Download Mycobacteria Nocardia Actinomyces

Institute of Medical Microbiology
Semmelweis University
Mycobacteria
Nocardia
Actinomyces
Prof. Károly NAGY
NAGY KÁROLY
MYCOBACTERIA (> 50 species, saprophitic)
aerobic, rod shape(0.4x3 µm), no spores or cilias
Can not be stained by Gram , once stained, reisist decoloration by acid or alcohol
Acid-fast bacteria
Stained by Ziehl-Neelsen acid-fast dye
high level resistance towards chemicals
Pathogenicity
Species
Reservoire
Disease
Pathogenic
M.tuberculosis
human
tbc
M.leprae
human
lepra
M.bovis
bovine, human
intestinal-,miliary tbc
Potentially
M.avium-
soil, birds, water
disseminated and lung tbc
Pathogenic
intracellulare
bovine
(frequent in AIDS )
M.kansasii
water, bovine
lung tbc
M.marinum
fish, water
sc.nodules, skin ulcers
M.scrofulaceum
soil, water
granuloma, cervical ly.ad
M.ulcerans
human, environment
sc.nodules, skin ulcers
M.fortuitum-chelonei soil, water, animals
sc.abscess,disseminated
Ziehl-Neelsen stain
M. tbc
„Cord-formation”
Gram negatíve
Gram positive
Complex (acid-fast)
acyl lipids
Lipid+LPS
porins
Mycolic acid
(mycolyltrehalose:
„cord-factor”)
D-arabinose
D-galactose
peptidoglycan
lipid bilayer
plasma memrane
Mycobacterium tuberculosis
Culture: aerobic, slow growth : cell division 18 h
Solid medium
Löwenstein-Jensen (egg,potato extract
Malachit-green, antibiotics)
3-8 weeks
Broth media
Sula (semisynthetic, Malachit-green)
Growth: clamps, bigger volumes
Mycobacterium tuberculosis
Pathogenesis
Tbc develops in < 5% of those infected
Source of infection:
Sick human
animal
alveols
Infection
Aerosol droplets
dust
per os (milk)
contacts
granuloma
lympnodes
caverna
Lung granuloma
Mycobacterium tuberculosis
Pathogenesis
alveolar macrophag
Surviving in phagolysosomes
2-4 weeks post infection:
CD4 T-cell cytokins activate macrophages
Granuloma and caverna formation:
cytokine toxycity, complement activation,
ischemia, macrophag enzym activity,etc.
High number of bacteria in sputum:
primer and secunder infection,
high resistance towards drying and chemicals !
Mycobacterium tuberculosis: Pathogenesis
Focal,cheesy necrosis:
Caverna formation
Mycobacterium tuberculosis (tbc): Clinical picture
Pulmonal:
lung (middle/lower lobes), lymphnodes, pleura
tünetek: weakness, fatigue,weight loss, caughing, spitting: yellow/green mucus,
blood in the sputum, short breath, night sweating, pain in chest, back
In those infected disease develops <2years: 5%, > 2 years : additional 5-10%
• clinical diagnosis
• x - ray
• microscopy
• culture
Mycobacterium tuberculosis (tbc): Clinical picture
Extrapulmonal :
•
•
•
•
•
haematogen or urogen dissemination, contact infectio
gastrointestional (infected milk)
genito-urinary system (kidney tbc)
bone (deformity)
skin tbc (erythema multiforme, aquarium disease)
scrofula (neck swelling, ulcer)
IMMUNITY
Gate of
entrance
Source of
infection
PRIMER
SECUNDER
M. tuberculosis: surviving strategies in macrophages
- high resistency of lipid/wax cell wall
- neutralisation of free radicals
- ammonia formation, which inhibits
* formation of phagolysosomes
* activity of lysosomal enzymes
„dormant” state
M. tuberculosis INDUCED IMMUNE DESTRUCTION
I. type
II.type
III. type
hypersensitivity
anaphylaxias
cytotoxikus
immunkomplex
IgE
pollen,animal
fur, penicillin
animal sera
IgG
Complement
Rh,
gyógyszer
IgG
Complement
bact.,virus,
fungi, etc,
animal sera
local,generalised,
odema, histamin
skinprobe
self cell
ADCC
lysis
-
Co activation
trombocyte
activation
-
IV.type
delayed, tuberculin type
T lymphocyte
intracellular
microbe
granuloma
formation
skinprobe
Tuberculin test: Mantoux - probe
Suitable to detect tbc infection or validation of the effect of BCG vaccination
Purified,standardised tuberculoprotein : M.tbc PPD (Purified Protein Derivate)
5 TU intracutan inoculation,
read after 48 h
< 10 mm induration: negatív
10-20 mm induration: BCG-hypersensistivity
> 20 mm induration: infekctious hypersensitivity
Not M. tbc specifc
Conversion (pozitív): M.tbc infection, BCG vaccination
Reversion (negatív): early infection, miliary tbc, meningitis, AIDS, immunosuppression,
morbilli,varicella, wooping cough , influenza, helmintiosis, old age
THE HISTORY OF TUBERCULOSIS
•Kr.e. 1000 egyptian mummies – bone destrucion, abscess
•Hyppokrates: aerosol, droplets infection
•Middle ages: „phtysis”, the disease of the lung
•Franz de la Boë (1614 – 1672) : „tuberculum”
•London, XIX.c.:every 3. death due to tbc
•Johan Lukas Schönlein (1793 – 1864): the clinical
definition of tuberculosis (1832)
•1882: Robert Koch: a ‘Koch-bacillus” the etiological factor
1890 – tuberculin, 1930- diagnostical meaning
•1906: Albert Calmette és Camille Guerin: a „BCG”,
the possibility of active immunization (1921)
•1930: a Lübeck catastrophy: the significance of virulent/
avirulens strains, not interchangeable
•1930: introduction of tbc screening programs,epidemy decrease
•1945: WW II: epidemy increase
•1950-1980: significant decreasing
•1992: WHO Tbc: global problem
•2000: WHO AIDS – Malaria – TBC GLOBAL EMERGENCY
Famous people who have had tuberculosis :
Calvin
Anton Chehov
Branwell Bronté
Emily Bronté
Frédéric Chopin
Descartes
John Keats
D.H. Lawrence
Vivien Leigh
Nelson Mandela
Moliere
George Orwell
Paganini
Edgar Allan Poe
Richelieu cardinal
Schiller
Jean J. Rousseau
Sir Walter Scott
P.B.Shelly
Spinoza
R.L. Stevenson
Desmond Tutu
Simonetta Vespucci
Margaret Gardner (a former Ms. World)
EPIDEMIOLOGY : TB Incidence 2001
per 100 000 pop
< 10
10 - 24
25 - 49
50 - 99
100 - 299
> 300
Tbc prevalencia - Hungary
RISK FACTORS
Tbc split by gender and age
MALES
HOMLESS
DIRCT CONTACT
IMMIGRANT
LONELY
FEMALS
„Frigyes Korányi” National TBC and Pulmonological Institute
INCIDENCE OF TUBERCULOSIS
•
•
•
•
TB is responsible for 25% of adult deaths in the developing world- more than those caused
by diarrhea, malaria and AIDS combined
South Africa has one of the highest incidences: >200/100 000
35 people die of TB every day in South Africa
The incidence in the 'first world' is less than 10/100 000
THE GLOBAL EMERGENCY
1.
2.
3.
4.
5.
8-12 million new infections with M. tuberculosis per year
2-3 million people die from TB per year
If present trends continue, deaths will exceed 4 million by 2004
There is also the emergence of multi-drug resistant M. tuberculosis
These trends, and the association of TB with HIV infection, has led to TB being declared
A GLOBAL EMERGENCY
by the World Health Organization
(1993)
Laboratory diagnosis
The basics of the effective treatment of tbc: early, rapid and accurate diagnosis
Microscopy od stained smear
104 bacterium/ml
low sensitivity
Cytocentrifuge
Isolation, culture
sensitivity
102 bacterium/ml
long culture time: 4-8 hét
(Sauton – and Dubos media )
Laboratory diagnosis
BacTec automats: radioactive palmitinic acid/CO2
fluorescent detection
turbidity
other color reaction
Rapid growth detection
4-14 nap
Biosensors:
<1h
Molecular detection: PCR, LCR
RFPL, DNA typing, DNS-chip
Drug sensitivity/ resistance
determination
( hours, 1-2 days)
Atypical and apathogenic mycobacteria
M. avium-intracellulare, M. kansasi , M. scrofulaceum
M. smegmatis, M. phlei, stb
induce mycobacteriosises
characteristics: occurrence in the nature
faster growth
pigment formation
niacin negativity
different drug resistancy
member of the normal flora
disease: local (skin, lung, lymphnodes, etc.) processes
no transmission from human to human,
nozokomial infections
generalized in AIDS
THERAPY
• Stop infectivity
• Inhibit drug resistance
• Prevent remission of infection
• Goal : complete recovery
Combination treatment, long time (6 -12 month) treatment
Initial, intense phase:
3 -4 anti tuberculotics against extracellular bacteria
Stabilisation phase:
fewer drugs against intracellular, slow growing bacteria
INH (isonikotinic acid hidrazid ) - Rifampicin - Pirazinamid
Ethambutol
(AIDS, extrapulmonal tbc, meningitis)
Ciprofloxacin,ethionamid,cycloserin
(Multiresistant M.tbc)
Clarithromycin,rifampicin,etambutol,clofazimin (M. avium-intracellulare)
Doxicyclin
( M. fortuitum-chelonei)
Multiresistant strains !
TBC – AIDS coinfections
PREVENTION
1. Prevention of infection:
General hygienic rules
Effective treatment of those infected
Eradication of infected cattles
2.
Vaccina: BCG inoculation
M.bovis live, attenuated strain BCG (Bacillus Calmette-Guerin)
2 - 42 day after birth, partial resistency
3.
Chemoprofilaxis:
INH monotherapy , Rifampicin
(min. 6 month)
Induces lepra (Hansen disease) , does not grow in media or cell culture,
Only in mouse sole and in armadillo.
Aerob, pálcika alakú, saválló baktérium : Ziehl – Neelsen festés
Laboratory diagnosis: from skin disorders, nose mucosa
Syphilis serological reactions are fals posistive in lepra
The bacteria grow intracellularly in skin histiocytes, endothel cells and superficial
nerves (Schwann-cells) . Optimal temperature: 30 C°
Tuberculoid lepra: normal cellular immunity,
few bacteria growing,
giant cells in granulomas
Lepromin skin tests: positive
Lepromatic lepra: immune response towards M.leprae is weak
skin, mucosa : large number of bacteria (histiocytes)
Lepromin skin test: negative
Immune response to only M.leprae is defective,
cellular and humoral immune response towards other
microorganisms are intact
Antibodies are not protective
Long incubation time: 10-15 year ! Gradual disease formation
Macular skin disorders:
Insensibility
ulcer
Nodular skin disorders: „ lion face” (facies leontina)
Fingers, extremities
exposed to amputation
because trophical
Disorders,
resorption of bones
resulting in
loss of nose cartilags
or digits
Dapson (sulfonamid residue)
Rifampin (inhibitor of bacterial RNS synthesis
Clofazimin
Boswelia carteri (Tömjénfa)
„Salai guggul”
Nocardia genus
Obligate aerob, Gram positive, moderate acid fast , filamental bacteria
Occurrence: widespread, soil, water
Domestic animals, dogs, cows (natural hosts)
In Humans:
N.asteroides
N. braziliensis
Nocardiosis: chronic, lobular pneumonia, miliary tbc-like
fever, weigh loss, chest pain. Lung abscess, haematogen
dissemination:central nerve system abscesses
Mycetoma: abscess in hand, leg, s.cutan connecting tissues
Laboratory diagnosis: sputum, pus, liquor smears
Gram- and acid fast staining
Treatment: Surgical removal
trimetoprim
sulfonamids
Actinomyces
Anaerobic, no spores, Gram positive, irregular shape rods
Actinomyces israelii: non obligate anaerobic, slow growth (7-10 days)
Actinomycosis
Pathogenesis:
2 -3 mm, yellow granules (mycelia) consisting of the bacterial bodies
Gram positive
Gram negative
Actinomyces mycelium
Actinomycosis
Pathogenesis: typical endogenous infection. Caries teeth, pharyngeal lavage, intestines,
Vaginal flora
Pathogenic process is initiated by: trauma, pyogenic infections, i.u. contraceptive devices
ABSCESS
FISTULA
SKIN
actinomycosis
DRAINING OF PUS
Pelvic inflammation
Lung actinomycosis
Therapy:
• Surgical removal
• Penicillin
• sulfonamids