MYCOBACTERIACEAE

BEDİA DİNÇ
MYCOBACTERIA
• Aerobic, acid-fast bacilli
• Neither gram-positive nor
gram-negative, stained
poorly by the dyes used in
Gram stain.
• The high lipid content
(approximately 60%) of
their cell wall makes
mycobacteria acid-fast.
• Mycobacterium tuberculosis, the cause of
tuberculosis
• Mycobacterium leprae, the cause of leprosy
• Atypical mycobacteria, such as Mycobacterium
avium-intracellulare complex (MAI, MAC) and
Mycobacterium kansasii, can cause
tuberculosis-like disease but are less frequent
pathogens.
• Mycobacterium chelonae (rapidly growing
mycobacteria), cause human disease in
immunocompromised patients or those in
whom prosthetic devices have been implanted
MYCOBACTERIUM TUBERCULOSIS
• Causes tuberculosis.
• Worldwide, M. tuberculosis causes more
deaths than any other single microbial
agent.
• Approximately one-third of the world’s
population is infected with this organism. It
is estimated that 1.7 million people/year die
and 9 million/year new cases occur.
• An estimated 500,000 people are infected
with a multidrugresistant strain of M.
tuberculosis.
Important Properties
• M. tuberculosis grows slowly
(has a doubling time of 18
hours, in contrast to most
bacteria, which can double in
number in 1 hour or less).
• Cultures of clinical specimens
must be incubated for 6 to 8
weeks before being recorded
as negative.
• M. tuberculosis can be cultured on
bacteriologic media, whereas M.
leprae cannot.
• Löwenstein-Jensen medium
contains complex nutrients (egg
yolk) and dyes (malachite green).
• The dyes inhibit the unwanted
normal flora present in sputum
samples.
• Since it is an obligate aerobe; it causes disease
in highly oxygenated tissues such as the upper
lobe of the lung and the kidney.
• The acid-fast property of M. tuberculosis (and
other mycobacteria) is attributed to long-
chain (C78-C90) fatty acids called mycolic
acids in the cell wall. Cord factor (trehalose
dimycolate) is correlated with virulence of the
organism.
• Relatively resistant to acids and alkalis and
NaOH is used to concentrate clinical
specimens by destroying unwanted bacteria,
human cells, and mucus but not the organism.
• Resistant to dehydration and survives in
dried expectorated sputum; important
in its transmission by aerosol.
• Strains of M. tuberculosis resistant to
the main antimycobacterial drug,
isoniazid (isonicotinic acid hydrazide,
INH), as well as strains resistant to
multiple antibiotics (called multidrug-
resistant or MDR strains), have become
a worldwide problem.
Transmission & Epidemiology
• Transmitted from person to person by
respiratory aerosols produced by coughing.
• The portal of entry is the respiratory tract,
and the initial site of infection is the lung.
• Most transmission occurs by aerosols
generated by the coughing of “smear-
positive” people.
• Mycobacterium bovis also causes
tuberculosis in humans. M. bovis is found in
cow’s milk, which, unless pasteurized, can
cause gastrointestinal tuberculosis in
humans.
• In tissue, it resides chiefly within
reticuloendothelial cells (e.g.,
macrophages).
• Macrophages kill most, but not all, of
the infecting organisms.
• The ones that survive can continue to
infect other adjacent cells or can
disseminate to other organs
Pathogenesis
• Primary tuberculosis, typically results in
a Ghon focus in the lower lung.
• Primary tuberculosis can;
• heal by fibrosis
• lead to progressive lung disease
• cause bacteremia and miliary tuberculosis
• cause hematogenous dissemination
resulting in no immediate disease but with
the risk of reactivation in later life.
• If the primary infection heals without
causing disease, it is called a latent
infection.
• Of those exposed to M. tuberculosis;
• approximately 90% develop latent infection and approximately 10%
develop disease.
• Of those who have latent infection;
• approximately 10% progress to active disease (reactivation) at a later
time, whereas 90% remain latent.
• Secondary tuberculosis usually
occurs because of reactivation of
latent tuberculosis infection.
• Occurs in the upper lobes.
• M. tuberculosis produces no well-
recognized exotoxins and does not contain
endotoxin in its cell wall.
• However, M. tuberculosis produces two
proteins that appear to play a role in
pathogenesis.
• tuberculosis necrotizing toxin (TNT)
• early secreted antigen-6 (ESAT-6), a protein
that reduces the innate immunity.
• There are two types of lesions:
• Exudative lesions, which consist of an
acute inflammatory response and occur
chiefly in the lungs at the initial site of
infection.
• Granulomatous lesions, which consist of a
Central area of giant cells (Langhans’
giant cells) containing bacilli surrounded
by a zone of epithelioid cells.
• A tubercle is a granuloma surrounded
by fibrous tissue that has undergone
Central caseation necrosis.
• Tubercles heal by fibrosis and
calcification.
Immunity
• After recovery from the primary
infection, resistance to the organism is
mediated by cellular immunity (CD4-
positive T cells and macrophages).
• Circulating antibodies also form, but
they play no role in resistance and are
not used for diagnostic purposes.
• Patients deficient in cellular immunity
are at high risk!!
PPD
• Prior infection can be detected by a positive
tuberculin skin test result, which is due to a
delayed hypersensitivity reaction.
• PPD is used as the antigen in the tuberculin
skin test.
• The skin test is evaluated by measuring the
diameter of the induration surrounding the
skin test site
• !!!! induration (thickening), not simply
erythema (reddening), must be observed.
• Induration of;
• 15 mm or more is positive; no risk factors
• 10 mm or more is positive; with high-risk factors, such as a homeless person,
an intravenous drug user, or a nursing home resident.
• 5 mm or more is positive in a person who has deficient cell-mediated
immunity (AIDS patients) or has been in close contact with a person with
active tuberculosis.
Clinical Findings
• Constitutional symptoms; fever, fatigue, night
sweats, and weight loss
• In pulmonary tuberculosis; cough and
hemoptysis.
• The chest X-ray findings in reactivation
tuberculosis of the lung include an infiltrate in
the upper lobe with or without a cavity.
• Scrofula is mycobacterial cervical lymphadenitis
that presents as swollen, nontender lymph
nodes, usually unilaterally.
• Lymphadenitis; the most common
extrapulmonary manifestation of tuberculosis.
• Erythema nodosum; tender nodules along the extensor
surfaces of the tibia and ulna, a manifestation of
primary infection seen in patients who are controlling
the infection with a potent cell-mediated response
• Miliary tuberculosis; multiple disseminated lesions.
• Tuberculous meningitis and tuberculous osteomyelitis,
especially vertebral osteomyelitis (Pott’s disease), are
important disseminated forms.
• Gastrointestinal tuberculosis; abdominal pain and
diarrhea accompanied by more generalized symptoms
of fever and weight loss (also caused by M. bovis).
• Oropharyngeal tuberculosis typically presents as a
painless ulcer accompanied by local adenopathy.
Laboratory Diagnosis
• Acid-fast staining of sputum or other specimens
• Either the Kinyoun version of the acid-fast stain or the older Ziehl-Neelsen
version can be used.
• The acid-fast stain has low sensitivity
• For rapid screening purposes, auramine stain, which can be visualized by
fluorescence microscopy, is used.
• Culture;
• After digestion of the specimen by treatment with NaOH and
concentration by centrifugation, the material is cultured on special
media, such as Löwenstein-Jensen agar or Middlebrook agar; up to 8
weeks.
• Nucleic acid amplification tests (NAATs) can be used to detect the
presence of M. tuberculosis directly in clinical specimens such as
sputum.
• Because drug resistance, susceptibility
tests should be performed.
• Since the organism grows very slowly,
and susceptibility tests usually take
several weeks, molecular tests are
available that detect mutations and
resistance can be used.
• A urine test for active tuberculosis,
detects the lipoarabinomannan antigen;
does not provide drug susceptibility, so
additional testing is required.
• Interferon-y release assay
(IGRA) ;blood cells from the
patient are exposed to antigens
from M. tuberculosis, and the
amount of interferon-y released
from the cells is measured.
Prevention
• The incidence of tuberculosis began to decrease markedly even before the advent of drug
therapy in the 1940s.
• At present, prevention of the spread of the organism depends largely on the prompt
Identification and adequate treatment of patients who are coughing up the organism.
• The use of masks and other respiratory isolation procedures to prevent spread to medical
personnel is also important.
• The use of the PPD skin test or IGRA tests to detect recent converters and to institute
treatment for latent infections.
• Groups that should be screened with the PPD skin test or IGRA tests include people with
HIV infection, close contacts of patients with active tuberculosis, low-income
populations, alcoholics and intravenous drug users, prison inmates, and foreign-born
individuals from countries with a high incidence of tuberculosis
• BCG vaccine
ATYPICAL MYCOBACTERIA
• Widespread in the environment.
• The atypical mycobacteria are sometimes called mycobacteria other
than tuberculosis (MOTT) or NTM. Infections caused by these
organisms are often called NTM infections.
• Classified into four groups according to their rate of growth and
whether they produce pigment under certain conditions
• Group I (Photochromogens);
• M. kansasii causes lung disease
clinically resembling tuberculosis.
• It is susceptible to the Standard
antituberculosis drugs.
• Mycobacterium marinum causes
“swimming pool granuloma,” also
known as “fish tank granuloma.”
• Group II (Scotochromogens)
• M. scrofulaceum causes scrofula, a
granulomatous cervical adenitis,
usually in children. (M.
tuberculosis also causes scrofula.)
• Enters through the oropharynx and
infects the draining lymph nodes.
• Can often be cured by surgical
excision of the affected lymph
nodes.
• Group III (Nonchromogens)
• Mycobacterium avium-intracellulare complex (MAI, MAC); composed of two
species, M. avium and M. intracellulare, that are very difficult to distinguish
from each other by Standard laboratory tests.
• Cause pulmonary disease clinically indistinguishable from tuberculosis,
primarily in immunocompromised patients such as those with AIDS who have
CD4 celi counts of less than 200/pL.
• Group IV (Rapidly Growing Mycobacteria)
• Mycobacterium fortuitum-chelonae complex; composed of two similar
species, M. fortuitum and M. chelonae.
• Saprophytes, found chiefly in soil and water, and rarely cause human disease.
• Infections occur in two populations: immunocompromised patients and
individuals with prosthetic hip joints and indwelling catheters.
• Mycobacterium abscessus; another rapidly growing mycobacteria acquired
from the environment, causes chronic lung infections, especially in cystic
fibrosis patients
• Mycobacterium smegmatis; not associated with human disease, part of the
normal flora of smegma, the material that collects under the foreskin of the
penis.
MYCOBACTERIUM LEPRAE
• Causes leprosy (Hansens disease).
• Has not been grown in the laboratory, either on artifıcial media or in
cell culture.
• The optimal temperature for growth (30°C) is lower than body
temperature; therefore, M. leprae grows preferentially in the skin and
superficial nerves.
• Grows very slowly, with a doubling time of 14 days.
• Acquired by prolonged contact with patients with lepromatous
leprosy, who discharge M. leprae in large numbers in nasal secretions
and from skin lesions.
Clinical Findings
• The incubation period averages several years
• In tuberculoid leprosy, hypopigmented macular or plaque like skin
lesions, thickened superficial nerves, and significant anesthesia of the
skin lesions occur
• In lepromatous leprosy, multiple nodular skin lesions occur, resulting
in the typical leonine (lionlike) facies
Laboratory Diagnosis
• In lepromatous leprosy, the bacilli are easily demonstrated by
performing an acid-fast stain of skin lesions or nasal scrapings.
Lipid-laden macrophages called “foam cells” containing many
acid-fast bacilli are seen in the skin.
• In the tuberculoid form, very few organisms are seen, and the
appearance of typical granulomas is sufficient for diagnosis.
• Cultures are negative because the organism does not grow on
artificial media.
• A serologic test for IgM against phenolic glycolipid-1 is useful in
the diagnosis of lepromatous leprosy but is not useful in the
diagnosis of tuberculoid leprosy.
• The diagnosis of lepromatous leprosy can be confırmed by
using the polymerase chain reaction (PCR) test on a skin
sample.
Treatment
• Dapsone (diaminodiphenylsulfone), but because sufficient resistance
to the drug has emerged, combination therapy is now recommended.
• Prevention; Isolation of all lepromatous patients, coupled with
chemoprophylaxis with dapsone for exposed children, is required.
• There is no vaccine.