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Mycobacteria
Dr.SriMulyaningsih

ImportantHumanPathogens
Mycobacteriumtuberculosis M cobacteri m t berc losis Mycobacteriumleprae (uncommon)

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LipidRichCellWallofMycobacterium
Mycolicacids

CMNGroup:
Unusualcellwall lipids(mycolic acids,etc.)
( (PurifiedProteinDerivative) )

Mycobacteriumtuberculosis
M.tuberculosis complexincludesseveralspecies: 1.Mycobacteriumtuberculosis 2.Mycobacteriumbovis unpasteurizedmilk;recent rashofcasesinUS 3.MycobacteriumbovisBCG 4.Mycobacteriumafricanum andMycobacterium 4 Mycobacterium africanum and Mycobacterium canetti=rarecausesoftuberculosisinAfrica 5.Mycobacteriummicroti=pathogenforrodents

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Organismcharacteristics
1.Aerobic,nonmotile,nonsporeformingbacillus 2.Highcellwallcontentofhighmolecularweight lipids mycolic acid 3.SLOWGROWTHRATE a.generationtimeof20hoursvs E.coli g generationtimeof20minutes f
b.38weeksbeforegrowthonsolidmedia; c.implicationsforlengthoftreatmentforcomplete sterilizationcomparedwithmostbacterialpathogens

PathogenesisofTuberculosis
Inhalationofsmall(15m)dropletnuclei containingM.tuberculosisexpelledby t i i M t b l i ll d b coughing,sneezing,ortalkingofanother individualwithcavitary tuberculosis PrimaryinfectionbyM.tuberculosis ofnon immunealveolarmacrophageswith p g unrestrainedproliferationwithintheinfected macrophages

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LungsaretheportalofentryexceptM.bovis inunpasteurized dairyproductsfromothercountries Inhalationofdropletnuclei(bacillus5microns):frominfectious personwithactivepulmonarytuberculosis,NOTjustpositive person with active pulmonary tuberculosis NOT just positive PPD a.cough:mostefficientat3000infectiousdropletnucleiper cough b.talking:similarquantityover5minutes c.sneezingmoreefficientthancoughing;singingintermediate betweentalkingandcoughing. b lk d h d.Bacillusremainsaliveandinfectiousinairforlongperiod; ventilationkeyinpreventingtransmission;isolationofpatient andmandatednumberofairexchangesinhospitalrooms

PathogenesisofTuberculosis
Disseminationofinfectedmacrophages throughthedraininglymphatics i t th th h th d i i l h ti intothe circulation Developmentwithin38weeksofaCD4+T celldependentcellmediatedimmune responsewithgranuloma formationand p g macrophageactivationatsitesofinfection

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PathogenesisofTuberculosis
Activeinfectionusuallytransformedinto latentinfection(exceptions:infants,AIDS) l t t i f ti ( ti i f t AIDS) WithdecrementinTcelldependentcell mediatedimmunity(yearslater)infection reactivatedwithdevelopmentoftuberculosis ( (HIVinfection,diabetesmellitus,renal , , disease,cancer,advancedage)

PathogenesisofTuberculosis
ReactivationofM.tuberculosis infectionwith partialimmunityproduceshightissue ti l i it d hi h ti concentrationsofmycobacterial antigens thatprovokeanintensemononuclearcell response(type4hyper sensitivityreaction)

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PathogenesisofTuberculosis
Densemononuclearcellinfiltratesdamage tissueduetoreleaseofactiveoxygenradicals ti d t l f ti di l andlysosomal neutralproteases Tissuedamageoccursascaseation necrosis thatprogressestoliquefactionnecrosisinthe absenceoftuberculosisdrugtreatment g

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ClinicalFeaturesofTuberculosis
Apicalcavitary lesionsinupperlobesoflung byXrayfilmofthechest b X fil f th h t PositivetuberculinskintestwithPPD (purifiedproteinderivative)

ChestXRayofPatientwithActive PulmonaryTuberculosis

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TuberculosisandtheDisadvantaged
Homelesspersons Intravenousdrugabusers Prisoninmates(Russiaandotherprevious statesoftheSovietUnion) RecentimmigrantstotheUnitedStates(Asia, LatinAmerica) Latin America) HIV1infection/AIDS

Epidemiology
Worldwide:WHOMaps:Estimatedincidencevs.case notifications 1.M.tuberculosisinfectsonethirdworldspopulation causes8millionnewcasesactivediseaseannually 2.Causes2milliondeaths=2ndonlytoHIVascauseof deathfrominfectiousagentworldwideamongadults 3.HIV/TBrelationshiphasexacerbatedproblemwithTB increasinginareaswithhighAIDSincidence E i i i ith hi h AIDS i id Especially i ll subSaharanAfrica 4.AbsolutenumbersofcasesofTBhighestinAsia

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Epidemiology
Downwardtrendinincidenceevenbeforeadventof antibiotics Annualdecreaseinmortalityandmorbidityof4%6%in developedcountries between1900andWW2: Betterlivingconditionslessconducivetoairborne spread. d Adventofantibioticslate1940s(Streptomycin)andINH in1952:Tuberculosisiscurable

Diagnosticprocedures:SPUTUM: staining,culturesandmolecular diagnostics

1.Acidfaststain: ZiehlNeelsen stain=fixedsmearcoveredwith carbolfuchsin,heated,rinsed,decolorized withacidalcohol;Kinyoun stainissimilarbut heatingunnecessary h ti SMEARPOSITIVITYMEANSATLEAST10,000 ORGANISMS/mL SPUTUM

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Diagnosticprocedures
2.Culture: a. S lid Solidmedia=LowensteinJensen(eggbased) di L t i J ( b d) b. Middlebrook 7H11(agarbased):candetect colonymorphology,mixedinfections;can detect10100organisms/mL;38weeks incubationtodetectorganisms CULTURENECESSARYTODETERMINEDRUG SUSCEPTIBILITIES

LowensteinJensenEggBaseMedium
Coagulatedwholeeggs Potatoflour Glycerol Definedsalts MalachiteGreen(0.025g/100mL) (Petragnani 0.052g/100mL) (ATS0.020g/100mL)

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Middlebrook AgarBase7H10Medium
Definedsalts VitaminsandCofactors Vit i dC f t Oleicacid Albumin Catalase Glycerol Dextrose MalachiteGreen(0.0025g/100mL)

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Diagnosticprocedures
3.Nucleicacidamplification candetectM.tuberculosiscomplexinfreshsputum: can detect M. tuberculosis complex in fresh sputum: developedworldtechnology toocostlyforresourcepoorcountries 4.DNAfingerprinting:Molecularepidemiologictool: RFLP(Restrictionfragmentlengthpolymorphism);also developedworldtechnology p g ; Restrictionendonuclease producesDNAfragments; separatefragmentsbyelectrophoresis;probeto repetitiveDNAsequence=Insertionsequence(IS)6110 numerouscopiesofIS6110presentinM.tuberculosis chromosomeathighlyvariablelocations

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Treatment
1. Alwaysuseatleast2drugs; usuallybeginwith3or4pendingsensitivities ll b i ith 3 4 di iti iti 2. Prolongedlengthnecessary: 69monthsif organismpansensitive 3. DirectlyObservedTherapyforallpatients a.Nooneis100%compliantage, sex,race, a No one is 100% compliant age sex race education b.Dailytreatmentforfirst2months;

Treatment
Drugs:ALLGIVENONCEDAILYTOGETHER:NEVERDIVIDE DOSES 1.Isoniazid=INH;bactericidalagainstdividingorganisms 2.Rifampin=RMP=bactericidal;Enablesshortcourse treatment drugdruginteractions:RMPispotentinducerofhepatic microsomal enzymes:cytochrome p450 3.Pyrazinamide=PZA;Enablesshorteningofregimenfrom9 monthsto6months months to 6 months 4.Ethambutol=EMB:Usedindrugresistanceandsituations whereINHorRMPcannotbeused (INHhepatotoxicity;RMPdrugdruginteractions)

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Prevention:BCG
Mostwidelyusedandmostcontroversialvaccineinthe world A.Whatisit? M.bovis strainattenuatedthroughserialpassage B.Doesitwork?
1.Largeststudy:India=noprotectionfromTBinfection 2.Otherstudies:England=protectionfromTBinfection 3.Prevalenceofnontuberculous mycobacteria ingivenregionmay interfere 4.Backgroundprevalenceoftuberculosisdeterminesutility

C.Whousesit? Newbornsvaccinatedinallhighprevalenceareasofworld shownonfirstmap

Mycobacteriumleprae

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MycobacteriumlepraeInfections

MycobacteriumlepraeInfections(cont.)

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Tuberculoidvs.LepromatousLeprosy
ClinicalManifestationsandImmunogenicity

Lepromatousvs.TuberculoidLeprosy

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LepromatousLeprosy(Early/LateStages)

LepromatousLeprosyPre and PostTreatment

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