MICROBIAL DISEASES OF THE RESPIRATORY SYSTEM

Structure and Function of the Respiratory System

2 Division of the Respiratory System

1. The upper respiratory system includes the nose, nasal cavity, and
sinuses.
2. The lower respiratory system includes the larynx, trachea, bronchi,
bronchioles, and alveoli.

Upper Respiratory Infections: Common Cold, Sinusitis, Pharyngitis,

Epiglottitis and Laryngotracheitis

Etiology: Most upper respiratory infections are of viral etiology. Epiglottitis and
laryngotracheitis are exceptions with severe cases likely caused by Haemophilus
influenzae type b. Bacterial pharyngitis is often caused by Streptococcus
pyogenes

Pathogenesis: Organisms gain entry to the respiratory tract by inhalation of

droplets and invade the mucosa. Epithelial destruction may ensue, along with
redness, edema, hemorrhage and sometimes an exudate.

Clinical Manifestations: Initial symptoms of a cold are runny, stuffy nose and
sneezing, usually without fever. Other upper respiratory infections may have
fever. Children with epiglottitis may have difficulty in breathing, muffled speech,
drooling and stridor. Children with serious laryngotracheitis (croup) may also
have tachypnea, stridor and cyanosis.

Microbiologic Diagnosis: Common colds can usually be recognized clinically.

Bacterial and viral cultures of throat swab specimens are used for pharyngitis,
epiglottitis and laryngotracheitis. Blood cultures are also obtained in cases of
epiglottitis.
Prevention and Treatment: Viral infections are treated symptomatically.
Streptococcal pharyngitis and epiglottitis caused by H influenzae are treated with
antibacterials. Haemophilus influenzae type b vaccine is commercially available
and is now a basic component of childhood immunization program.

2. Lower Respiratory Infections: Bronchitis, Bronchiolitis and Pneumonia

Etiology: Causative agents of lower respiratory infections are viral or bacterial.

Viruses cause most cases of bronchitis and bronchiolitis. In community-acquired
pneumonias, the most common bacterial agent is Streptococcus pneumoniae.
Atypical pneumonias are cause by such agents as Mycoplasma pneumoniae,
Chlamydia spp, Legionella, Coxiella burnetti and viruses. Nosocomial
pneumonias and pneumonias in immunosuppressed patients have protean
etiology with gram-negative organisms and staphylococci as predominant
organisms.

Pathogenesis: Organisms enter the distal airway by inhalation, aspiration or by

hematogenous seeding. The pathogen multiplies in or on the epithelium, causing
inflammation, increased mucus secretion, and impaired mucociliary function;
other lung functions may also be affected. In severe bronchiolitis, inflammation
and necrosis of the epithelium may block small airways leading to airway
obstruction.

Clinical Manifestations: Symptoms include cough, fever, chest pain, tachypnea

and sputum production. Patients with pneumonia may also exhibit non-
respiratory symptoms such as confusion, headache, myalgia, abdominal pain,
nausea, vomiting and diarrhea.

Microbiologic Diagnosis: Sputum specimens are cultured for bacteria, fungi

and viruses. Culture of nasal washings is usually sufficient in infants with
bronchiolitis. Fluorescent staining technic can be used for legionellosis. Blood
cultures and/or serologic methods are used for viruses, rickettsiae, fungi and
many bacteria. Enzyme-linked immunoassay methods can be used for detections
of microbial antigens as well as antibodies. Detection of nucleotide fragments
specific for the microbial antigen in question by DNA probe or polymerase chain
reaction can offer a rapid diagnosis.

Prevention and Treatment: Symptomatic treatment is used for most viral

infections. Bacterial pneumonias are treated with antibacterials. A polysaccharide
vaccine against 23 serotypes of Streptococcus pneumoniae is recommended for
individuals at high risk.

Strep throat

Strep throat is caused by Group A Streptococcus bacteria. It is the most common

bacterial infection of the throat.

Causes

Strep throat is most common in children between the ages of 5 and 15, although
it can happen in younger children and adults. Children younger than 3 can get
strep infections, but these usually don't affect the throat.

Strep throat is most common in the late fall, winter, and early spring. The
infection is spread by person-to-person contact with nasal secretions or saliva,
often among family or household members.

People with strep throat get sick 2 – 5 days after they are exposed. The illness
usually begins suddenly. The fever often is highest on the second day. Many
people also have sore throat, headache, stomach ache, nausea, or chills.

Strep throat may be very mild, with only a few of these symptoms, or it may be
severe. There are many strains of strep. Some strains can lead to a scarlet fever
rash. This rash is thought to be an allergic reaction to toxins made by the strep
germ. On rare occasions, strep throat can lead to rheumatic fever if it is not
treated. Strep throat may also cause a rare kidney complication.
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Pharyngitis/ Strep Throat

Clinical features of Group A Beta Hemolytic Strep Pharyngitis

1. unusual before three years of age and greatest between 5-15

2. Sore throat-usually sudden onset
3. Fever
4. Abdominal pain/vomiting
5. Absence of runny nose, conjunctivitis, diarrhea, and cough
6. More frequent in late winter and spring, uncommon in summer
7. transmitted by oral and nasal secretions

Physical findings in Streptococcal Pharyngitis

1. red pharynx with exudate on tonsils and petechiae on soft palate

2. bilateral tender anterior cervical adenopathy
3. Scarlet Fever- sandpapery red rash that is primarily on the trunk. There is
circum- oral pallor and a strawberry tongue. There may be Pasita lines in
the antecubital fossa area. May be accentuated in the underpants area.
Can be pruritic and will often peel at the end of the illness. Patients with
scarlet fever are not sicker than others without rash.
4. Sensitive and specificity not high enough to make the diagnosis without
culture confirmation.

Viral causes of pharyngitis-often will have cough, conjunctivitis, hoarseness and

rhinorrhea

1. Adenovirus
2. EBV
3. HSV
4. Influenza and Parainfluenza
5. Enteroviruses

Other bacterial causes of pharyngitis-benefit of antimicrobial therapy not proven

1. Chlamydia- benefit of antibioitcs not proven

2. M. pneumonia- benefit of antibiotics not proven
3. N. gonorrhea
4. Group C and G Streptococcus- self limited and not associated with the
development of rheumatic fever.

Diagnosis of Streptococcal pharyngitis

1. Because symptoms and physical findings are not reliable to make the
 diagnosis of strep pharyngitis, throat culture or antigen detection test must
be performed, Throat culture on sheep blood agar and incubate for 24
hours. The throat culture is 90-95% sensitive. Technique is important and
must get the posterior pharynx and avoid the uvula and soft palate The
number of colonies on sheep blood agar is not important. A bacitracin disc
will differentiate GABS from non Group A. Also may do a rapid strep test
which is less sensitive(80-90%) and as specific(95%) as the throat culture.
If rapid test is positive treatment may be initiated. If negative, you must
plate a throat culture. It is suggested to do two swabs at one time so that if
the rapid test is negative, you don't have to swab the throat again.
2. It is not necessary to culture contacts unless they are symptomatic
3. All suspected streptococcal pharyngitis patients must be cultured or have
a + rapid strep test prior to starting antibiotic treatment.
4. It is imperative to only culture appropriate patients to avoid picking up the
10% of the population that are "carriers" of strep. These are patients that
have GABHS in heir throats without clinical symptoms and a serologic
response. Also, are patients that have persistent positive throat cultures
following adequate treatment with antibiotics. The patient is clinically well.
These patients are not contagious and are not at increased risk for Acute
Rheumatic Fever.
5. Reculturing after course of treatment is not recommended.

Treatment

1. Oral penicillin for 10 days or LA Bicillin IM.

2. If penicillin allergy. , erythromycin po There has been an increased of
erythromycin resistance with the increased use of macrolides. The
incidence decreased with their withdrawal from treatment regimens
3. Treatment for carrier state if there is a family member with ARF, parental
anxiety(strep neurosis), ping pong spread of strep infections, or patient is
considering tonsillectomy for recurrent positive cultures. Treatment is oral
rifampin during the last 4 days of oral course of penicillin, oral rifampin
with LA bicillin, cephalosporins, or oral clindamycin.
4. Patients are not contagious 24 hours after starting therapy and may return
to school

Complications of Strep pharyngitis

1. Acute rheumatic fever may be prevented treatment of the strep pharyngitis

within 10 days of onset of symptoms. Acute post streptococcal
glomerulonephritisis not prevented by therapy

2. Peritonsillar abscesses
Scarlet fever is a disease caused by an erythrogenic exotoxin released by
Streptococcus pyogenes. The term Scarlatina may be used interchangeably with
Scarlet Fever, though it is commonly used to indicate the less acute form of
Scarlet Fever that is often seen since the beginning of the twentieth century.[1]

It is characterized by:

• Sore throat
• Fever
• Bright red tongue with a "strawberry" appearance
• Characteristic rash, which:

• is fine, red, and rough-textured; it blanches upon pressure

• appears 12–48 hours after the fever
• generally starts on the chest, armpits, and behind the ears
• spares the face (although some circumoral pallor is
characteristic)
• is worse in the skin folds. These are called Pastia lines
(where the rash runs together in the arm pits and groins) appear
and can persist after the rash is gone
• may spread to cover the uvula.

• The rash begins to fade three to four days after onset and desquamation
(peeling) begins. "This phase begins with flakes peeling from the face.
Peeling from the palms and around the fingers occurs about a week
later."[2] Peeling also occurs in axilla, groin, and tips of the fingers and
toes.[3]

Diagnosis:The infecting strain must be isolated on culture media and identified

using biochemical or enzyme-based tests.

Diphtheria is an infectious disease caused by the bacterium Corynebacterium

diphtheriae. This disease primarily affects the mucous membranes of the
respiratory tract (respiratory diphtheria), although it may also affect the skin
(cutaneous diphtheria) and lining tissues in the ear, eye, and the genital areas.