MICRO MYCOBACTERIUM

MYCOBACTERIA TB
M. tuberculosis
ö 70 species of mycobacteria Comple Slow Pigmented +
M. bovis
ö 2 major pathogens x
o M. tuberculosis Photochro
Runyon M. kansasii
o M. leprae Slow -mogen -
Group I M. marinum
ö MOTTS (1)
Runyon M. gordonae
Scotochro-
ORDER: Actinomycetales Group M. Slow -
mogen (2)
FAMILY : Mycobacteriaceae II scofulaceum
GENUS: Mycobacterium M.
Runyon Non-
intracellulare
Group Slow pigmente -
The Taxonomic Tree For Selected Mycobacteria And Related Species M. avium
III d
M. xenopi
Actinomycetales
Runyon
M. fortuitum Rapid -
ORDER Group
M. chelonei (3)
IV
(1) pigment formed in the presence of light only
FAMILY Mycobacteriaceae Actinomycetacae Streptomycetacea
(2) pigment formed in the presence or absence of
ee
light
(3) growth in 1 week
GENUS Mycobacterium Streptomycea
THE GLOBAL EMERGENCY
 8-12 M new infections/yr
Nocaria Actinomyces
 2-3M people die from TB/yr
 Emergency of MDR(Multi-drug resistance) M.tb

Mycobacterium NTMM Di na S. proteus CELL WALL

SPECIES tuberculosis tlga May isa pa
di ko na din  Unique : waxy, hydrophobic and high lipid content 60% of dry weight :
complex mabasa
M. tuberculosis (sori) mabasa o Mycolic acids – long chain, branches fatty acids
M. africanum  Form pseudo outer membrane responsible for unusual staining
M. bovis
 Responsible for hydrophobicity
M. microti
 (+) adjuvant properties, responsible for dev’t of DTH
All Mycobacteria Are;  All mycobacterial pathogens are intracellular pathogens
ö Acid fast o The walls help organism to survive w/in the macrophages
ö Aerobic
ö Contain mycolic acids TUBERCULOSIS
ö Genomes have 59-66% GC content  Chronic granulomatous disease caused by
M. tuberculosis
Ancient disease
 Prehistoric human bones
o tuberculous damage
 Mummies (+) AFB
RUNYON CLASSIFICATION SCHEME  Drawing from ancient Egyptian times:
Medical Significant Mycobacteria o Tuberculous deformities
Representati Growt Niaci
Pigment
ve Species h n

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MICRO MYCOBACTERIUM

MYCOBACTERIUM TUBERCULOSIS

MORBIDITY TREATMENT,
BACTERIA PATHOGENESIS TB INFECTION TB DISEASE AND LABORATORY DIAGNOSIS CHEMOPROPHYLAXIS,
MORTALITY AND PREVENTION
Mycobacterium Antigenic Structure Site of Infection TB disease Clinical based an demo of M. tb in a Drug Therapy
tuberculosis Complex  Cell wall structures;  Inhalation of droplet 1. 1° TB or primary complex diseases Symptoms: clinical specimen • DOTS ( Direct Observed
 M. tuberculosis o Polysaccharides, nuclei • due to - sputum, pleural Therapy, short -course)
2. 2° TB or post primary TB or
biopsy, brocho-
 M. africanum proteins, peptides  Aerosols, contain 1-3 org overprodu o cornerstone of Tb
reactivation TB seen after a alveolar washings,
 M. bovis cytoplasmic  Suspended in the air ction of treatment
prolonged period of LTBI fibreoptic
 M. microti proteins indefinitely TNF  3 mos -sterilize
3. relapse after an inerim period of bronchoscopy,
 Obligate pathogen  Seibert proteins A and  Inhaled by person being being cured M. tb survivors of • severe lesion
Man : principal host B elicit skin reactions infected weight biopsy specimen of  3 anti-Tb
previous tx grow again. Effective tx lung, CSF, gastric
more potent than PPD  Taken up by alveolar does not completely eliminate M. tb loss agents
Morphology macrophages • night washing, biopsy from  INH, RIF, PZA,
pop’n other anatomical site
 Slender, straight Virulence factors  1 org enough to establish 4. Re-infection TB sweats (Ethambutol)
or slightly curved,  NO toxins infection • Successful infection by another • chronic • INH, PZA - need to be
Pattern of culture Interpretation of AFB Stain
non-motilr non-   Tb is spread from person Tb strain occurs despite cough (> activated by
sporogenous, non- o Virulent: to person through the air. previously acquired immunity 2 weeks mycobacterial enzymes
encapsulated serpentine cords The dots in the air duration) (KatG and
bacilli w/ bacilli in represent droplet nuclei TB Inactive Disease • hemoptysi Pyrazinamidase)
 0.2-0.5 x 1-4μ parallel containing tubercle  (+) residual organ damage s o Mutations in the
 Gm(+) arrangement bacilli  Tb org no longer actively activating enzymes
o Avirulent : multiplying TB DEATHS can lead to R
ZIEHL-NEELSEN STAIN random brush – Common Sites of TB  Viable dormant org persist and Mortalities • Multi-Drug Resistance
 Red rods in blue heap pattern  Brain contained by the granulomatous dependent on (MDR) - simultaneous R
background  Cord factor – trehalose  Larynx rxn • site and to INH and RIF
dimycolate  Bone type of (rifampicin)
AFB  Catalase  Kidney Occurs: spontaneously (30%) disease o R to the first line
 Attributable to  Tuberculoproteins  Lymph node As treatment outcome (95%) • timeliness anti-Tb agents is
high lipid content  Pleura Completely treated non-R cases of due to mutations in
Pathogenesis  Lung diagnosis the target proteins
Physiology Progression of TB • appropriat for these drugs
Airborne  deposit in  Spine
 Cultural People who are exposed to TB may or eness of o mutations in target
alveolar space of lungs 
characteristics may not develop TB infection. People with interventi proteins
engulfed by macrophages Lesions
o Slow growing 1. Exudative : lungs – primary TB infection may or may not develop TB on  INH : katG,
(divides q18- Portion : resist intracellular lesion disease. The risk of developing TB inhA and inhB
24 hrs) 2. Ghon Complex: diagnosis disease is highest in the first two years 30-40% of  RIF: B sub-unit
destruction  persist 
o Lowenstein – from X ray after infection. sputum (+) of the DNA
multiply and kill the
Jensen or Parenchymal exudative lesion untreated die dependent RNA
macrophages stimulate and
BACTEC + draining lymph nodes TB Infection vs. TB Disease within 1 yr polymerase,
inflammatory focus  Mature
3. Granulomatous tubercle: 50-70% die rpaB
 Small, dry, scaly into a granulomatous lesion
Heal by fibrosis and within 5-7 yrs  PZt.:
colonies with (tubercle)  caseous necrosis
calcification 1.5 M people pyrazinamidas
corrugated  erosion of tubercle into an die annually e
surfaces adjacent airway  cavitation
 Obligate aerobes  Infects alveolar  Streptomycin:
 release of massive ribosomal
macrophages
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MICRO MYCOBACTERIUM

numbers of bacilli into the  Phagocytosed by the Number of mutations (s12

Microbial Robustness sputum macrophage bacilli seen protein and
1. Resistant to effects  Found in membrane – Interpretation 16S rRNA)
of  Resistant host : tubercle bound particles known as
 Drying – phagosomes Chemoprophylaxis
 calcified
Infected mphagosome 0 in at least Indication:
remains alive  Cheesy necrosis 
100 fields • patients with (+) PPD
and virulent in  Early in infection : spread does not mature, remains
NO AFB Seen test >10mm w/in 48-72
dried sputum; distally in a state similar to early
stored x 12 yrs endosome hrs
 Indirectly thru lymphatics  Phagosome does not • children exposed to risk
 Sunlight –  hilar or mediastinal LN 1-9
of infection
destroyed in acidify or fuse w/ +
 Directly into the lysosome • patients with (+) PPD
direct sunlight circulation by erosion
within  Infected macrophage is who undergo immune
into pulmonary vessel unable to kill the organism suppression
o 2hrs in 10-299
cultures ++
(1) Droplet nuclei containing Exposure to M.Tb Prevention
o 20-30 hrs in tubercle bacilli are
sputum Major factors that determine • live, attenuated M bovis
inhaled, enter the lungs, risk: strain (BCG)
 If (-) sunlight 300 and above
and travel to the alveoli 1. Number of infectious • Newer vaccines?
o Sputum +++
(2) Tubercle bacilli in alveoli cases in the
remains • attenuated M. tb strains
(3) Brain, lung, kidney, bone community
viable or subunit vaccines
(figur eto.. di ko Makita) 2. Duration of their
o 6-8 months presented as naked
(4) Special immune cells infectiousness
in dried DNA
form a hard shell (in this 3. Number and nature of
sputum example, bacilli are in interactions between
o Weeks in the lungs) an infectious case and
putrefying (5) Hard shell breaks down a S contact
sputum and tubercle bacilli (susceptible)
 Droplets escape and multiply (in population density,
adhering to dust this example TB disease family size, age of
are infectious x develops in the lungs) source of infection,
1-1 ½ weeks gender
2. Resistant effects of  Extrapulmonary 4. Climactic conditios
chemicals hematogenous
 Difficult to dissemination ; seeding Infection with M.Tb Microbiological Diagnosis
disinfect 5% of other organs ( spleen, Risk factors microscopic investigation
solution of liver, kidneys ) 1. The infectious patient • Ziehl Neelsen
phenol eventually re-inoculation • (+) droplets • Auramine O stain (AFB)
 S: heat, of the lungs  serve as • # bacilli in the
pasteurization, origin of reactivation sputum culture (2-8 weeks)
UV light
2. Exogenous/environme • decont'n and conc'n of
ntal factors specimen
Transmission
• The number and • solid medium -
 Inhalation of droplet
size of infectious Lowenstein-Jensen
nuclei
droplet nuclei • liquid medium -
 Aerosols, contain 1-3
org • Duration of (Middlebrook)
 Suspended in the air exposure of the
S person to the Acid fast Staining
indefinitely
particle density Characteristic:
 Inhaled by person
• Air circulation • Red rods with Zeihl-
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MICRO MYCOBACTERIUM

being infected and ventilation Neilson (carbol-fuchsin)

 Taken up by alveolar dilutes the conc stain due to high
macrophages of infectious glycolipid content
 1 org enough to droplet nuclei
establish infection 3. Host factors Laboratory
 Tb is spread from - immune • Sputum culture after
person to person competence concentration or
through the air. The digestion with KOH
dots in the air (destroys other
represent droplet undesired organisms)
nuclei containing • Collect several
tubercle bacilli specimens
• Collect sputum early in
the morning (increases
bacterial concentration)
• Acid fast staining (Zeihl-
Neilson or Kinyoun)
• Fluorescent microscopy
techniques
• Culture of the organisms
on specialized media (L-J
and MIddlebrook agars)
• PPD skin testing (DTH)

Molecular diagnosis
• demo of M. tb DNA or
RNA in the specimen
• RNA and mRNA - better
indication of
mycobacterial cell
viability

Tuberculin Skin Test

(Mantoux)
• tuberculin - partially
purified extract of M.
tuberculosis proteins
(PPD)
• evokes a DTH response
(basis)

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MICRO MYCOBACTERIUM

C TB Infection Guidelines For

lass TB Disease (in Interpretation of the
T the lungs) Mantoux Test
ype
s
D Tubercle bacilli in Diameter of Induration (in
esc the body
ripti mm)
on Persons for Whom the
Reaction is Considered
Tuberculin skin Positive
test reaction
0 usually positive
No
exp ≥5
osu Chest x-ray
Immunosuppressed, a
re usually normal recent close contact with
to Chest x-ray active TB, abnormal chest
TB usually abnormal X-ray consistent with TB
Not
infe
cte
Sputum smears ≥ 10
d
No and cultures Foreign-born (country with
hx negative. high TB prevalence), low
of Sputum smears income, injection drug
exp and cultures users. residents of
osu positive. correctional facility or
re, nursing home, > 70 yr, <
neg 18 yr, healthcare workers,
ativ No symptoms mycobacterial lab
e Symptoms such employee, medical
rxn as cough, fever, condition associated with
s to weight loss increased risk of TB (DM,
tub prolonged corticosteroids,
erc gastrectomy, chronic
ulin Not infectious malabsorption, silicosis, ≥
skin Often infectious 10 % below IBW)
test before treatment

1 Not a case of TB
≥ 15
E A case of TB All others
xpo
sur
e of
TB
No
evi
den
ce
of
infe
ctio
n
Hx
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MICRO MYCOBACTERIUM

MYCOBACTERIUM LEPRAE

TUBERCULO MICROBIOLO WORLD HEALTH

BACTERIA EPIDEMIOLOGY PATHOGENESIS LEPREMATOUS LEPROSY
ID LEPROSY GY ORGANIZATION
Leprosy Endemic Areas of CLINICAL POINTS • Diffuse or nodular lesions • Few well • Resembles Case Definition of
• Ancient disease the World • Macules, papules or nodular lesions • (+) many AFB’s (multibacillary) defined M. tb Leprosy
• M. leprae - first WHO: • Areas of anesthesia lesions under the 1 or more of the
• Clumps of cells may occur intra- and
pathogen to be Brazil, Madagascar, • Few AFB’s light following features:
• Thickened nerves extracellular masses in capsular material
recognized and Mozambique, Tanzania, (paucibac microscop o Hypopigmented
• Superficial infection on cooler areas of the body (globi)
demonstrated in and Nepal have 90% of illary) e; (+) or reddish skin
(skin – nose, outer ears), testicles, superficial nerve • Sensory loss due to nerve damage
human tissue cases (1-2 million new • Predomin pleomorph lesion(s) with
endings • Predominant humoral response, little CMI
( Hansen, 1872) cases annually ic forms definite loss of
• (+) Continuum of disease from Lepromatous ant CMI
• Occurs worldwide) • Multiple nodular lesions → Typical leonine
• Spontane • NEVER sensation
Leprosy to Tuberculoid Leprosy o Involvement of
predominantly in (lionlike) facies been
• Immediate forms: ous
SEA, but also in Africa Incubation Period • After onset of tx, patients often develop cultured in the peripheral
o Borderline leprosy regressio
and the Americas o a few weeks erythema nodosum leprosum (ENL) – sign of the lab nerves
o Indeterminate Leprosy n occurs
following restoration of CMI (thickening with
o 1 M active cases
exposure
• Cases in • Cultured loss of
worldwide in 1997 • Painful nodules along extensor surfaces of children
o several years (30 CLINICAL FEATURES: DUE TO transiently sensation)
o 2 M ; irreversible tibia and ulna; neuritis and uveitis in the
deformities due to yrs) • Skin anesthesia results in burns or trauma →
DIAGNOSIS mouse
o Skin smear (+)
infected DIAGNOSIS for AFB
leprosy • Few footpad
o incidence: Transmission • Resorption of bone leads to loss of features (nose; • AFB Stain of skin lesions or nasal scrapings
o NOT highly organism • Intracellul Eradication
 2: 1 males to fingertips) • Foam cells – lipid laden macrophages s seen ar
infectious Programs
females • Infiltration of the skin and nerves leads to contain many AFB in the skin • Typical pathogen
o common among Classified on the
 1:1 Africa thickening and folding of the skin • False (+) serologic test for SY granulom – escapes
household basis of clinical
• Chronic, • A person living in endemic area with the a – into the manifestations or on
contacts FEATURES OF LEPROSY
communicable following cardinal signs: sufficient cytoplasm results of skin smears
o inhalation of • Localized areas of anesthesia due to nerve
disease caused by M. o Skin lesions + Definite sensory loss, of the host o Skin smears:
infectious agents degeneration
leprae with or without thickened nerves cell (-) :
o ? Insect bites, 
• Nasal secretions are most likely infectious material; o (+) Skin smear (found in small • Takes 20 –
• Clinical spectrum of inoculation Paucibacillar
low infectious ability, may take 3-4 yrs proportion of cases) 30 days to y Leprosy
disease reflects: through broken
• Children are more susceptible than adults • Clinical Classification: divide
bacterial proliferation (intact) skin  (+) :
and accumulation at o infectious: shed • Tx: 1-2 year combination therapy – Dapsone, o If lesion: • WHO Multibacillar
the site of infection from nasal Rifampin, Clofazimine  Single: Paucibacillary leprosy recommen y Leprosy
• immunological mucous ds two
response membranes esp indices for Diagnosis
• peripheral neuritis if (+) ulceration quantificat Lepromin skin test:
o can survive in ion of o PPD based on
• Peripheral nerves,
nasal secretions infection proteins
skin and mucous 1. BI
membranes are x 36 hrs isolated from
affected o humans: M. leprae
- o Used in
• M. leprae only grows reservoir of
Bacteri epidemiologica
on the colder infection
al l suveys to
surfaces of the body o found: wild, nine-
index detect
• Rarely an immediate banded
- Measu occurrence of
cause of death armadillos
re subclinical
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MICRO MYCOBACTERIUM

 main source bacter infection

Mycobacterium leprae for research ial
• 1400 BC – Leprosy load Treatment
dates back to Classification of Leprosy 2. MI • Dapsone:
biblical times Mainstay of
• 50-100 cases are - treatment
diagnosed in the US Morpho • Multidrug
annually now logical therapy (MDT)
(increase in 1985 index o Never treated
due to immigration - Measu with a single
from SE Asia re drug
• Morbidity is more bacter o Treatment for
important than ial at least 2
mortality today: 15- viabilit years or until
20 million cases y lesions free of
worldwide organisms
• Clinical picture is o Thalidomide:
99% of the severe ENL
diagnosis reactions
supportive
M. leprae Growth ● Multibacillary
Characteristics leprosy
• Does not grow well o Rifampicin:
above 30°C. No 600 mg once
systemic disease a month
• Obligate intracellular o Dapsone: 100
parasite; won’t grow mg daily
on artificial medium o Clofazimine:
300 mg once
• Armadillo tissue is also
a month and
used for culture 50 mg OD
• Paucibacillary
leprosy
o Rifampicin:
600 mg once a
month
o Dapsone: 100
mg daily
o Duration: 6
months
o Single skin
lesion (ROM)
single dose
Rifampicin,
Ofloxacin,
Minocycline

Prevention
• Isolation of ALL
lepromatous px

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MICRO MYCOBACTERIUM

• Chemoprophylaxi
s: Dapsone
• NO vaccine

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MICRO MYCOBACTERIUM

RESISTANCE APPEARANCE OF DISEASE

NO RESISTANCE

Tuberculoid
Lepromatous
TUBERCULOID

• Intact CMI
BORDERLINE • Deficient CMI

LEPROMATOUS
• Non-progressive disease
• Progressive disease
• Non-progressing
disease
• Macular skin lesions • Macular skin lesions
• Few bacilli in lesions • Nodular skin lesions
• CD4+ helper T-cells
• IL-2, IFN-gamma &
IL-12 promote healing • Few bacilli present
• Abundant bacilli

• Progressive disease
• Nodular skin lesions • Severe asymmetric nerve
• Abundant bacilli in involvement
lesions • Symmetric nerve involvement
• CD8+ suppressor T-
cells
• IL-4 & IL-10 suppress • Sudden onset
healing • Slow onset

INDETERMINATE • Skin infiltrated with TH1 cells

• Ab levels are high

• IL-2, IFN-γ & IL-2

INFECTION • IL-4 & IL-10

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MICRO MYCOBACTERIUM

MYCOBACTERIA OTHER THAN TUBERCULOSIS (MOTT)

GROUP I – GROUP II - GROUP III - GROUP IV – RAPIDLY

BACTERIA OTHER MOTT
PHOTOCHROMOGENS SCOTOCHROMOGENS NONCHROMOGENS GROWING
• Environmental mycobacteria o Mycobacterium o Mycobacterium o Mycobacterium avium- o Mycobacterium • Mycobacterium ulcerans
o Generally cause opportunistic infections kansasii scrofulaceum intracellulare complex fortuitum-chelonei o 3rd most common
o Person to person transfer does NOT take place  Produce lung  Scrofula (MAI or MAC) complex mycobacterial
o Generally R to drugs used for tx to Tb and systemic  Granulomatous  M. avium; M.  M. fortuitum; infection in humans
o Combination of 5 or 6 agents may have to be used disease adenitis enters intracellulare M. chelonei o Causes Buruli ulcer
• Classified according to: rate of growth, whether they identical to Tb, through  Most common  Saprophytes o Occurs widely
produce pigment frequently PPD oropharynx bacterial cause of found in soil
throughout west
o Group I (+)  Infects disease in AIDS and water
Africa
Photochromogens  Can infect old draining lymph  AIDS: CD4, 200/uL  Rarely cause
 o Treatment
tuberculous nodes o Habitat human disease
 Yellow to orange colony when exposed to light  Antibiotics
lung lesions o Habitat  Water and soil  Skin and soft
o Group II unsuccessful
o Treatment  Environmental o Treatment tissue
 Scotochromogens  Surgical excision
 RIF, INH, water source  For life infections
 Produce pigment in the dark
Ethambutol  Saprophyte from  Highly R to anti- (_____-ndi
o Group III
 Surgical human RT tuberculous drugs nnman xa
 Nonchromogens resection makita, 1 word
o Treatment  Initial: macrolide+
 Little or no yellow orange pigment irrespective of lng xa kc maliit
 Surgical incision others: Rifabutin
(+) or (-) of light lng un space.
o Group IV Senxa) of
 Grow rapidly (< 7 days) puncture
wounds
o Occur in:
 Immunocompr
omised px
 Individuals with
prosthetic hip
joints and
indwelling
catheters
o Treatment
 R to anti-tb
drugs
 Multiple drugs
+ surgical
excision
 DOC: Amikacin
& Doxycycline
o Mycobacterium
abscessus
 Causes chronic
lung infections
 Infections of
skin, bone,
joints
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MICRO MYCOBACTERIUM

 Highly
antibiotic R
o Mycobacterium
smegamatis
 Not associated
with human
disease
 Part of N flora
of smegma

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MICRO MYCOBACTERIUM

Runyon’s classification of Atypical Mycobacteria

Group
Growth Rate
Pigment Formation in
Typical Species

Light
Dark

I
Slow
+
-
M. kansasii
M. marinum

II
Slow
+
+
M. scrofulaceum

III
Slow
-
-
M. avium
M. intracellularae

IV
Rapid
-
-
M. fortulum
M. fortulum-chelonei complex

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MICRO MYCOBACTERIUM

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13