Transcribed

by Ana Sangadala

December 9, 2014

Infectious Diseases Lecture 18 Mycoplasma, Legionella by Dr. Boylan

Slide 1- Protoplasts, Spheroplasts, L-forms
An organism. Before I get into that, I have to differentiate that other form that loses
its cell wall. They are ordinary bacteria that can lose their cell wall under antibiotic
pressure. Gram positive organisms that lose their cell wall are called protoplasts.
Gram positives like staph aureus. Gram negative organisms like E. coli that lose their
cell wall are called spheroplasts. If either protoplasts or spheroplasts can actually
grow and divide, they are called L forms. And in fact, there are many infections in
the body. Lets take staph for example. You have bone infections, joint infections, hip
replacement infections caused by a staph protoplast. In other words, a staph that
has lost its cell wall. Especially if a surgeon gives you prophylaxis of an antibiotic
like cephalosporins which effect the cell walls, the organism may be prompted to
lose its whole cell wall, so the antibiotic is useless. It has nothing to do with genes of
resistance. It simply has to do with the loss of the wall. These antibiotics operate by
putting holes in the wall basically. So now you have an organism that can survive the
antibiotic pressure. And they do exist. If they divide and grow, theyre called L
forms. These organisms revert back to the parent form. If you grow them in the
laboratory, and they grow in hyperosmotic media. They need a lot of outside
pressure as you know. The internal pressure of bacteria is pretty high. 15 atm, 5
atm, 30 atm, depending upon the species, so you would think you need to have some
sort of osmotic force. In the joint, you have constant traded fluids that provide that
and there are many places in the body that provide a hyperosmotic condition where
they can survive. So what would you do to treat a mycoplasm? Exactly! And thats
whats done, like a tetracycline or some other drug. Maybe even one of the floxacins.
Ciprofoxacin, for example, a quinolone. And you know there are other drugs like
macrolides like erythromycin. Those are the three main ones. Even sulfa drugs can
do both go inside a cell and outside a eukaryotic cell because these tend to attach on
the surface of a cell and they go slightly into a cell.

Slide 2- Mycoplasma
So yes, you want something that interferes with protein synthesis rather than cell
wall synthesis. And also something that gets into the cell in case these organisms can
get into your eukaryotic cell. Other antibiotics like penicillins and cephalosporins
dont go inside your cell to get an organism. Now, mycoplasma dont usually grow on
regular agar like what you would grow a staph or a strep. It requires a triphasic
medium to grow usually. On rare occasions, you can see them very very pinpoint,
you need a hand lens to see them growing on the surface of a blood agar plate, lets
say. And most often, theyre missed, so you need a hand lens. The colonies only
measure 20-500 micrometers in size and most of the colonies have a fried egg
appearance if you were to see them. Theres a reason for that and well discuss that.

Slide 3- Presumptive Diagnosis RS
This is an example of a triphasic medium and this is a presumptive diagnosis of RS, a
respiratory syndrome. In fact, the mycoplasma pneumonia can give rise to a
respiratory infection and it has a medium, triphasic medium on your left, thats red.

Transcribed by Ana Sangadala

December 9, 2014

If the organisms start to grow on this medium, it will turn to yellow because of the
acid production. Lets say that you can evidence that there must be something
growing and you tend to look at it with a microscope. One of those binocular scopes
that can visualize lets say 10-100 power.

Slide 4- Incubation of Flask
And heres the flask itself, what it looks like. Theres an agar surface. Theres a liquid
medium to provide nutrition. And theres a gas. This gas is usually is carbon
monoxide and we usually add a couple of disks of chemicals which suppress normal
flora because if you have a respiratory infection caused by mycoplasma pneumonia,
person coughs up secretions, they are put into this medium but there are other
organisms. Up to 500 different organisms. So you tend to add things that kill off
those organisms and selectively allow the mycoplasma to grow.

Slide 5- Inoculation of Flask
This is an example of how such a flask would be inoculated. And theres a disk
already there. They usually are two or three disks that are added with different
chemicals. One is a thalium sulfate, which kills most organisms, but doesnt kill the
mycoplasma.

Slide 6- Picture
And this, I dont know if you can see it so well, but this is the fried egg appearance I
was talking about. You see the outer thin layer? Like the white of the egg? And a
dense center like the yolk. This is mycoplasma pneumonia. One colony. Heres
another. This is mycoplasma hominis. You can see it here. The center is not so
visualized in this slide, but I will show you other slides that show you a fried egg.
The only one that doesnt have a fried egg appearance is the Ureaplasma
urealyticum. This is all it has, its like the dense center is all you see. Theyre dwarf
colonies in ureaplasma. Mycoplasma pneumonia causes respiratory infections as the
name implies. And the ureaplasma urealyticum and the mucoplasma cause
genitourinary tract infections as the name implies. And in fact, reaplasma requires
urine, so guess where you may find it? In the GU tract in addition to some sterols.

Slide 7- Picture
Now heres the colony for mycoplasma pneumonia. Fried egg appearance as I
mentioned.

Slide 8- M. pneumoniae colony
Heres the hominis. Again, fried egg appearance, not as nice as the pneumonia.

Slide 9- M. hominis colony
And heres the ureaplasma urealyticum. This is just the blow up of the slide previous
to this. See the swarf colonies.

Slide 10- Picture

Transcribed by Ana Sangadala

December 9, 2014

The reason you have a fried egg appearance is the surface of the agar on the
triphasic medium has to be scratched. Usually a pipette or a swab can be used to
scratched the surface. And then you inculate it with the specimen. Usually its a
respiratory or a GU type specimen. And you see here growing as a colony. The
colony will be growing over the surface. As it grows over the surface, it gets bigger
and bigger until it finally comes to the surface. And when you look down on it, this
part is very dense. This part is transparent and thats what gives it the fried egg
appearance on this triphasic medium.

Slide 11- M. pneumoniae
All of you have probably had a mycoplasma infection. Its sometimes called atypical
pneumonia. You may hear a physician sometimes say, oh heres the walking
pneumonia. This is the organism. Its not really a frank pneumonia. Its a pneumonic
process where the bronchi are infected. Not the lobes of the lung. Of course if you let
it go and if you have an immunosuppressed person, it can cause a lung infection.
And its sometimes called primary atypical pneumonia. Again, its the airways that
are infected in primary atypical pneumonia. And it can cause a primary hemolytic
anemia because of production of something called cold hemagglutinins. This is an
immunoglobulin M antibody. An antibody thats produced early on. Immunoglobulin
G antibodies would follow this. There is a serological test to identify patients who
have had mycoplasma pneumonia. We see many, by the way, that takes weeks. We
dont have time to wait. We do have another test, an alternative test, that can
provide information in one hour and Ill touch on that in a minute. But I dont want
to lose sight of the fact that this organism is diagnosed by the clinical features. When
you listen to the chest with a stethoscope, you listen to the lobes of the lung and you
dont hear any rails. The perking sounds. But you listen to the center of the chest, the
lumen, the bronchi, you hear the infection there. So again, its an infection of the
airways, not of the lungs. And it is treated as we mentioned with those drugs tht
affect protein synthesis or DNA synthesis.

Slide 12- Pathogenesis
Now, the pathogenesis of the organism is fairly straightforward. There is an
adhesive protein, the P1 protein that interacts with the glycoprotein receptor at the
base of cilia. And of course, it attaches to the cilia and can cause ciliostasis. In other
words, the cilia are not going to be moving to get rid of the organism and the mucus.
Its sort of stiff and its caused because of this attachment. Where it attaches. And it
also stimulates cytokines, so you do get systemic effects from your immune
response.

Slide 13- Figure 2
Heres a good picture of the mycoplasma attaching right at the base of this cell. And
you can see the cell here. And these mycoplasma.

Slide 14- Picture of a cell

Transcribed by Ana Sangadala

December 9, 2014

This is a one cell with many mycoplasma. This happens to be, I believe, a mouse cell.
And look at all the cells attached. So you can have quite a number of organisms
attached to an individual cell.

Slide 15- Transmission
How do you get mycoplasma pneumonia, a respiratory infection? Well, like most, an
aerosol. Somebody coughs, sneezes, or talks in your face. Close aerosolized droplets.
And remember droplets are different. Aerosolized droplets are different from
airborne. Airborne, like Tb type organisms, that are transmitted by being carried in
the air dont settle to the ground from gravity. It takes a long time for them to settle
and they go with the currents. If theres any wind or any movement of air, they move
along with the air. These aerosol droplets are heavy. Theyre not less than 5
micrometers in diameter and they fall because of gravity. So if somebody sneezes,
although the sneeze can travel, it usually hits the floor at a certain point. So you have
to be at relative proximity to a person coughing, sneezing, or talking at you. So thats
how you get it. Its mostly a disease of children and young adults. Its uncommon in
under five and over twenty years old. Everywhere has it. Theres 15 million, dont
hold any water. You dont test them anyway Its very hard to estimate annually in
the United States. There are many cases that are called post influenza in the elderly
population that are not counted. So recently, statistics are way higher than 15
million. As the population grows, so too will the number of these infections. Many
people can overcome it on their own. But elderly or immunosuppressed people
require antibiotic therapy.

Slide 16-Figure 42-4
Heres the reason why. This organisms is so difficult to identify. If you look at the
infection on this side, and you look at the time frame, this is in weeks. One, two,
three weeks. Theres an incubation period of one to three weeks. So you could be
exposed and not come down with anything for one to three weeks, but you can
usually culture it here at about, a little before the second week, before you get
symptoms. But nobodys going to culture at that time unless you have an outbreak,
epidemiologically. Unless you have symptoms, youre not even going to go to your
doctor, where you get treated or realize you have an infection. The big problem is
that you do get in this period, about 2-3 quarter of weeks. You usually start to get a
fever or a headache, whats called a prodon (sp?) of infection. Much like you would
with influenza, you get the prodon. But influenza comes quick and hits you, muscles,
etc. Here, you get the fever, headache, you feel like youre coming down with
something but you dont quite know what. And you feel like youre getting
respiratory symptoms about 3 and a half weeks into things. And look at the culture
capability. Its starting to wane. If you stay with it for a while, and people for
whatever reason, they have a cough, or a lingering feeling that theyre coming down
with something but its not quite there. They may wait until its too late to culture it.
Then you may have to resort to immunological testing, serological testing to say this
si what you had. And treatment can eradicate or shorten the course somewhat. A
great deal, but not completely because the body has to clean up the mess and you
still have lingering symptoms for a while, so its an interesting infection. That is why

Transcribed by Ana Sangadala

December 9, 2014

diagnostic testing that exists in the laboratory is not great, except for the break
through technology of PCR. There is a test called the film array PCR. This test which I
established at NYU deals with twenty three analites. Any organism that we know of
that can cause a respiratory illness is included in those 23. Including this organism,
mycoplasma. So we can in one hour, from specimen, dead or alive. The organism
doesnt have to be alive, PCR will detect it. So even if it comes here, it will be
detected. And we run this full array, swab the upper respiratory or oropharyngeal
or nasopharyngeal and we take the sample and put it into this microarray. And
twenty three analites are tested in one hour. Thats the technology that you will be
privy to. As dentists, you have the same technology available as I mentioned in the
summer when we talked about identification of bacteria. Culture of the technology
takes too much time. Here, you have non culture of the penant, and exact
information. And these twenty three include all viruses, including new viruses, the
enterovirus 68 that can cause respiratory infection. It has all the influenzas,
adenovirus, you name it, its there. Plus the bacteria, bordatella pertussis-whooping
cough, legionella pneumonia which we are going to discuss next, and this organism
mycoplasma. So 23 analites. This film array is available for other areas of the body.
For example, STDs. We have 23 STD organisms identified in oen hour. GI
pathogens-salmonella, shigella, campylobacter, eucinia, the whole works, parasites,
fungi, in the intestines-1 hour. Swab a stool, identification-1 hour. And we tell you
exactly what you have including all of the E. coli, enterotoxins, Shigella, everything,
which is amazing to me. Its interesting how in the past, you would have to work
with batteries of media and try to culture it and grow organisms and then identify
them. It took so long. Patient either got well with empiric therapy, or they didnt.
Now, you have specific therapy. It cuts down time in a hospital or institution. And
you can provide exact antibiotic coverage rather than empiric coverage. Thats the
way to the future. Unfortunately, many institutions cant afford this technology so it
would only be at major medical centers like NYU, Sinai, Columbia, Cornell.

Slide 17- Table 42-3
This shows you the old way of testing. Its almost moot to talk about it. You should
know there are serological tests that can be done for very cheap that can
retrospectively say, this person had primary atypic pneuomina. But here we are,
PCR film array, 1 hour, TAT. Turn Around Time. The same thing with the
bacteriologic testing that we currently do using the bimarrow specialized test where
in 10 minutes, we can identify a bacterium in the laboratory. That also is in your
profile. As these tests get cheaper, more and more people will be using them and it
will save lives.

Slide 18- M. hominis
Now, briefly, the hominis. There are two neuropathogenic organisms and GU
organisms. Genitourinary tract. Mycoplasma hominis and the ureaplasma
urealyticum. Both of those are GU organsisms. The mycoplasma pneumonia is a
respiratory organism. Can you think of a circumstance where the mycoplasma
pneuomina might be found in the GU tract? Or vice versa? Maybe thats the easy way
to do it. What if a babys coming down the GU tract? Can it get a mycoplasma homnis

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December 9, 2014

is the respiratory tree? Yes. These organisms are not restricted. They dont know
enough but they do usually reside in the GU tract. This and the ureaplasma. And they
do give rise to, they can cause CNS infections and infect the oral cavity and half the
adults have antibody. Thats why I said you likely might have had an incident of
mycoplasma pneuomonia. If you are immunologically competent, usually you will
recover on your own. If you are immunosuppressed, even simply by age, youre
more likely to get full blown course of primary atypical. Now sexual contact
obviously, if its in the GU tract, is the way you can get it. And it can give rise to pelvic
inflammatory disease as the slide tells you and it can be involved in post
spontaneous, actually, premature birth. Spontaneous abortion. Both because of the
ureaplasma urealyticum.

Slide 19- U. urealyticum
The only thing you need for this organism, it requires urea. Thats why it gets the
name ureaplasma urealyticum. And it causes the same thing. All of these organisms
are fairly similar in that they can cause problems for new borns. In some men, this
can give rise to non gonococcal ureitis. NGU. By non gonococcal, we mean no pus
oozing out of the, etiher the meatus of the male urethra or inside the cervix of a
woman. You dont see pus. You see a clear fluid like material, or a reddening. A
hyperemia, its called on the surface of the penis. And thats what NGU stands for.
There is one other organism by the way. The genitalium, on occasion, its been
involved in non gonococcal urethritis. In addition to the first three organisms, be
aware of the M. genitalium, but the give away is the genitalium. Its easy for you to
get that. It causes non gonococcal urethritis. In a female, its more difficult to notice
that, but in a male, you can notice it quite easily.

Slide 20- Mycoplasma Isolated in Humans
And there are others. As a matter of fact, this list as tripled. Dont worry about it. I
just wanted to show you there are other organisms that can give rise to a similar
infection.

Slide 21- Legionella (Title)
Any questions on that one? Its relatively straightforward. By the way, any test
questions I give is based on the notes. I see that the bulk of the class is not here, so I
guess theyre reading notes. Why dont we all stay at home and do it by facetime?
Thats a joke. In case the dean reads that. Now, legionella.

Slide 22- 1976 Outbreak
Now this is an interesting organism. Legionella pneumophila is in every single body
of water. Pool water, your drinking water. When you go to your fountain, you suck
up some water, you have legionella coming in with some of the bolus. But it doesnt
cause you harm usually. If you are, how we say in this figure, thats what they use.
The CDC estimates that people who are immunosuppressed by AIDS are 55 or older.
Thats kind of young these days. 55 or older, youre more likely to come down with
infection, if youre high risk. As opposed to younger people, they generally overcome
it. If you have other immunological disorders, you can also be at high risk. Legionella

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was first discovered at the 1976 summer Olympics. I believe it was the summer
Olympics and it was this strange disease that befell Legioneirre while they were
staying at the hotel. Unknown to most people or to all of us at the time, was that this
organism is part of the portable water supply. Mainly because we didnt know how
to grow it. This organism doesnt need much to grow and it is environmental in all
bodies of water. And 182 were infected, 29 died. Thats what caused everybody to
figure out whats going on here. Eventually it was discovered that the organisms was
called legionella pneumophila. Because it likes the respiratory tree and it killed most
of these American league heirs who were well in their 60s and 70s when they met
pneumonia and they died of hypoxia, suffocation. There are more than 39 species
now and every time I change this, another 4-5 species are found, so it really is of no
consequence. Whats important really, is that 85% of all infections are of serotype 1
Legionella pneumophila species. And unknown to everyone was on the roof in the
water trough coolers of air conditioning coils where the hot air passed through to
cool, that heated up the ambient temperature of those pools of water open to the
sunlight, where cyanobacteria grew and served as food for the legionella
pneumophila growing as a biofilm in those troughs. Unknown to everyone, when the
steam, that was created by the hot coils, disappated some of that moisture, and that
moisture was picked up by the wind and was dropped on the side of the building,
where the air intakes were so these legionella organisms were pulled into the hotel
air conditioning systems. That fresh air went into the rooms, out of the vents in
quite a few of the rooms, which is how they got legionella. You dont get legionella
from another person. You get it from the environment. Thats what happened here.
Now we have covers for those air conditioning troughs and the troughs are never on
the same side as where the air intake vents are. And we put chromium salts, which
is a poison to the legionella, into the water. Its now not portable water, but its just
there to cool off the coil and its sealed from the sunlight. And now we dont have
that incidence of legionella. However, we do have legionella in showers. The head of
the shower is one of the biggest problems in hospitals. Even though Ill talk about it
later, Ill touch base on it now. The shower head sometimes builds up a scum that
many of you are aware of. You need a brush to get it off. In that scum are biofilms of
legionella. Every once in a while, when that biofilm is released into the face of the
person taking a shower, and if you are immunosuppressed for any reason
whatsoever. For example, any AIDS patients can get legionella that way. So at NYU,
and in most other hospitals, we change the head of the shower every year. Its
thrown away. We use plastic heads that cost about a dollar a piece. So every year,
they routinely unscrew it, throw it away, but a new one on. So that way you dont
have the residual problem. Its also a problem of other organisms like
mycobacterium of various types. It doesnt matter which species, that can give rise
to infection also.

Slide 23- Legionella
Ubiquitous in any moist environment. Water, worldwide. Lakes, streams, air
conditioning, and cooling as I mentioned, showers, even hot tubs. It survives in
portable water because its not killed with the current concentration of chlorine
used in your water supply. And it usually survives in intracellular amoeba. In the

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wild, in the lakes, its an amoeba inside and it survives. Or it can survive in you
alveolar macrophage, much like TB. Its a gram negative not usually seen on gram
stain, but whenever you cant see a bacterium using any of the known stains,
whether its an acid fast bacterium, we use acid fast staining or gram staining for
regular bacteria, USE A SILVER STAIN. It is visible on silver. Like the syphilis
organism, its very hard to see. You need a silver stain to see it or dark field
microscopy. We never knew. It only requires iron and cysteine, the amino acid
cysteine, to grow. Those two things, nothing else it requires. And thats why we
developed buffered charcoal yeast extract media, which has iron salts and cysteine
and they grow beautiful on that. They possess these very branched fatty acids which
are very similar to what thermophilic bacteria, environmental thermophiles. Those
kind of bacteria you find at Yellowstone. The boiling springs at Yellowstone, they
have this same type fatty acid. They survive in temperatures up to 65 degress
centigrade. Thats past pasteurization. Thats about 150 degrees farenheit
approximately. 150-155. Thats quite high and they survive, so at NYU and most
other hospitals, we purge the hot water system by raising the temperature to 180
degrees farenheit periodoically. We close systems, open systems, let it cool off, and
bring it back down to 105 or 110. The hot water. And in addition, we use a copper
silver water treatment system. As portable water comes in from the outside, its
treated. The silver ion and copper kills it and then we reclaim the ions so they dont
cause problems to people.

Slide 24- Chart
And heres the idea, the penumophila serotype 1, it produces most fo the infection.
There are other serotypes of legionella and there are other legionella species. You
dont have to know them other than pneumoophila but you should know there are
many others.

Slide 25-Pathogenesis
They do have a pathogenic ability. They bind to the Cr3cell receptor on
mononucleatic phagocytes, the monocytes. And after endocytosis, they multiply in
the alveolar macrophages. All the monocytes, they take them in by endocytosis. And
again like TB, phagolysosome fusion is inhibited. Thats how they survive, They
prevent the link so the enzymes are not killing the organisms. They too produce the
enzymes, lipases, nucleases, which can kill host cells and the primary cell mediated
immunity is whats at play with a minor role for the humoral immunity. Thats how
we eventually eliminate them if we survive the infection.

Slide 26-Summary of Legionella Infections
This just again talks about hypochlorination. This talks about using macrolides,
especially erythromycins like azithromycin as the choice of drugs. It is worldwide
and it affects the elderly and immunologically impaired. And they survive well in the
biofilm. Those are some of the features you should be aware of.

Slide 27-Comparison of Disease Caused by Legionella

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One last thing. Did you ever hear of the suck building syndrome? Anybody ever
heard of that? A while back, maybe 20 years ago, everybody talked about the sick
building syndrome. Big office buildings that dont open windows. Had stale air, sick
building. This organism is the cause of that syndrome. Its called Pontiac fever. It has
a 90% attack rate. So its not relying on your immunologic capacity. Itll infect
anybody in the room, or most anybody. Its not person to person transmitted. You
dont need any underlying pulmonary condition like COPD, which you would find
legionella pneumophila requiring, an immunological disorder or a chronic disease.
Here its an epidemic disease in the late summer, autumn, for legioneires disease.
And also throughout the air in the buildings. Here its throughout the year totally.
Not requiring summer, heat, air conditioning, and other features. This can give rise
in 1-2 days to a syndrome that is self limited more like an allergic reaction. People
say I think I have an allergy, I have a stuffed nose, I have a headache, and thats what
this organism causes. Its more like an allergic type reaction that a person has. Its
very unlikely to cause mortality, death, to anyone. Unless you have a particular type
that may be part of the air and you inhale it and it becomes really a legionaires
disease. But in reality the mortality of legionaires disease is up to 20% higher if
diagnosis is delayed and antibiotics are not given. So legionaires disease can be fatal
to a certain population but not Pontiac fever. Thats called the sick building
syndrome.

Slide 28- Table 23-1
And here again the pneumonia is caused by any of these legionella. And theres
legionaires disease, but primarily its caused by pneumophila. And here Pontiac
fever is only called by 2. Legionella pneumophila and legionella feeleii. Yes? (student
asks question). No. Same with the flu. The same question comes up. Theyre both
caused by organisms. However, people in the winter tend to cohort in buildings,
right? Inside. Its too cold outside, its 2 degrees. Were inside. So youre
congregating and more likely in a crowd to spread whatever goody you have.
However, in the summer, youre more likely to be outside going out for lunch,
walking, less inside. Also the heat, dry heat tends to dry out your mucosal surfaces
making you more likely to come down with something because you need moisture
in your mucous membranes in order to effectively eradicate organisms challenging
you. In addition, influenza and certain organisms survive better in the winter.
Theyre more prevalent in the winter. This is why you see the flu season more likely
in the winter and in the spring when its still cool and in the fall, late fall, when its
cool. Certainly, you could be out without a jacket, you could be wet and cold and
your resistance is lowered, thats a factor that can be considered. Many people tend
to get wet and are out without proper covering and you get a chill. You can lower
resistance but the infection is caused by an organism.

Slide 29- Picture of a slide
Now heres what you would see if you had pneumonia. Some mucous. Heres the
white cells, phagocytic cells, you see no organisms. Thats a gram stain. You see
nothing. However

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Slide 30-Picture of slide

If you were to use a silver stain on that same sputum, look at what you see, silver
staining organisms. Some of them pleomorphic, bacillus shaped, some are ovoid.
You see the organism. Thats what was done to identify that it was a bacterium that
infected the legionella, Legionaires people.

Slide 31- Picture of a slide
You could also use immunofluorescence. By coating the bacteria with antibody and
they will fluoresce. That has been tagged with a fluorescent compound.

Slide 32- Treatment and Control
Treatment we mentioned the types of drugs, the tets, the macrolides, the
fluoroquinolones. Ugh..Its almost impossible to eradicate. You can reduce the
legionella in hotel water and in hospitals. And you support patients that go into
shock as best as you can as well as assist with ventilation since hypoxia usually kills
them.

Slide 33- Rickettsiaceae
Now, can we go directly into this and finish it up? You can hit the road at your
leisure. Since we have a precious few. Rickettsiaceae. This is a very important group
of organisms. Each of the organisms you got are extremely important in medicine
and in dentistry. Whether you realize it or whether you were treating a patient for
any of these or not doesnt matter. You will be subject to these organisms out there
so you need to take the proper precautions. I know my dentist, he masks up. I say
you know Im free of disease. He says I dont care and so he masks up. Hes got
goggles, hes got all this apparatus. I say, you know we dont have Ebola here.
Anyway

Slide 34- Rickettsia, Ehrlichia and Coxiella
So its important for you to understand as educated clinicians, various diseases.
Now, the ricketsiaseae are organisms that are very tiny. Again, each of these
organisms that were talking about today are very unique. This one is the smallest
organisms, which is pleomorphic. And look, 0.3 microns to 1. 1 is the highest, largest
length. Its pretty hard to see in the microscope. You really gotta look at 1000 power.
And this organism as well as its sister organisms, Ehrlichia and another one called
Coxiella and there is one other I didnt put here. It was related to Ricketsia. It used to
be called Rochalimaea Quintana. Now, its called Bartonella Quintana, as another
organisms thats related to it. Its been identified as an outgrowth of the AIDS
epidemic. That organism is called Barotnella Henselae. Im not holding you
responsible for those but I want you to be aware that there are many other
organisms you should be aware of. But these are the ones that are most important.
And by the way, this Coxiella is on the bioterror list. Its one of the bioterror
organisms on the US Army infectious disease group. Now, ricketsiae, ehrlichia, and
coxiella, each organisms has the unique capacity to adhere to a specific area and
usually causes specific diseases but its not restricted to only those areas you know,
but on the main, or on the whole, thats where you would find them. For example,

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lets just do this first. There are aerobic obligate intracellular parasites. When
theyre intracellular, you need only specific antibiotics to kill them because
penicillins dont get into eukaryotic cells. Neither do any beta lactams. And similar
antibiotics dont get into eukaryotic cells. So there are 3-4 main groups. The
tetracyclines, macrolides, and quinolones are the 3 main ones, but sulfur does
manage to get in cells too. Those are the only antibiotics you can use against these.
There are a couple of others that you might on occasion use, like rifampin. It can get
inside a cell. That interferes with the RNA polymerase. But on the main, on the
whole, the three main groups, you know. So because theyre energy parasites, they
have to exchange. Theyre not like viruses that have to acquire a living cell to
reproduce itself. Here they had to swap ADP for ATP in the cell that they infect. So,
theyre energy parasites. Thats how they get their energy. They stain best with
Giemsa, which is a specialized colored stain. And also Gimenez which is a silver
stain. Silver is the best way to identify organisms that are not easily seen by gram
stain. And all of these organisms maintain an animal or arthropod reservoir. Theyre
transmitted by ticks, mites, lice, and fleas. Those are the arthropods involved. So
there are the insecta portion of arthropods, and the arochnida portion of
arthropods. Now, coxiella is an exception because its carried by the tick, but coxiella
is excreted in tick feces. Usually youll find a tick on a sheep for example. You get a
sheep shearer, they shear the wool. They can inhale all the fecal matter from ticks
unknowingly and come down with coxiella infection. In fact, it still requires a tick,
but indirectly. The tick has to put feces on the animal and its inhaled by the person
dealing with the animal. But all the others are direct, ticks, mites, lice, and fleas.
Theyre transmitted directly. Why is it necessary for arthropod transmission of
ricketsiae? These tiny organisms that require obligate intracellular parasites. What
would the reason be? Take a guess. Its no quiz here. (student responds) Exactly.
Theyre perishable. They dont survive in the environment too long. Thats the key
here. Obligate intracellular parasite.

Slide 35- Diagram
Alright. Now, you can see. This I dont think you have to worry about. Its a
dendogram. It shows the relationship between some ehrlichia here and some
ehrlichiae here and rickettsia here. And heres legionella. Its off a shoot here and
heres coxiella bernetsia. Thats closer to the environmental organisms. And there
are other organisms like bulvachia (sp?) thats pretty close to these two. By the way,
bulvachia (sp?) is out there. This is called midichloria mitochondria because it
actually lives inside the mitochondria. Its a very tiny bacterium that lives within
your mitochondria thats within a cell. That should shock you. Well, it did when I
first found out many years ago. So you have organisms living within organelles of
cells.