NEISSERIA o Meningococci and gonococci grow best on

- Includes genera Neisseria, Kingella, Eikenella, and 32 media containing complex organic
other genera. substances, such as:
- Gram-negative cocci (usually occur in pairs – ▪ Heated blood
diplococci) ▪ Hemin
- Exclusively pathogenic for humans and typically are ▪ Animal proteins
found associated with or inside polymorphonuclear ▪ Atmosphere of 5% CO2
cells (PMNs) o Both – rapidly killed by:
o Neisseria gonorrhoeae (gonococci) ▪ Drying
o Neisseria meningitidis (meningococci) ▪ Prolonged exposure to sunlight
- Gonococci and meningococci ▪ Moist heat
o 70% DNA homology ▪ Many disinfectants
- Meningococci o Both – produce autolytic enzymes that result in
o Have polysaccharide capsules rapid swelling and lysis in vitro at 25°C and
o Rarely have plasmids alkaline pH.
o Found in upper respiratory tract
o Cause meningitis NEISSERIA GONORRHOEAE
- Gonococci - Oxidize only glucose
o Have plasmids - Differ antigenically from other neisseriae
o (-) polysaccharide capsules - Produce smaller colonies
o Cause genital infections - Gonococci that requires arginine, hypoxanthine, and
uracil tend to grow most slowly on primary culture.
Morphology and Identification - On non-selective subculture agar media → larger
- Typical organisms colonies containing nonpiliated gonococci are also
o Aerobic formed.
o Gram-negative - Opaque and transparent variants of both the small and
o Nonmotile diplococcus large colony types also occur
o Approximately 0.8 um in dm - Opaque color → associated w/ the presence of
o Individual cocci → kidney bean shaped. surface-exposed protein, Opa.
o Pairs → flat or concave sides are adjacent.
- Culture Antigenic Structure
o Media: - Heterogeneous
▪ Sheep blood agar - Capable of changing its surface structures in vitro (and
▪ Chocolate agar in vivo) to avoid host defenses. Surface structures
▪ Selective agar media include the following:
• Modified Thayer-Martin agar o Pili (Fimbriae)
• Martin-Lewis agar ▪ Hairline appendages that extend up to
• GC-Lect agar several micrometers from gonococcal
• New York City medium surface.
o N. Gonorrhoeae → requires enriched ▪ Enhance attachment to host cells and
chocolate agar and/or selective media for resistance to phagocytosis.
optimal growth. ▪ Made up of stacked pilin proteins.
o Selective media contain: ▪ Amino terminal of the pilin – contain
▪ Vancomycin – suppression of Gram- high percentage of hydrophobic
positive bacteria amino acids.
▪ Colistin - suppression of Gram- o Por
negative bacteria ▪ Extends through the gonococcal cell
o Colistin-resistant (both) + N. Lactamica membrane.
o When grown on suitable media, gonococci and ▪ Forms pores in the surface through
meningococci form: which some nutrients enter the cell.
▪ Glistening, elevated, mucoid colonies ▪ May impact intracellular killing of
1-5mm in dm. gonococci w/n neutrophils by
o Colonies are: preventing phagosome-lysosome
▪ Transparent or opaque fusion.
▪ Nonpigmented ▪ Variable resistance of gonococci to
▪ Nonhemolytic killing by normal human serum
o Yellow pigmentation depends whether Por protein
▪ N. Flavescens selectively binds to complement
▪ N. Cinera components C3b and C4b.
▪ N. subflava o Opa proteins
▪ N. Lactamica ▪ Function in adhesion of gonococci
o Opaque, brittle, wrinkled colonies w/n colonies and in attachment of
▪ N. sicca gonococci to host cell receptors such
o Nonpigmented or pinkish gray opaque as:
colonies • Heparin-related compounds
▪ Moraxella • CD66
- Growth characteristics • Cinoembryonic antigen-
o Grow best under aerobic conditions related cell adhesion
o N. gonorrhoeae → capable of growing under molecules
anaerobic conditions ▪ Express 1-3 types of Opa
o When spotted on a filter soaked w/ • Each strain has 11-12 genes
tetramethyl-p-phenylenediamine o Rmp (Protein III)
hydrochloride (oxidase) → rapidly turn dark ▪ Antigenically conserved in all
purple. gonococci.
o (+) catalase (except. N. elongata)
 ▪ A reduction-modifiable protein (Rmp) o Progress to the uterine tube → salpingitis
and changes its apparent MW when in (fibrosis and obliteration of tubes)
reduced state. o Infertility occurs in 20% of women in women w/
▪ Associates w/ Por in the formation of gonococcal salpingitis
pores in the cell surface. o Chronic gonococcal cervicitis and proctitis →
o Lipooligosaccharide (LOS) often asymptomatic
▪ Does not have a long-O-antigen side - Gonococcal bacteremia leads to:
chain. o skin lesions (hemorrhagic papules and
▪ Toxicity in gonococcal infections is pustules) on the:
largely attributable to endotoxic ▪ Hands
effects of LOS. ▪ Forearms
▪ Cause ciliary loss and mucosal cell ▪ Feet
death → fallopian tube explant model ▪ Legs
▪ o Tenosynovitis and suppurative arthritis
o Other proteins ▪ Knees
▪ Lip (H8) ▪ Ankles
• Surface exposed protein that ▪ Wrists
is heat-modifiable like Opa - Gonococcal endocarditis
▪ Fbp (ferrin-binding protein) o Uncommon but severe infection
• Similar in MW to Por, - Complement deficiency – frequently found in patients
expressed when the available with gonococcal bacteremia
iron supply is limited - Gonococcal ophthalmia neonatorum
▪ IgA1 protease o Infection of the eye in newborns
• Splits and inactivates IgA1 o Acquired during passage through an infected
canals
Genetics and Antigenic Heterogeneity o If untreated → blindness
- Have evolved mechanisms for frequently switching o Prevention: erythromycin ointment
from one antigenic form (pilin, Opa, or LPS) to another
antigenic form of the same molecule. Diagnostic Laboratory Tests
- pilin, Opa, or LPS → surface-exposed antigens – - Specimens
important in the immune response to infection. o Pus and secretions from: → culture and smear
- Molecules’ rapid switching from one form to another ▪ Urethra, cervix
helps gonococci elude the hist immune system. ▪ Rectum
- Contains several plasmids. ▪ Conjunctiva
- 95% of strains have a small, “cryptic” plasmids of ▪ Throat
unknown function. ▪ Synovial fluid
- Two other plasmids contain genes that code for o Blood – necessary for systemic illness
o TEM-1type (penicillinases) B-lactamases - Smears
▪ Causes resistance to penicillin. o Gram-stained smears for urethral or
o Gene tetM endocervical exudates
▪ Tetracycline resistance into the ▪ Reveal many diplococci w/n PMNs
conjugative plasmid. ▪ PRESUMPTIVE DIAGNOSIS
o Stained smears of the urethral exudate from
Pathogenesis, Pathology, and Clinical Findings men
- Only piliated bacteria appear to be virulent. ▪ Sensitivity of 90%
- Gonococci that form opaque colonies, isolated from: ▪ Specificity of 99%
o men w/ symptomatic urethritis o Stained smears of endocervical exudates
o uterine cervical cultures at midcycle ▪ sensitivity of 50%
- Gonococci that from transparent colonies, frequently ▪ specificity of 95%
isolated from: o NAATs (nucleic acid amplification tests) or
o men w/ asymptomatic urethral infection cultures → should be done for women
o menstruating women o Stained smears of conjunctival exudates →
o patients w/ invasive gonorrhea can be diagnostic value
▪ salpingitis o Gram-stains of specimens from throat and
▪ disseminated infection rectum → not helpful due to sites being
- Gonococci attacks mucous membranes of the: frequently colonized by commensal,
▪ genitourinary tract nonpathogenic neisseriae.
▪ eye - Culture
▪ rectum o After collection (immediately) pus or mucus is
▪ throat streaked on enriched selective medium –
o producing suppuration that may lead to tissue MODIFIED THAYER-MARTIN MEDIUM (MTM)
invasion, followed by chronic inflammation – and incubated in an atmosphere of 5% CO2
and fibrosis. at 37°C.
- Men usually have: o To avoid overgrowth of contaminants –
o Urethritis selective media contain anti-microbial drugs.
o Yellow, creamy pus ▪ Vancomycin
o Painful urination ▪ Colistin
o As suppuration subsided in untreated infection ▪ Nystatin
→ fibrosis occurs → leading to urethral ▪ Trimethoprim
strictures o If immediate incubation not possible →
o Urethral infection (in men) – can be specimen placed in a CO2 containing
asymptomatic. transport-culture system.
- Women o 48hrs after culture → presumptive –
o Primary infection is in endocervix appearance on gram stained smear and (+)
o Extends to the urethra and vagina → giving rise oxidase test
to mucopurulent discharge o Other definitive identification
 ▪ Chromogenic enzyme substrate test - Meningococcal antigens – found in blood and CSF of
▪ Immunologic test methods (co patients w/ active disease.
agglutination assays) - Outer membrane of N. Meningitidis consists of:
- Nucleic Acid Amplification Tests (NAAT) o Proteins and LPS
o Preferred tests from genitourinary specimens ▪ Play major roles in organism virulence.
o Excellent sensitivity and specificity in high - Two porin proteins – Por A and Por B
prevalence populations o Important in controlling nutrient diffusion into
o Advantages: the organism and also interact w/ host cells.
▪ Better detection - Opacity proteins (comparable w/ Opa)
▪ More rapid results o Play a role in attachment
▪ ability to use urine as specimen - Piliated
o disadvantages: o To initiate binding to nasopharyngeal epithelial
▪ poor specificity of some assays cells and other host cells such as endothelium
because of cross-reactivity w/ and erythrocytes.
nongonococcal N. species. - Lipid A disaccharide of meningococcal LPS
o Not recommended for tests of cure – because o Responsible for many of the toxic effects found
nucleic acid may persist in patients specimens in meningococcal disease.
for up to 3 weeks after successful treatment.
- Serology Pathogenesis, Pathology, and Clinical Findings
o Serum and genital fluid contains → IgG and IgA - Humans – the only natural hists
antibodies against: - Portal of entry – nasopharynx
▪ Gonococcal pili - Invasive meningococcal disease (IMD)
▪ Outer membrane proteins o Infants and children – highest incidence
▪ LPS - Entry to nasopharynx → attach to epithelial cells w/ the
o Some IgM of human sera → bactericidal for aid of pili → form transient microbiota w/o producing
gonococci in vitro symptom → may reach bloodstream → meningococcal
o In infected individuals – antibodies to bacteremia → initial symptoms “flu-like” infections
gonococcal pili and outer membrane proteins - Meningitis – most common complication of
can be detected by: meningococcal bacteremia
▪ Immunoblotting o Usually begins w/ a headache, vomiting,
▪ Radioimmunoassay photophobia, confusion, and stiff neck → to
▪ Enzyme-linked immunosorbent assay coma w/n few hours
(ELISA) tests - Fulminant meningococcemia – more severe
▪ These tests are not useful as o Presenting w/ high fever, hemorrhagic rash
diagnostic aids. o Disseminated intravascular coagulation
o Ultimate circulatory collapse w/ bilateral
Immunity hemorrhagic necrosis of the adrenal glands w/
- Protective immunity to reinfection does not appear to subsequent adrenal failure
develop as part of the disease process because of the ▪ WATERHOUSE-FRIDERICHSEN
antigenic variety of gonococci. SYNDROME
- Meningococcemia
Treatment o Thrombosis of many small blood vessels in
- For uncomplicated urethritis, cervicitis, and proctitis many organs
o Injectable ceftriaxone 250 mg IM once plus o Interstitial myocarditis, arthritis, and skin
either azithromycin or doxycycline lesions
- Azithromycin – safe and effective for pregnant women - Meningitis
- Doxycycline – contraindicated to pregnant women o Meninges – acutely inflamed
o Thrombosis of blood vessels
Epidemiology, Prevention, and Control o Exudation of polymorphonuclear leukocytes
- Mechanical prophylaxis (Condoms) - Neisseria bacteremia is favored by the:
o Provides partial protection o absence of bactericidal antibodies (IgM and
- Chemoprophylaxis IgG)
o Limited value because of the rise in antibiotic o inhibition of serum bactericidal action by
resistance to gonococcus blocking IgA antibody
- Gonococcal ophthalmia neonatorum o complement deficiency (C5, C6, C7, or C8)
o Prevented by application of:
▪ 0.5% erythromycin ophthalmic Diagnostic Laboratory Tests
ointment - Specimens
▪ 1% tetracycline ointment o Blood – culture
o CSF – smear and culture
NEISSERIA MENINGITIDIS o Puncture material or biopsies from petechiae -
Antigenic Structure smear and culture
- At least 13 serogroups of meningococci have been o Nasopharyngeal swab – suitable for carrier
identified by immunologic specificity of capsular surveys
polysaccharides. - Smears
- 6 most important serogroups associated with disease o Gram-stained smears of the sediment of
in humans: • Centrifuged spinal fluid
o A, B, C, X, Y, and W-135 • Petechial aspirate
o Group A polysaccharide is a polymer of N- ▪ Shows typical Neisseria w/n PMNs
acytel-mannosamine-1-phosphate (leukocytes) or extracellularly
o Others, capsule is composed of sialic acid - Culture
moieties o CSF specimens
- Meningococcal capsules – allows the organism to be ▪ sheep blood agar and chocolate agar
overlooked by the host immune system (molecular ▪ incubated at 37°C in an atmosphere of
mimicry) 5% CO2
 o Modified Thayer-Martin medium (MTM) – favors
growth of Neisseria
▪ Inhibits other bacteria
▪ Used for nasopharyngeal cultures
o Colonies are:
▪ Gray, convex, and glistening, w/ entire
edges
▪ (+) oxidase
▪ Gram-negative diplococci
▪ PRESUMPTIVE IDENTIFICATION
o Spinal fluid and blood – yield pure cultures
- Serology
o Antibodies to meningococcal polysaccharides
can be measured by:
▪ Latex agglutination
▪ Hemagglutination tests
▪ Bactericidal activity

Immunity
- Associated w/ the presence of specific, complement-
dependent, bactericidal antibodies in the serum
- Immunizing antigens for group A,C, Y, and W-135 are the
capsular polysaccharides.
- For Group B – two vaccines
o 4CMenB (Bexero)
o Trumenba
- Three vaccines against
o Serogroups A, C, Y, and W-135
- One
o C and Y
- Routine vaccination of all young adolescents (11-12 yo)
before high school w/ booster dose at age 16 yo using
an approved conjugate vaccine – NOW
RECOMMENDED

Treatment
- DOC: Penicillin G
- Alternative drugs:
o Chloramphenicol
o 3rd-generation cephalosporins (ceftriaxone or
cefotaxime)

Epidemiology, Prevention, Control

- Serogroup A – responsible for the majority of outbreaks
in sub-Saharan Africa
- Serogroup B – most often cause of sporadic infections
- Chemoprophylaxis
o Rifampin – BID for 2 days
▪ Adults - 600mg orally
▪ Children <1 month - 5mg/kg
▪ Children 1 month older – 10mg/kg
o Ciprofloxacin – single dose
▪ Adults 500 mg
o Ceftriaxone
▪ Children <15 yo – 125mg IM single
dose
- Droplet and standard precautions for the first 24 hrs of
antimicrobial therapy