Streptococcus pyogenes

Characteristics Virulence Factors and MOA/Pathogenesis Clinical Manifestations and Disease Process Diagnosis, Treatment and DOC
Streptococcus Antigenicity of cell wall Cell Envelope: 3 Mechanisms: ARF – 2 major or 1 major and 2 minor We want to prevent ARF!
pyogenes carbohydrate. GAS = M Protein – Prevents phagocytosis by PMNs 1) Pyogenic inflammation – pharyngitis/Strep 5 major manifestations: Unclear – APSGN & PANDAS
(GABHS) NAG + rhamnose. and inhibits complement by binding factor H. Throat 1) Joint swelling
Main virulence F for Rheumatic Fever. M Infants and small kids, Subacute nasopharyngitis 2) ❤ Pancarditis (endo, myo, peri) Antibiotics most beneficial hastening
B-Hemolysis proteins will also mimic Ab in heart and cause with serous discharge, tendency to extend to 3) Nodules (Subcutaneous) resolution of S/S, initiated within first
issues with mitral valve (molecular mimicry). middle ear and mastoid, cervical 4) Erythema marginatum 2 days of illness. Helpful in
Cultivation: Fastidious lymphadenopathy, persists for weeks, low grade 5) Syndenham Chorea preventing ARF if initiated up to 9
Protein F and LTA. F binds fibronectin surface of
(BAP), Mesophile (35- host cells. LTA attaches to pharyngeal
fever. 4 minor manifestations: days of symptom onset.
37⁰C for growth and epithelium. Older kids/adults, Acute nasopharyngitis; 1) Arthralgia
hemolysis), Capnophile tonsillitis, intense erythema and edema, purulent 2) Elevated ESR or C-reactive protein B-lactam
(growth in CO2 and Capsule – composed of hyaluronic acid and exudates, cervical lymphadenopathy, high fever 3) Fever Penicillin V – DOC for GAS
obligately fermentative) appears as “self” to immune system. Inhibits >38C 101F, self-limiting ~5 days. 4) Prolong PR interval Amoxicillin - Yummy for kids (not)
phagocytosis. Similar signs/symptoms: Mono, Diptheria, Reactive ARF – Protect with 10 days duration of effective tissue
Cells: Gram (+), Arranged Adenovirus, Gonococcal prophylactic penicillin levels
in chains or pairs, Enzymes: Possible relapse if <7 days of therapy
Catalase (-). Nonmotile Streptolysin O – Oxygen labile, destroys RBCs 2) Toxin-mediated – Scarlet fever The Centor Criteria
and WBCs. Hemolysis on BAP (deep cuts and in Requires lysogenized S. pyogenes to release SpeA 1) Tonsillar Exudates B-lactam hypersensitivity
situ). Immunogenic, ab from systemic or exotoxin. Can superimpose on streptococcal 2) Tender anterior cervical Use 2nd or 3rd gen cephalosporins,
Epidemiology/Populatio pharyngeal infection.
n affected and individual pharyngitis. Punctate, blanching erythematous adenopathy less cross reactive. Macrolides:
Streptolysin S – Serum induced, Destroys RBCs rash that spreads to ears, axilla, chest to trunk 3) Fever by Hx azithromycin, clarithromycin,
most susceptible and WBCs, Hemolysis on BAP (surface colonies
and extremities. Sandpaper skin. Pastia Lines 4) Absence of cough erythromycin (ACE)
and in situ. Elaborated – presence of Serum.
Epidemiology: Most (Thomson sign) – petechial lesions. Circumoral
common bacterial C5a peptidase – degrades C5a Pallor, Strawberry tongue, Desquamation. 2 Main Tests: Clindamycin if regional macrolide
infection of the throat. RADT – high sensitivity, few/no false resistant strain.
Humans are the only Deoxyribonuclease A-D – Degrades DNA, 3) Immunologic disease negatives
reservoir, colonizes both makes purulent exudates less viscous for ARF, 1-4wks after untreated GABHS, Type II Microbiologic – swab posterior Do not prescribe:
nose and skin. Source of pathogen mobility Hypersensitivity, Protein M ab exhibit molecular pharynx and tonsils, used to inoculate Sulfanamides
infection. Acute cases in mimicry with joints and heart. blood agar. Fluoroquinolones (ciprofloxacin,
all ages. Peaks at 5-15 Streptokinase/fibrinolysin – generates plasmin Reactive ARF, recurrence of GAS. Damaged left- levofloxacin)
years of age. More (clot buster) side heart valves (mitral and aortic). Aschoff Bacitracin Sensitivity – A disk. >99% Tetracyclines (doxycycline)
prevalent during Winter bodies. GAS inhibited. 90-95% non-GAS do
and Early Spring. Hyaluronidase – breaks hyaluronic acid in CT not. No vaccine available, though one is
APSGN, Type III Hypersensitivity. SpeB, ag-ab being developed for M protein.
S. Pyogenes cell envelope proteinase complexes deposit in basement membrane of PYR Test – ID GAS from other B- Two required components
Transmission –
(necrotizing fasciitis). Prevents PMN
Respiratory droplets – glomeruli. Activation of complement, recruitment hemolytic strep Broad coverage – Immunogenic to
recruitment, cleaves IL-8.
pharyngitis. Skin to skin of PMNs. Destruction by proteolytic enzymes. variable M Proteins
contact. Fomite SIC – Inactivates MAC Presentation: Puffy face, Hematuria, NAAT – PCR No autoimmune Response –
transmission rare. Hypervolemia vaccinations does not result in ARF.
SpeA super antigen, responsible for Serological Tests, ASO
toxemias, STSS, Scarlet fever
Otitis, Sinusitis, Diphtheria and Pertussis
Disease Epidemiology and those affected
Otitis Externa Predisposing F:
Moisture (swimmer’s ear), Insertion
of foreign objects, trauma, chronic
skin diseases.
Otitis Media and Sinusitis
Diphtheria Vaccine preventable (DTaP – 5 step
pediatric series, Tdap/Td boosters.
Disease found worldwide in poor
urban areas where vaccine-induced
autoimmunity is low. Maintained in
population by asymptomatic carriage
in immune individuals. Person-to-
person spread via respiratory
droplets or skin contact. Uncommon
in developed countries.
Pertussis/Whooping Cough Human Reservoir only. Endemic dz
w/ periodic large-scale epidemics. No
permanent immunity after infection
or vaccination, adult care-givers
with minor disease often transmit
infection (like rotavirus or
parainfluenza viruses). Must
maintain coverage rate in most
susceptible age groups.
Causative Agents with Virulence Factors
Pseudomonas aeruginosa – Gram (-), swimmers
ear, sinus trap, can invade the bone. Blue/green
pigment.
Staphylococcus aureus – Gram (+), Coagulase (+).
“any organ will do, just get me there”
Streptococcus pneumonia – Gram (+), lancet
shaped diplococci. Virulent strains are
encapsulated. A-hemolysis on blood agar.
Hypersensitive to optochin (P disk).
Haemophilus influenzae – Gram (-) coccobacilli,
non-typeable strains.
Moraxella catarrhalis - Gram (-) diplococci,
Oxidase (+), B-lactamase producer.
Corynebacterium diphtheria
Major Virulence F – A-B Exotoxin, protein
synthesis inhibitor, ribosylates EF2 and induces
rapid cell death. Produced when iron
concentrations are low.
Attaches to mucosal surfaces of nasopharynx or
skin, but disease is primarily toxin mediated.
Bordetella Pertussis – Small gram (-) coccobacilli.
Grows aerobilcally on enriched agar.
Virulence F: Filamentous hemagglutinin,
pertussin toxin and adenylate cyclase toxin
induce hyper production of respiratory secretions
by increasing cAMP (slide 30)
In addition to endotoxin, adhesions and
exotoxins.
Clinical Manifestations and Disease Process
Inflammation of the external auditory canal
Presenting signs/symptoms:
otalgia and otorrhea
Fever >38.3 C indicates more than localized involvement.
Otitis Media
Inflammation of the middle ear, including tympanic
membrane. Associated with fluid buildup (can burst with pus)
in the middle ear space.
Sinusitis
Inflammation within paranasal sinuses; may or may not be
purulent. Orbital cellulitis
Respiratory disease most common, cutaneouos forms/formites
Pharyngeal colonization. Sudden onset of malaise, exudative
pharyngitis, low grade fever, and lymphadenitis.
Formation of pseudomembrane = network of fibrin + bacteria
+ WBCs + necrotic epithelial cells.
Progress form localize to systemic impacts on cardiac, renal,
and nervous systems.
Catarrhal stage: Inflammation of mucous membranes,
nonspecific respiratory tract syndrome. Insidious onset.
Patients are highly contagious at this stage.
Paroxysmal stage: attacks or spasms (up to 50x/day). “Whoop”
due to labored inspiration. Can lead to complications due to
vomiting and increased pressure.
Convalescent stage: Recovery over several weeks. Serious
complications include pneumonia, encephalopathy, seizures
and death.
Diagnosis, Treatments, and DOC
Dx: Examination of ear and gram stain
Tx: Debris removal, Topical application of corticosteroids
and antimicrobial agents, Oral antibiotics if fever is present
or extension of disease is evident.
Otitis Media
Dx: Clinical presentation, culture and gram stain.
Tympanocentesis
Tx: DOC amoxicillin. Tympanostomy.
Sinusitis
Dx: Clinical presentation and Hx, nasal cytology (biopsy), CT
scan, allergy testing.
Tx: Varies. Nasal irrigation, Analgesics, OTC decongestants,
antibiotics, nasal steroids, nasal surgery.
Dx: Mimics streptococcal pharyngitis but progresses to
create pseudomembrane, cardiac and neurologic signs. Bull
neck.
Culture – use Loeffler’s medium or Cysteine-tellurite agar.
Staining – club-shaped gram (+) bacilli, Volutin granules.
PCR for toxin, Non-toxigenic can still produce disease.
Tx: Anti-toxin immediately, and ab therapy with
erythromycin or penicillin. Vaccination on recovery
(exotoxin evades immune system)
Presumptive Dx: Serology – ELISA detecting Igs to pertussis
toxin or adhesins. 4-fold increase in paired sera or high
initial titer is indicative of recent infection.
Definitive Dx: Culture on enrich medium, Bordet-Gengou
agar, Regan-Lowe agar. Must be processed rapidly and with
care since they are sensitive to drying.
Tx: Erythromycin, but therapy is primarily supportive.
Prevention – DTaP (series) or Tdap/Td (booster), all contain
inactivated pertussis toxin and bacterial adhesins or other
virulent factors.
 Community Acquired Pneumonias (Typical)
Organism and Epidemiology
Streptococcus pneumoniae
Occurs in colder, wetter months, viral infections
increase risk of pneumococcal pneumonias
(synergy). Incidence greater in children and
adults >65yo.
Asymptomatic carriers are major reservoir.
Organism aspirated and allowed to replicate,
resulting in dz.
Haemophilus Influenzae
Most are opportunistic. Nontypeable (no
capsule) in normal flora. Prevalent in
debilitated hosts: Asthma, COPD, smoking,
immune compromised.
Type b (Hib) can cause pneumonia in infants
and young children.
Klebsiella pneumoniae (can cause both CAP
and NP)
Normal intestinal flora. Found in oral pharynx
of 5% healthy peeps and recovered from
pharynx of hospitalized patients. Important
cause of HAP infections and can cause
secondary disease with other infections.
*Slides 41-44 on general diagnosis of CAP. Gold standard diagnosis – presence of infiltrate on plain chest radiograph. Sputum stain useful.
General Characteristic
Features
Gram (+) lancet shaped
diplococcus, a-hemolytic with
greenish colonies. Optochin (P
disk) sensitive. Encapsulated
strains are virulent
Non-motile, gram (-) coccobacillus
LOS
Encapsulated or not. Capsule not
required for disease.
Colonies require RBCs for growth
but do not have hemolytic
properties.
Non-motile, gram (-) bacillis
Coated by thick mucoid (slimy)
capsule.
Found in normal flora of mouth,
skin, and intestines.
Causes pneumonia in alcoholics
and persons suffering from
diabetes mellitus. Often seen in
homeless population.
Catalase (+), Oxidase (-)
Virulence Factors and MOA/Pathogenesis
Capsule – Major virulence F. Basis for serotype and vaccine.
Inhibits phagocytosis by interfering with C3b opsonization.
Pneumolysin – Forms transmembrane pores, lyses, and activates
complement.
Teichoic acid – potent immunomodulatory
Protection: IgA Protease – Degrades host secretory IgA.
Hydrogen Peroxide – elimination of competing bacteria.
Binding: Pili – Helps colonize URT. Activates production of TNF.
Surface Proteins – Choline binding proteins, adhesins that
interact with carbs on the surface of pulmonary epithelium.
Autolysin and pneuomolysin – dampen host immune response.
PRP (polyribosylribitol phosphate) capsule – major virulence F.
Resistant to phagocytosis by PMNs.
Neuraminidase and IgA protease (all virulent strains).
Fimbriae – required for colonization in nasopharynx.
LOS results in loss of cilia, inflammation, sloughing of damaged
epithelial cells.
Polysaccharide capsule – primary virulence F. Antiphagocytic and
prevents MAC mediated cell lysis.
LPS
Adhesins – fimbrial or non-fimbrial. Organism gains access to
lungs after host aspirates oropharyngeal microbes into LRT.
Causes necrotizing CAP with preference for upper lobes.
Clinical Manifestations and
Disease Process
Signs/Symptoms: sudden fever, chills,
chest pain, rust colored sputum with
cough, bacteremia, CXR shows
consolidation in lungs.
Also responsible for otitis media,
sinusitis. Disseminations: bacteremia,
meningitis, arthritis peritonitis.
Infection from nontypeable strains due
to imbalance of colonization. Non-
encapsulated strains also possess
adhesins that bind to mucins on ciliated
epithelial cells of respiratory tract.
Severe illness with rapid onset. Often
fatal even with antimicrobial treatment.
Necrotic destruction of alveolar spaces,
inflammation and hemorrhage in lungs.
Acute onset of fever. Currant Jelly
sputum. Infection can lead to abscess,
cavitation, and pleuritic chest pain.
Diagnosis, Treatment and DOC
Dx: colonies small, round, and green. a-
hemolysis. Capsule not required for growth.
Optochin sensitive. Bile solubility test (will lyse
cells) specific to S. pneumoniae. Quellung Rxn
to observe capsules. Agglutination tests for
polysaccharides. Genetic probe test (16S).
Prevention
Vaccines: 23-valent capsular polysaccharide
vaccine, recommended for people >65yo and
those with predisposing factors. 13-valent
capsular polysaccharide vaccine, 80% of
infections in children ≤ 6yo. Conjugated to
carrier protein (more immunogenic)
DX: Gram stain, serological test for
encapsulation. Culture on chocolate agar with
added X (Hemin) and V (NAD) factors at 37C in
CO2 enriched incubator. Blood agar growth
achieved as satellite phenomenon. Should be
catalase and oxidase (+).
ID with LAT (Latex Particle Agglutination Test)
Prevention
One of three different Hib conjugate vaccines.
Dx: Gram stain/culture mucoid capsule.
Currant Jelly sputum, CXR reveals cavitation.
Mortality rate is 50% regardless of tx. Produces
B-lactamase.
 Hospital Acquired Pneumonias (Nosocomial)
Organism and Epidemiology
Pseudomonas aeruginosa
Plant pathogen!
Widespread in the
environment. Inhabits plants,
water, and moist soil. Frequent
or transient carriage on skin and
in feces. Opportunistic
pathogen in hospital.
Transmission via fomites,
plants, fruits, hands.
Staphylococcus aureus
Occurs worldwide. Human
carriers in anterior nares and
perineum. Transmission via
close contact with patients or
hospital personal and
respiratory droplets, ingestion
from food, shedding from skin
lesions etc.
General Characteristic Features
Gram (-), aerobic, motile bacillus (single
flagellum)
Clinical isolates have pili
Blue-green due to:
Pyoverdin – green; siderophore
Pyocyanin – blue; virulence factor
Used in Bioremediation
Gram (+)
B-hemolysis
Facultative halophile, Growth with
mannitol fermentation.
Virulence Factors and MOA/Pathogenesis Clinical Manifestations and Disease Process Diagnosis, Treatment and
DOC
Pyocyanin – blue pus pigment, catalyzes ROS production. Damages Not extremely virulent, requires significant break in host Dx: BAP and MacConkey, water
tissues. defense. Opportunistic! soluble blue green pigment,
fruity smell, tinge sputum or
Exotoxin A – A-B toxin, inhibits protein synthesis. Causes ciliastasis Infections: Urinary tract, Pneumonia following respiratory pus, patient may fluoresce.
(trachea), resulting in immunosuppression. therapy, Eye Ears and skin (contaminated hot tubs and contact
lenses), Burn patients, CF (common cause of death)
Elastases LasA and LasB – two proteins work synergistically. Elastolytic
activity (30% of lung tissue is elastin) Pneumonia
Primary – limited to patients on inhalation therapy w/
Alginate – mucoid polysaccharide/slime layer. Adherence – lung nebulization
infections, inhibits mucociliary escalator; important in CF. Secondary – Associated with immunosuppression.
Antiphagocytic glycocalyx, inhibits complement and ab binding.
In most patients – Toxicity and progressive cyanosis,
Pili – attachment to host cells development of empyema (Pus in body cavity)
LPS (endotoxin) – Fever, shock, DIC, tissue necrosis. In CF patients – Chronic and recurrent episodes. Infection
confined to respiratory tract with bilateral and residual
damage.
Cell associated Can affect any body site. Dx: Gram Stain, colonies from
Microcapsule (EM) – polysaccharide, serotype 5 and 8 Cutaneous infection – stye, furuncle, carbuncle, impetigo positive cultures of blood. Test
Protein A – binds to Fc of IgG, interferes with phagocytosis and Deep infections – bones, joints, deep organs, soft tissues for + catalase and coagulase
complement. Wound infections – umbilical, surgical activity.
Clumping F cell wall protein binds fibrinogen converted to fibrin = Systemic Toxicity – scalded-skin, toxic shock, food poisoning.
bacterial aggregation. B-hemolysis
Respiratory Infections
Extracellular enzymes Inhalation pneumonia – CAP several days after onset of Growth on Mannitol Salt Agar
Coagulase (+) – binds prothrombin = staphylothrombin. Converts influenza. Ranges from local consolidation, patchy infiltrates,
fibrinogen to fibrin – localized clotting. abscesses, and military pattern of small nodules.
Hyaluronidase, Nucleases, Lipases, Neuraminidase Aspiration pneumonia – HAP via aspiration or intubation
Treatment of HAP (Slides 36-41)
Catalase (+) – inhibits phagocytic killing, interferes with Hematogenous Pneumonia – due to release of infected
myeloperoxidase system thrombus from venus system or tricuspid vegetation.
Staphylokinase (fibrinolysin) Antimicrobial ASAP.
Penicillinase (Blactamase) Empyema
Drugs for non MDR
Toxins Predisposing F – Staphylocidal defects of PMNs eg CGD. Severe Piperacillin (Tazobactam, B-
Exfoliatins – Lyse epithelial junctions (desmosomes) diabetic decompensation. Presence of foreign body. lactamase inhibitor), Cefepime,
TSST-1 – super antigen, major systemic effects w/ cytokines Levofloxin (fluoroquinolone –
Enterotoxins – super antigen, release of cytokines, act on neural R in DNA gyrase inhibitor)
upper GI tract. Activates vomiting center. Ex. SeA-E and G
Cytotoxins (a, b, g, and d) – lyse variety of cells Drugs for MDR (slide 39)
Panton-Valentine Leukocidin (PVL) – bicomponent cytotoxin,
responsible for leukocyte destruction and tissue necrosis. Severe
necrotic hemorrhagic pneumonia. CAP if PVL.
 Epidemiology and Etiology
Difficult to eradicate due to long term treatment,
spread of infection, MDR and XDR strains, and
inadequate treatment.
Epidemiology of MTB
Humans are the only reservoir, transmission is person
to person and aerosol droplet nuclei. ~3/droplet, able
to move into alveoli and initiate infection. Virulence
varies, MDR and XDR.
Bimodal age distribution:
Older – failure of immune system, new infection =
progressive primary dz. Possible reactivation of latent
infection.
<5 Years of age and the immunocompromised –
Progressive primary for both, lymphohematogenous
dissemination, tubercular meningitis in young.
Risk Factors: Close contact, long term care facilities,
low income/inner city, Alcohol or IV drug use,
malnutrition, DM, Silicosis, Immunosuppression.
Etiology of M. Tuberculosis Complex
-Obligate aerobes
-Facultative intracellular pathogens – Macrophages
-Non-motile, bacilli, usually slender and slightly
curved.
-Acid Fast (AFB)
-Gram positive-like cell wall but does not gram stain.
-Heat Sensitive, killed by pasteurization @68.2C; 32s.
Used to eliminate M. bovis from milk.
-High conc. of mycolic acid. “waxy” bacteria
-Cells and colonies are hydrophobic and clump.
-High lipids -> lack of antigenicity
-Slow growth rate – doubling time 15-20hrs (MTB)
-Resistant to acidic/alkaline compounds, detergents,
and antibiotics.
-Colonies – Ruff, Buff, and Tuff
-No Glycocalyx, endotoxins, exotoxins, or necrotizing
enzymes.
-Damage/Disease due to our immune system (DTH).
Virulence Factors
1) Mycolic acids: Long hydrocarbon chain, prevent
dehydration, Resist H2O2, Acid-fast stain, resist
phagocytes, reduces permeability to molecules
(gram stain, ab).
2) Mycoside – Carbohydrate that links two mycolic
acids together.
Cord Factor – mycoside, growth in serpentine
cords, virulent strains (+). Factor for granuloma
(tubercle) formation.
Sulfatides – Mycosides with attached sulfates.
Promotes facultative intracellular growth and
inhibits phagosome and lysosome fxn.
LAM (lipoarabinomannan) – Inhibits CMI,
interferes with T-cell activation and inhibits IFN-y
activation of macrophages. Promotes phagocytosis
by macrophages.
Clinical Manifestations
Primary Disease
S&S – Primarily fever, 14-21 days. Physical exam
normal. 25% will experience chest pain and
pleuritic chest pain. Radiograph – hilar
adenopathy.
Inspired droplet nuclei in middle to lower zones of
lungs. Initial pneumonitis with PMNs and edema.
Eventually enter inactivated alveolar macrophages
and multiply (LAM and Sulfatides)
Macrophages travel to hilar lymph node and
present antigens (ESAT-6 and CFP-10) to TH cells. TH
activate macrophages at infection site to release
IFN-y and TNF-a. Ab production not effective.
Macrophages promote granuloma production with
lytic enzymes. Granulomas consist of macrophages,
giant cells, fibroblasts, and collagen fibers that can
calcify. “Ghon foci”
Granuloma w/ viable MTB in low pH and low O2
can induce spore-like state = LTBI. Also CMI and
DTH to MTB. (+) for TST and IGRA.
Clinical Manifestations cont.
Progressive Primary Disease
When granulomas cannot contain MTB.
Worsening pneumonia. Same S&S as
secondary dz with formation of apical lung
granulomas and cavities. Contagious.
Tuberculous meningitis can be fatal in
children from spread of MTB in lymph.
Reactivation or Secondary TB from LTBI
Due to impairment of CMI (stress, drugs,
hormones, malnutrition, HIV etc). Apices of
lungs most common site due to high O2
tension.
S&S LTBI
Insidious. Cough, weight loss, fatigue, fever,
night sweats; chest pain. Lesions progress
from caseous necrosis and liquefy,
discharging TB into bronchi or blood vessels.
This leads to distribution of droplet nuclei to
environment, and progressive pneumonia
and tuberculosis in host.
Miliary Tuberculosis
Spread of primary infection via lymph or
latent focus with subsequent spread.
Initiated by blood dissemination of MTB.
Tissue surrounding BV is lysed, affects
vascular orgams: liver, spleen, bone marrow,
and brain. Spread from lung (primary) or
extrapulmonary site (secondary). Millet-
seed granulomas/ tubercles form.
Pott Disease
MTB present in vertebral bodies. Chronic
back pain. Untreated can lead to destruction
of vertebrae and permanent disability.
Diagnosis
Dx: Four components
1) Tuberculin skin test (TST or Mantoux or
PPD) or IGRA (IFN-y Release Assay)
2) Medical Hx/clinical presentation
3) CXR – Rules out pulmonary TB in (+)
TST
4) Bacteriologic exam – Sputum (≥104
CFU/ml for (+) result)
PPD – activates memory T cells, initiates
Type IV CMI. (+) indicates current or
previous MTB. False (+) in those with BCG
vaccination or infection with M. bovis an M.
kansasii. Limitations in anergic
immunocompromised individuals, but check
with Mumps; Candida ag. DTH response =
true (-) TST. Recently infected individuals
may not show (+) (DTH requires 4 weeks).
(+) result is induration.
QuantiFERON – TB (IGRA)
Single office visit with blood draw. Uses
ESAT-6 and CFP-10 to stimulate T-cells to
produce IFN-y. IFN-y is then quantified.
Bacteriologic Exam
Biochemical tests to MTB
Niacin (+), Nitrate-reductase (+), Catalase (+)
Ab sensitive to 4 first line Ab:
Rifampin, Isoniazid, Pyrazinamide,
Ethambutol. RIPE
Treatment
Tx: Treat for at least 6-9 mo. Pt with MDR up
to 2 yrs.
LTBI – Isoniazid (INH)
MTB Disease – RIPE, never add single drug to
failing treatment. Monitor with cultures. RIPE
every day, 56 doses; 8 wks. INH and RIF every
day, 128 doses ; 18 wks.
MDR – resistant to two of the first line drugs
INH and Rifampin.
XDR – Resistant to INH and Rifampin and
second-line drugs Fluoroquinolones and 1 of 3
injectable drugs (Kanamycin, Amikacin,
Capreomycin)
New Drugs
Bedaquiline – new and blocks proton pump
and ATP production. Downside is elongation
of QT interval.
Delamanid – inhibits cell wall synthesis.
Elongates QT interval.
Vaccine Development (slide 93)
Replace BCG, Boosters, Immunotherapeutic.
NTM AND NOCARDIA Opportunistic Respiratory Tract Bacteria
Organism and epidemiology
MAC Mycobacterium avium complex
M. avium, M. intracellulare, chimaera
Worldwide and most common pulmonary dz.
Enter body through inhalation or ingestion. No
person to person transmission. NTM infections
usually longer than MTB, therefore longer
treatment course, lower success.
Host susceptibility increased by
inherited/acquired defects in T-cell and
macrophage pathway.
1) IFN-y deficiency
2) Ab to IFN-y
3) Use of TNF-a inhibitors (infliximab)
4) CD4 lymphopenia due to HIV or other.
M. kansasii – found in tap water. Pulmonary
disease resembles MTB.
Major risk factors: COPD, male >50 yo, area
Nocardia spp. Nocardia and Nocardiosis
Saprophytic, soil bacteria. Not part of human
microbiota. Can disseminate to any organism.
Infections highest in Southwest due to dry,
dusty, and windy conditions. This facilitates
aerosolization and dispersal of fragmented
nocardial cells.
Not transmitted from person to person
Exogenous infections from ubiquitous
organisms from soil rich with organic matter.
General Characteristics
Free-living in environment, ubiquitous in
environment (Water, soil and plants.
4 clinical syndromes
1) Pulmonary disease in older people w/ or
w/o underlying dz
2) Superficial lymphadenitis
3) Disseminated dz in severely
immunocompromised
4) Skin and soft tissue infections.
Weakly gram (+) aerobic bacilli
Strong Acid-Fast
Slow growing. Small, flat, translucent, smooth
colony. No CORDING or clustering., Grows well
on middlebrook agar
Nocardia nova complex – systemic. N. farcinica
is most virulent
N. brasilienses – skin and soft tissue
Gram (+) and weakly Acid-Fast
Branches filaments in tissues and cultures.
Strict aerobic bacilli
Biochemistry:
Catalase (+)
Gelatin liquefaction
Growth on nonselective media
Slow growth (1wk colonies), Dry to waxy, White
to orange. 35C and 45C growth temps. Aerial
filaments in agar.
16S rRNA PCR/sequencing, RFLP to analyze hsp
and 16S rRNA genes.
Virulence
Like MTB, Intracellular growth
Disease – due to
immunogenesis, lack of
granuloma formation and
overgrowth of microbe
Resistant to disinfection. Not
killed by standard drinking
water chlorination
Virulence – Same as MAC
Intracellular growth, high
numbers disrupt organ fxn,
disease due to host immune
system.
Create L-forms = cell wall
deficient variants.
Cell surface-associated SOD
to resist ROS of PMNs
Clinical Manifestation and Disease Process
HIV (-)
Fibrocavitary dz - elderly men, hx of alcohol
consumption.
Fibronodulary dz – elderly women – bronchiectasis.
Fastidious with repressed coughing (Lady Windermere’s
Syndrome) Tall and slim women with skeletal
abnormalities. Cough and sputum production
Lymphadenitis – children 1-4 yo, unilateral cervical
nodes, cervical adenitis
HIV (+)
Not seen in developed countries due to ART.
HEART/HAART
MAC infections are pulmonary or disseminated.
Initial infection colonizes GI tract then hematogenous
spread to other tissues/organs.
Symptoms – fever, weight loss; night sweats; diarrhea
Lymph dissemination (DMAC). Granulomas not
effective. Organs enlarge and dysfxn follows.
Disseminated dz – CD4 count falls <50 cells/ul. Pt not
able to develop CMI, no activation of macrophages or
granuloma formation.
Nocardiosis –opportunistic and common in pulmonary d
Bronchopulmonary infections occur after
Colonization of oropharynx by inhalation, and aspiration
of oral secretion into lower airways.
CMI is crucial in containing Nocardia spp. Sensitized T-
cells stimulate cellular response.
Greatest Risks in Immunocompromised (glucocorticoid
therapy, malignancy, organ and hematopoietic stem cell
transplantation, HIV)
Chronic Pulmonary dzs: bronchitis, emphysema, asthma,
bronchiectasis, pulmonary alveolar proteinosis PAP
(impaired macrophage and PMN fxn).
No specific signs, may mimic or exacerbate underlying
dz. Fever, night sweats, weight loss, fatigue, anorexia etc
Special tropism for neural tissue
Lots of imaging findings (Slide 53)
Diagnosis and Treatment
Dx: CXR, (+) culture by 2 separate sputum samples OR 1
bronchial wash/lavage OR biopsy with mycobacterial
histopathology and culture (+) sputum. Nucleic acid
probes. MAC and M. kansasii
Tx: Isolation not required. Patients not infectious. AB
therapy for both HIV (+) and (-). Combinations
Clarithromycin/Azithromycin + Ethambutol +
Rifampin/Rifabutin (HIV+ and ART). *EMB and RIF are
hepatotoxic
HIV (-) continue until sputum cultures are negative for
one year.
HIV (+) but no MAC infection, chemoprophylaxis. Can
discontinue 3 months after CD4 >100 cells/ul
HIV (+) with MAC, lifelong treatment. Begin treatment
for two weeks, then ART to avoid IRIS.
Multi-drug therapy
INH, Rifampin, Ethambutol
For rifampin resistance
INH, Ethambutol, Clarithromycin, +/- TMP/SMX
Dx: Definitive – isolation and ID of organism from clinical
specimen. Requires extended incubation – 1 wk. Grows
on BYCE (buffered charcoal yeast extract), prevents
overgrowth of faster growing bacteria and modified
Thayer-Martin medium (N. gonorrhoeae)
Examine multiple sputum or pus samples. Speciation and
susceptibility testing. PCR.
CXR and CT useful in monitoring course of infection
Tx: Standard DOC Trimethopim and sulfamethoxazole
(TMP/SMX)
Empiric coverage – severe infection, 2-3 antimicrobials
(slide 60)
IV Therapy 3-6 weels, switch to oral if no CNS dz.
Duration (IV then oral) - Pulmonary – 6-12 months.
 Organism and Epidemiology
Mycoplasma pneumoniae
Chlamydia
Legionella pneumophila
Disease often emerges in
common source of outbreaks.
Agent is tough and
environmentally persistant. Not
communicable person-to-
person. Flint, Michigan.
Severe disease requires careful
management and supportive
therapy. Prevention is extremely
difficult due to the ubiquitous
and tough nature of the
organism. Avoid sources of
aerosols and minimize risk
factors.
General Characteristics
Smallest and genetically least complex
free-living bacteria. No cell wall, stain
weakly, resist cell wall inhibitors.
Incorporate sterols in plasma membrane.
Cultures slow, colonies exhibit fried egg
appearance.
Tin, Non-motile, coccoid shaped. Obligate
intracellular parasite. Energy parasites
that remove ATP from host.
Binary fission in inclusion bodies
Gram (-) stain but have no peptidoglycan
in cell wall. CRPs and disulfide bonds link
MOMPs to serve peptidoglycan function.
Elementary body
Reticulate body (intracellular
reproduction)
Organisms initially infect the epithelial
cells of the respiratory tract but can
spread. Pathogenesis is result of cell
destruction and inflammation.
Gram (-) basilly, but not easily stained.
Fastidious
Single, polar flagellum
B-lactamase producer
Catalase and Oxidase (+)
Grows aerobically, but requires a
specialized growth medium.
BCYE is commonly used; often
supplemented with Ab to make medium
selective. Inform lab if suspect.
Water associated!
Virulence Factor
Colonization and irritation of airways
P1 adhesion protein mediates
attachment to ciliated epithelium.
ROS produce ciliostasis and damage.
Elementary body – spore analogue.
Host thinks this is food. Will replicate
once inside, similar to viruses.
Clinical Manifestations Diagnosis and Treatment
Most common cause of bacterial atypical pneumonia Dx: CXR reveals patchy interstitial pneumonia.
S&S: non-productive cough that can last 1-2 mo, inspiratory crackles, fever, Cold agglutinin assay – IgM that binds to
malaise, chills. May cause tracheobronchitis, pharyngitis, rhinitis, and otitis. surface of RBCs at 4C. Culture of sputum not
Relapse common, infection does not provide long lasting immunity. useful.
Tx: Doxycycline or Macrolides
Chlamydia trachomatis – Infant pneumonia Dx:
Two biovars: trachoma and LGV C. trachomatis
Spread from mother to infant during birth. (+) maternal vaginal infection, diffuse B/L
Incubation period variable. Symptoms 2-12 weeks after infection. Can last up interstitial infiltrates, abnormal lung sounds,
to months. infants often have inclusion conjunctivitis.
Rhinitis, staccato cough, diffuse rales, tachypnea, hx of failure to thrive. Infants C. pneumoniae
will be afebrile. Conjunctivitis is often concurrent. Interstitial infiltrates and abnormal lung sounds.
CXR will not rule out the other organisms.
Chlamydophila pneumoniae
Bronchitis, atypical pneumonia, and sinusitis. Immunofluorescent Assay to detect IgM/IgG.
Humans are the only reservoir. Transmitted person to person through Titer >16 or four-fold increase of igG in paired
inhalation of EB in respiratory droplets. Common cause of Chlamydial atypical sera.
pneumonia, but exact incidence is unknown.
Cell culture/microscopy – intracellular
Most infections are asymptomatic or mild, with persistent non-productive inclusions.
cough and malaise. Severe infections: Unilateral lobe involvement. Symptoms
can last for months. Tx: Doxycycline or Macrolides
Pontiac Fever Dx: Culture is the gold standard. Requires
Self-limited illness, treatment unnecessary. Symptoms last 2-5 days and specialized medium and growth is slow.
resolve spontaneously. Fever, chills, malaise, myalgia, headache, no signs of Urinary Ag tests – EIA test 95% sn and sp. Only
pneumonia. detects infections with serogroup 1
Ab detection – IFA or ELISA, a four-fold or
Legionnaires disease (legionellosis) greater increase in antibody titer (≥128) is
Severe, acute atypical pneumonia with high mortality rate. 2-10 day considered diagnostic.
incubation period. Abrupt onset of symptons: fever, chills, dry/nonproductive
cough, headache, GI and neurologic symptoms (Nausea, vomiting, diarrhea,
pain, lethargy, altered mental status).
Death is due to shock or respiratory failure.
Risk Factors include large inoculum, any compromise in pulmonary or immune
fxn. Smoking, Chronic heart, lung or renal disease, immunosuppression,
elderly, Cancer/surgery, whirlpool bath, plumbing, alcohol.
ATYPICAL ZOONOTIC PNEUMONIAS
Organism and Epidemiology
F. Tularensis, Tularemia
Bio-warfare, Notify!, BSL-3 handling
tularensis (Type A) Most virulent
holartica (Type B)
Associated with handling rabbits and small rodents.
Vectored by deer flies or ticks.
Coxiella burnetii, Q Fever
Bio-warfare, Notify!, BSL-3 handling
Survives in raw milk, excreta, and soil. Slaughter house
workers most commonly infected by aerosol.
Phase I Highly infectious, LPS. Phase II non-infectious
Transmission between ticks and vertebrates/ruminants
Chlamydia psittaci, Psittacosis
Psittacines: parrots, parakeets, cockatoos. “parrot
fever”
Bio-warfare, Notify!, BSL-3 handling
Aerosol exposure to the feces of infected birds. 10d
incubation period
Rhodococcus equi
First human case in 1967; 12 cases before 1982
Recovered from surface soil contaminated with horse
manure. Many cases with horse farms. Aerosolized on
dry, windy days.
Characteristics
Gram (-), Fastidious, aerobic
coccobacillus
Facultative intracellular bac targeting
macrophages
Hardy under adverse environmental
conditions
Gram (-), obligate intracellular
protobacterium
Very hardy – Endospore-like stage,
drying, low temp pasteurization 60C
for 30’
Gram (-), Obligate intracellular bacteria
Infectious form: elementary bodies,
tough outer membrane, inactive.
Intracellular form: Reticulate bodies,
metabolically active.
Gram (+) coccobacillus
Red pigment on fresh colonies
Geographical Area
ID in Tulare county, CA in 1911
ID in Queensland, AU. Found
globally except in New Zealand.
Found where there are wild or
unregulated pet psittacines.
+/- global distribution
Clinical Manifestation
Pneumonic – aerosol exposure, high mortality.
Bronchopneumonia, bronchitis, tracheitis. Multiple
necrotizing granulomas destroying alveolar septa. Lobar
pneumonia. Hilar LN enlargement, non-productive cough +
retrosternal pain.
Ulcerglandular – skin wound, insect bite
Oropharyngeal – GI, ingestion of infected material
Typhoidal – systemic
Pneumonitis, granulomatous hepatitis, endocarditis
Acute (w/in 2 wks of exposure). Flu-like with pneumonia and
fever. Hepatitis. Phase II Ab predominate.
Chronic (<5%) Patients with Heart disease or immune
deficient. Persists >6mo, endocarditis, Phase I Ab.
Range of severity. Flu-like to bronchial pneumonia + sepsis
(high mortality). Patchy inflammation in the lungs with well
demarcated areas of consolidation.
Fever, sore throat, photophobia.
Enlarged/congested heart, liver, spleen, kidney.
Hx of immune dysfunction. Pneumonia.
Extrapulmonary skin, brain abscesses (rare), may occur
independent of pulmonary dz or months after pulmonary
disease has resolved.
Diagnosis and Treatment
Dx: Patient Hx, Culture lymph nodes, sputum etc.
Growth on chocolate agar within 3 days. Serology
4-fold increase over two weeks, single titer ≥160.
Tx: Primary: Streptomycin, gentamicin
Tetracyclines, B-lactam resistant. Low mortality
with treatment.
Prevention: Insect repellant, avoid reservoirs and
vectors. No Vaccine.
Dx: Patient hx, Serology, Indirect
immunofluorescence, PCR
Tx: Doxycycline wks to mos.
Post Q-Fever fatigue syndrome – constant fatigue,
night sweats, severe headache, insomnia,
photophobia.
Pevention: Know risks, pasteurize, vaccine in
Australia.
Dx: Patient Hx, PCR, Serology – complement
fixation, immunofluorescence (IgM)
Tx: Doxycycline, Macrolides = fluoroquinolones.
Prevention: Avoid sick birds, No vaccine.
Dx: Patient Hx, Sputum, culture etc., blood
culture. Easy to grow, often dismissed as
contaminant.
Tx: Increasing resistance globally. Macrolide or
fluoroquinolones + rifampin.
CNS penetration with neurologic disease.
Prevention: Treat immune disorder, Prophylactic
azithromycin in lung transplant patients.
ARD – VIRAL INFECTIONS OF THE UPPER RESPIRATORY TRACT
Organism and Epidemiology
Rhinovirus
Infections are hyperendemic in winter with greatest
incidence in children and young adults. >50% URT
infections may be caused by this virus.
Transmission by aerosol and fomites. Hands are major
vector in person to person transmission.
Adenovirus
Human reservoir only, spread by aerosol, fomites, close
contact, fecal-oral route. Fingers may spread virus to
eyes.
Coronavirus
Spread by aerosols and droplets, fecal matter. Infection
sporadic or in winter-spring outbreaks.
SARS - bats, detect by PCR, Ab detection.
MERS
Characteristics
Picorna viruses aka small RNA viruses. Structurally
similar to polio virus.
SS (+) sense RNA
Nonenveloped, able to persist in environment
Canyon hypothesis, Binding site for ICAM-1 is located
deep in the capsomere cleft.
33C optimum. Tissue infection may be due to
temperature preference.
DS DNA
Nonenveloped
Capsid has complex structure
Lytic, persistent, and latent infections. Infections of
epithelial cells of respiratory and enteric organs. Viral
DNA replication and assembly in cell nucleus.
SS RNA (+)
Virus is enveloped, capsid with helical symmetry.
Pleomorphic virions with crown like surface.
Optimal Temp is 33-35C
Infects epithelial cells of respiratory tract
Clinical Manifestations
Acute Respiratory Diseases (ARD)
Infections of nasal cavity and pharynx, upper respiratory infections.
Nasal Discharge/obstruction
Sneezing, cough, malaise, throat discomfort with 2-4 days incubation.
Fever or other indication of constitutional involvement are sometimes
present.
Disease is more severe in small children. However infections are
typically benign, transitory, and self-limited.
Adenovirus Diseases
Primary targets are children and young adults.
Pharyngitis, most frequent cause in adults, peak incidence in winter
months.
Pharyngoconjunctival fever, one sided conjunctivitis with preauricular
adenopathy, swimming pool associated, eyedrops.
Pertussis-like syndrome of young adults, military, college dorms, close
quarters and stress.
Coronovirus Diseases
Affects all ages with peak incidence in pediatric patients. Casuse gut
infections as well as ARD.
Diagnosis, Treatment and control
Handwashing and disinfection of objects are best means
of control. Supportive, symptomatic relief. Ab not
effective.
Picovir (pleconaril) – binds to virion and interferes with
infection
Cold Eeze/Zicam – Zinc gluconate, antagonizes virion
uncoating.
Ag detection, rapid tests available. PCR to detect
genome.
Adenovirus can establish latency. Patients may release
virions for long periods and can be detected when it is
not causing a particular disease.
Vaccines against type 4 and 7 for military recruits.
Nonpermissive cell infection converted to cancer cells,
though no event has happened in people.
No specific antiviral therapy, no vaccine.
CROUP – VIRAL INFECTIONS OF THE RESPIRATORY TRACT
Organism and Epidemiology
Parainfluenza Viruses
Originally thought to be true influenza virus.
Paramyxovirus family (RSV, measles, mumps).
Seasonal upsurge in cases with type 1 and 2
with Fall-Winter having the greatest
incidences. No permanent immunity after
infections. Repeat infections with homotypic
virus are observed and subjects serve as
reservoirs.
Respiratory syncytial virus (RSV)
A child is more likely to be RSV infected if she
was born in April – September (the six
months preceding RSV season), is in a family
with older children, attends daycare, lives in
crowded conditions, or was not breast fed.
Expect annual outbreaks each winter. Very
prevalent in young children.
Person-to-person contact spread by contact,
fomites, respiratory route. Adults get
reinfected and transmit RSV to newborns.
Characteristics Clinical Presentation Diagnosis, Treatment and control
Paramyxovirus Croup Dx: Direct viral isolation and culture from throat
Syndrome of fever, hoarseness, and barking cough in children 6-18 mos of age. swabs
Nonsegmented Complications of upper respiratory tract infection that creates tracheal constriction
below the vocal cords. Direct FAB test or RT-PCR
(-) sense ssRNA
PIV type 1 > PIV type 2 >>> RSV Tx: Supportive treatment.
Enveloped
PIV Clinical Presentation No vaccines. Manage symptoms.
4 known serotypes. Hemagglutinin (the infectious part) Entry via droplets into upper respiratory tract epithelial cells (nasal turbinates and
and neuraminidase activities on same peplomer ciliated epithelium of respiratory tract). 2-6 day incubation.
molecule. Novel Fusion (F) protein causes syncytia
formation. Symptoms – harsh cough, rhinitis, sore throat, shortness of breath.
May invade lower airways.
In children, the inflammatory response to infection causes tracheal constriction below
the vocal cords – barking cough, worsening at night.
PIV is the most frequent cause of croup. Type 1 mainly, sometimes type 2 and 3.
Complications: Otitis media and Parotitis.
Paramyxovirus RSV Clinical Manifestations. Dx: clinical presentation and time of year, Virus
Creation of giant cells – fused multinucleated cell syncytia. Respiratory disease ranges culture (difficult), rapid spin Ag detection by
Ability to create giant fused structures (It’s in the name). form mild to serve pneumonia. immunofluorescence or ELISA on nasal washings.
Older children and adults – Upper Respiratory tract infections.
Like other paramyxovirus with small capsid. Infants – bronchiolitis/pneuomonia, sometimes croup. Formation of syncytia and Tx: Supportive care, Ribavirin (a guanosine
inflammation results in excess mucus production, narrowing and plugging of bronchi analogue) is used for severe cases. Passive
(-) sense ssRNA, helical and bronchioles. Symptoms include fever, cough, dyspnea often with tachypnea, and immunization with anti-RSV for high risk infants – 5
cyanosis. monthly doses beginning in November. Human
Enveloped. monoclonal Ab now employed.
Damage to the host’s epithelial cell is a direct result of viral invasion and the host’s
RSV lacks Hemagglutinin and neuraminidase activities. immune response to the infection. Prevention difficult, easy to transmit in hospital
Infection via G protein spike setting. Hand wash!
cell fusion via F spike.
No vaccine even though there is only a single virus
serotype.
INFLEUNZA – VIRAL INFECTIONS OF THE RESPIRATORY TRACT
Organism and Epidemiology
Orthomyxoviridae family
Nomenclature:
Type / Location of discovery/ isolate # /
Year of isolation / Antigenic type
Ex: A/Hong Kong/68/H3N2
A found in endemics, epidemics, and
pandemics. B restricted to epidemics due to
host range. Frequency high in Winter
season.
Seronegative individuals at greatest risk,
most cases in children and young adults.
Significant risk to children <5yo.
Influenza A affects birds, pigs, horses, and
humans. Influenza B affects humans and
seals.
1918 Flu was exceptional due to:
1) Early appearance (October) and left
quickly.
2) Exceptional lethality rate
3) Killed patients rapidly and directly
4) Highest death rate was in young adults
5) Certain nonstructural proteins with
roles in defeating host immune
response
Difficulty in preventing pandemics:
Influenza is completely unpredictable.
Global surveillance is inadequate.
Current vaccine production wont be fast
enough. Current methods rely on
embryonated chicken eggs. Virus could kill
chickens and reduce eggs and devastate
seasonal vaccine production, leaving people
vulnerable to ordinary flu.
Hard to scale up in emergency
Summer emergence will give us enough
time. Winter emergence would not.
Characteristics
Segmented ssRNA, capsid with helical
symmetry, virion enveloped.
3 genera (Influenzavirus A, B, and C) defined by
nucleocapsid proteins. Large number of
Influenzavirus A subtypes based on envelope
proteins H and N.
H – virion attachment and entry
N- progeny virion release and spread
Antigenic change - Type A mutate frequently
and reassert complete gene segments.
Antigenic Drift – Point mutation in H or N genes
Antigenic Shift – Recombination involving inter-
virus exchanges of complete genome segments
encoding H or N gene or others. Results in
sudden changes in antigenic composition
resulting in pandemics.
Clinical Presentation
Short incubation time (1-2 days). Abrupt onset of
symptoms, Respiratory tract entry.
Symptoms – fevers, aches, chills, cough. Children may
get GI symptoms as well.
Illness persists for ~1wk. Make sure patients are not
suffering from secondary infections such as Strep
pneumonia. Rates of infection are highest in children,
but complications, hospitalizations, and deaths are
more prevalent in elderly and those with underlying
medical conditions.
Complications
Pulmonary – Primary influenza viral pneumonia. Viral
destruction of ciliated epithelium, setting stage for
secondary (bacterial) pneumonia: S. pneumoniae, S.
aureus – toxic shock, H. influenza type B. Return of
fever is an ominous sign.
Reye Syndrome – Acute systemic disorder, edematous
encephalitis, and fatty liver tissue. Primarily observed
in children aged 6 mo – 15 yrs and correlated with
Influenza A/B or chickenpox infection treated with
aspirin or Pepto Bismol.
Guillain-Barre Syndrome – autoimmune demyelination
of peripheral nerves. Primarily involves arms and legs,
but any muscle may be affected. Numbness, tingling,
pain, and paralysis. Risk of GBS due to natural
infection is thought to be greater than typical risk
from vaccines.
Nosocomial infections – Influenza A and B in hospitals,
nursing homes, and closed populations. High antigen
dose activated vaccine used in >65 yo.
Diagnosis and Treatment
Dx: Direct viral isolation from throat Vaccine Target Groups
nasopharyngeal swabs. Rapid Ag tests. 1) Persons >65 yo
Hemagglutination test 2) Residents in nursing homes or similar
3) People with chronic pulmonary or
cardiovascular disorders
4) People with Asthma, diabetes, renal
dysfxn, hemoglobulemias or
immunosuppression.
5) Pediatric pts on aspirin (reye risk)
Tx: Supportive, symptomatic relief. 6) Healthcare workers
Adamantane antivirals – Amantadine and Vaccine Adverse effects
Rimantadine, Matrix protein M2 inhibitors for type Pain at site of injection. Induction of
A only. Stops uncoating/penetration by preventing infection symptom; fever, aches, malaise.
acid-dependent conformational change in H Allergic reaction (egg or neomycin
protein. Blocks iron pores. sensitivity). Gullain-Barre syndrome.
Neuraminidase inhibitors – active on both
influenza A and B. blocks neuraminidase active sit,
prevents sialic acid cleavage. Must be applied
within 48 hours of disease onset.
Relenza – Zanamivir (inhaler)
Tamiflu – Oseltamivir (oral)
Influenza Vaccines – Inactivated (IIV), Live (LAIV
(FluMist) now available but not recommended.
For >65 yo
High dose vaccine (4-fold increase over standard)
Flu AD – Adjuvant Trivalent inactivated vaccine
(TIV), oil in water plus flu ag enhances immune
response.
Intradermal TIV
Quadrivalent Flu vaccines – contain 2 type A
viruses and 2 type B viruses.
Egg-free production methods – cell culture based
inactivated vaccine (ccIIV3) and recombinant
hemagglutinin ag (RIV3)
Opportunistic Mycoses
Organism and Epidemiology
Candidiasis
Most exist as commensals
C. albicans found in mucosal
microbiota. Contribute to hospital
acquired blood stream infections.
Can progress to systemic or
disseminated candidiasis if not
treated. Mostly caused by C.
albicans and C. dubliniensis.
Risk Factors:
Physiological – pregnancy, elderly,
infant
Traumatic – burn, infection
Hematological – Cellular immune
deficiency, AIDS, CGD, Aplastic
anemia, leukemia, lymphoma
Endocrinological – diabetes,
hypothyroidism
Iatrogenic – oral contraceptives,
Ab, steroid, chemotherapy,
catheter
Cryptococcosis
Underlying cellular
immunodeficiency prior to
infection (AIDS, lymphoma).
C. neoformans
Found in Pac. Northwest, South
America, Australia, New Zealand.
ID in goats and eucalyptus trees.
Natural reservoir: soil, bird
droppings.
Dz follows inhalation of
desiccated yeast cells. Starts as
skin or pulmonary infection then
may progress to CNS =
meningoencephalitis.
Characteristics
Dimorphic, thin walled fungus
Unicellular budding yeast – commensal
Filamentous mold – pathogenic
Strict aerobe, favors moist environment
Cell wall made primarily of glucan and mannan
Creamy white colonies on media.
Catalase (+)
Morphology – budding yeast (blastoconidia), pseudohyphae,
germ tubes, hyphae, chlamydoconidia. *C. glabrata only forms
yeast cells.
Pseudohyphae – produced when budding cells fail to detach.
Germ tube (C. albicans, C. dubliniensis) – formed in serum at
37C. Grow into true hyphae.
Chlamydospore or chlamydoconidia – thick walled large
spores that form in nutritionally deficient medium.
ID – carbohydrate fermentation, uptake of CHOs, nitrogen, and
other elements.
Micr: Encapsulated yeast (India ink).
Macr: Creamy, mucoid colonies. Grow on SDA and PDA
Serotypes A-D
C. Neoformans – A, D, A/D
C. Gattii – B and C
Urease (+)
Virulence/pathogenicity factors
Adhesins
Germ tube – more adhesive than yeast
cell
Biofilms – adherence to plastic surfaces
(catheters etc)
Secreted Aspartyl Proteases – degrade
host immune factors and cellular
components. Function at wide pH range.
Phospholipase – assists in penetrating
mucosal surfaces.
Heat shock proteins
Capsule – Evades phagocytosis
Diphenol oxidase (laccase) – forms
melanin from phenol containing
substrates. (turns colonies brown, useful
diagnostically)
Ability to grow at 37C
Clinical Presentation Diagnosis and Treatment
1) Cutaneous and subcutaneous Dx:
Oral (thrush) – AIDS. Epithelial cells, yeast, and pseudohyphae. Specimen sites
Vaginal – Diabetics Blood – systemic candidiasis
Onychomycosis – invasion of nails and nail plates CSF
Dermatitis Materials from removed catheters
Diaper Rash *Though not the only cause of diaper rash Tissue samples – stained with 10% KOH
2) Systemic Sputum not useful (Normal flora)
Caused by indwelling catheters, surgery, IV drug use or damage to
skin or GI tract. Transient infections in immunocompetent hosts Direct microscopic examination
but usually resolved by host. Large gram (+) cells, Yeast cells,
Pseudohyphae, True hyphae
Problematic in immunocompromised hosts, infections can develop
anywhere. Eg. Kidneys, heart (endocarditis, valvular diseases, Culture
tricuspid valve), eyes, meninges. SDA, PDA, Routine bacteriological media,
Chromagar
3) Chronic Mucocutaneous
Typically infection of the skin and mucous membranes. Rare Tx:
disease that manifests with genetic backgrounds. Early childhood Cutaneous – Topical antifungals:
onset, associated with cellular immunodeficiency and Ketoconazole, miconazole, nystatin. Oral:
endocrinopathies. fluconazole, itraconazole
Systemic and Chronic Mucocutaneous –
Amphotericin B, Fluconazole,
itraconazole. *chronic, use lifelong azole,
usually fluconazole.
Infections initiated by inhalation of yeast cells. Pulmonary Dx:
infections may be asymptomatic or mimic flu. Can resolve Samples – CSF, sputum, aspiration from
without intervention. skin lesion
Direct exam – India ink
Problematic in immunocompromised. Results in systemic Culture – SDA, PDA, Birdseed agar in
infections following multiplication of yeast cells. Yeast form mixed infections, growth at 37C, growth
prefers CSF: on CGB medium.
Cryptococcal meningoencephalitis Serology – detection of capsule Ag in
Fever, headache, stiff neck, change in mental status. CSF and serum by latex agglutination
Increase in CSF amount and pressure, low glucose test.
May present with lesions on tissue.
All cases of meningoencephalitis are ultimately fatal. Tx: Amphotericin B (+ flucytosine). Life-
long fluconazole prophylaxis following
1) Pulmonary – Asymptomatic/flu-like/cavitation primary treatment in AIDs patients.
2) Disseminated – Meningitis (acute/chronic). Fluconazole can penetrate the CSF.
Cryptococcoma, skin lesions. *C gattii has more extensive
infections.
Opportunistic Mycoses II
Organism and Epidemiology
Aspergillosis
Aspergillus fumigatus is most common.
Commonly found in refrigerator molds and
composted materials.
Powdery mold with small conidia that aerosolize.
Inhalation can lead to severe allergic reaction.
Immunocompromised hosts conidia may
germinate to produce hyphae that are capable of
infiltrating tissues.
Risk Factors:
1) Immunosuppresion, diabetes, exogenous inf.
2) Inhalation of spores – Hypersensitivity rxn
3) Ingestion of contaminated products
Pneumocystis pneumonia (PCP)
Caused by Pneumocystis jiroveci (formally P.
carinii).
Atypical fungus – no natural reservoir, not
culturable, host specific, communicable, not
susceptible to azoles or amphoteric B.
Associated with AIDs CD4 count <200.
Characteristics
Natural reservoir – air and soil
Infected tissue – vascular invasion, preexisting
cavities.
Micr: septate, hyaline hyphae (dichotomous
branching, acute angle), vesicle, microconidia
Macr: Powdery mould colonies, aerial hyphae
with long conidiaphores.
Alveolar macrophages engulf and destroy conidia
(2-3um). In Immunocompromised patients:
Decreased phagocytosis,
Conidia swell in lung and Germinate,
Form hyphal structures, Can invade tissues blood
vesels, cavities, may develop aspergilloma.
Two distinct forms
Trophozoite – thin walled, infectious form
Cysts – thick wall, spherical, multinucleate.
Stained with toluene blue, calcofluor white, or
silver stain.
Extracellular pathogen
Virulence/pathogenicity factors Clinical Presentation
Small hyphae, rapid growth and differentiation 1) Allergic aspergillosis
Asthma
Surface Adhesins, Sialic Acid – for binding to Allergic bronchopulmonary aspergillosis (ABPA)
epithelial cells
2) Aspergilloma and Extrapulmonary
Toxins Aspergilloma (fungal ball, lungs and paranasal
Gliotoxin – affects mucociliary escalator sinuses). Conidia enter preexisting cavity,
Verruculogen – decreases resistance of epithelia germinate, and produce hyphae.
to invasion. Otomycosis (external otitis)
Ribonucleotoxin – interferes with PMN attack of Onychomycosis
fungus Eye infection (conjunctival, corneal, intraocular)
Catalase (+) – helps survive in oxidative stress 3) Invasive Aspergillosis (fatal if untreated)
Pulmonary
Host tissue destruction Disseminated: GI, brain, liver, kidney, heart, skin,
elastase eye
Proteinases
Phospholipase C 4) Mycotoxicosis – some species produce
Aflatoxins (originally in A. flavus). Increases
severity of infections. Require lower
concentrations, some are carcinogenic
(hepatocellular carcinoma)
Communicable! S&S: Fever, non-productive cough, SOB, weight
loss, night sweats, CXR reveals B/L infiltrates.
Dz occurs when both cellular and humoral
immunity are impaired, leads t defective clearing
of alveolar macrophages.
Pathophysiology: Attacks fibrous tissue of lungs,
thickening of alveoli, result in hypoxia.
Diagnosis and Treatment
Dx:
Samples – Sputum, tissue (lung biopsies)
Direct exam – septate hyphae and conidia in
sputum; intravascular hyphae in tissue
Culture – SDA (grow it at least 2 cultures)
Serology – Allergy (detection for IgE), invasive
infection (detection of galactomannan Ag in
serum – ELISA)
Tx:
Allergic – steroid
Aspergilloma – surgery, amphotericin B
Local, superficial inf. – Nystatin
Invasive Inf. – surgical debridement +
posaconazole. Amphotericin B, itraconazole (less
sever infections).
Dx:
CXR – widespread pulmonary infiltrates, ground
glass appearance in both lungs.
ID – Lung biopsy tissue, sputum observed for
organism, PCR, (+) results are not definitive.
Tx: TMP-SMZ, +/- steroid use to reduce
inflammation.
SYSTEMIC (ENDEMIC) MYCOSES
Organism and Epidemiology
Coccidioidomycosis, San Joaqin Valley Fever
Soil Fungi
Endemic to Southwest USA and areas of
Latin America
C. posadasii (AZ, Mexico, Central and South
America)
C. Immitis (arid valleys of ZA)
Soil borne organism in the mold form
(athroconidia and hyphae). Grows as mold in
1-2 wks on SDA. Mostly a problem in people
and dogs (and other animals).
S&S similar to TB and syphilis.
Infections occur in endemic areas most often
during summer and fall, during dry months
when dust is high.
BSL3
Histoplasmosis
Histoplasma capsulatum
Eastern USA (Midwestern?) – especially Ohio
and Mississippi River Valleys & Parts of Latin
America and Africa
Transmission – aerosol of microconidia
Soil dwelling, especially enriched with bird
droppings or bat guano.
Teleomorph (sexual reproductive stage) –
Ajellomyces capsulatus
Anamorph (asexual reproductive stage)
Three variants producing dz in humans,
dogs, and cats.
Characteristics
Arthrospores = arthroconidia
Bipahsic, not dimorphic: Spherule and mole. Lack
the yeast form.
Spherule – membrane rich in lipids and surrounded
by giant cell. Referred to as endosporulating
spherule and produces 200-300 uninucleate
endospores. Endospores are released and form new
spherules, cycle repeats. Susceptible tissue include
lungs, skin, cardiac, bones, and CNS.
Mycelia and Hyphae – alternating barrel-shaped
arthrospores with disjunctor cells in nature.
Coccidioidin – hyphal Ag that is used in
immunodiagnosis.
Dimorphic species
Uninucleate budding cells (blastoconidia)
Mold features macro and microconidia
Tuberculate (finger-like) macroconidium
Facultative intracellular parasite (macrophage and
PMN)
Culture: yeast at 37C and cotton mold 25C. Slow
growing (12wks)
Virulence Factors or Pics :P
Virulence Factors
Yeast releases Urease,
ammonia, and bicarbonate.
Enables yeast to raise pH and
blunt the killing action of
phagolysosome.
Clinical Presentation
Arthroconidia are inhaled (low infective dose w/
incubation period of 7-20 days)
Spherules w/ endospores develop into new
spherules. Patients usually asymptomatic and have
self-limiting symptoms.
Cavitary lesion
Primary Condition – similar to CAP or influenza
(fever, fatigue, lymphadenopathy, cough, headaches, night sweats,
muscle aches, joint paint). Constellation
of fever,
arthralgia, erythema nodosum (delayed Type IV
Hypersensitivity, good prognosis!) common. Also,
Erythema Multiforme. May develop into diffuse
pneumonia in patient.
Disseminated Disease – Preference for Lungs, skin,
bones, joints and CNS. Any organ can be involved.
More likely to occur in Asians, African Americans,
Hispanics. Also higher prevalence during 3rd
trimester of pregnancy due to elevated estradiol
and progesterone. Immunodeficient patients more
likely to develop disseminated infections
Inhaled microconidia converted to yeast cells can
lead to pulmonary disease.
Influenza-like illness marked with non-productive
cough and fever, but infection is self-limiting. Yeast
cells may be phagocytized by alveolar
macrophages and transported deeper into body.
Disseminated into liver and spleen because fungus
targets the reticuloendothelial system that has a
lot of macrophages. Causes hepatosplenomegaly.
Granulomatous foci in lungs and spleen.
Clincal findings of disseminated dz:
Fever, pulmonary illness, weight loss,
hepatomegaly, CNS symptoms, splenomegaly,
lymphadenopathy, meningitis, GI lesions.
Diagnosis and Treatment
Dx:
Isolate organism, ID spherule, or serologic testing. . Sputum
and bronchoalveaolar lavage produce spherules.
PAS – should reveal giant cells w/ spherules.
10% KOH for viewing on fresh mount
Culture on SDA agar at 25C, but highly contagious as
arthrospores BSL3.
Imaging may show cavity or nodules
IgM and IgG Ab
Lab workers at risk
Tx:
DOC: Triazoles like fluconazole and itraconazole or
amphotericin B.
Begin therapy before lab confirmation. Moths of therapy
may be requires when treating server pulmonary and
disseminated disease.
Corticosteroids are contraindicated in humans but steroids
and cough suppressant may relieve symptoms.
Dx:
Direct microscopic exam: Yeast in histologic sections or in
Giemsa-stained smears of marrow or blood.
Isolate and culture from sputum, urine, lesions, or buffy
coat (coagulated plasma and WBCs).
Note tuberculate macroconidia in culture
Histoplasmin (latex agglutination, immune diffusion)
indicates exposure but not definitive for dz.
Nucleic acid probe available.
Tx:
Chronic pulmonary and disseminated – itraconazole or
amphotericin B
SYSTEMIC (ENDEMIC) MYCOSES II
Organism and Epidemiology
Blastomycosis
Blastomyces dermatitidis
Sexual stage is Ajellomyces dermatitidis.
Characterized as CGD
Non transmissible from person to person
or animal to person.
Endemic to Ohio and Mississippi River
Basins and other US states, Mexico,
Central America, and parts of Africa.
Great lakes and Ohio River Valley.
Paracoccidioidomycosis
Paracoccidioides brasiliensis
Confined to central and South America
Soil dwelling
Characteristics Virulence Factor Clinical presentation Diagnosis and Treatment
Thermally dimorphic Infection due to inhaling microconidia or mycelial fragments Dx:
Yeast @ 37C from soil Metastatic skin lesions likely means
Mold @ 25C disseminated dz
Pulmonary dz: acute and chronic pulmonary dz often mimics
Appears as multinucleate in tissue and exudates with influenza (fever, dyspnea, exercise intolerance etc) and Broad-based yeast in wet mount (KOH smear of
broad-based budding cell. subclinical infections are also possible. pus, exudate, skin, and biopsy material)
In culture, hyphae bear conidia, including Extrapulmonary cutaneous granulomas Exoantigen detected by agar gel
chlamydospores immunodiffusion
Dissemination into skin, eyes, and bone
Slow growing (2wks) Culture on SDA
Nucleic probe
ELISA
Tx: Disseminated dz requires aggressive therapy
DOC: itraconazole or amphotericin B
Yeast – Multiple buds Pneumonia and disseminated disease. Possible self-limiting Tx: itraconazole or amphotericin B (2 year
treatment)