Agent-Host-Environment

Mycobacterium tuberculosis is a nonmotile, acid-fast, obligate aerobe. The bacilli

are 2-4 um in length and have a very slow generation time of between 15 and 20
hours. The cell wall of the mycobacterium is unique in that it is composed mainly of
acidic waxes, specifically mycolic acids. M. tuberculosis is unusually resistant to
drying and chemicals, contributing to the ease with which it is transmitted.M.
tuberculosis is an acid-fast bacteria, and neither Gram positive nor Gram negative.
When Gram stained, it gives the appearance of ghost cells (3, 4). The ZiehlNeelsen stain may be used to identify M. tuberculosis, and if present will appear
pink in color on the slide. It is a nonmotile rod-shaped obligate aerobe that does
not form spores. Mycolic acids are present in the cell walls of M. tuberculosis which
are composed of peptidoglycan. Two types of media are used to grow M.
tuberculosis Middlebrook's medium which is an agar based medium and
Lowenstein-Jensen medium which is an egg based medium. It is catalase negative,
and it is positive for nitrate reduction test and urease test. Tubercle bacilli have a
rather limited temperature range of growth: their optimal growth temperature is 3537 C but they fail to grow at 25 or 41 C. Most other mycobacteria grow at one or
other, or both, of these temperature
Virulence- The pathogenesis of M. tuberculosis begins by the host breathing in
droplet nuclei from an infected person. The bacteria are deposited in the alveolar
spaces of the lungs, and the alveolar macrophages engulf them. Some of the
infectious bacilli resist phagocytosis by the macrophages, and can survive and
multiple within the macrophage causing it to rupture. M. tuberculosis can inhibit
phagosome-lysosome fusion which can create a safe environment for it to survive
within the macrophage. Additionally, the composition of the cell wall especially cord
factor can be toxic to macrophages and other mammalian cells. The cell wall of M.
tuberculosis contains a high concentration of lipids which allows it to be resistant to
varying pH levels of the intracellular and extracellular fluids allowing for survival.
The mycolic acids and other glycolipids in the cell wall of M. tuberculosis also
impede the entry of chemicals which can also contribute to resistance of many
antibiotics, and it can cause the organism to grow slowly and be more resistant to
chemical agents and lysosomal components of phagocytes than most bacteria. M.
tuberculosis is a very slow growing bacterium which may also contribute to its
virulence by initially evading the immune system to begin its attack on the bacteria,
or the slow-growth may not elicit a sufficient response from the immune system to
eliminate it. However, M. tuberculosis does cause a severe inflammatory response
of the host which can cause significant tissue damage. M. tuberculosis can also
secrete proteins known as the antigen 85 complex which bind fibronectin, and may
help in isolating the bacteria from the immune system. M. tuberculosis does not
produce any known toxins, but they do produce pili known as Mycobacterium
tuberculosis pili or MTP which aid them in adherence and initial colonization and add
to their virulence factors.
Dose- Mycobacterium tuberculosis has an incredibly low infectious dose of less than
10 microorganisms

Poor Nutrition- Poor nutrition leads to proteinenergy malnutrition and

micronutrients deficiencies which lead to immunodeficiency. This secondary
immunodeficiency increases the host's susceptibility to infection and hence increase
the risk for developing tuberculosis (Poor nutrition and an inadequate diet weaken
the immune system and increase the chances of infection and developing active
TB). Low body weight is associated with risk of tuberculosis. A body mass index
(BMI) below 18.5 increases the risk by 2 to 3 times. An increase in body weight
lowers the risk. Further studies have provided more evidence of a link between
vitamin D deficiency and an increased risk of contracting tuberculosis. Globally, the
severe malnutrition common in parts of the developing world causes a large
increase in the risk of developing active tuberculosis, due to its damaging effects on
the immune system. Along with overcrowding, poor nutrition may contribute to the
strong link observed between tuberculosis and poverty
Concurrent diease -is when Persons who have been recently infected with TB
bacteria. Persons with medical conditions that weaken the immune system (such as
DM, HIV) People with diabetes mellitus are at increased risk of contracting
tuberculosis,[15] and they have a poorer response to treatment, possibly due to
poorer drug absorption.[16]
Low immunity- Some people develop TB disease soon after becoming infected
(within weeks) before their immune system can fight the TB bacteria. Other people
may get sick years later, when their immune system becomes weak for another
reason.Overall, about 5 to 10% of infected persons who do not receive treatment for
latent TB infection will develop TB disease at some time in their lives. For persons
whose immune systems are weak, especially those with HIV infection, the risk of
developing TB disease is much higher than for persons with normal immune
systems. Tuberculosis is a serious health threat, especially for people living with HIV.
People living with HIV are more likely than others to become sick with TB

Poverty-TB is a disease of poverty. It is widely recognized that the poorer the

community, the greater the likelihood of being infected with the TB germ and
developing clinical disease. A lack of basic health services, poor nutrition and
inadequate living conditions all contribute to the spread of TB and its
Impact upon the community. An absence of good quality health care facilities is
common in poor communities. With no health services to diagnose or treat patients,
there is a longer delay between disease and cure, perpetuating the spread of TB.

Crowding- Crowding has been identified as a risk factor for TB transmission in

communities where persons with TB disease live, crowded housing leads to an

increased risk in terms of exposure to M. tuberculosis. The risk of exposure is also

increased if there is limited air movement in an enclosed space. (In a study
overcrowding (3persons/room)
Poor Ventilation- transmission of M. tuberculosis bacteria to a non-infected person
is more likely if there is poor ventilation. It is noted that occupancy density, room
volume and air change rate are all directly correlated with the number of new TB
infections among persons who share airspace Inadequate air change rates, negative
airflow and recirculation of air have been identified with respect to TB transmission.
The smaller the droplet, the longer it can linger in the air after the infected person
has left the area, allowing increase probability of inhalation by another person.
Infection is acquired by inhalation of M. tuberculosis in aerosols and dust. Airborne
transmission of tuberculosis is efficient because infected people cough up enormous
number of mycobacteria.
Infection-HIV is a major risk factor for tuberculosis. The risk of developing TB is
estimated to be between 20-37 times greater in people living with HIV than among
those without HIV infection. TB is a leading cause of morbidity and mortality among
people living with HIV. HIV infection is commonly listed as the highest risk-factor for
becoming infected with TB, as well as greatly increasing a person's risk for
developing active tuberculosis. Because HIV/AIDS depletes the immune system,
opportunistic infections become serious problems. (An opportunistic infection is an
infection that is kept under control in an immuno-competent person, but becomes
too much for the immune system when infected with HIV.) People with healthy
immune systems can become infected with TB but only about 5% develop active
disease. In the population with latent TB, the infection may lie dormant for years,
becoming active disease only when the body's immune system is weakened, as
occurs with HIV infection (2). Tuberculosis is a serious health threat, especially for
people living with HIV. People living with HIV are more likely than others to become
sick with TB