the nuclear membrane; replication of viral DNA and assembly of
capsids take place within the nucleus. With HSV, it is known that tegument protein transactivates
expression of the first set of genes.
These proteins are of 3 types:
1. Immediate early (α) – mainly regulatory functions
2. Early (β) – includes many enzymes invloved in DNA replication.
3. Late (γ) – structural proteins of capsid, glycoproteins
Pathogenesis
Primary infection
The typical lesion produced by HSV is the vesicle. The underlying layer of basal epithelium is usually intact,
as vesicles only occasionally penetrate the subepithelial layer. The roof of the vesicle breaks down, and an
ulcer forms: this happens rapidly on mucous membranes and non-keratinizing epithelia; on the skin the ulcer
crusts over, forming a scab, and then heals.
After resorption or loss of the vesicle fluid the damaged epithelium is regenerated. Natural killer cells play a
significant role in early defense by recognizing and destroying HSV-infected cells.
During replication phase at the site of entry in the epithelium, virus particles enter through the sensory nerve
endings and are transported along the axon to the nerve body in the sensory (dorsal root) ganglion by
retrograde axonal flow. In some ganglion cells a latent infection is established in which the neurons survive
but continue to harbor the viral genome.
Latent infection
In latency, viral DNA exists as free circular episomes. Very few virus genes are expressed in the latent state.
HSV-2 latency in the sacral ganglia has been demonstrated. Either type may become latent in other ganglia.
Herpes viruses' DNA passes along the nerve axon back to the nerve ending where infection of the epithelial
cells may occur.
The interval between the stimulus and the appearance of clinically obvious lesions is 2-5 days.
Oral infection
Classically, the first infection presents as an acute, febrile gingivostomatitis in children. Vesicular lesions
ulcerate rapidly and are present in the front of the mouth and on the tongue. Gingivitis is usually present.
Vesicles may also develop on the lips and skin around the mouth and cervical lymphadenopathy occurs.
There may be an associated mononucleosis in the older patient; pharyngitis is also notable.
Skin infection
Herpetic whitlow: Hand infections with HSV are not uncommon. Three presentations may be seen:
· The classical primary lesion on the fingers or thumb of the toddler with herpetic stomatitis, due to
autoinoculation
· Associated with HSV-2 and genital herpes and seen in young adults
Eczema herpeticum: a severe form of cutaneous herpes. Extensive ulceration results in protein loss and
dehydration, and viremia can lead to disseminated disease with severe, even fatal, consequences.
Eye infection
There may be conjunctivitis, or keratoconjunctivitis associated with corneal ulceration. The presence of
typical herpes vesicles on eyelid margins is a useful clinical guide but is not always seen. The majority of
eye infections are HSV-1.
HSV may reach the brain in several ways. Viremia has been detected during primary herpetic stomatitis, and
infection may be carried within cells into the brain and meningitis.
HSV encephalitis (HSVE): this is a rare condition, but is the commonest sporadic fatal encephalitis
recognized in developed countries. Fever and malaise is followed by headache and behavioral change
sometimes associated with a sudden focal episode such as seizure, or paralysis; coma usually proceeds death.
Cerebrospinal fluid (CSF) collected in the acute stages of HSVE should be sent to a laboratory.
Genital tract infection
Genital infection may be acquired by auto-inoculation from lesions elsewhere on the body, but most often
results from intimate sexual contact, including oralgenital contact. The lesions are vesicular at first but
rapidly ulcerate:
· In the male, the glans and shaft of the penis are the most frequent sites of infection
Neonatal herpes
HSV-2 is acquired by passage through an infected genital tract at birth. Virus dissemination to internal
organs is the most serious complication, in which the infant shows signs of general sepsis, including fever,
poor feeding and irritability. Pneumonia and jaundice develop, with or without signs of meningitis or
encephalitis.
Lab ID:
Inoculation of human cell tissue culture with a sample of vesicle fluid or genital swab is the method to
demonstrate presence of HSV.
Infected cells can be detected within 24h by use of immunofluorescence or immunoperoxidase with Ab
against viral early proteins.
Treatment:
Acyclovir (or famciclovir, and topical penciclovir)
The enveloped virions released from the nucleus remain closely attached to microvilli along the cell surface
and the infection being passed from cell to cell.
Pathogenesis
Varicella
This is a disease predominantly of children. characterized by a vesicular skin eruption. Virus is thought to
enter through the upper respiratory tract, or conjunctivae, and multiply in local lymph tissue for a few days
before entering the blood and being distributed throughout the body. Following replication in reticulo-
endothelial sites, a second viraemic stage procedes the appearence of the skin and mucosal lesions.
The clearence of virus-infected cells is dependent on functional cell-mediated immune mechanisms,
cytotoxic T cells and antibody-dependent cell cytotoxicity in particular.
Clinical features: the incubation period averages 14-15 days. The patient is infectious for 2 days before and
up to 5 days after onset , while new vesicles are appearing. Initially macular, the rash rapidly evolves
through papules to the characteristic clear vesicles. Sexondaru bacterial infection of skin lesions is the
commonest complcation.
A variety of organs may be affected, producing myocarditis, arthritis, glomerulonephritis and appendicitis.
The two most frequent problems are related to the lungs and the central nervous system.
PNEUMONIA:viral penumonitis is a most serious complication. Cough, dyspnoea, tachypnoea and chest
pain begin a few days after the rash.
CENTRAL NERVOUS SYSTEM: neurological complications include the common but benign cerebellar
ataxia syndrome.
VARICELLA IN PREGNANCY: varicella virus canc ross the placenta following viraemia in the pregnant
woman, and infect the fetus. Two types of intra.uterine infection are noted:
1. The fetal varicella syndrome is a consequence of fetal infections with VZV in the first half of
pregnancy.
2. Neonatal (congenital) varicella occurs when varicella develops within the first 2 weeks of life,
following maternal varicella in late pregnancy.
Zoster
The latent virus is found in neurones and in satellite cells in sensory ganglia, and more than one region of the
genome is transcribed.
It seems likely that virus reaches the ganglion from the periphery by travelling up nerve axons, as HSV does,
but there is also the possibility that during viraemia some vifrus enters ganglion cells.
Reactivation of VZV manifested as zoster can occur at any age in a person who has experienced a primary
infection.
More than one episode of zoster is uncommon in any individual. The stimulus to reactivation is not known,
nor the details, but virus does appear to travel from sensory ganglia to the peripheral site. The zoster is
usually limited to one dermatome.
Clinical features: prodromal paraesthesia and pain in the area supplied by the affected sensory nerve are
common before the skin lesions develop. The evolution of the rash is similar, with some new vesicles
appearing while the earliest ones are crusting.
POSTHERPETIC NEURALGIA: this is the most common complication of zoster. It is defined as intractable
pain persisting for 1 month or more after the skin rash. Constant pain at the site, or stabbing pains or
paresthesiae may continue over 1 year or much longer.
OPHTALMIC ZOSTER: involvement os th ophtalmic division of the trigeminal nerve occurs in up to one-
quarter of zoster episodes, with ocular complications. Corneal ulceration, stromal keratitis and anterior
uveitis may result in permanent scarring, so this complication may threaten sight when the nasociliary branch
is involved. Ramsay-Hunt syndrome (facial palsy with aural zoster vesicles) suggest that motor neurones can
also be involved.
Lab ID:
Reacting epithelial cells scraped from base of vesicles with the strains described in HSV or hybridization
with specific VZV DNA probes.
Treatment:
IV adminitration of acyclovir
Vaccine: live attenuated vaccine for children older than 1 or non immune adults at risk of being exposed
- The classical infectious mononucleosis (glandular fever) of adolescents in the developed world
This virus cannot be grown in human fibroblast or epithelial cell lines. This lymphotropic virus is classified
as a gammaherpesvirus.
The full replication cycle of EBV is now known to take place in certain differentiated epithelial cells. EBV
receptors are expressed on mature resting B lymphocytes and similar receptors are present on cells of
stratified squamous epithelium – in the oropharynx, salivary glands and ectocervix.
The latent state of EBV infection is maintained in a subset of resting memory B lymphocytes, and perhaps in
certain epithelial cells. Specific EBV early RNA species are found in all cells infected with the virus. A
variable number of EBV genes are expressed in the latent state.
Pathogenesis:
Infection of oropharyngeal epithelial cells occurs initially, then infection of B lymphocytes, which
disseminate through the circulation, with the potential to enter a productive phase and release virus
elsewhere in the body. Most shedding of virus, however, takes place in the oral cavity.
Recovery from primary EBV infection is associated with humoral and cellular response. Thus, large initial
infective doses result in high number of circulating infected B lymphocytes.
Infectious mononucleosis:
The disease known as infectious mononucleosis or glandular fever is a primary EBV infection seen
predominantly in the 15-25 year age group. The onset is abrupt with a sore throat, cervical lymphadenopathy
and fever, accompanied by malaise, headache, sweating and gastrointestinal discomfort. Pharyngitis may be
severe, accompanied by a greyish-white membrane and gross tonsillar enlargement.
Acute airway obstruction, splenic rupture (rare) and neurological complications include meningitis,
encephalitis and the Guillain-Barre syndrome.
Lab ID:
Atypical lymphocytes may be observed in the blood smear of a person with IM.
Paul-Bennell test based upon the fact that polyclonal stimulation of B cells by EBV results in non-specific
elevation of all Ig (agglutination test).
Treatment:
12 Cytomegalovirus
It is a member of the β-herpesviridae family.The full name for the virus infecting humans is human
cytomagalovirus (HCMV). Tha name was chosen on account of the swollen state of infected cells as seen in
culture and in tissues. The replication cycle is significantly larger and the nuclei of productively infected
cells contain a large inclusion body, giving a typical appearence.
In vivo the virus replicates in epithelial cells in salivary glans, the kidney and in the respiratoty tract.
Pathogenesis
Generally it is acquires during childhood (majority of people have Abs against it by agulthood).
- Ususally asymptomatic infection and children shed viruses by body fluids like tears or saliva, and
infection occurs by intimate contact with these fluids.
- In adults, the virus can be also transmitted by semen and vaginal secretions, by organ transplants
(specially of Ab+ donors, because the presence of Abs implies the presence of persistent virus), or
by blood donors and breast milk.
- HCMV can also cross the placenta and infect the fetus in utero.
- CMV persists in the host for life. Recurrent infections may follow reactivation of latent
(endogenous) virus, or re-infection with another (exogenous) strain. Latency is probably
established in monocytes and macrophages but also n kidneys and liver.
MONONUCLEOSIS: primary infections as an adult is infectious monucleosis (hepatitis, fever and
lymphocytosis but pharyngitis and lymphadenopathy are unusual) The difference would be the abscence of
heterophile Abs. Can be associated with HIV infection.
CYTOMEGALIC INCLUSION DISEASE: HMCV is the most common interauterine virus infection. Of
infants born from women experiencing their first CMV infection during pregnancy, 35-50% will become
infected. This problem ranges from fetal death to various degrees of liver, spleen, blood forming organs or
CNS damages (retardarion, teinites, encephalitis...).
INFECTION IN THE COMPROMISED PATIENT: the complications of CMV in cellular
immunodeficiency include: pneumonitis, encephalitis, retinitis, oesophagitis/colitis, hepatitis, pancreatitis or
adenitis.
Host responses
The host response to primary CMV includes IgM, IgG and T cell responses. CMV early genes transactivate
other viral and cellular genes and this may be an important interaction with HIV, leading to the production of
HIV from latently infected cells. Because CMV infects mononuclear cells, there is a degree of
immunosuppression associated with the acute infection.
from recurrent infection by IgG seroconversion or HCMV specific IgM.
Lab ID
ELISA will distinguish primarily
Treatment:
Inhibitors of HCMV DAN polymerase: genciclovir (generally), cidofovir (retinitis).
13. Poxviruses
It belongs to the famili Poxviridae. Poxviruses are the largest animal viruses. The DNA is envelopped and
their virions are big enough to be seen as dots by light microscopy. It’s replication occurs in cytoplasm.
It caused variola or small pox, which is the first infectious disease to be declared as erradicated from the
world (due to availability of very effective attenuated vaccine, stable antigenic structure of variola, no
assynptomatic cases...)
Clinical features:
SMALL POX virus spreads from person to person by the respiratory route. After infecting mucosa cells in
the upper respiratory tract without producing symptoms it spreads to the regional lymph nodes and, after
transient viraemia, infected cells throughout the body. Multiplication of viruses in these cells led to a second
and more intense viraemia which heralded the onset of clinical illness. During the first few days of fever the
virus multiplied in skin epithelial cells, leading to the development of focal lesions and the characteristic
rash. Macules progressed to papules, particularly on the face. There are two kinds of smallpox: variola major
and variola minor (very mild).
Infected upper RT -> regional LN and small vessels of skin -> first viraemia -> cells of all body -> second
viraemia -> rash, bleeding, carsiovascular collapse
MOLLUSCUM CONTAGIOSUM: the lesions of this mild disease are small copper-coloured warty papules
that occur in the trunk, buttocks, arms and face. It is spread by direct contact or fomites. The lesion consists
of a mass of hypertrophied epidermis that extends into the dermis. When material from the lesion is crushed,
some of the inclusions burst open, and from them large numbers of virions escape. Lesions can persist for as
long as 2 years, and re-infection is common.
Lab ID
Observation of DNA containing intracytoplasmic inclusion bodies in cells scapped from lesion.
Immunization: Vaccinia vaccine (attenuated cowpox) is gven nowadays only in military and laboratory
workers.
14. Papillomaviruses
Papillomavirus belongs to the Papovaviridae family. They are non envelopped and have icosahedral DNA.
They infect the squamous epithelia and mucous membranes and are responsible for many varietis of warts
and fibropapillomata. Although the lesions are usually benign, their association with tumours is documented.
Clinical features
CUTANEOUS WARTS: cutaneous warts commonlyinfect the keratinized epithelium of the hands and feet,
frequently seen in young children and adolescents.
They usually disappear spontaneously but occasionally may be resistant to treatment.
ANOGENITAL WARTS: these lesions are commonest in sexually active adults. In women they are found
on the vulve, within the vagina or on the cervix.
In men the most common sites for lesions are the shaft of the penis, peri-anal skin or the anal canal.
Subclinical and latent infections of the genital tract are common.
OROLARYNGEAL LESIONS:
Recurrent respiratory papillomatosis: this is a rare condition characterized by the presence of benign
squamous papillomata on the mucosa of the respiratory tract. Peaks of incidence are in children under 5
years if age and adults after the age of 15 years. Children axquire the disease by passage through an infected
birth canal, while adults acquire the disease from orogenital contact with an ifected sexual partner. The
disease presents with hoarseness of voice or, in children, with an abnormal cry. As the lesions grow they
may cause stridor and upper airway obstruction which can be life-threatening. Malignant conversion of
laryngeal paipllomas has been described.
Oral papillomatosis: a variety os paipllomata and binign lesions associated with HPV occur in the oral
mucosa and tongue.multiple lesions may develop on the buccal mucosa. It is axquired during orogenital
contact with an infected sexual partner.
Lab ID
Diagnosis of cutaneous warts done by inspection
Immunoassay for viral antigens or DNA hybridization – important to determine if it is benign or malignant.
Treatment:
Warts generally are eitehr surgically removed or destroyed by liquid N2. Laser vaporixation or cytotoxic
chemicals.
Cidofovir – applied topically , inhibits DNA synthesis
Interferon – laryngeal papillomas
Vaccine is present
The incubation period varies widely, from 40 days to 6 months, but is often about 2-3 months. A prodromal
illness occurs in some patients, who complain of malaise and anorexia accompanied by weakness and
myalgia. Arthralgia also occurs and may be accompanied by an related to circulating immune complexes
containing HBsAg.
In the acute stage there are signs of inflammation in teh portal triads: the infiltrate is mainly lymphocytic.
In chronic hepatitis, damage extends out from the portal tracts, giving the piecemeal necrosis appearance. As
the disease progresses fibrosis develops and, eventually, cirrhosis.
Infectious HBV is present in all body fluids of infected person, so all of them can be a source of infection
ACUTE DISEASE: HBV replicates in the hepatocytes. During replication HBcAg and HBeAg are also
present at the cytoplasmic membrane. These antigens induce both B and T cell responses; damage to the
hepatocyte can result from antibody-dependent, NK and cytotoxic T cell action.
PERSISTENCE OF HBV: persistence of HBV is indicated by the continued presence of HBsAg and HBV
DNA in the blood for more than 6 months.
In the neonate, infection occurs in the presence of maternal IgG anti-HBc and tolerance to HBeAg which can
cross thew placenta. This will have the effect of masking HBcAg on hepatocyte membranes and thus will
prevent its recognition by cytotoxic T cells and other immune mrchanisms. Carriers may continue to
replicate virus to high levels without evidence of liver damage. It ends with the disappearance of HBeAg and
the appearence of anti-HBe. The change happens at a variable time after infection, but each 5-20% of
patients go through this transition, usually associated with a period of liver cell damage. This is often, but not
always, accompanied by the disappearence of HBV DNA from the blood, signalling a transition from high to
low infectivity carrier status. A carrier may undergo several episodes of hepatitis. Eventually, -hbv may
disappear in 1-2% of carriers each year.
CHRONIC LIVER DIASEASE AND HEPATO CELLULAR CARCINOMA: chronic liver damage results
from continuing, immune-mediated destruction of hepatocytes expressing viral antigens.
Hepatocellular carcinoma (HCC) is one of the 10 most frequent tumours in the world, anf there is
considerable evidence that 80% are caused by chronic infection with HBV. There may be an interval of 30-
40 years between infection and tumour development.
The mechanism of carcinogenesis is not yeat clear, although it is usually associated with cirrhosis.
The rate of progression to cirrhosis and HCC varies according to the age of infection and stage, the state of
the patient’s immune system, geographic factors and genetic factors.
Lab ID
Antibodies against HBs, Hbe and HBc
Treatment
Prolonged treatment with interferons
Prevention
Active immunization with HBsAg – children up 12 years old
Passive immunization with Hepatitis B immunoglobulin – contaminated people
16. Non-A, non-B hepatitis viruses
Hepatitis D virus
- Found in nature only as coinfection with HBV.
- Circular RNA with negative polarity that code for δ antigen (HDAg)
- Enveloped which has HBV coded HBsAg -> HBV is thus a helper virus for HDV.
Transmission: same as HBV but less sexually transmitted
Diseases: simultaneous primary coinfection with HBV that will cause acute hepatitis similar to HBV one but
with more risk of developing fulminant hepatitis and the likelihood of its progression to chronic coinfection
is greater and risk for HCC and cirrhosis are increased as well.
Primary coinfection of HDV of chronically HBV infected individuals
HBV ->incubation –> chronic HBV infection -> + HDV -> severe acute hepatitis -> chronic disease.
Lab ID
Determining δ antigen or antibodies against it.
Hapatitis C virus
Enveloped virus with 3 structural proteins. Capsid protein, viral RNA, 2 other proteins are encelop
associated.
Most common posttransfusion, intravenous drug users or on patients that are hemodyalised (also sexually
transmitted and from mother to child)
Lab ID
ELISA detection of IgM and IgG
Lab ID
ELISA detection of IgM and IgG
17. Parvoviruses
Are icosahedral andlack envelope. This family is divided into whether the virus is able of independent
replication (autonomous parvovirus) or requires coinfection with helper DNA virus (adenoassociated
viruses).
Replication
The virus attaches and penatrates into the host cell -> DNA released into the nucleus -> sysnthesis of non-
structural proteins –> sysnthesis of structural proteins and viral DNA -> assembly of virus + lysis of host cell
Replication of parvoviruses requires host cells in which DNA synthesis is in progress (the damage is limited
to specific tissues that are mitotically active, soit is not surprising that disease of haemapoetic system and the
fetus frequently feature).
Dependoviruses
Adenoassociated viruses (AVV) were isolated from children with mild disease, usually in association with
adenoviruses of different serotypes. It was first thought that only adenoviruses could supply the necessary
helper functions but more recently herperviruses, human paipllomaviruses (HPV) and vaccinia have all been
shown to be able to provide helper functions for AVV replication.
There is as yet no evidence if an association with an acute disease.
AVV is highly prevalent in the female genital tract. Infectious virions have been found in cervical epithelium
and HPV was also frequently present. AAV DNA has also been demonstrated in broncho-alveolar lavage
samples, again frequently together with HPV DNA. Teh interaction with the helper virus is beneficial to
AAV but usually inhibits the replication of the helper. AAV may therefore be beneficial to the host.
Erythroviruses (B19)
The virus is infectious when given in the form of nasal drops. One week later there is an intense viraemia
and virus is excreted in the nasal secretions. The viraemia lasts for onle a few days before there is a brisk
antibody response, initially of the IgM calss but followed rapidly by the appearence of IgG antibody.
Erythroid percursors are absent from the bone marrow and there is consequent disappearance of reticulocytes
from the peripheral blood and a small fall in the hemoglobin level.
The rash and arthralgia associated with B19 infection occur during the third week after inoculation. They
follow the disappearance of the viraemia and occur at a time when there is an easily detectable immune
response it is assumed that the rash and arthralgia are immune mediated.
In infected fetuses there appears to be a persistent infection with damage to hematopoietic cells, leading to
anaemia, which is one of the factors responsible for hydrops fetalis. The reason is that sich indiciduals
produce only small amounts of antibody in response to infection and none of it is capable of neutralizing the
virus.
18. Poliovirus
Are small , non enveloped, icosahedral virus with single-stranded RNA with positive polarity.
The poliviruses. Coxsakieviruses and echoviruses are described as enteroviruses because they are all found
in the intestines and are excreted in the feaces.
Specific neutralizing antibodies are considered to be the major mechanism of protection against infection.
Enteroviruses have a number of features in common:
- They attach to cells in the intestinal tract by specific receptor sites and replicate in cells of the
intestinal tract.
- Theu commonly cause asymptomatic immunizing infections, which protect against future
infectionswith the sme virus.
- They can give rise to viraemia
- They occasionally cause infection of the central nervous system and other target organs.
- They are commoner in children than in adults
Polioviruses have affinity for the nervous tissue. There are 3 types of poliovirus infection:
1. Asymptomatic infection or a mild, transient „influenza-like― illness. The virus us excreted in the
faeces for a limited time, and an immunological response develops which portects against re-
infection with the same strain.
2. Infections with the same ssymptoms as above and evidence of the involvement of the central
nervous system with headache, neck stiffness and back pain (meningitis).
3. Paralytic poliomyelitis in which the patient develops paralysis. The paralysis is usually flaccid due
to the destruction of lower motor neurones, although invasion of the brain stem by the virus can
lead to inco-ordination of muscle groups and painful spasms
Pregnat women in the third trimester of pregnancy can have severe disease, but there is no firm evidence of
congenital defects in infants born to mothers with poliomyelitis. Maternal infection axquired late in
pregnancy may lead to perinatal infection and disease of the newborn.
Treatment: symptomatic
Prevention
Live attenuated (Sabin) or attenuated (Salk) poliovaccines
19. Enteroviruses other than poliovirus
Echoviruses: most echovirus infections cause few or no clinical symptoms. Infection can be widespread in a
community, although only a few suffer from clinical illness. Symptoms occur following a short incubation
period of 3-5 days (simple fever, upper respiratory symptoms or diarrhoea). Non-specific rashes of fleeting
duration have been reported.
The onset the meningitis is abrupt, with severe headache and vomiting. Symptoms are self-limiting, and after
a variable convalescent period a full recovery is made, although rare cases of paralysis have been recorded.
Certain types cause haemagglutination of human group O erythrocytes. The virus reacts with a receptor
present on group O cells. Temperature, pH and age of the red blood cell donor influence this property.
Coxsackieviruses:
Groups A – these viruses give rise to a number of different illnesses. Aseptic meningitis, indistinguishable
clinically from that caused by other enteroviruses. Herpangina is an acute feverish disease, usually in young
children, characterized by lesion in the mouth cinsisting of papules on the anterior pillars of the fauces.
Hand, foot and mouth disease presents as a painful stomatitis with a vesicular rash on the hands and feet.
Group B – Epidemic myalgia is characterized by fever and the sudden onset of agonizing stich-like pains in
the muscles of the chest, epigastrium and hypochondrium.
21. Orthomyxoviruses
Enveloped RNA with its own RNA-dependent RNA transcriptase that synthesizes viral mRNA from RNA.
It has an helical nucleocapsid from which the segment contains not only viral RNA but also 4 proteins: NP
(nucleocapsid protein) and 3 proteins involved in the synthesis and replication of viral DNA). Its replication
occurs in the nucleus.
The viruses are divided into Influenza A, B and C but only A and B have medical importance.
They have haemaglutinin (H protein) and neuraminidase (N protein) as the 2 spikes proteins on the surface.
Pathogenesis
The virus is transmitted by respiratory droplets. The destruction of respiratory epithelial cells is attributed to
host immune response, specifically cytotoxic T-cells. The symptoms are chills, high fever, muscle aches and
extreme drowsiness. The disease lasts 4-5 days after which there is a gradual recovery. There is a risk of
development of pneumonitis in elderly people, young people or people with chronic cardiac or pulmonary
problems.
Types and subtypes
Influenza virus is classified as type A, B and C depending on their M and NP proteins. Thus all type A
viruses share common internal antigens different from those shared by B.
Classification into subtypes depends on antigens associated with H and N proteins. Human influenza viruses
are therefore classified into H1N1, H2N2, H3N2...
Antigenic drift: minor antigenic changes in H and N proteins that occur each year
Antigenic shift: involve change of subtype H1N1 -> H3N2 (occurs each 10-20 years)
The consequences of this antigenic variation is that people become immunologically unprotected which
might give rise to an epidemics or even pandemics.
If there is antigenic shift a new vaccine needs to be taken. antibodies made against H protein are
neutralizing.
Treatment
Given before disease or early stages: Amantadine and Rimantadine - they stop viral uncoating by inhibition
of M2 membrane protein -> INFLUENZA A
For uncomplicated acute illness in adults and adolescents 12 years or more. Zanamivir (inhalation) and
oseltamivir (orally) are given. -> INFLUENZA A + B
Prevention
Formalin inactivated Influenza virus vaccine is recommended for the elderly people in high risk groups or
patients with chronic pulmonary or cardiac disease.
22. Respiratory syncitial viruses and parainfluenza virus
Respiratory syncytial virus
RS virus is placed in the genus Pneumovirus because of a lack of a haemagglutinin, a haemolysin or a
neuraminidase. The nucleic acid is negative-sense single-stranded RNA . RS virus has no haemagglutinin
but has a G glycoprotein instead. It is a receptor for cell attachment but not red blood cells, and differs in
chemical compisition from the HN protein of other paramyxoviruses. There are fusion (F), matrix (M),
polymerase and nucleocapsid proteins. The F proteins is probably responsible for both virus penetration and
spread in the host.
There are two subtypes, A and B.
The most serious illness caused by RS virus is bronchiolitis in young babies leading to hyperinflation of the
lungs but it is also associated with minor upper tract infections. This infection is potentially life-threatening,
particularly in those who are immunosuppressed or immunodeficient.
Recovery is apparently complete, although it has been suggested that the infection predisposes to chronic
respiratory tract disease (asthma, bronchiectasis, etc).
Parainfluenza virus
Parainfluenza is a negatively-stained virions. The outer surface of the virion is a pleomorphic envelope
consisting of a lipoprotein membrane derived from host cell membrane and covered by projections.
Paramyxovirus particles are easily deformed by external forces, may assume a variety of shapes and break
up more easily than orthomyxoviruses.
The envelope surface projections are of two kinds:
- The HN, with heamagglutinin (H) and neuraminidase (N) functions.
- F glycoproteins, which cause cell membranes to fuse
There are also matrix proteins, M which line the inner surface of the envelope. All the paramyxoviruses
carry an RNA-dependent RNA polymerase within the virion.
Within the enveloped virion is a genome of single-stranded negative-sense RNA complexed with protein to
form a helical nucleocapsid.
Therw are four types of parainfluenza viruses (1-4) with antigenically distinct epitopes.
Parainfluenza viruses attach via the haemagglutinin to sialic acid containing receptors on the cell surface.
The F protein then fuses the viral envelope with the cell membrane. RNA-dependent RNA polymerase
carried within the virion is required to produce subgenomic-sized mRNA transcripts, which are translated to
produce some of the early virus-specific polypeptides.
The viral components are assembled beneath the cell membrane and the surface HN and F proteins are
incorporated into a stretch of membrane, converting it to viral envelope. This evaginates and buds off,
enclosing a nucleocapsid.
The parainfluenza viruses are mostly associated with:
- Croup, a harsh brassy cough in children. It is due to a combination of tracheitis and laryngitis
- Minor upper respiratory tract illness
- Some cases of bronchiolitis and ―failure to thrive‖
The incubation period is from 3 to 6 days, during which the virus spreads locally within the respiratory tract.
Both viruses are transmitted by respiratory dropletsor contaminated hands carrying the viruses to nose or
mouth.
Treatment
Ribovirin admintrated by aerosol.
23. Mumps virus
It is an enveloped virus, with negative polarity RNA, which belongs to the paramyxoviridae family. The
spikes on the envelope carry either a combined haemogglutinin and neuraminidase (HN) or a fusion (F)
protein. The envelope also contains a matrix (M).
Infection is probably by droplet into the respiratory tract. The incubation period is 14-18 days and is
followed by generalized illness with localization in the salivary gland, usually the parotids. The generalized
phase is the usual ―flu-like‖ illness with fever and malaise, followed by developing pain in the parotid
glands, which then swell rapidly. Much of the swelling is due to the blockage of the efferent duct.
Neurological involvement is common in mumps though the majority of cases are not clinically apparent.
However, clinical meningitis remains the most common serious complication of mumps.
Mumps meningitis is rarely fata and complete recovery is usual. Meningo-encephalitis has been described,
but is much rarer.
The best known complication, in postpubertal males, in orchitis. This, though painful and causing softening
and atrophy of the affected testicle, is usually unilateral and rarely causes sterility. Oophoritis also occurs in
girls.
Prevention
Live attenuated vaccine present (MMR)
24. Measles virus
Measles is an enveloped virus with single stranded RNA from the genus morbilivirus.
It has some important functional differents. The virion structure includes:
- spikes, carrying a haemagglutinin but not a neuraminidase function
- an F protein that is also a haemolysin
- a matrix protein, M, below an envelope lipid bilayer
There is only one serotype of measles virus.
Measles is an acute febrile illness, mostly in childhood, after an incubation period of 10-12 days. The onset
is the ―flu-like‖, with high fever, cough and conjunctivitis. Koplik’s spots (red spots with a bluish-white
centre on the buccal mucosa) may be present at this stage. After 1-2 days the acute symptoms decline, with
the appearance of a widespread maculopapular rash.
Over the next 10-14 days, recovery is usually complete as the rash fades, with considerable desquamation.
Complications include:
- giant cell pneumonia, more common in adults
- otitis media
- post-measles encephalitis
The pneumonia is due to direct invasion with virus, but the role of virus in the other two is uncertain.
Measles encephalitis can cause severe and permanent mental impairment in those it does not kill. It is rare
but disastrous.
One further complication of measles is subacute sclerosing panencephalitis (SSPE), which occurs in
children or early adolescents who have had measles ealy in life, usually under 2 years of age. It is a
progressive and inevitably fatal degenerative disease. Within infected cells is a defective form of measles
virus, which, because it is unable to induce the production os a functional M protein, is not released as
complete virus from the cells. Patients deteriorate over several years, losing intellectual capacity before
motor activities.
Treatment
Life attenuated vaccine (MMR)
25. Arboviruses: alphaviruses
Alphaviruses are an enveloped, RNA virus. It has 3 structural proteins: C protein, E1 and E2 proteins
(glycoproteins that form hemagglutinin containing spikes that project from lipid bilayer).
Alphaviruses ester cells by receptor-mediated endocytosis. The nucleocapsid id then released into the
cytoplasm where it binds to ribosomes, and the non-structural proteins are translated directly from the
genomic RNA.
Infection by arboviruses is initiated when mosquitoes or other arthropods deposit saliva in extravascular
tissues while blood-feeding. The initial site of replication is the Langerhans cell. Alphavirus replication
appears to stimulate:
- the migratory response of the Langerhans cell to the lymph nodes
- the accumulation of leucocytes in the draining lymph node, where local replication produces
viraemia
Arboviruses induce high titres of viraemia. 1-4 days after parenteral inoculation or following bites by
infected arthropods.
Inoculation of α-viruses by mosquito -> patient has viraemia -> viruses may be seeded in various target
organs (e.g. CNS in encephalitis virus)
Invasion of the central nervous system (CNS) via the olfactory nervous tract may ensue in some infections
while other viruses cross the blood-brain barrier. In alphaviral infections accompanied by rash and arthritis,
virus replication and necrosis occurs in the epidermis and possibly the muscles, tendons and connective
tissue. Infection of macrophages may mediate musculoskeletal pathology via suppression of cytokine
induction.
Antibodies are first detected when the fever subsides, usually within 5-10 days after infection, and may
persist for many years. Antibodies are of the IgM class for 1-7 weeks after incubation; subsequently they are
of the IgG class.
Arboviruses capable of producing encephalitis typically cause a spectrum of disease:
· in apparent infection
· acute encephalitis
Within the central nervous system, arboviruses multiply in and induce necrosis of neurons, which in turn
become surrounded by microglia, forming glial knots.
Perivascular cuffing with mononuclear cells affects many cerebral blood vessels. Usually there is
concomitant meningitis with accumulation of mononuclear cells in the subarachnoid space and hyperemia of
adjacent capillaries.
The tissue tropism of arboviruses can be divided into three categories:
· infections of the CNS (e.g. encephalitis, aseptic meningitis)
· infections of the visceral organs (e.g. hepatitis and hemorrhagic fevers)
· febrile infections
Treatment
Venezuelan equine encephalitis vaccine
Treatment
Live attenuated vaccine yellow fever
Formalin inactivated vaccine
Rubella is a single-stranded RNA virus with an envelope and is the only member of the genus
Rubivirus. It an icosahedralcapsid and there are 3 major virion plypeptides: C and the envelope
glycoproteins E1 and E2.
Only one antigenic type of rubella virus is recognized.
POSTNATAL RUBELLA: the incubation period for postnatal primary rubella is 12-21 days. Virus
may be excreted in the throat for up to a week efore and after the rash. The characteristic clinical
features are:
· A macular rash, which usually appears first on the face and then spreads to the trunk and
limbs
· General features such as minor pyrexia, malaise and lymphadenopathy also occur, with the
suboccipital nodes being those most commonly enlarged and tender
· Arthralgia is uncommon in children but may occur in up to 60% of adult females. The joints
commonly involved are the fingers, wrists, ankles and knees
· Encephalitis and thrombocytopenia are rare complications of rubella and usually recovery is
complete
Rubella appears to prezent to prezent little danger to the immunocompromised patient, in whom the
clinical features are similar to those seen in normal individuals.
CONGENITAL RUBELLA: in the fetus is infected during a primary Materna infection a wide spectrum
of abnormalities may occur. The classical congenital rubella syndrome (CRS) triad consists of
abnormalities of the eyes, ears and heart.
Abnormalities of the eyes include cataracts, micro-ophtalmia, glaucoma and pigmentary retinopathy,
which may result in blindness.
Bilateral or unilateral sensorineural deafness may be present at birth.
There are many possible heart defects, with a patent ductus arteriosus, pulmonary artery and valvular
stenosis, and ventricular septal defect being the most common
Rarely, a persistent infection of the central nervous system occurs called progressive rubella subacute
panecephalitis, which is similar to the subacute sclerosing encephalitis cause by measles
Pathogenesis
Rubella virus is transmitted by the air-borne route. Infection is established in the upper respiratory tract,
and, towards the end of the incubation period, a viraemia occurs and seeds the target organs such as the
skin and joints. Most of the clinical features are probably a consequence of the host’s immune response
to the virus.
During the viraemia the virus is able to infect the differentiating cells of the fetus.
Treatment
Live attenuated rubella vaccine given routinely during childhood
29. Arenaviruses
Members of the family Arenaviridae have a single-stranded RNA genome. The genome has two segments: L
(large) and S (small). The virions are spherical enveloped particles. The genome is encapsid in a helical
nucleocapsid. The lipid envelope is derived from the plasma membrane.
The virions contain not only virus genome but also host ribosomes.
The arenaviruses that affect humans are grouped as New World and Old World viruses.
Replication
Arenaviruses can replicate in a number of mammalian hosts and in most tissues. Growth is restricted in
terminally differentiated cells such as lymphocytes or macrophages.
Treatment
Ribavirin benifits both lassa fever and southamerican haemorrhagic fever.
30. Filoviruses
Marburg and Ebola, the two members of the Filoviridae, are enveloped viruses with a single-stranded,
unsegmented, helical nengative sense RNA genome.
Infection was related directly or indirectly to blood or tissues of vervet monkeys.
Replication
Filoviruses can be grown in a variety of cell lines. The mode of entry is not known but is pressumed to
involve membrane fusion. Filovirus replication takes place in the cytoplasm and the large inclusions are
formed. Mature virus is released as nucleocapsids bud through areas of plasma membrane.
Lab ID
made by ELISA of antiviral antibodies
Treatment
Supportive treatment is all that can be offered to patients.
Rotaviruses
Rotavirus infections are usually mild to moderately severe in developed countries but can become very
severe and cause high mortality in developing countries. Rotavirus also cause diarrhoea.
Pathogenesis
Rotaviruses replicate exclusively in the differentiated epithelial cells at the tips of the villi of the small
intestine. Progeny virus is released in large numbers into the intestinal lumen ready to infect other cells.
Biopsies show atrophy of the villi with reactive crypt hyperplasia and lymphocytic infiltrates in the lamina
propria. The cellular damage leads to malabsorption of nutrients, electrolytes and water, and the crypt
hyperplasia to hypersecretion.
The infection is followed by a local, humoral and cell-mediated immune response and s normally overcome
within a week. Rotavirus-specific IgA enteric antibodies, which are secreted into the gut, are the best known
correlate of protection.
Clinical features
The onset of symptoms is abrupt after a short incubation period of 1-2 days. Diarrhoea and vomiting are seen
in the majority of infected children and last for 2-6 days. Although symptoms of respiratory tract infection
are frequently observed at the time of rotavirus infections.
Rotavirus infections can be life-threatening if children are already malnourished.
Lab ID
ELISA for antiviral antibodies
Treatment
Rapid and efficient replacement of fluids and electrolytes IV.
Replication
Retroviruses differ from other RNA viruses in that they replicate and produce viral RNA from DNA copy of
the virion RNA. The best studied method of attachment of HIV to cells is by the interaction of the external
envelope glycoprotein gp120 with part of the CD4 molecule of T helper lymphocytes and other clls.
After this, entry of the virus occurs by fusion of the viral envelope with the cellular membrane. Once the
RNA is released into the cytoplasm, the reverse transcriptase acts to form the double-stranded DNA copy,
which is circularized, enters the nucleus and is spliced into the host cell DNA . Once inserted into the host
DNA, infection with HIV is permanent. The virus may stay latent or enter a productive cycle.
Clinical features
HTLV-1 infection
It is associated with adult T cell leukemia/lymphoma. The disease is an acute T cell proliferative
malignancy; clinically, the features are leukemia, generalized lymphadenopathy and hepatosplenomegaly
with bone marrow and skin involvement. Also a non-Hodgkin T cell lymphoma is associated with HTVL-1.
HTVL-1 is the cause of a neurological disease, tropical spastic paraparesis.
Lab ID:
Detection of antibodies to the virus: tests for anti-HIV
Detection of the virus itself: PCR, tests for p24 anrtigen, virus isolation
Treatment
- HTVL-1
Interferon and inhibitors of reverse transcriptaase may have a role.
- HIV
Therapy: combination of antiretrovirotics (HAART = highly active antiretroviral treatment)
zidovudin, lamivudin, nevirapin, saquinavir etc.
Pathogenesis
Replication occurs in the jejunum. The villi in the proximal part of the small intestine were broadened and
blunted, and the enterocytes covering the damaged villi were cuboidal and vacuolated. At the same time the
numbers of intra-epithelial lymphocytes and neutrophils were increased. Epithelial cells remained intact but
the microvilli were disarranged and reduced in length.
The symptoms are similar between calicivirus and astrovirus, but vomiting, sometimes projectile, is more
frequently reported in calicivirus infection involving adults the illness resembles ―gastric flu‖, i.e. diarrhoea,
headache, fever, aching limbs and malaise.
Transmission
Fecal-oral route folowing ingestion of contaminated food or water (cold foods, shellfish, water, etc)
Lab ID
antiviral antibodies by ELISA
Treatment
No specific treatment for these infections.
34. Coronaviruses
The most studied coronaviruses are IBV (infectious bronchitis virus) and MHV (mouse hepatitis virus). The
particles are pleomorphic and enveloped.
The genome is encoded in non-segmented single-stranded positive-sense RNA.
It is now accepted that there two species of human coronavirus (HCoV) causing respiratory disease. Human
enteric coronavirus (HECV) is a likely third species.
The confirmed species os coronavirus may readily be distinguished from each other by their limited host
range. Serological studies of the N, M and S proteins have revealed antigenic relationships.
Coronavirus attach to either protein or carbohydrate on host cells. The viruses replicate in the cytoplasm with
a growth cycle. They bud not from the plasma membrane but from the rough endoplasmic reticulum into
intracytoplasmic vesicles. These are transported via the Golgi apparatus to the plasma membrane through
which they are released by exocytosis.
Clinical features
Coronavirus show:
- marked species specificity
- strong tissue tropism
They usually infect via the gut and/or respiratory tract. Infections of the liver and CNS are well recognized.
Coronaviruses can also infect neural cells, in which they may persist, and macrophages.
HUMAN CORONAVIRUS: the only significant condition known to follow HCoV infection is upper
respiratory tract disease, and it is estimated that coronaviruses cause up to 30% of ―common colds‖.
Coronaviruses may cause severe lower respiratory tract infection in the very old and very young, including
premature infants.
There is some evidence that they may cause pneumonia in immunocompromised patients. The incubation
period is from 2 to 4 days. Symptoms outlast virus shedding and typically persist for a week, probably as a
result of secondary-bacterial infection.
- CNS INVOLVEMENT: these viruses are undoubtedly neuro-invasive and they may have a role in the
aetiology of multiple sclerosis, but whether their presence is causative or incidental is presently unclear.
Treatment
Symptomatic only
35. Rhabdovirus
Members of the family must be enveloped, single-stranded RNA viruses. Two genera are known whose
members have important roles in animal or human disease.
This genus has rabies virus as its prototype. Lyssavirus has rabies virus as its prototype. Vesiculovirus,
whose members are associated with the disease vesicular stomatitis.
Transmission: raccoons, skunks, squirrels, foxes and bats work as reservoirs. Bite of an animal infects
humans.
Rabies is a distressing disease that develops rapidly into an acute encephalomyelitis, often frenzied initially,
then subsiding into delirium, coma and death. A prominent feature is hydrophobia.
Rabies virus typically is bullet-shaped. Its inner nucleoprotein core of single-stranded RNA enclosed in
nucleoprotein (N) with helical symmetry provides the group antigen for the genus.
The viral membrane or matrix (M) protein lies between the core and the outer lipoprotein envelope.
Extraction of the outer envelope releases a glycoprotein (G) that can induce the formation of neutralizing
antibody.
Virus attaches via the glycoprotein of the envelope. In neural tissue virus attachment occurs at
neuromuscular junctions via the acetylcholine receptors. Entry is by endocytosis. Replication occurs in
cytoplasm.
Accumulation of cytoplasmic viral protein inclusions (Negri bodies) may be visible by light microscopy after
appropriate staining. This has long been a useful diagnostic feature.
Clinical features
Rabies may present as a:
- Predominantly encephalitic disease – furious rabies
- Paralytic illness – dumb rabies
In humans, about two-thirds suffer the encephalitic form and die within 7 days, the rest initially present as
paralytic the develop encephalitis, and death may not occur for 2-3 weeks. Survival is exceedingly rare.
The incubation period in humans can be very variable.
The virus spreads to gain access to the nerves via the motor end plates. Once within the nerve fibers it is out
of reach of any circulating antibody as it travels along the axons towards the central nervous system. The
manifestations of illness are:
- Initially, fever, malaise and headache
- Then, symptoms related to the wound site e.g. tingling, pain, lumbar weakness and ascending
paralysis after leg bites, and numbness, hyperesthesia and pain with increasing shoulder weakness
after hand or arm bites.
Diagnosis
Postmortem – Negri bodies
Viral nucleic acid by PCR
Prevention
Killed rabies virus vaccine
Post exposure: thorough cleaning of wound + passive immunization with antirabies immunoglobulins
Pathology
Extracerebral exposure to prions results in their multiplication in lymphoreticular and other peripheral tissues
after infection but infection of CNS results in typical clinical effects. Accumulation of PrP in form of
amyloid fibrils (cytoplasmic vesicles in neurons, extracellular amyloid plaque) -> extensive vacuolation,
neuronal loss and microglial proliferation.
Symptoms: CDJ: rapidly progressive dementia, behavioral disturbances ending in death within a year.
Prevention:
Decontamination of CDJ brain specimen, animals showing signs of illness are killed.
MYCOLOGY / PARASITOLOGY
Some yeasts are commensals of man and cause endogenous infections when there is some imbalance in the
host. Only ringworm (dermatophyte) infections are truly contagious.
Types of infection
SUPERFICIAL MYCOSES: diseases of the skin, hair, nail and mucous membranes are the most common of
all fungal infections.
· Ringworm is a complex of diseases affecting the keratinous tissues of hair, nail and the horny layer
of the skin; it is caused by a group of closely related mould fungi called dermatophytes which can
colonize and digest keratin.
· Yeast infections affect the skin, nail and mucous membranes of the mouth and vagina, and are
usually caused by commensal Candida species. Infection is generally endogenous in origin but
genital infection can be transmitted sexually.
SUBCUTANEOUS MYCOSES: they result from the traumatic inoculation of saprophytic fungi from soil or
decaying vegetation into the subcutaneous mycoses are mycetoma, chromomycosis and sporotrichosis
SYSTEMIC MYCOSES: deep-seated fungal infections generally result from the inhalation of air-borne
spores produced by the casual moulds, present as saprophytes in soil and on plant material. They are mostly
caused by dimorphic fungi.
· Coccidioidomycosis
· Blastomycosis
· Histoplasmosis
· Paracoccidioidomycosis
These infections are being seen with increasing frequency in patients compromised by disease or drug
treatment. In transplant patients, for example, these fungi are among the most frequent causes of mortality
due to infection.
Pathogenesis
It is clear that infection most often arises due to deficiencies in the host rather than because of any inherent
pathogenic properties of the fungus.
Antigenic variation on the surface of Candida cells may help the organism to avoid host defenses. Cellular
immunity is suppressed by cell wall mannan, the capsular mucopolysaccharide and melanin.
Pathogenesis
Sometimes there is only dry scaling or hyperkeratosis, but more commonly there is irritation, erythema,
edema and some vesiculation. More inflammatory lesions with weeping vesicles, pustules and ulceration are
usually caused by zoophilic species.
Treatment
Removal of infected skin, topical application of antifungal antibiotics such as miconazole or
clotrimazole.
Oral antifungals are required to treat infections of the nail and scalp.
Superficial candidosis
Superficial Candida infections involving the skin, nails and the mucous membranes of the mouth and
vagina are very common. Candida albicans accounts for 80-90% of cases, but other species, notably
C. tropicalis, C. krusei, C. glabrata, C. parapsilosis, C. guilliermondii and C. lusitaniae may occur.
Candida species, usually C. albicans, are found in small numbers in the commensal flora.
Yeast overgrowth and infection occur when the normal microbial flora of the body is altered or when
host resistance to infection is lowered by disease.
Pathogenesis
Mucosal infection: this is the commonest form of superficial candidosis. Discrete white patches
develop on the mucosal surface.
In oral candidosis white flecks appear on the buccal mucosa and the hard palate and the surrounding
mucosa is red and sore. Infection may spread to the tongue.
Vaginal infection: itching, soreness and non-homogeneous white discharge accompany typical white
lesions on the epithelial surfaces of the vulva, vagina and cervix. The perivulvar skin may become
sore and small satellite pustules may appear around the perineum and natal cleft. Vaginal candidosis
is common, especially during pregnancy.
Chronic oropharyngeal candidosis: may extend to give esophageal infection, is very common in
AIDS patients.
Skin and nail infection: Candida infections of the skin almost invariably occur at moist sites such as
the axillae, groin, perineum, submammary folds and occasionally the toe clefts.
Chronic mucocutaneous candidosis: this is a rare form of candidosis. Takes the form of a persistent,
sometimes granulomatous, infection of the mouth, skin and nails.
Lab ID
Candida species grow well on Sabouraud medium or on blood agar at 25-37ºC.
Treatment
Most superficial infections respond well to topical therapy with an imidazole. In oral candidosis,
miconazole is used.
Pathogenesis
Small, well demarcated, non-inflammatory, scaling macules are usually present on the upper trunk or neck;
these may appear hypopigmented or hyperpigmented.
Treatment
Pityriasis vesicolor responds well to selenium sulphide or azoles.
Hair
White piedra: this disease, caused by the yeast Trochosporon beigelii, results in soft, white greyish or light-
brown nodules on the hair shafts, mainly in the axillae. The hair often breaks at the point of infection,
leaving hairs with a clubbed or swollen end. Shaving of the affected area is usually sufficient to effect a cure.
Black peidra: caused by Piedraia hortae, is characterized by the presence of black, hard nodules up to 1 mm
in diameter. Shaving to remove infected hairs is a satisfactory treatment.
Otomycosis
About 10-20% of chronic ear infections are due to fungi. The commonest causes are species of Aspergillus,
in particular A. niger. Treatment with topical antifungals is usually successful, although relapse is common.
Mycotic keratitis
Fungal infections of the cornea are secondary to injury, bacterial infection and treatment with antibacterial
agents and steroids. They are caused by Aspergillus and Fusarium species. Treatment is with topical
antifungal agents, in particular natamycin.
4. Subcutaneous mycoses
Mycetoma
Mycetoma is a chronic, granulomatous infection of the skin, subcutaneous tissues, fascia and bone, which
most often affects the foot or the hand. It may be caused by one of a number of different actinomycetes
(actinomycetoma) or moulds (eumycetoma). Infection follows traumatic inocculation of the organism into
the subcutaneous tissue from soil or vegetable sources, usually on thorns or splinters.
A large number of organisms have been implicated in this disease, including species of Madurella,
Exophiala, Acremonium, Pseudallescheria, Actinomadura, Nocardia and Streptomyces. Within host tissues
the organisms develop to form compacted colonies.
Pathogenesis
Localized swollen lesions, which develop multiple draining sinuses, are usually found on the limbs.
There is often a long period between the initial infection and formation of the characteristic lesions; spread
from the site of origin is unusual but may occur.
Treatment
Actinomycetoma responds well to rifampicin in combination with sulphonamides or co-trimoxazole. In
eumycetoma, chemotherapy is ineffective and radical surgery is usually necessary.
Chromoblastomycosis
Is a chronic, localized disease of the skin and subcutaneous tissues, characterized by crusted, warty lesions
usually involving the limbs. The principal causes are Fonsecaea pedrosoi, F. compacta, Phialophora
verrucosa and Cladosporium carrionii.
Treatment
Promising results have been obtained with terbinafire and with itraconazole either alone or in combination
with flucytosine.
Phaeohyphomycosis
Non-specific solitary subcutaneous lesions caused by any black fungus. Diagnosis is often made at surgery,
and treatment is by excision.
Sporotrichosis
Is a chronic, pyogenic granulomatous infection of the skin and subcutaneous tissues which may remain
localized or show lymphatic spread. It is caused by Sporothrix schenckii.
Pathogenesis
Most frequent presents as a nodular, ulcerating disease of the skin and subcutaneous tissues, with spread
along local lymphatic channels. Typically, the primary lesion is on the hand with secondary lesions
extending up the arm. The primary lesion may remain localized or disseminated to involve the bones, joints,
lungs and, in rare cases, the CNS. Disseminated disease usually occurs in debilitated or immunosuppressed
individuals.
Treatment
Prolonged therapy is usually required. For the cutaneous form, treatment with potassium iodide or
itraconazole is satisfactory. In disseminated disease, intravenous amphotericin B is required.
Treatment
Intravenous amphotericin B is the standard therapy, but oral fluconazole, itraconazole or ketoconazole are
also used.
Histoplasmosis
H. capsulatum is found in soil enriched with the droppings of birds and bats, and infection results from the
inhalation of spores.
Pathogenesis
Most infections arre asymptomatic. Sometimes an acute influenza-like illness develops with fever and a non-
productive cough. These infections are usually self-limiting, but patients are frequently left with discrete,
calcified lesions in the lung.
Pathogenesis
Infection follows inhalation of the cells or basidiospores of C. neoformans which, in nature, are thought to be
small, allowing the organism to enter deep into the lung. The disease is more common in the men than
women.
A mils, self-limiting pulmonary infection is believed to be the commonest form of cryptococcosis. Lesions
may take the form of small discrete nodules, which may heal with a residual scar or may become enlarged,
encapsulated and chronic (cryptococcoma form).
The meningeal form of cryptococcosis can occur in apparently healthy individuals, but occurs most
frequently in patients with abnormalities of T lymphocyte function.
Treatment
In immunocompetent individuals, cryptococcosis may be treated with oral fluconazole or itraconazole.
Intravenous amphotericin B in combination with flucytosine is usually the treatment of choice for
immunocompromised individuals.
Aspergillosis
The most important are A. fumigatus, A. niger, A. flavus, A. terreus and A. nidulans
Pathogenesis
ALLERGIC ASPERGILLOSIS: Asthma with eosinophilia is a more chronic form, which manifests as
episodes of lung consolidation and fleeting shadows on chest radiography; the fungus grows in the airways
to produce plugs of fungal mycelium which may block off segments of lung tissue and which, when coughed
up, are a diagnostic feature.
ASPERGILLOMA: The fungus colonizes preexisting (often tuberculous) cavities in the lung and forms a
compact ball of mycelium, eventually surrounded by a dense fibrous wall.
Patients are either asymptomatic or have only a moderate cough and sputum production. Surgical resection is
most often used to treat this condition.
INVASIVE ASPERGILLOSIS: this form occurs in severely immunocompromised individuals who have
serious underlying illness. Neutropenia is the most common predisposing factor and A. fumigatus is the
species most frequently involved.
The lung is the sole site of infection in 70% of patients, but dissemination of infection to other organs occurs
in many cases. Fungus invades blodd vassels, causing thrombosis; septic emboli may spread the infection to
other organs, especially the kidneys, heart and brain.
PARANASAL GRANULOMA: A. flavus and A. fumigatus may colonize and invade the paranasal sinuses
and the infection may spread through the bone to the orbit of the eye and brain.
Treatment
Allergic forms of aspergillosis are treated with corticosteroids. Aspergilloma is treated by surgical excision.
In invasive aspergillosis, the treatment of choice is intravenous amphotericin B.
Systemic candidosis
An iatrogenic infection encountered among certain groups of hospital patients, who carry more yeasts in the
mouth and gastro-intestinal tract than the normal population.
Infection may be localized, e.g. in the urinary tract, liver, heart valves (endocarditis), meningites or
peritoneal cavity, or may be widely disseminated and associated with a septicaemia (candidaemia).
Candidaemia is seen mainly in postoperative or immunosuppressed patients; in some patients it clears
spontaneously, or disappears when contaminated intravenous catheters are removed. However, some patients
with candidaemia, notably those treated with cytotoxic drugs or corticosteroids, develop generalized or
localized deep-seated infection.
Common sites of involvement in disseminated infection include the kidney, liver, spleen, brain and gastro-
intestinal tract; pulmonary infections are rare. One common sign of deep-seated candidosis is the presence of
white lesions within the eye (Candida endophthalmitis). Candida endocarditis usually follows surgery for
valve replacement.
C. albicans accounts for most cases of systemic candidosis.
Treatment
The treatment of choice for most forms of systemic candidosis are:
- intravenous amphotericin B (conventional or liposomal)
- intravenous or oral fluconazole
Zygomycosis
Ia relatively rare, opportunistic infection caused by saprophytic mould fungi, notably species of Rhizopus,
Mucor and Absidia.
The best known form of the disease is rhinocerebral zygomycosis, a rapidly fulminating infection which is
almost invariably associated with acute diabetes mellitus, or with debilitating diseases such as leukaemia or
lymphoma. There is extensive cellulitis with rapid tissue destruction, most commonly spreading from the
nasal mucosa to the turbinate bones, paranasal sinuses, orbit and brain. The condition is rapidly fatal if
untreated.
Pulmonary and disseminated infections can occur in severely immunocompromised individuals.
Treatment
High doses of intravenous amphotericin B control of any diabetes and aggressive surgical intervention.
7. Antifungal drugs
- Amphothericin B and Nystatin bind to ergosterol present in cell membranes of fungal cell. There they
form pores that disrupt membrane function, resulting in cell death.
- Imidazole antifungal drugs (= clotrimazole) and triazole antifungal drugs (fluconazole) block
demethylation of lanosterolto ergosterol
* amphotericin B + flucytosine - broad spectrum antimycotics
* nystatin, clotrimazole - local antimycotic
8. Candida
Superficial candidosis
Superficial Candida infections involving the skin, nails and the mucous membranes of the mouth and
vagina are very common. Candida albicans accounts for 80-90% of cases, but other species, notably
C. tropicalis, C. krusei, C. glabrata, C. parapsilosis, C. guilliermondii and C. lusitaniae may occur.
Candida species, usually C. albicans, are found in small numbers in the commensal flora.
Yeast overgrowth and infection occur when the normal microbial flora of the body is altered or when
host resistance to infection is lowered by disease.
Pathogenesis
Mucosal infection: this is the commonest form of superficial candidosis. Discrete white patches
develop on the mucosal surface.
In oral candidosis white flecks appear on the buccal mucosa and the hard palate and the surrounding
mucosa is red and sore. Infection may spread to the tongue.
Vaginal infection: itching, soreness and non-homogeneous white discharge accompany typical white
lesions on the epithelial surfaces of the vulva, vagina and cervix. The perivulvar skin may become
sore and small satellite pustules may appear around the perineum and natal cleft. Vaginal candidosis
is common, especially during pregnancy.
Chronic oropharyngeal candidosis: may extend to give esophageal infection, is very common in
AIDS patients.
Skin and nail infection: Candida infections of the skin almost invariably occur at moist sites such as
the axillae, groin, perineum, submammary folds and occasionally the toe clefts.
Chronic mucocutaneous candidosis: this is a rare form of candidosis. Takes the form of a persistent,
sometimes granulomatous, infection of the mouth, skin and nails.
Lab ID
Candida species grow well on Sabouraud medium or on blood agar at 25-37ºC.
Treatment
Most superficial infections respond well to topical therapy with an imidazole. In oral candidosis,
miconazole is used.
Systemic candidosis
An iatrogenic infection encountered among certain groups of hospital patients, who carry more yeasts in the
mouth and gastro-intestinal tract than the normal population.
Infection may be localized, e.g. in the urinary tract, liver, heart valves (endocarditis), meningites or
peritoneal cavity, or may be widely disseminated and associated with a septicaemia (candidaemia).
Candidaemia is seen mainly in postoperative or immunosuppressed patients; in some patients it clears
spontaneously, or disappears when contaminated intravenous catheters are removed. However, some patients
with candidaemia, notably those treated with cytotoxic drugs or corticosteroids, develop generalized or
localized deep-seated infection.
Common sites of involvement in disseminated infection include the kidney, liver, spleen, brain and gastro-
intestinal tract; pulmonary infections are rare. One common sign of deep-seated candidosis is the presence of
white lesions within the eye (Candida endophthalmitis). Candida endocarditis usually follows surgery for
valve replacement.
C. albicans accounts for most cases of systemic candidosis.
Treatment
The treatment of choice for most forms of systemic candidosis are:
- intravenous amphotericin B (conventional or liposomal)
- intravenous or oral fluconazole
9. Pneumocystis carinii
Pneumocystis carinii is a fungus, but its morphology, behaviour and response to antimicrobial agents are
more typical of a protozoan.
The organism was originally described as a cause of atypical pneumonia in malnourished infants and it is a
common cause of pneumonia, which is fatal in patients with AIDS.
Around 10-40% of HIV-negative patients undergoing immunosuppressant treatments for malignancy,
connective tissue disease or organ transplantation also develop P. carinii pneumonia, with mortality rates of
40-50%.
In addition to pneumonia, other as yet unrecognized forms of Pneumocystis infection may exist.
Broncho-alveolar lavage or biopsy may be needed to establish the ciagnosis.
P. carinii is sensitive to co-trimoxazole.
Pathogenesis
Malaria is characterized by severe chills, high fever and sweating, often accompanied by headache, muscle
pains and vomiting. Falciparum malaria, unlike the other forms, may progress (especially in primary
infections) to coma, convolutions and death. This condition, cerebral malaria, is associated with the
adherence of parasitized red blood cells to the endothelium of brain capillaries.
Lab ID
Thick blood stream with Giemsa stain
Thin blood smear is used when more detail is needed to determine the species involved
Treatment
The standard treatment for acute malaria was chloroquine. However, resistance to that drug in P. falciparum
is now widespread . The most reliable alternative to chloroquine is quinine (or quinidine).
LAB ID
Acid fast – ZN stain, difficult to find
Complement fixing test (CFT)
Serological test – Abs to T. gondii (ELISA, one specific feature is that instead of IgM + IgG we mostly
search for IgA + IgG antibodies. IgA antibodies are typical for recent infections, IgG for ―status after‖ an
infection.
Treatment
Spiramycin – during pregnancy
Clindamycin – Cerebral toxoplasmosis
Cryptosporidium parvum
From animals or water (fecal-oral route)
Severe diarrhea if immunocompromised patients (acute, watery, non-bloody)
It can also cause Cryptosporidiosis – parasitic disease of intestinal tract (anorexia, nausea, vomiting,
abdominal pain)
In healthy people is usually mild, self-limiting disease.
LAB ID
See stool for oocysts – ZN method
Treatment
Nitazoxanide and fluid replacement
Transmission
ingestion of cysts -> formation of trophozoites -> penetration of cell wall -> multiplication of trophozoides
within colon wall -> may invade epithelia -> ulceration ->systemic invasion (liver abscess) -> cysts
discarded with feces
Lab ID
examination of stool sample
Treatment
Not all strains of E. histolytica are invasive. Nevertheless, it is not possible readily to distinguish pathogenic
from non-pathogenic strains in asymptomatic cyst excreters.
Acute amoebiasis is usually effectively treated with metronidazole or tinidazole. Chloquine is also useful in
ameobic liver abscess.
Transmission
Ingested cyst (water) -> trophozoid formation in duodenum where they attach to wall but don’t invade
Lab ID
fecal examination; ELISA test to measure giadia Ag
Treatment
Giardasis can be treated with 5-nitroimidazoles such as metonidazole or, on rare occasions when this fails,
with mepacrine.
Treatment
The organism is responsible for a mild vaginitis, with discharge, which ordinarily responds to treatment with
metronidazole or tinidazole.
15. Trypanosoma
Trypanosomes have a complex life cycle involving an insect vector. The diseases that are caused in humans,
African trypanosomiasis (sleeping disease) and South American trypanosomiasis (Chaga’s disease), are
restricted in distribution according to the habitat of the insect host.
African trypanosomiasis
Tsetse flies act as the insect vector. Cattle and wild antelope act as reservoirs of infection.
Pathogenesis
Following the bit of an infected tsetse fly, a localized trypanosomal chancre may appear transiently, but
invasion of the bloodstream rapidly occurs. The parasites multiply in blood.
Swollen lymph glands in the posterior triangle of the neck are often present. In untreated, the disease
inexorably progresses to involve the central nervous system (CNS) with the classic signs of sleeping sickness
and, ultimatly, death.
Pathogenesis
Extensive cardiomyopathy, sometimes with gross distension of other organs (mega-oesophagus and mega
colon). Death is usually from heart failure.
Lab ID
Detection of motile trypanosomes in Giemsa staining smears of body fluids, CSF, blood and lymph nodes
aspiration and generally specific serological tests are used as confirmation.
Treatment
African sleep disease: early stage -> suramin or pentamidine
late stage -> melarsoprol
South American Chaga’s disease: nitrofuran has been used with modest success.
16. Leishmania
Leishmania species are intracellular parasites of the reticulo-endothelial system. There are only two
morphological forms: amastigostes (non-flagellate forms), which occur in the infected lesion, and
promastigotes (flagellate forms that lack and undulating membrane), which occur in the insect vector.
The parasites are transmitted by sandflies.
Pathogenesis
Cutaneous leishmaniasis (oriental sore) causinga boil-like swelling on the face or other exposed oart of the
body. The central part of the lesion may become secondarily infected with bacteria, but the leishmania
organisms reside in the raised, indurated edge of the lesion. With some species a more severe disseminated
cutaneous leishmaniasis may occur. Parasites of the Leishmania mexicana complex may cause a destructive
lesion of the outer ear (Chiclero’s ulcer).
In mucocutaneous leishmaniosis (espundia), which is associated with the l. braziliensis complex, disifguring
lesions of the mouth and nose may be caused. The most serious form of leishmaniasis is visceral
leishmaniasis which is a life-threatening disease involving the whole of the reticulo-endothelial system.
Lab ID
Examination of Giemsa stained tissue and fluid samples for amastigote. Cutaneous and mucocutaneous
disease can be diagnosed from tissue samples.
Treatment
Difficult because available drugs have high toxicity and failure rates. Prevalent antimonials are conventional
therapy.
Ascaris lumbricoides
This is the common roundworm.
In warm, moist condition, infective larvae develop within fertile eggs, but do not hatch. Such eggs can
survive for long periods in soil. If ingested, the eggs hatch in the duodenum and the larvae penetrate the gut
mucosa to reach the bloodstream. They are carried to the pulmonary circulation, where they gain access to
the lung and undergo two moults before migrating via the trachea to the intestinal tract. Havng completed
their round-trip, theuy mature in the gut lumen and live for several years.
Pneumonic symptoms may accompany the migratory phase and the adult worms may invade the biliary and
pancreatic ducts. Moreover, heavy infection with those large worms can cause intestinal obstruction. Allergy
is also sometimes a problem.
The dog ascarid, Toxocara canis, may accidentally infect man. Larvae hatch in the small intestine and
penetrate the gut wall, but they are unable to complete their migratory phase. Instead, they find their way to
remote parts of the bidy, a condition known as visceral larva migrans.
Trichuris trichuria
This is the common whipworm. Like those of ascaris, they develop infective larvae in warm, moist
conditions, but the ova do not hatch outside the body. However, after ingestion and hatching, there is no
migratory phase and adult worms develop directly in the large intestine.
Infection is usually trivial, though massive infections can cause rectal prolapse in young children, and a form
of dysentery is described.
Hookworm
The two species produce indistinguishable thin-walled eggs which hatch in soil. The larvae undergo several
moults before infective larvae are produced. These are capable of penetrating unbroken skin, and in this way
they gain access to the bloodstream to begin a migratory phase similar to that of ascaris. When they reach the
gut they attach by their mouthparts to the mucosa of the small intestine.
Hookworms ingest blood and, moreover, move from site to site in the gut mucosa, leaving behind small
bleeding lesions. These two facts are responsible for the chief pathological manifestation of heavy infection
with hookworms: iron deficiency anaemia.
Strongyloides stercoralis
Human infections arise after penetration of infective larvae through skin and there is a migratory phase
involving the lungs. However, human infection appears to be restricted to female worms, which attach to the
gut mucosa and produce eggs that contain fully developed larvae; these hatch within the intestinal lumen so
that larvae, not eggs, are found in faecal samples.
Symptoms are usually benign.
Enterobius vermicularis
This is the common threadworm, which infects children. Adults live in the large intestine and are
occasionally found in the appendix. Mature, gravid females crawl through the anus at night and lay their
eggs in the peri-anal area. These eggs contain fully developed larvae. Ingestion of these eggs initiates a fresh
infection. Symptoms are restricted to itching (pruritus ani) associated with the deposition of eggs.
Since eggs are not discharged by the worm into faeces, faecal examination is not appropriate in the
laboratory diagnosis of the threadworm infection.
Treatment
Most effective are the benzimidazole derivatives, especially albendazole and mebendazole.
Wuchereria bancrofti
This filarial worm is transmitted by the bite of various species of mosquito throughtout the tropical belt of
the world. The larvae invade the lymphatics, usually of the lower limbs, where they develop into adult
worms. Presence of the adult worms causes lymphatic blockage and gross lymphoedema, which sometimes
leads to the bizarre deformaties associated with bancroftian filariasis, elephantiasis.
Embryonic forms (microfilariae) are liberated liberated into the bloodstream. Microfilariae remain in the
pulmonary circulation during the day, emerging into the peripheral circulation only at night, to coincide with
the bitting habits of the insect vector.
Loa loa
It is transmitted by biting flies (Chrysops species). The adult worms live in subcutaneous tissue and wander
round the body, provoking localized reactions known as Calabar swellings an sometimes migrating across
the front of the eye.
The sheath microfilariae of Loa loa exhibit diurnal periodicity, so that, unlike those of W. bancrofti, they
appear in peripheral blood only during the day.
Brugia malayi
Can cause elephantiasis. Microfilaraemia usually shows a nocturnal periodicity.
Onchocerca volvulus
It is transmitted by species of black-fly. Adult worms develop in subcutaneous and connective tissue, and
often become encapsulated in nodules, which form on bony parts of the body, such as the hip, elbow and the
head. The microfilariae are not found in blood, but live in the superficial layers of the skin causing itching
and, in heavy chronic infections, gross thickening of the skin. The eye is commonly invaded by
microfilariae, which may cause corneal and retinal lesions that lead to blindness. The condition is known as
river blindness.
Mansonella species
They are transmitted by biting midges. The unsheathed microfilariae appear in the bloodstream and exhibit
no periodicity. They are generally regarded as non-pathogenic.
M. streptocera causes skin infections similar tot hose of O. volvulus.
Treatment
Diethylcarbamazine (DEC) has been used for many years for the treatment of all forms of filariasis. It
effectively kills microfilariae, but is not reliably lethal to adult worms.
Suramin kills the adult worms, but is much more toxic than DEC.
Dracunculus medinensis
This is the Guinea worm. The infective larvae develop within water fleas and human infection is normally
acquired through infected drinking water. The larvae penetrate the gut mucosa and grows to maturity in
connective tissue.
After fertilzation, the female worm incubates the larvae to maturity and, when ready to give birth, emerges to
the skin surface to provoke an intensely irritating blister.
Trichinella spiralis
Trichinella spiralis has an extremely wide host range. Human infections are usually acquired by eating
undercooked pork products. The infected larvae lie dormant in skeletal muscle and are related when the meat
is digested. Male and female worms develop to maturity attached to the mucosa of the small intestine. The
larvae penetrate the gut wall and migrate to skeletal muscle, where they enter the quiescent phase. Most of
the symptoms of trichinosis, which can be severe, even life-threatening, are associated with the migration of
larvae.
19. Trematodes
The flukes are a diverse group of worms that share a similar life cycle involving a snail host and, often, a
second intermediate host that provides the vehicle for the transmission of infection.
Life cycle
When excreted, trematode eggs often contain a fully developed ciliated organism called a miracidium. In
water, the miracidium escpes, either through a lid-like operculum in the egg shell, or by osmotic rupture of
the egg. The miracidium penetrates the appropriate species of snail and undergoes several stages of asexual
reproduction before emerging as a free-swimming body called a cercaria. The cercariae encyst in the muscle
of fish, crabs. Men become infected by ingesting the encysted metacercariae.
Clonorchis sinensis
Infection is acquired from uncooked freshwater fish, notably carp. The metacercariae excyst in the small
intestine and pass into the bile ducts, where they mature.
Infection is commonly asymptomatic, but fibrosis of the bile ducts with impairment of liver function may
occur in heavy, chronic infections.
Fasciola hepatica
Human infections have usually been associated with eating wild watercress from infected sheep pastures.
The adult worm can cause biliary fibrosis and obstructive jaundice.
Unlike other trematode infections, fascioliasis does not reliably respond to praziquantel, and treatment with
antihelminthic triclabendazole or the more toxic chlorophenol derivative bithionol may be required.
Paragonimus westermani
Human infection follows ingestion of raw, infected muscle of freshwater crabs and crayfish. The
metacercariae penetrate through the gut wall and diaphragm to reach the lung, where they develop to
maturity. Occasionally the larvae find their way to the brain. Pulmonary infection usually provokes the
production of sputum, in which the characteristic large eggs can be found, often associated whith flecks of
altered blood. Praziquantel is used for treatment.
Intestinal flukes
Infection is often acquired by the habit of opening water chestnuts with the teeth. The adult flukes live
attached to the wall of the small intestine, and produce a large number of eggs that resemble those of F.
hepatica.
Infection is usually asymptomatic unless the worm burden is large.
Schistosoma species
Human infection follows exposure to cercaria in water harbouring infected snails. The cercariae penetrate the
skin, often causing a transient dermatitis, called swimmer’s itch. Once in the bloodstream, the schistosomula
migrate to the liver, where they develop into mature male and female worms.
The mature worms migrate to the small veins of the rectum or the bladder. Eggs, which contain a fully
developed miracidium, are passed through the bladder wall into the urine.
Pathogenesis
Most of the serious manifestations of schistosomiasis are associated with the deposition of eggs, with the
formation of granuloma and fibrotic lesions of the liver, bladder or other organs. Such effects may herald
malignant changes.
Treatment
Praziquantel is effective against all the human schistosomes and is the drug of choice.
20. Cestodes
Taenia species
Taenia saginata, the beef tapeworm, is much more prevalent than the related T. solium, the pork tapeworm.
Human infection is acquired by eating raw and undercooked beef or pork conatining the encysted larval
stage, the cysticercus. The larvae hatch in the small intestine, and attach to the mucosal surface. The worm
grows backwards from the head. Eggs start to be produced in the uterine canal. This becomes grossly
distended as more eggs are produced, so that the fully gravid segments at the end of the worm become
nothing more than bags full of eggs.
Eggs are not laid. They are retained within the proglottids, which become detached from the end of the worm
and are passed with the faeces. Animals become infected by ingesting the eggs.
Considering the size of the worm, infection, is usually remarkably asymptomatic. However, in the case of T.
solium, eggs may hatch in the human host and form cysticerci. When the lodge in the brain, they may cause
a serious epileptiform disease, cerebral cysticercosis.
Diphyllobothrium latum
This is the fish tapeworm. The mature adult worm lays numerous operculate eggs within which a ciliated
body called a coracidium develops. This hatches in water and is ingested by the water flea. After a period
development, the larva awaits ingestion by a freshwater fish in which it invades the muscle.
Human infection is usually asymptomatic, although a form of pernicious anaemia caused by competition for
dietary vitamin B12 has been described.
Treatment
Niclosamide or praziquantel is used for treatment.
Hymenolepsis nana
Hymenolepsis nana is only 2-4 cm long - dwarf tapeworm. It has a very simple life cycle with no known
intermediate host.
Treatment
Infection is usually asymptomatic; heavy infections can be treated with praziquantel or niclosamide.
Echinococcus granulosus
This is the tapeworm of the dog and other canine species and usually, humans are an intermediate host.
Sheep are the usual intermediate host.
After ingestion of the eggs, larvae hatch in the small intestine, penetrate the gut mucosa and are carried by
the bloodstream to various organs (commonly the liver), where they are filtered out by the capillaries. The
larva starts to grow, eventually forming a cystic cavity.
The cyst may die and calcify, but it often continues to grow inexorably, eventually seriously compromising
the function of the organ in which it is situated.
Treatment
Cysts of E. granulosus can often be removed surgically. Some success has been obtained with benzimidazole
derivatives, notably albendazole, and with praziquantel.
CLINICAL MICROBIOLOGY
Conjunctivitis
usually of viral origin and accompanies acute upper respiratory tract infection
- in adenovirus: follicular conjunctivitis, pharyngoconjunctival fever, epidemic hematoconjunctivitis
- it can have other origins such as herpetic keratoconjunctivitis or hemorrhagic conjunctivitis
(enterovirus)
Treatment: local
bacterial origin:
- acute: suppurative such as with Strep. pneumoniae. S. aureus and in children other causes might be
possible while inclusion C. trachomatis.
- chronic: Staph. aurus, C. trachomatis
- allergic
Oropharyngeal infections
acute tonsilitis and pharyngitis:
- usually viral (rhinovirus, coronavirus, adenovirus, EBV and coxsackievirus - herpangina)
- bacterial: acute tonsilitis or tonsillopharyngitis due to Strep. pyogenes, rare but significant: N.
gonorrhoeae + C. diphteria
Treatment: bacteriological exam is recommended in all cases including ―typical tonsilitis‖. When
Streptococcus pyogenes are found - penicilin G
!azythromycin + erythromycin should only be used in allergic people. besides bactriological exam, CRP
should also be determined.
10. Etiology and laboratory diagnosis of chronic meningitis & brain abscesses
Chronic meningitis:
bacteria - M. tuberculosis
Moulds and yeasts - Aspergillus or Cryptococcus neoformans
Encephalitis (acute of viral origin):
Tick borne encephalitis
HSV
Acute brain abscesses (only bacterial):
Mixed aerobic + anaerobic flora
Staphylococcus
Streptococcus
Chronic brain abscesses:
bacteria: M. TB, Nocardia Asteroides
parasite: Cysticercus cellulosae (T. solium)
! Punction or excision for bacteriology, mycology and histology
Cystitis
- most common UTI, generally caused by intestinal microflora, ascendent infection.
- symptoms: dysuria, pollakiuria (urgent need to pee but peeing just a little bit)
Pyelonephritis
- can be ascendent or hematogenous
- EPEK = E. cole, Proteus, Enterobacter and Klabsiella
Urethritis -> STDs
UTIs can be:
● non-complicated: generally caused by E. coli (80%), Enterococcus (15%), Proteus mirabilis and the rest is
other Enterobacter.
● accompanying structural abnormalities (e.g.: prostate hypertrophy, urinary stones, pregnancy, catheter)
● accompanying functional disorders (vesicouretral reflux, DM...)
- complicated UTIs are 80% of the tissue caused by EPPEK, enterococcus. Proteus miribilis ,
Pseudomonas aeruginosa and the E. coli while the rest is caused by other Enterobacter, Candida...
How to take a urine sample: 1. through cleaning of genitalia
2. middle stream of urine only
3. use sterile vessel
4. pour urine into a sterile tube
5. if not possible to process it within 2h -> place specimen into 4ºC for 18h.
Microbiologists are interested in the kind of microbes prescut in urine sample but also the amount of
microbes present (increased number = UTI; decreased number = contamination)
- urine is inoculated on culture media by means of a calibrated loop usually taking 1 μl of urine.
CFU = colony forming unit = 1 bacterial /yeast cell
Type of specimen, Type of microbe Significant number
symptoms (CFU/ml)
Generally for urine exam you use blood agar but chromogenic media may also be used (oriented for the most
frequent urinary pathogens and their colonies have different colors) and according to requirements further
media might be used.
Primary urine pathogens: E.coli + other Enterobacter, Enterococci, S. agalactiae, Staphylococci, yeasts
(mainly Candida) and Pseudomonas aeruginosa.
Lab: generally samples are taken from urethra (males and females) and cervix (in females) and microscopy
or culture is performed.
2 swabs are made, 1 to inoculate directly onto the warmed culture media and another is used to make a film
on the slide.
Microscopy: it is important specially in acute gonorrhoea in males and symptomatic gonorrhoea in females.
Media: combine ChA + medium with antibiotics
Biochemistry: oxidase +, glucose+, maltose-
Therapy: many strains are now resistant to penicilin and tetracyclines so ceftriaxone is used.
Syphilis
- early syphilis: primary . secondary - latent - tertiary
Treatment: penicillin (one dose of benzathin penicillin in 1ry syphilis, 3 times after a week in 3rd syphilis of
benzathin penicillin)
Lab: direct detection: darkfield microscopy from exudative lesions (ulcus durum)
indirect detection: nontreponema test (cardiolipin Ag) - RRR (fast, cheap, early positive, reflects activity)
or treponema test - MHA-TP, ELISA, WB (sensitive, more expensive more specific)
Hemophylus Ducreyi
- causes ulcus molle, more common in tropical countries
- it causes genital ulcerations (more easy to catch HIV) and purulent lymphadenitis
- cultured on enriched media (ChA + suplements)
Chlamydia Trachomatis
- causes lymphogranuloma venereum, more common in tropical + subtropical carriers.
- purulent lymphadenitis with fistulae + scarring devastating pelvic region in females
- serology - CFT (complement fixation test) with Chlamydia antigen
HIV
- laboratory: detection of antibodies, antigens and viral load
- treatement: HAART
OSTEOMYELITIS
It is the name given to infections of the bone. It may be either acute or chronic in nature.
Acute osteomyelitis...
Over 90% of acute osteomyelitis cases are caused by Staphylococcus aureus but Streptococcus pyogenes and
Haemophilus influenzae may also cause acute infection of the bone although infection with Haemophilus
influenzae is rare due to the widespread use of Hib vaccine.
Bone is infected by bacteria circulating in the blood stream, which seed the infection. Typically, acute
osteomyelitis affects the growing points of long bones since blood flow is sluggish through these regions.
This allows opportunity for bacteria in the circulation to settle and to set up an infection at these sites.
Although rare, it is most often seen in children and adolescents who are growing rapidly. Sometimes is may
be caused by spread of infection from adjacent tissues and in these cases the infection is likely to be
polymicrobial.
Chronic osteomyelitis..
The bacterium Mycobacterium tuberculosis is the most common cause of chronic osteomyelitis. This
condition results from the secondary spread from a pulmonary infection. Unlike acute osteomyelitis, chronic
osteomyelitis caused by mycobacterium tuberculosis is most likely to affect the vertebrae. Other bones,
including those of the hip and knee and bones of the hands and feet may be involved in chronic
osteomyelitis. Pressure on the spinal cord caused by chronic osteomyelitis may be sufficient to cause
paralysis below the affected region.
Other bacteria causing chronic osteomyelitis include salmonellas and other coliform bacteria, pseudomonas
aeruginosa and spirochaete Treponema pallidum. T. Pallidum may cause bone lesions in children suffering
from congenital syphilis.
Lab ID
In Acute osteomyelitis bone culture is the definitive test. Open bone biopsy has the highest detection rate but
culture can be performed on samples obtained by needle aspiration. Any pus obtained should be collected in
a sterile syringe or container and sent to the lab for urgent Gram staining. Joint fluid can also be collected for
culture. In biochemical tests the ESR and CRP are elevated and the white cell count is increased but the
count rarely rises above 15,000/mm3.
In chronic osteomyelitis bone biopsy performed through non-infected soft tissue provides the best specimen.
Blood cultures are rarely positive. Raised ESR/CRP may be the only alteration in lab values in chronic
osteomyelitis.
Supporting evidence may be obtained from x-rays and various other radiological techniques.
ARTHRITIS
In arthritis, the affected joint becomes swollen, painful and red. This may be a direct consequence of
infection of the joint or because of an immunological reaction. In septic arthritis, joints become infected by
bacteria that spread either through the bloodstream or through direct inoculation of the joint, for example
through trauma.
The most common cause of septic arthritis in otherwise healthy joints is Staphylococcus aureus. Salmonellas
and Haemophilus influenzae may cause septic arthritis in children. Septic arthritis is also a rare complication
of gonorrhoea and is most often seen in women who otherwise have an asymptomatic Neisseria gonorrhoeae
infection. Although septic arthritis typically affects one joint, a monoarthritis, in gonococcal arthritis several
joints may be affected simultaneously; it is polyarthritis. Arthritis may occasionally be caused by
Mycobacterium tuberculosis. This chronic condition typically affects the hip or the knee joints.
Joints may become inflamed because of an immunological reaction to infection elsewhere in the body. A
number of viruses cause reactive arthritis through generation of circulating immune complexes. Hepatitis B
virus and rubella virus are notable causes of reactive polyarthritis. Rheumatic fever is a rare complication of
infection caused by streptococcus pyogenes. It is an immunological disease affecting joints and endothelial
tissues. Streptococcal antigens that cross-react with host tissues provoke an immune response following
infection. These initiate the damage seen in rheumatic fever.
Lab ID
Several lab tests are used to diagnose infectious arthritis. The definitive test involves culturing the fluid from
the involved joint after aspiration or incision and drainage. Gram stains are often unreliable, although they
provide initial clues. Synovial fluid analysis usually reveals a turbid fluid with leukocyte counts greater than
100,000 mm3 in 30-50% of cases. In bacterial arthritis, the level of polymorphonuclear leukocytes often
approaches 90%. Low joint fluid glucose levels and high lactate levels are indicative of septic arthritis, but
are non specific. Peripheral blood leukocyte counts are usually elevated in children, but are often within
normal limits in adults. Radiography may show joint space widening and soft tissue swelling in infections
more than 2 weeks old.
transplantation may
be done.
Immunodeficiency disorders impair the immune system's ability to defend the body against foreign or
abnormal cells that invade or attack it (such as bacteria, viruses, fungi, and cancer cells). As a result, unusual
bacterial, viral, or fungal infections and rare cancers may develop.
There are two types of immunodeficiency disorders:
Congenital (primary): These disorders are present at birth and are usually hereditary. They typically
become evident during infancy or childhood. All are relatively rare.
Acquired (secondary): These disorders develop later in life and often result from use of a drug or from
another disorder, such as diabetes or human immunodeficiency virus (HIV) infection. They are more
common than congenital immunodeficiency disorders.
Some immunodeficiency disorders shorten life span. Others persist throughout life but do not affect life
span, and a few resolve with or without treatment.
Causes
Congenital immunodeficiency: These disorders are caused by a genetic abnormality (often X- linked-only
boys are affected). As a result, about 60% of people with congenital immunodeficiency disorders are male.
Congenital immunodeficiency disorders are classified by which part of the immune system is affected:
various immune functions, such as killing bacteria and other foreign cells and making foreign cells easier for
other immune cells to identify and ingest. The affected component of the immune system may be missing,
reduced in number, or abnormal and malfunctioning. Problems with B cells are the most common congenital
immunodeficiency disorders, accounting for more than half.
Acquired immunodeficiency disorders:These most commonly result from drugs (mainly
immunosuppressants, which are used to treat serious disorders). Immunosuppressants are used to
intentionally suppress the immune system. For example, some are used to prevent rejection of a transplanted
organ or corticosteroids, a type of immunosuppressant, are used to suppress inflammation due to various
disorders, such as rheumatoid arthritis. However, immunosuppressants also suppress the body's ability
to fight infections and perhaps to destroy cancer cells. Chemotherapy and radiation therapy can also suppress
the immune system, sometimes leading to immunodeficiency disorders.
Immunodeficiency disorders may result from almost any prolonged serious disorder. For example, diabetes
can result in an immunodeficiency disorder because white blood cells do not function well when the blood
sugar level is high. Human immunodeficiency virus (HIV) infection results in acquired immunodeficiency
syndrome (AIDS), the most common severe acquired immunodeficiency disorder.
Undernutrition—whether of all nutrients or only one—can impair the immune system. When undernutrition
causes weight to decrease to less than 80% of recommended weight, the immune system is often impaired. A
decrease to less than 70% usually results in severe impairment.
Symptoms
People with an immunodeficiency disorder tend to have one infection after another. Usually, respiratory
infections develop first and recur often. Most people eventually develop severe bacterial infections that
persist, recur, or lead to complications. For example, sore throats and head colds may progress to pneumonia.
However, having many colds does not suggest an immunodeficiency disorder.
Infections of the skin and the membranes lining the mouth, eyes, and digestive tract are common. Thrush, a
fungal infection of the mouth, may be an early sign of an immunodeficiency disorder. Sores may form in the
mouth. Ear infections and skin infections by bacteria or viruses are also common. Bacterial infections (for
example, with staphylococci) may cause pus-filled sores to form (pyoderma). Warts (caused by viruses) may
form.
Many people lose weight.
Infants or young children may have chronic diarrhea and may not grow and develop as expected (called
failure to thrive). The earlier symptoms begin in children, the more severe the immunodeficiency.
Other symptoms vary depending on the severity and duration of the infections.
Diagnosis
Doctors must first suspect that an immunodeficiency exists. Then they do tests to identify the specific
immune system abnormality.
Doctors suspect immunodeficiency when a severe or an unusual infection recurs often or when an organism
that normally does not cause severe infection (such as Pneumocystisor cytomegalovirus) causes severe
infection. The results of a physical examination may also suggest immunodeficiency. Rashes, hair loss,
chronic cough, weight loss, and an enlarged liver and spleen are often present. Lymph nodes and tonsils may
be extremely small in some forms of immunodeficiency, whereas in other types the lymph nodes may be
swollen. Certain symptoms may suggest a particular disorder to doctors.
To help identify the type of immunodeficiency disorder, doctors ask at what age the person began to have
recurring or unusual infections. Infections in infants younger than 6 months usually indicate an abnormality
in T cells. Infections in older children usually indicate an abnormality in B cells and antibody production.
The type of infection may also help doctors identify the type of immunodeficiency disorder.
Doctors ask the person about risk factors, such as diabetes, use of certain drugs, exposure to toxic
substances, and the possibility of having close relatives with immunodeficiency disorders (family history).
The person is asked about past and current sexual activity and use of intravenous drugs to determine whether
HIV infection could be the cause.
Tests: Laboratory tests are needed to confirm the diagnosis of immunodeficiency and to identify the type of
immunodeficiency disorder. A blood sample is taken and analyzed to determine the total number of white
blood cells and the percentages of each main type of white blood cell. The white blood cells are examined
under a microscope for abnormalities. Antibody levels, the number of red blood cells and platelets, and the
levels of complement proteins are determined. If any results are abnormal, additional tests are usually done.
Skin tests may be done if the immunodeficiency is thought to be due to a T-cell abnormality. The skin test
resembles the tuberculin skin test, which is used to screen for tuberculosis. Small amounts of proteins from
common infectious organisms such as yeast are injected under the skin. If a reaction (redness, warmth, and
swelling) occurs within 48 hours, the T cells are functioning normally. No reaction suggests a T-cell
abnormality.
People whose families are known to carry a gene for a hereditary immunodeficiency disorder may wish to
have genetic testing to learn whether they carry the gene for the disorder and what the chances of having an
affected child are. Talking with a genetic counselor before testing is helpful. Several immunodeficiency
disorders, such as X-linked agammaglobulinemia, Wiskott-Aldrich syndrome, severe combined
immunodeficiency, and chronic granulomatous disease, can be detected in a fetus by testing a sample of the
fluid around the fetus (amniotic fluid) or the fetus's blood (prenatal testing). Such testing may be
recommended for people with a family history of an immunodeficiency disorder when the mutation has been
identified in the family.
Opportunistic infections: Infections that take advance of the debility of the immune system and in normal
individuals do not have a clinical manifestation.
Candidiasis
Herpes Zoster – Generally constitutes one of the first clinical associations to HIV infection. The clinical
diagnosis is done by the observation of cutaneous lesions over the nerve tracks (which can or not be
accompanied by pain or hemorrhagic process).
Pneumocytis carinii – see question D9
TB (pulmonary) – Pulmonary tuberculosis (TB) is a contagious bacterial infection that mainly involves the
lungs, but may spread to other organs. It is caused by the bacteria Mycobacterium tuberculosis (M.
tuberculosis). You can get tuberculosis by breathing in air droplets from a cough or sneeze of an infected
person. he primary stage of the disease usually doesn't have symptoms.
When symptoms do occur, they may include:
Cerebral toxoplasmosis - Toxoplasmosis is an infectious disease caused by the one-celled protozoan parasite
Toxoplasma gondii. Can be fatal. Cats, the primary carriers of the organism, become infected by eating
rodents and birds infected with the organism. When symptoms do occur, they may include:
Visceral leishmaniose - also known as kala-azar, black fever, and Dumdum fever, is the most severe form of
leishmaniasis. Leishmaniasis is a disease caused by protozoan parasites of the Leishmania genus. The
clinical symptoms are ferver, asthenia, weight loss, anemia, change in hepatic functions.
T. pallidum - ✓ ✓ ✓ ✓
L. - - ✓ - -
monocytogenes
Rubellavirus ✓✓ ✓ - ✓ ✓
CMV ✓ ✓ ✓ ✓ ✓
Parvovirus ✓/ ✕ ✓ ✓/ ✕ - -
VZV ✓ - - ✓/ ✕ ✓
HSV - ✓
Toxoplasma ✓ /✕ ✓ ✓✓ ✓ ✓
gondi