CHAPTER IV

PATHOGENIC GRAM NEGATIVE

COCCI
Learning objectives
At the end of this chapter, the student will be able to:
1. Discuss the general characteristics of the genus Neisseria.
2. List the virulence factors of N. gonorrhoea.
3. Discuss the pathogenesis and clinical manifestation of N.
meningitidis.
4. Differentiate N. gonorrhoea from N. meningitidis using
biochemical tests..
 Genus Neisseria
General characteristics
 They are non-motile, gram-negative intracellular diplococci
 Rapidly killed by drying, sunlight, heat, and disinfectants
 Ferment carbohydrate producing acid but not gas
 Are kidney-shaped with adjacent concave sides.
 Grow best on complex media under aerobic conditions
containing
5%co2
 Are oxidase positive.
 .The main species of medical importance are:
- N. meningitidis
- N.gonorrhoea.
• Neisseria species grow best on media containing: Heated blood,
hemin, animal protein, 3- 10% Co2 and other supplements.

• The organisms are sensitive to: drying, sunlight, moist heat and
disinfectants.
4.1 Neisseria gonorrhoeae
The name ‘gonorrhoea’ derives from the Greek words gonos
( seed) and rhoia ( flow), and described a condition in which
Semen fluid from the male organ without erection.
General characteristics
 An obligate parasite of the human urogenital tract.
 Has no polysaccharide capsule but has multiple serotypes
based on the antigencity of its pilus protein.
 There is a marked antigenic variation in the gonococcal pili as
a result of chromosomal rearrangement.
 More than 100 serotypes are known.
Virulence factors

1. Pili
 Hair like appendages that mediate initial attachment to non –

ciliated human cells ( e.g. epithelium of vagina , fallopian tube

and buccal cavity.

 Made from pilin proteins.

 Resistance to phagocytosis (interferes with neutrophil killing)

2. Por protein (Protein I)
 Pores on the surface of bacteria through which nutrients enter
the cell.
 Promotes intracellular survival by preventing phago-lysosome
fusion in neutrophils.

3. Opa (Protein II)

Important for firm attachment and invasion of bacteria to host

cells.

4. RMP (protein III)

 Outer membrane protein found in all strains of N. gonorrhoeae
 It is associated with por in the formation of pores in the cell.
 Protects other surface antigens (por proteins and lipo
oligosaccaride) from bacterial antibodies.
5. Lipooligosaccharide (LOS)
 Is responsible for most of the symptoms / toxicity of
gonorrhea

due to endo-toxin effect of LOS.

 Gonococcal LOS triggers an intense inflammatory response.

 Subsequent activation of complement, attraction and feeding

by phagocytes, and the lysis of the phagocytes themselves,

contributes to the purulent discharge.

6. Transferrin and lactoferrin binding proteins

Mediate acquisition of iron for bacterial metabolism.

7. Beta- lactamase

Hydrolyzes beta -lactam ring in penicillin.

Pathogenesis and clinical manifestations
 Gonorrhea in adults is almost invariably transmitted by sexual

Intercourse
 Gonococci attack mucous membrane of genito urinary tract,

eye, rectum and throat.

 In males there is urethritis, with yellow, creamy pus and
painful urination.
 In females , primary infection is in the endo-cervix and
extends to the cervix and vagina giving rise to muco-purulent
discharge.
 Gonococcal ophthalmia neonatorum is iinfection of the eye of
the new born during passage via infected birth canal.
 Clinical manifestation
In Women: In Men:
 Creamy or yellow, pus-like or bloody  Creamy or yellow, pus-like discharge from the
vaginal discharge penis
 Excessive bleeding during menstrual  Painful urination (burning sensation)
period  If not treated early it may lead to Epididymitis an
 Lower abdominal pain
inflammation of the testicles that may cause
 Painful intercourse
sterility
 Painful urination (burning sensation)  may develop to Disseminated Gonococcal
 The disease can spread into the womb
Infection
and fallopian tubes, resulting in Pelvic
Rectal infection:
Inflammatory Disease (PID) which may
 Creamy, pus-like discharge from rectum
lead to infertility in up to 10% of infected
 Itching
women and ectopic pregnancy
 Painful bowel movement with blood in feces
 Rectal bleeding
Laboratory diagnosis

Specimen: Urethral swab, cervical swab, eye swab.

Smear: Gram-negative intracellular and/or extra diplococci.

Figure . ….. Left: N. gonorrhoeae Gram stain of pure culture

Right: N. gonorrhoeae Gram stain of a pustular exudates
Culture: Requires an enriched media like chocolate
agar,
Thayer-Martin agar and/or Modified New York City
medium..
Grows best in carbon dioxide enriched aerobic
atmosphere with
optimal temperature of 35-370c.
 On culture, Neisseriae species form convex, elevated and
mucoid. colonies
• On Thayer - Martin and Chocolate agar media, colonies are
transparent or opaque and non - pigmented.

Growth characteristics
• Most Neisseriae grow best under aerobic conditions but
some grow under anaerobic situations
• Ferment carbohydrate and produce acid without gas
Serology: Antibodies to gonococcal pili & outer
membrane

proteins using RIA and/or ELISA.

Genetic probes : For detection of nucleic acids.

Treatment
Drug of choice (CDC) : Ceftriaxone, doxycycline, ciprofloxacin,
or oflaxacin. Penicillin resistance due to beta- lactamase enzyme
producing N. gonorrhoeae have been identified.
For ophthalmia neonatorum - 1% silver nitrate , 1% tetracycline
or 0.5% erythromycine eye ointments.
Prevention and control
 Early detection and treatment of cases.
 Using condom
 Health education
 There is no effective vaccine to prevent gonorrhea
4.2 Neisseria meningitidis
 N. meningitidis has a prominent antiphagocytic polysaccharide

capsule. N. meningitidis strains are grouped on the basis of their

capsular polysaccharides, into 12 serogroups, some of which are

subdivided according to the presence of outer membrane protein

and lipopolysaccharide antigens.

 The organism tends to colonize the posterior nasopharynx of

humans, and humans are the only known host. Individuals who

are colonized are carriers of the pathogen who can transmit

disease to nonimmune individuals.

• Medically important sero-groups in humans disease are
encapsulated strains belonging to A, B, C, Y and W135.
• Sero -groups C and A are associated with epidemic disease.
• Meningitis is the inflammation of the meninges of the brain
or spinal cord.
Virulence factors
 Meningoccal endotoxin (LOS) : is responsible for many
toxic effects.
 Capsule : Protects bacteria from anti body mediated
phagocytosis.
 Pili : Allow to colonization of nasopharynx.
Pathogenesis and clinical manifestations

Infection with N. meningitidis has two presentations:

Meningococcemia, characterized by skin lesions, and acute

bacterial meningitis
• Infection is by inhlation of the bacteria, which attach to
epithelial cells of the nasopharyngeal and oropharyngeal
mucosa, cross the mucosal barrier, and enter the bloodstream.
 The onset of meningococcal meningitis may be abrupt or insidious.

 Fulimenant meningo cocci (with/without meningitis) characterized

by:

- Fever

- Petechiae (minute hemorrhagic spots in the skin) or purpura

(hemorrhages into the skin). Occurs from first to third day of
illness in 30 to 60% of patients with meningococcal disease.
 Pulmonary insufficiency developed within a few hours, and many

patients die within 24 hours of being hospitalized.

 Meningitis begins suddenly with intense headache,vomiting,

photophobia, stiff of the neck or spinal rigidity (meningeal

irritation), neurologic signs (coma or convulsions) in 1/3 of

patients.
 The most severe form of meningococcemia is the life
threatening Water House Friderichsen syndrome, which is
characterized by high fever, shock, widespread purpura,
disseminated intravascular coagulation and adrenal
insufficiency.
Diseases caused by Neisseria meningitidis includes :
 Pyogenic (purulent) meningitis

 Meningococcal bacteremia (Water House

Friderichsen syndrome)
 Meningococcal encephalitis

 Pneumonia

 Arthritis and endocardiatis

 Urethritis.
Laboratory diagnosis
 Specimen: Cerebrospinal fluid, blood
 Smear: Gram-negative

 Culture: Transparent or grey, shiny, mucoid colonies in

chocolate agar after incubation at 35-37Oc in a CO2 enriched
atmosphere. intracellular diplococci
 Serology: Antibodies to meningo- coccal polysacharides can
be measured using: latex agglutination or hemagglutination
tests.
Biochemical reactions

Species Glucose Lactose Maltose Sucrose

Neisseria Positive Negative Negative Negative
gonorrhoeae
Neisseria Positive Negative Positive Negative
meningitidis

Drug of choice: Penicillin, Chloramphenicol, Cefotaxime

ceftriaxone
Vaccination is available for sero groups A, C, Y and W135.
No effective vaccine for sero group B as it is poorly
immunogenic in humans.