MISCELLANEOUS BACTERIA

KATHLEEN ROSS S. CALIGAGAN, MD, FPSNM Legionella Listeria Gardnerella Actinobacillus Bartonella Calymmato-bacterium Flavobacterium Streptobacillus

LEGIONELLA

Legionella pneumophila thin, pleomorphic, motile (flagellated), aerobic, gram-negative slow-growing, facultative intracellular that can invade and replicate inside an amoeba in the environment non-acid-fast, non-sporulating, nonencapsulated, non-fermentative, nonpigmented oxidase- , catalase-, and gelatinasepositive produces beta-lactamase enzyme Legionella pneumophila Gram-negative, pleomorphic, motile, rodshaped, aerobic, facultative intracellular bacteria stains poorly due to its unique lipopolysaccharide-content (14 to 17carbon branched-chain fatty acids and ubiquinones) in the outer leaflet of the outer cell membrane requires L-cysteine and iron salts for growth detected by culture on buffered charcoal yeast extract (BCYE) agar with cysteine causative agent of human Legionellosis or Legionnaires disease and the lesser form, Pontiac Fever

PATHOGENESIS Invades and replicate in human alveolar macrophages and monocytes (not effectively killed by PMNs) Entry into the cells is by a unique form of phaocytosis involving coiling of a single pseudopod around the bacterium Once internalized, the bacteria surround themselves in a membrane-bound vacuole that does not fuse with lysosomes Ribosomes, mitochondria and small vesicles accumulate around vacoules containing the bacteria The bacteria multiply within the vacoules until they are numerous by using a type IVB secretion system (known as Icm/Dot) to inject effector protein (Ank proteins) into the host. These effectors are involved in increasing the bacterias ability to survive inside the host cell Cells are destroyed and bacteria are released Infection of other macrophages occur RESERVOIR: Amoeba Environmental water sources ponds, lakes, creeks cooling towers, hot water & airconditioning systems Evaporative condensers, whirlpool spa, hot tubs, shower heads, humidifiers, tap water and water distillation systems, decorative fountains Soil, dust, aerosols MOT: Airborne transmission from water & dust Aspiration of contaminated water No human-to-human transmission (not contagious) LEGIONELLOSIS Is a collection of infections caused by Legionella pneumophila (serotype 1 & 6) and related bacteria. the severity of legionellosis varies from: 1. mild febrile illness, Pontiac fever , to a 2. potentially fatal form of pneumonia, Legionnaires disease

principally affects those who are susceptible due to age, illness, immunosuppression and other risk factors, such as preexisting respiratory disease, DM, renal disease or malignancy, heavy smokers and alcoholics Incidence of clinically significant disease is highest in men over age 55 years causes both nosocomial (health-care acquired) pneumonia, and community-acquired pneumonia major form of travel-associated pneumonia second most frequent cause of severe pneumonia requiring ICU admission Cell-mediated immunity is the primary host defense mechanism (activation of macrophages produces cytokines that regulate antimicrobial activity against Legionella). Humoral immunity may play a secondary role. It has been shown by autopsy that L. pneumophila can spread from the respiratory system to the spleen, liver, kidney, myocardium, bone, bone marrow, joints, inguinal and intrathoracic lymph nodes and digestive tract causing EXTRAPULMONARY SYNDROMES

COMPLICATIONS: causes an acute fibrinopurulent pneumonia with alveolitis and bronchiolitis may infect the lymph nodes, brain, kidney, liver, spleen, bone marrow, and myocardium (extrapulmonary syndrome) RISK FACTORS: Cigarette smoking Chronic lung disease (emphysema, chronic bronchitis) Deficiency in cell-mediated immunity (Organ transplantation) Steroids or immunosuppressive tx Cancer chemothrerapy Diabetes mellitus ESRD PE: Fine or coarse tremors of the extremities Hyperactive reflexes Abence of deep tendon reflex Signs of cerebral dysfunction

a. LEGIONNAIRES DISEASE

CHEST RADIOGRAPH Fluid accumulation within the lung consolidation Empyemalung cavitation Pleural effusion Bronchopleural fistula (a hole between the bronchus and lung lining, allowing air to leak

an acute bacterial pneumonia usually affects elderly, immunocompromised patiets, patients with preexisting respiratory disease, DM, renal disease or malignancy, heavy smokers and alcoholics lacks characteristic signs & symptoms there is no typical syndrome not everyone exposed to the organism will develop symptoms of the disease

b. PONTIAC FEVER

is an acute, self-limiting, influenza-like illness without pneumonia (nonpneumonic) unlike Legionnaires disease, Pontiac fever has a high attack rate, affecting up to 95% of exposed individuals, thus tends to occur in outbreaks milder respiratory illness than Legionnares disease

INCUBATION PERIOD: 2-10 days CLINICAL MANIFESTATIONS: anorexia, malaise, myalgia, headache, high fever, chills, dry cough followed by productive cough, SOB, diarrhea, pleural and abdominal pain

Legionella on Buffered Charcoal-Yeast Extract (BCYE) agar colonies are slow-growing, round or flat with varying colors from colorless to iridescent pink or blue and are translucent or speckled

CLINICAL MANIFESTATION: fever, cough, chills, myalgia, malaise and headache. Dizziness, photophobia, neck stiffness and confusion may also occur INCUBATION PERIOD: 24-48 hours is self-limiting, persisting for approximately 1 week.

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DIAGNOSIS: Sputum, bronchial washing, blood & urine culture & sensitivity using Buffered Charcoal Yeast Extract (BCYE)agar Immunodiagnostic procedures Direct flourescent antibody Polymerase Chain Reaction Urinary antigen test TREATMENT: Macrolides (Azithromycin) Quinolones (Ciprofloxacin, Levofloxacin, Moxifloxacin, Gemifloxacin, Trovofloxacin) Tetracycline, Doxycycline, Minocycline, Trimethoprim- sulfamethoxazole and Erythromycin PREVENTION: Hyperchlorination Superheating of water

BARTONELLA

BARTONELLA

HUMAN DISEASES

DISTRIBUTION

gram-negative, facultative intracellular, flagellated (motile), pleomorphic, slowgrowing parasites Opportunistic pathogens but can also infect healthy people transmitted by insect vectors such as fleas, sand flies and mosquitoes difficult to isolate in the laboratory but can stained with Warthin-starry silver ipregnation Three Bartonella species are currently considered important causes of human disease Bartonella bacilliformis Bartonella henselae Bartonella quintana

Bartonella bacilliformis
Reservoir: -human

Carrions disease/bartenollosis (Oroya fever & Verruga peruana) Bacteremia

Peru Ecuador Colombia World wide

infection occur only in the Andes. Cases elsewhere in the world are found in travelers) Transmitted by sandflies of genus Lutzomyia (previously known as Phlebotomus) No animal reservoir known, only humans Human can be bacteremic for months

Bartonella henselae
Reservoir: -human

Cat-scratch disease Bacillary angiomatosis Peliosis hepatitis in HIV patients Endocarditis in immunocompromised Bacteremia Neuroretinitis Henoch-Schonlein purpura Rheumatic manifestations Verterbal osteomyelitis Lutzomyia verrucarum: Female vector 1st STAGE: OROYA FEVER Acute or Hematic stage Serious infectious anemia 2nd STAGE: VERRUGA PERUANA Chronic or Eruptive stage Benign skin eruption

PATHOPHYSIOLOGY: B bacilliformis uses a polar flagellum for motility, adheres to and invades RBCs. After entry, the organism replicates in vacuoles. This species also makes an endothelial cellstimulating factor that causes proliferation of both endothelial cells and blood vessels. B henselae and B quintana do not bind to intact human erythrocytes in the same way that B bacilliformis does; however, these organisms make a protein binder that adheres to feline RBC membranes, and they penetrate into endothelial cells. Both species also initiate production of an endothelial cellstimulating factor. B quintana also invades endothelial cells and forms bacterial aggregates that are taken internally by the invasome, a unique phagosomal structure. These proliferate and make intracellular blebs. Erythrocytes may serve as a reservoir for Bartonella species Bartonella Gram-negative, pleomorphic, motile, rodshaped, facultative intracellular bacteria

1st stage: OROYA FEVER

Acute/Hematic stage during which intraerythrocytic parasitism occurs Characterized by the rapid development of severe anemia due to red blood cells destruction, splenomegaly, hepatomegaly, and hemorrhage into the lymph nodes Infection is sudden, potentially lifethreatening associated with high fever and low levels of circulating RBCs & transient immunosuppression Lasts for 2 -4 weeks Mortality rate of untreated Oroya fever is 40%

Bartonella quintana
Reservoir: -cat

Trench fever Bacillary angiomatosis Endocarditis Bacteremia

World wide

(1) Bartonella bacilliformis

causative agent of Carrions disease Grows in a semisolid nutrient agar containing 10% rabbit serum and 0.5% hemoglobin 10 days incubation agar becomes turbid, and granular organisms can be seen in Giemsa-stained smears

COMPLICATIONS in 1st stage: neurobartonellosis (neurologic involvement) and the prognosis in this case is very guarded. It can present as spinal meningitis or as paralysis. In the acute stage, the most feared complication is overwhelming infections by mainly Enterobacterias, Salmonella, and other parasites such as Toxoplasmosis. DIAGNOSIS in 1st stage: stained blood smears and blood cultures in semi-solid medium, peripheral blood smears show anisomacrocytosis with many bacilli adherent to RBC. Thrombocytopenia is also seen and can be very sever

CARRIONS DISEASE
Endemic in South America, mainly in the Andes mountain of Peru, Ecuador and Colombia (transmission is limited to the Andes Mountains at elevations of 10003000 meters because of the habitat of the sand fly. Outbreaks of B bacilliformis

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2nd stage: VERRUGA PERUANA

Chronic /Eruptive stage consists of angiomatous tumours benign vascular skin eruption with raised, reddish-purple nodules that occur in crops Occurs 1-2 months after acute illness and lasts for 1 year No anemia and produces little systemic reaction and no fatalities Bartonella can be seen in the granulomas

(2) Bartonella henselae

small, pleomorphic, gram-negative rod present mainly in the walls of capillaries near follicular hyperplasia or within microabsecesses causative agent of Cat-scratch disease (CSD) associated with bacillary angiomatosis, and peliosis hepatis in HIV patients, and bacteremia and endocarditis in immunocompetent/compromised patients distributed worldwide & occurs in approx 1 per 10,000 persons Cats are the main reservoir transmitted to cats by the cat flea Ctenocephalides felis

neck). The enlarged lymph node is painful and tender which may last 2-3 months or longer and may suppurate ATYPICAL SYNDROME: include Unknown Origin Fever, Parinaud's oculoglandular syndrome, encephalopathy, neuroretinitis, and encephalopathy CAT-SCRATCH DISEASE self-limiting most patients can remain afebrile or asymptomatic A primary inoculation lesion at the site of a bite or scratch: a vesicle at the inoculation site appears 5-10 days after exposure Enlarged lymph glands develop 1 week to 2 months after exposure

(3) Bartonella quintana

causative agent of Trench fever/Five-day fever/Quintan fever/Wolhinie fever/Urban trench fever is a worldwide disease and causes febrile outbreaks emerging as a recognized cause of disease among homeless, alcoholics, people with AIDS (immunocompromised). humans are the only known reservoir transmitted by the human body louse Pediculus humanus corporis poor sanitation and lack of personal hygiene strongly correlate with transmission by the body louse mortality rates are very low is a self-limited relapsing febrile illness. Affected persons regularly recover, even without treatment Pediculus humanus corporis main vector of Bartonella Quintana

DIAGNOSIS in 2nd stage: o Blood culture are usually positive o Tissue biopsy wth silver stain (eg. Warthin-Starry method, Steiner) o Serologic testing o PCR Verruga peruana lesions develop as crops with onset weeks to months later in untreated survivors. These lesions begin as small nodules and subsequently grow. Highly vascular mulaire lesions then form and begin to ulcerate, bleed, and heal via fibrosis over several months. Various stages of small to larger nodules, mulaire lesions, and fibrosis may occur simultaneously. TREATMENT (CARRIONS DISEASE): generally treated with macrolides, tetracyclines, aminoglycosides, or chloramphenicol (Chloramphenicol has been primarily used to treat Oroya fever) for a duration of at least 3 weeks If documented, the guidelines recommend a regimen consisting of doxycycline for 6 weeks plus gentamicin (1 mg/kg IV q8h for 14 d) in the acute phase of Carrin disease, ciprofloxacin and alternatively, chloramphenicol plus penicillin G. in the eruptive phase of Carrin disease, rifampin and alternatively, azithromycin or erythromycin PREVENTION (CARRIONS DISEASE): Vector control Good sanitation and good personal hygeine

Ctenophalides felis main vector of Bartonella henselae from cat to cat

2.2. BACILLARY ANGIOMATOSIS

is a vascular proliferative disease involving mainly the skin, and other organs seen among immunocompromised individuals (e.g. AIDS & transplant patients) Cutaneous lesions: presents as enlarging red papule (cranberry like) with surrounding scale and erythema Erythromycin or doxycycline for minimum of 2 months Bacillary Angiomatosis: Osseous lesion

3.1. TRENCH FEVER

Also known as Five-day or Quintan fever (it is name as such because the symptoms reappear at five days interval) or Wolhinie fever or Urban trench fever (it is name as such because it is found among alcoholics and homeless people) INCUBATION PERIOD: 15-25 days CLASSIC CLINICAL MANIFESTATION: include a febrile illness of acute onset with recurrence, headache, dizziness and shin pain, and sometimes maculopapular rash on the trunk Clinical manifestations range from asymptomatic infection to severe illness COMPLICATIONS: Liver abscesses and spleen abscesses (without endocarditis) in immunocompetent /compromised patients Bacteremia & systemic illness

2.3. PELIOSIS HEPATITIS

is a vascular proliferation of a cystic blood-filled spaces surrounded by a fibromyxoid matrix containing the bacteria Non-specific S/Sx: malaise, fever, weight loss associated by peliosis of the spleen, bacillary angiomatosis of the skin in HIV patients

2.1. CAT-SCRATCH DISEASE

TYPICAL SYNDROME: 1st week after scratch: presence of a distal scratch and/or red-brown skin papule or vesicle at the inoculation site 2nd 3rd week: manifested by fever, headache, body malaise, gradual regional lymph nodes enlargement (axilla, groin,

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epithelial cells covered with many gramvariable bacilli Gardnerella vaginosis clue cells covered with many gram-variable bacilli

BACTERIAL VAGINOSIS (BV)

is the most common vaginal infection in women of childbearing age It happens when the normal balance of bacteria in the vagina is disrupted and replaced by an overgrowth of Gardnerella (the vagina has an acidic environment due to the presence of the resident anaerobic microflora lactobacillus)

Actinobacillus ureae Actinobacillus hominis both occur in the respiratory tract of healthy humans and may be involved in the pathogenesis of sinusitis, bronchopneumonia, and meningitis Actinobacillus actinomycetemcomitans occurs in the human oral microflora and may cause periodontal disease, endocarditis, abscess, osteomyelitis

Calymmatobacterium granulomatis gram-negative, nonmotile, encapsulated rod with safety-pin appearance and presence of Donovan bodies

GRANULOMA INGUINALE or DONOVANOSIS

first known name for this condition was "serpiginous ulcer. Also known as donovanosis, granuloma genitoinguinale, granuloma inguinale tropicum, granuloma venereum, granuloma venereum genitoinguinale, lupoid form of groin ulceration, serpiginous ulceration of the groin, ulcerating granuloma of the pudendum, and ulcerating sclerosing granuloma characterized by small, painless ulcerative genital lesions nodules burst, creating an open, fleshy, oozing lesions (leakage of mucus and blood from the highly vascular lesions)the ulcers ultimately progress to destroy of internal and external tissues

GARDNERELLA
only member of its genus facultative anaerobic, nonmotile, nonflagellated, nonsporeforming, nonencapsulated gram-variable rod (gram-variable because it has a grampositive cell wall, that is so thin it can appear either gram-positive or gramnegative under the microscope. Although it appears microscopically as a gramvariable rod, it is officially categorized as a gram-negative rod). causative agent of bacterial vaginosis (so named vaginosis because no inflammatory cells are present) as a result of a disruption in the normal vaginal microflora produces a pore-forming toxin, vaginolysin, which affects only human cells typically isolated from normal female genitourinary tract (may also be detected from other sources, such as blood, urine, pharynx) grows as small, circular, convex, gray colonies on chocolate agar; it also grows on HBT agar. A selective medium for G. vaginalis is colistin-oxolinic acid blood agar. It is associated microscopically on wet smears with clue cells, which are

RISK FACTORS: having a new sex partner or multiple sex partners douching use of intrauterine device (IUD) for birth control not using a condom

TREATMENT: Beta-lactam antibiotics (Penicillin) Aminoglycosides Tetracycline Chloramphenicol Actinobacillus actinomycetemcomitans facultatively aerobic, gram-negative, immotile and nonspore-forming, oval to rod-shaped, slow-growing coccobacilli

CALYMMATOBACTERIUM

gram-negative, nonmotile, encapsulated rod was initially called Donovania granulomatis, named after the Donovan bodies but was recently reclassified under the genus Klebsiella since the capsule that surrounds the bacterial cell appears similar to that of Klebsiella Micoscopically, it has a safety pin appearance with presence of characteristic Donovan bodies (diagnostic sign) Causative agent ot Granuloma inguinale or Donovanosis

GRANULOMA INGUINALE or DONOVANOSIS small, painless, beefy-red ulcerative genital lesions nodules burst, creating an open, fleshy, oozing lesions (leakage of mucus and blood from the highly vascular lesions) the ulcers ultimately progress to destroy internal and external tissues

ACTINOBACILLUS
facultative aerobic, gram-negative, immotile and nonspore-forming, oval to rod-shaped, slow-growing coccobacilli occurring as pathogens in mammals, birds, and reptiles Medically important species:

Donovan bodies intracellular inclusions found in the cytoplasm of mononuclear phagocytes or histiocytes from tissue samples of patients with granuloma inguinale gram-negative, encapsulated, rodshaped, organisms they appear deep purple when stained with Wrights stain

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CHRYSEOBACTERIUM

previously classified under the genus flavobacterium, which is primarily known to cause disease in freshwater fish, but some specie can be pathogenic to human (opportunistic pathogen) aerobic to facultative anaerobic, nonspore forming, nonmotile, long, thin, gram-negative rods oxidase-positive, proteolytic, and weakly fermentative they characteristically produce yellow, orange, red, or yellow-brown colonies (chromogenic colonies on solid media) found in soil, fresh and salt water, sink drains, faucets and on contaminated medical equipments Causes nosocomial infections primarily among neonates Meningitis is the primary manifestation Occasionally colonize the respiratory tract Often resistant to many antimicrobial drugs but can be susceptible to erythromycin, rifampin, cotrimoxazole

extremely fastidious organism, microaerophilic, slow-growing Culture using Trypticase soy agar or broth enriched with 20% blood, serum, or ascitic fluid "cotton ball" appearance on media, while colonies on agar appear circular, convex, grayish, smooth, and glistening after 5 days of growth, some colonies may demonstrate the "fried-egg" appearance seen with the L form.

refractory pericardial effusion, bronchopneumonia, pneumonitis, periarteritis nodosa, volvulus, and overwhelming septicemia If left untreated, it carries a mortality rate of 10 13%

Can be found in raw mild, pasteurized fluid milk, cheeses, ice cream, raw vegetable, fermented raw-meat sausages, raw and cooked poultry, meats fish

Listeria monocytogenes facultative intracellular, short, gram-positive, nonsporforming, motile, rod-shaped bacteria with peritrichous flagella

Causative agent of: Rat-bite fever Haverhill fever Streptobacillus monilliformis Gram-stained smear on blood agar medium, demonstrating pleomorphic gram-negative bacilli in chains and clumps with irregular, lateral bulbar swellings Gram stain appearance of synovial fluid showing Gram negative bacilli and numerous polymorphs Gram stain appearance of S moniliformis after passaging showing filamentous Gram negative bacilli with bulbous swellings arranging into chains and clumps Rat bite mark (arrow) over base of right thumb 10 days after being bitten.

Flavobacterium Aerobic to facultative anaerobic, non-spore forming, nonmotile, long, thin, gram-negative rods

HAVERHILL FEVER
caused by Streptobacillus moniliformis via oral route from contaminated food, milk or water characterized by fever, rash, chills, headache, vomiting, muscle pain, polyarthritis, polyarthralgia, and bacteremia, and by weight loss and diarrhea in children Steps in the invasion of cells and intracellular spread by L. monocytogenes. The bacterium apparently invades via the intestinal mucosa. It is thought to attach to intestinal cells by means of D-galactose residues on the bacterial surface which adhere to D-galactose receptors on susceptible intestinal cells The bacterium is taken up (including by non phagocytic cells) by induced phagocytosis, which is thought to be mediated by a membrane associated protein called internalin. Once ingested the bacterium produces listeriolysin (LLO) to escape from the phagosome. The bacterium then multiplies rapidly in the cytoplasm and moves through the cytoplasm to invade adjacent cells by polymerizing actin to form long tails. VIRULENCE FACTORS 1. Growth at low temperatures a peculiar ability to multiply at low temperatures as low as 0C (permits multiplication in refrigerated foods).

STREPTOBACILLUS

RAT-BITE FEVER
caused by either Streptobacillus monilliformis or Spirillum minor S. moniliformis infection - more common in North America S. minus infection - also known as sodoku, is more common in Asia is a systemic illness classically characterized by relapsing fever, rash, and migratory polyarthralgias associated with the bite of a wild or laboratory rat COMPLICATIONS: erythrophagocytosis, hepatosplenomegaly, interstitial pneumonia, and lymph node sinus hyperplasia, endocarditis, myocarditis, degenerative changes in the kidneys and liver,

highly pleomorphic, filamentous, nonmotile, aerobic, facultative anaerobe, non-acid-fast, gram-negative rods in chains that usually appears straight but may be fusiform and may develop characteristic lateral bulbar swellings.

LISTERIA

exists in two variant types: 1. Bacillary form 2. L form inducible or spontaneously occurring cell wall-deficient growing with a "fried-egg" colony morphology nonpathogenic

Listeria monocytogenes facultative intracellular, short, grampositive, nonsporforming, motile, rodshaped bacteria with peritrichous flagella exhibits characteristic tumbling endover-end motility at room temp (2025oC) but not at body temp (37oC) (motility test rapidly differentiates listeria from diphtheroids that are member of the normal flora of the skin) catalase positive, oxidase negative, and expresses a Beta hemolysin which causes destruction of red blood cells

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2.

3.

4.

Motility the ability of the bacteria to move themselves into, within and between host cells by polymerization of host cell actin at one end of the bacterium ("growing actin tails") that can propel the bacteria through cytoplasm. In addition, its flagellar motility can enable the bacteria to spread outside of the immediate host environment Adherence & invasion It has a cell wall surface protein called internalin that interacts with E-cadherin, a receptor on GI epithelial cells Produces a toxin Toxins Listeriolysin O (LLO) mediate escape of bacterium from the phagosom before phagolysosome fusion occurs Acts as hemolysin lyses host cells by forming a pore in the cell membrane phosphatidylinositol-specific phospholipase C (PI-PLC) & phosphatidylcholine-specific phospholipase C (PC-PLC) Acts as hemolysin disrupt membrane lipids such as phosphatidylinositol and phosphatidylcholine (lecithin) Zn++ dependent protease which may act as some sort of exotoxin ImaBA an operon which encodes a 20 kDa protein located on the bacterial surface. The protein LMaA induces delayed type hypersensitivity and other CMI responses

OPERON is a functioning unit of a genomic material containing a cluster of genes under the control of a single regulatory signal or promoter one of the most virulent foodborne pathogens with 20 to 30 percent of clinical infections resulting in death Causative agent of human listeriosis

LISTERIOSIS
a serious infection caused by eating food contaminated with the L monocytogenes bacteria. is the leading cause of death among foodborne bacterial pathogens (with fatality rates exceeding even Salmonella and C botulinum) affects primarily pregnant women, newborns, and adults with weakened immune systems. the two main clinical manifestations are sepsis and meningitis.

COMPLICATIONS: Pregnant women perinatal human listeriosis or granulomatosis infantiseptica Immunocompromised patients meningioencephalitis and bacteremia, and rarely focal infections DIAGNOSIS: Blood and spinal fluid culture ON MuellerHinton agar TREATMENT: Ampicillin + gentamycin = drugs of choice Ampicillin + erythromycin Trimethoprimsulfamethoxazole

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