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M265 Medical Microbiology

Microbial Pathogenesis and Virulence Ref:

Burtons Microbiology for the Health Sciences, 9 th Ed, ch.14 Jawetz, Melnick, & Adelberg's Medical Microbiology, 24th ed, ch 9

Lectures # 14 & 15

Dr. Samer Swedan

Outline
Introduction Infection Versus Infectious Disease Why Infection Does Not Always Occur Symptoms of a Disease Versus Signs of a Disease Latent Infections Primary Versus Secondary Infections Steps in the Pathogenesis of Infectious Diseases Virulence Virulence Factors (Attributes That Enable Pathogens to Attach, Escape Destruction, and Cause Disease)

Four Periods or Phases in the Course of an Infectious Disease

Localized Versus Systemic Infections Acute, Subacute, and Chronic Diseases

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Introduction
Pathogenicity means the ability to cause disease. Pathogenesis refers to the steps or mechanisms involved in the development of a disease.

Infection Versus Infectious Disease

An infectious disease is a disease caused by a microbe, and the microbes that cause infectious diseases are collectively referred to as pathogens. Microbiologists reserve the word infection to mean colonization by a pathogen; the pathogen may or may not go on to cause disease; A person can be infected with a pathogen, but not develop disease.

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Why Disease Does Not Always Occur

The microbe may land at an anatomic site where it is unable to multiply. The indigenous microflora may produce antibacterial factors (i.e., bacteriocins) that destroy the pathogen. The individuals nutritional and overall health status often influences the outcome of the pathogen-host encounter. The person may be immune to that particular pathogen. Phagocytes present in the blood may destroy the pathogen.

Many pathogens must attach to specific receptor sites before they are able to multiply and cause damage.
Antibacterial factors may be present at the site where the pathogen lands. Indigenous microflora of that site may inhibit growth of the foreign microbe (i.e., microbial antagonism).

Four Periods or Phases in the Course of an Infectious Disease

The incubation period The prodromal period The period of illness The convalescent period

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Localized Versus Systemic Infections Localized Infections Once an infectious process is initiated, the disease may remain localized or it may spread; examples of localized infections are pimples, boils and abscesses. Systemic Infections When the infection spreads throughout the body it is said to have become a systemic or generalized infection; an example is miliary tuberculosis caused by Mycobacterium tuberculosis.

Acute, Subacute, and Chronic Diseases An acute disease is one that has a rapid onset, and is usually followed by a relatively rapid recovery; examples are measles, mumps, and influenza. A chronic disease has a slow onset and lasts a long time; examples are tuberculosis, leprosy, and syphilis. A subacute disease is one that comes on more suddenly than a chronic disease, but less suddenly than an acute disease; an example would be bacterial endocarditis.

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Latent Infections
Latent infections are infectious diseases that go from being symptomatic to asymptomatic, and then, later, go back to being symptomatic.
Examples include syphilis and herpes virus infections such as cold sores, genital herpes, and shingles.

Symptoms of a Disease Versus Signs of a Disease

A symptom of a disease is defined as some evidence of a disease that is experienced by the patient; something that is subjective; for example, aches or pains, ringing in the ears, blurred vision, nausea, dizziness, etc. There are symptomatic and asymptomatic diseases. In a symptomatic disease, the patient is experiencing symptoms. In an asymptomatic disease, the patient is not experiencing any symptoms. A sign of a disease is defined as some type of objective evidence of a disease; for example, elevated blood pressure, abnormal heart sounds, abnormal pulse rate, abnormal laboratory results, etc.

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Primary Versus Secondary Infections

One infectious disease may commonly follow another; in such cases, the first disease is referred to as a primary infection and the second disease is referred to as a secondary infection. Example: serious cases of bacterial pneumonia frequently follow mild viral respiratory infections. During the primary infection, the virus causes damage to the ciliated epithelial cells of the respiratory tract; these cells are then unable to clear opportunistic bacterial pathogens from the respiratory tract, leading to the secondary infection (e.g. pneumonia).

Steps in the Pathogenesis of Infectious Diseases A common sequence of steps in the pathogenesis of infectious diseases is: 1. Entry of the pathogen into the body. 2. Attachment of the pathogen to some tissue(s) within the body 3. Multiplication of the pathogen. 4. Invasion or spread of the pathogen. 5. Evasion of host defenses. 6. Damage to host tissue(s).

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Entry of the pathogen into the body: - Normal skin and mucous membranes provide the primary defense against infection. To cause disease, pathogens must overcome these barriers.

Frequent portals of entry of pathogenic bacteria: Respiratory (upper and lower airways) Gastrointestinal (primarily mouth) Genital and urinary tracts. Abnormal areas of mucous membranes and skin (e.g. cuts, burns, and other injuries) are also frequent sites of entry.

The infection process: 1- Once in the body, bacteria must attach or adhere to host cells, usually epithelial cells. 2- Upon establishing a primary site of infection, they multiply and spread directly through tissues or via the lymphatic system to the bloodstream. This infection (bacteremia) can be transient or persistent. Bacteremia allows bacteria to spread widely in the body and permits them to reach tissues particularly suitable for their multiplication.

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The infection process: e.g. Streptococcus pneumoniae S. Pneumoniae (pneumococci) is present in 5%-40% of healthy people. Occasionally, pneumococci from the nasopharynx are aspirated into the lungs; aspiration occurs most commonly in debilitated people and in settings such as coma when normal gag and cough reflexes are diminished. Infection develops in the terminal air spaces of the lungs in persons who do not have protective antibodies against that capsular polysaccharide type of pneumococci. Multiplication of the pneumococci and resultant inflammation lead to pneumonia. The pneumococci enter the lymphatics of the lung and move to the bloodstream. Between 10% and 20% of individuals with pneumococcal pneumonia have bacteremia at the time the diagnosis of pneumonia is made. Once bacteremia occurs, the pneumococci can spread to secondary sites of infection (eg, cerebrospinal fluid, heart valves, joint spaces). The major complications of pneumococcal pneumonia are meningitis, endocarditis, and septic arthritis.

The infection process: e.g. Vibrio cholerae The infectious process in cholera involves ingestion of Vibrio cholerae, chemotactic attraction (i.e. migration) of the bacteria to the gut epithelium, motility of the bacteria by a single polar flagellum, and penetration of the mucous layer on the intestinal surface. The V. cholerae adherence to the epithelial cell surface is mediated by pili and possibly other adhesions. Production of cholera toxin results in flow of chloride and water into the lumen of the gut, causing diarrhea and electrolyte imbalance.

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Virulence
The term virulent is sometimes used as a synonym for pathogenic. There may be virulent (pathogenic) strains and avirulent (nonpathogenic) strains of a particular species. Virulent strains are capable of causing disease; avirulent strains are not. For example, toxigenic (toxin-producing) strains of Corynebacterium diphtheriae can cause diphtheria, but nontoxigenic strains of C. diphtheriae cannot. Thus, the toxigenic strains are virulent, but the nontoxigenic strains are not.

Virulence, cont.
Sometimes, the term virulence is used to express the measure or degree of pathogenicity. Example: It only takes 10 Shigella cells to cause shigellosis, but it takes between 100 and 1,000 Salmonella cells to cause salmonellosis. Thus, Shigella is more virulent than Salmonella.

Example: Some strains of Streptococcus pyogenes (e.g., the flesh-eating strains) are more virulent than other strains of S. pyogenes.

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Virulence Factors
Virulence factors are attributes that enable pathogens to attach, escape destruction, and cause disease (i.e. factors that determine ability to cause infection and disease) Virulence factors are phenotypic characteristics that are dictated by the organisms genotype.

Bacterial Virulence Factors: (1) (2) (3) (4) (5) (6) (7) (8) (9) Adherence factors Invasion of host cells and tissues Toxins Enzymes Antiphagocytic factors Intracellular pathogenicity Antigenic Heterogeneity The requirement for Iron Ability to form Biofilms

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Virulence Factors
Examples:

Adhesins (ligands) - special molecules on the surface of pathogens are considered to be virulence factors because they enable pathogens to recognize and bind to particular host cell receptors. E.g. Pili
Pili (bacterial fimbriae) are considered to be virulence factors because they enable bacteria to attach to surfaces, such as tissues within the human body.

Adhesins and Receptors

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Examples of Virulence Factors

- Many virulence factor genes are carried on extrachromosomal genetic elements (e.g. plasmids). However, bacterial chromosomes may contain virulence genes; Usually in areas termed Pathogenicity Islands (PAIs). Pathogenicity Islands (PAIs): - Large groups of genes that are associated with pathogenicity and are located on the bacterial chromosome - Examples of virulence genes present in PAIs: genes for toxins, adhesions, lytic enzymes, antibiotic resistance, and iron uptake.

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Regulation of Bacterial Genes and Virulence Factors: - Bacteria are extremely adapted to their environments.

- Bacterial genes are only expressed when required to conserve energy.

- Virulence Genes are usually expressed upon entry into the host.

How does the bacterium know that it entered a host? - It senses changes in one or multiple signals such as: Temperature, Iron availability, Osmolarity, pH, Specific ions (e.g. Ca2+) or nutrients. Examples: - Corynebacterium diphtheriae (having the gene for the diphtheria toxin) will only express the toxin when iron levels are low. - Expression of virulence genes of Bordetella pertussis is enhanced when the bacteria are grown at 37C

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Invasion of host cells and tissues: - Some bacteria can invade (enter) host cells (e.g.
Yersinia spp., N. gonorrhoeae, Listeria monocytogenes, and Shigella spp.)

while others invade the tissues without becoming intracellular (e.g. Salmonella spp.).

Toxins: Two types: 1. Exotoxins 2. Endotoxins (Lipopolysaccharides i.e. LPS)

Exotoxins: - Can be made by Gram-negative and Grampositive bacteria - Highly toxic - Highly antigenic - Can be inactivated using formalin to create Toxoids (i.e. formalin-inactivated toxin) which can be used as vaccines. - Composition: Two protein subunits: A subunit provides the toxic activity and B subunit mediates attachment to host cells and entry.

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Exotoxins: Examples: - Diphtheria toxin (C. diphtheriae): inhibits host cell protein synthesis.

- tetanospasmin (Clostridium tetani): prevents the relaxation of muscles Spastic paralysis

Exotoxins: Examples (Continued): - Botulinum toxin (Clostridium botulinum): Prevents the contraction of muscles leading to flaccid paralysis. - Clostridium perfringens (in wounds) produce several toxins that are necrotizing and hemolytic such as the alpha toxin (a lecithinase) and the theta toxin (a cytolysin).

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Endotoxins: - i.e. Lipopolysaccharides (LPS) of Gramnegative bacteria. - Derived from cell walls and are usually released upon bacterial death. - Endotoxins are heat-stable (i.e. survive boiling). Components: 1. O-specific polysaccharide: induces specific immunity. 2. Common core polysaccharide. 3. Lipid A with KDO: responsible for primary toxicity.

Endotoxins: The pathophysiologic effects of LPS are similar regardless of their bacterial origin [except for those of
Bacteroides species, which have a different structure and are less toxic] .

LPS in the bloodstream interact with receptors on macrophages and monocytes and other cells of the reticuloendothelial system IL-1, TNF, and other cytokines are released, and the complement and coagulation cascades are activated fever, leukopenia, and hypoglycemia; hypotension and shock resulting in impaired blood flow to essential organs (e.g, brain, heart, kidney); intravascular coagulation; and death from massive organ dysfunction.

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Enzymes: Examples: - Clostridium perfringens produces a lecithinase and a collagenase that degrade tissues thus promoting bacterial spread in tissues. - Staphylococcus aureus produces a coagulase that leads to clotting of plasma and formation of fibrin clots around the bacterium to protect it from phagocytosis.

Enzymes:
Examples (continued): - Many bacteria produce Cytolysins i.e., they 1. Kill tissue cells 2. or dissolve/lyse Red Blood Cells (i.e. hemolysins) 3. or kill leukocytes (i.e. leukocidins) e.g. Streptolysin O, for example, is produced by group A streptococci and is hemolytic for red blood cells from many animals.

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The major mechanisms by which pathogens cause disease are the exoenzymes or toxins that they produce.

Antiphagocytic Factors: These factors allow bacteria to evade phagocytosis or intracellular killing by phagocytic cells. Example: - Polysaccharide capsules of Streptococcus pneumoniae, Niesseria meningitidis. Intracellular Pathogenicity: Some bacteria possess mechanisms (virulence factors) that allow them to survive inside host cells. Example: - Mycobacterium tuberculosis

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Antigenic Heterogeneity: Bacteria have three types of surface antigens: 1. O antigen: the lipopolysaccharide side chain 2. H antigen: the flagella 3. K antigen: the capsule - Antibodies against these antigens are protective against that specific type of bacteria but are not protective against another type. E.g. antibodies against the E. coli O7 protect from reinfection with E. coli O7 but not with E. coli O1.

Antigenic Heterogeneity: Examples - There are more than 150 E. coli O types and more than 100 E. coli K types. - Some bacterial such as Niesseria gonorrhoeae and Borrelia recurrentis (causes relapsing fever) can make frequent changes in their surface antigens to evade the immune system.

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Ability to form Biofilms:

- A biofilm is an aggregate of interactive bacteria attached to a solid surface or to each other and encased in an exopolysaccharide matrix.

Ability to form Biofilms:

- Biofilms form a slimy coat on solid surfaces and occur throughout nature. - Biofilms are important in human infections that are persistent and difficult to treat. A few examples include Staphylococcus epidermidis and Staphylococcus aureus infections of central venous catheters, eye infections with contact lenses, in dental plaque, and with Pseudomonas aeruginosa airway infections in cystic fibrosis patients. - Biofilms may protect bacteria from the immune system and from antimicrobial agents.

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