content BACTERIAL INFECTION „ Pyogenic gram positive cocci „ Bacterial infection of childhood „ Sexually transmitted bacterial disease „ Enteropathogenic bacteria „ Clostridial infection „ Bacterial infection with animal reservoirs or insect vectors „ Bacterial infection with immunocompromised host „ Filamentous bacteria „ Mycobacterial infection Ratirath Samol, MD. „ Clamydia infection „ Mycoplasma infection RATIRATH SAMOL, MD „ Rickettsia infection

Pyogenic gram positive cocci

Pyogenic gram positive „ Staphylococcal infection cocci - coagulase positive (S. aureus) - coagulase negative (S. epidermidis, S. saprophyticus ) „ Streptococcal infection - S. pyogenes (group A) - S. agalactiae (group B) - S. pneumoniae -S. mutans

Staphylococcus spp. Streptococcus spp.

1 Staphylococcus aureus

„ Furuncles - infection in and around hair follicles - common in scalp, face, axillary „ Carbuncles - infection around hair follicle and produce draining sinuses „ Hydradenitis suppurativa furuncles - infection in sweat gland

carbuncles

Staphylococcus aureus Staphylococcus aureus

„ Osteomyelitis „ Food poisoning - infection in bone - diarrhea, nausea, vomiting „ Toxic shock syndrome (TSS) - symptom present < 6 hours after - infection in surgical wound, tampons produce high fever, nausea, vomiting and contaminated food shock

Staphylococcus aureus SSSS

„ Staphylocoocal scalded skin syndrome (SSSS) - severe skin infection - organism produce exfoliatin that destroys granulosa of epidermis Æ bullae, rupture, skin scald - other organs : lung, heart valve, bone

2 Staphylococcus epidermidis Staphylococcus saprophyticus

„ causes opportunistic infections in „ common cause of urinary tract infections in catheterized patients, patients with young women. prosthetic cardiac valves, and drug addicts.

Streptococcal infection α-hemolytic streptococci

„ 3 types „ S. pneumoniae is a common cause of - α hemolytic streptococci community-acquired pneumonia and eg. S. pneumoniae, S. viridans, S. mutans meningitis in adults - β hemolytic streptococci „ S. viridans are part of the normal oral flora eg. S. pyogenes (group A), S. agalactiae (group B) but are also a common cause of endocarditis - γ hemolytic streptococci (non-hemolytic) „ S. mutans is the major cause of dental caries eg. S. faecalis (group D)

β-hemolytic streptococci Pharyngitis

„ S. pyogenes (group A) „ Infection in throat (tonsillitis) - pharyngitis „ Clinical: high grade fever, sorethroat - scarlet fever „ Complication : - erysipelas - glomerulonephritis, rheumatic fever - impetigo - cross reaction of immune system to M - cellulitis protein of bacteria

3 Scarlet fever

„ Common in childhood „ Erythematous rash at trunk, extremities and face except around the mouth (circumoral pallor), strawberry tongue „ Cause by erythrogenic toxin

Scarlet fever Erysipelas

„ Erythematous rash, rapid distribution at face, particullary both cheeck „ Rash at trunk, extrimities (uncommon)

strawberry tongue

circumoral pallor

Erysipelas Impetigo

„ Infection in epidermis „ Erythrematous papule Æ pustule „ May be caused by S. pyogenes or S. aureus

4 Cellulitis Cellulitis

„ Infection in deep dermis „ S. pyogenes invade through wound „ Pustule in deep dermis „ Clinical : fever, erythrematous skin lesion

β-hemolytic streptococci Bacterial infection of „ S. agalactiae (group B) - meningitis childhood - chorioamnionitis - septicemia

Diphtheria Bacterial infection of childhood

„ Diphtheria „ Caused by Corynebacterium diphtheriae (gram positive bacilli) „ Pertussis (Whooping cough) „ Transmitted as respiration „ Haemophilus influenzae infection „ Immunization with diphtheria toxoid (formalin-fixed „ Neisseria meningitidis infection toxin) does not prevent colonization with C. diphtheriae but protects immunized people from the lethal effects of the toxin.

5 Diphtheria Pertussis

„ Tracheal colonization may lead to - Mucosal erosion, exudate „ Bordetella pertussis infection(gram negative coccobacilli ) (pseudomembrane) → obstruct airway „ Toxin-mediated damage to the heart, nerves, „ Common in childhood (<5 yrs) liver, or kidneys „ Causes as laryngotracheobronchitis, ciliated respiratory epithelium necrosis „ Clinical: severe cough (whooping)

Haemophilus influenzae infection Neisseria meningitidis infection

„ gram negative coccobacilli „ Gram negative diplococci „ 6 serotype (a-f), type b causes as severe „ Caused by disease - meningitis (fever, stiff neck, headache, „ Caused by shock and dead) - pneumonia - vasculitis (petechiae and purpura at skin - meningitis and internal organs) - upper respiratory infection (otitis media, sinusitis, epiglottitis)

Meningitis Bacterial meningitis เชื้อที่เปนสาเหตุ

„ Streptococcus pneumoniae 50% „ Neisseria meningitidis 25% „ Group B streptococci 15% „ Listeria monocytogenes 10% „ Haemophilus influenzae (type b) <10%

From Harrison ed. 16th N. meningitidis

6 Sexually transmitted bacterial disease

Sexually transmitted „ Gonorrhea bacterial disease „ Chancroid (soft chancre) „ Granuloma inguinale „ Syphilis

Gonorrhea Gonorrhea

„ Nesseria gonorrhoeae (gram negative diplococci) „ Caused by - male: urethritis, epididymitis - female: endometritis, salpingitis, PID

- neonatal infection: conjunctivitis, Nesseria gonorrhoeae blindness

Chancroid (soft chancre) Chancroid (soft chancre)

„ Haemophilus ducreyi (gram negative bacilli) „ Clinical feature: - Painful multiple genital ulcer and dirty based ulcer - 50% inguinal lymphadenitis

7 Granuloma inguinale Syphilis

„ Treponema pallidum (spirochete) „ Calymmatobacterium granulomatis (gram negative „ 3 stages coccobacilli) - primary syphilis „ Clinical feature: - raised, soft red papule and ulcer at - secondary syphilis genital area Æ chronic inflammation Æ scar - tertiary syphilis

Syphilis Primary syphilis

„ Primary syphilis - chancre : painless, a clean based ulcer and regression 3-6 weeks - inguinal lymphadenopathy - microscopic: chronic inflammation and organisms

Syphilis Syphilis

„ Secondary syphilis „ Secondary syphilis - condyloma lata (exudative plaques in - systemic dissemination to many organs eg. perineum, vulva, scrotum) skin, LN, meninges, liver, mucous membrane - white mucous patch (rash at mucous - common presentation: rash at trunk, extremities, palm, sole appears from 2 wks to membrane at mouth, genital organs) 6 months after chancre heals - fever, anorexia, alopecia - microscopic: chronic inflammation, many organisms

8 Secondary syphilis Syphilis

„ Tertiary syphilis - 1/3 of untreated patient develop tertiary syphilis (no organisms) - syphilitic aortitis (80%) Æ aortic regurgitation, aneurysm - neurosyphilis Æ paralysis, seizure - gumma : granulomatous inflammation in any organs eg. skin, bone, liver

Tertiary syphilis Congenital syphilis

„ Intrauterine infection of fetus „ Common in primary and secondary syphilis (many organisms) of pregnant women „ Organisms transferred to fetus by placenta „ Causes late abortion, stillbirth, or death soon after delivery „ 2 stages - early syphilis

syphilitic aortitis with aneurysm - late syphilis

Congenital syphilis Congenital syphilis

„ early syphilis (< 2 yrs) „ late syphilis (> 2 yrs) - extensive cutaneous rash containing many - Hutchinson triad spirochetes eighth nerve deafness - Osteochondritis with collapse of the bridge interstitial keratitis (blindness) of the nose (saddle nose) notched central incisors (hutchinson teeth) - Periostitis with bowing of the tibia

9 notched central incisors Laboratory diagnosis

„ Nontreponemal antibody test - detect Ab againt cardiolipin in blood - RPR, VDRL - screening test, follow up - false positive : SLE, acute infection, leprosy -cureÆ negative result

Laboratory diagnosis

„ Antitreponemal antibody test - detect Ab againt T. pallidum Enteropathogenic bacteria - FTA-Abs, MHATP - positive after infection 4-6 wks and continuous positive until cure

Enteropathogenic bacteria Salmonella infection and typhoid fever

„ Salmonella infection and typhoid fever „ Gram negative bacilli „ Shigella infection „ Salmonella typhi „ Campylobacter infection - caused by typhoid fever „ Cholera - contaminated food and water „ Helicobacter pylori - organisms contaminates in feces of „ Escherichia coli carrier

10 Salmonella infection and typhoid fever Typhoid fever

„ Salmonella typhi (typhoid fever) - septicemia, fever,abdominal pain - bacterial replication in macrophages of Peyer patches of terminal ileum Æ nodule - ulcer along the intestine Æmucous bloody diarrheaÆ shock

Shigella infection Campylobacter infection

„ Gram negative bacilli „ Comma shaped, flagellated gram negative „ S. boydii, S. flexneri, S.dysenteriae „ Common pathogen: C. jejuni „ Infection small and large intestine „ Transmitted by contaminated food „ „ Transmitted by fecal-oral route Inflammation of jejunum continues to anus „ s/s: diarrhea, fever „ s/s: dysentery (cramping, tenemus, mucous bloody diarrhea) „ Microscopic: ulcer, neutrophils „ Microscopic: ulcer of intestine covered by neutrophils, enlarged mucosal lymphoid follicles

Cholera Mechanism of cholera

„ Vibrio cholerae (comma shaped, flagellated gram negative) „ Many serotypes (01 serotype=pathogen) „ s/s: massive rice-watery diarrhea „ Gross: non-specific „ Micro: scant neutrophils

11 Escherichia coli Escherichia coli

„ Gram negative bacilli „ Bacteria produce toxins Æ damage enterocytes and „ Flora in lower intestines (colon) vascular endothelial cells „ assists with waste processing, vitamin K „ Clinical features: production, and food absorption - abdominal pain and diarrhea „ cause several intestinal and extra-intestinal infections eg. urinary tract infections (UTI), meningitis, pneumonia

Helicobacter pylori Helicobacter pylori

„ Curvilinear gram negative bacilli „ Caused by chronic gastritis, peptic ulcer „ Clinical features: epigastric pain, nausea, vomiting „ Associated with gastric carcinoma and lymphoma

Clostridial infection

Clostridial infection „ Clostridium perfringens „ Clostridium tetani „ Clostridium botulinum „ Clostridium difficile

12 Clostridium perfringens Clostridium perfringens

„ Food poisoning „ Gas gangrene (myonecrosis) „ Necrotizing enteritis - organisms invade through ulcer - enterotoxin of C. perfringens (type C) - toxin destroy RBC, platelet, muscle induces necrosis and hemorrhage of small (myonecrosis with gas forming) intestine - s/s : abdominal pain, n/s, bloody diarrhea, dead (24 hrs)

Clostridium tetani Mechanism of C. tetani

Organisms produces neurotoxin (tetanospasmin) „ Caused by tetanus Toxin travel along peripheral nerve to „ Organisms invades to the wound anterior horn cells of spinal cord „ Tetanus neonatorum : contaminated instruments Inhibit neurotransmitter from inhibitory neuron Continuous muscle contraction

Trismus or lockjaw, risus sardonicus , opisthotonos, dysphagia, dyspnea

Clostridium botulinum Clostridium difficile

„ grows in inadequately sterilized canned foods „ overgrows other intestinal flora in antibiotic- and releases a potent neurotoxin (botulinum) treated patients, releases toxins, and causes that blocks synaptic release of acetylcholine pseudomembranous colitis and causes a severe paralysis of respiratory and skeletal muscles

13 pseudomembranous colitis Bacterial infection with animal reservoirs or insect vectors

Bacterial infection with animal reservoirs or Plague insect vectors

„ Caused by Yersinia pestis (gram negative „ Plague intracellular bacilli) „ Anthrax „ Resurvior: fleas „ Leptospirosis „ Infected by fleas bite „ Cat-scratch disease „ 3 syndrome - bubonic plague - septicemic plague - pneumonic plague

Plague Anthrax

„ Bubonic plague - enlarged LN with hemorrhagic necrosis Æ „ Bacillus anthracis (gram positive bacilli) involved skin Æ shock „ Reservoirs: goat, sheep, cattle, dog, pig „ Septicemic plague „ Spores form in soil, dead animals - septicemiaÆ DIC, no enlarged LN Ædead „ 3 group „ Pneumonic plague - cutaneous anthrax - respiratory droplet transmission Æ - inhalational anthrax pneumonia with hemorrhagic necrosis and pleuritis Æ dead - gastrointestinal anthrax

14 Anthrax Leptospirosis

„ cutaneous anthrax (95%) - spores invade woundÆ painless papule and „ Leptospira interrogans (spirochete) vesicle Æulcer, regional enlarged LNÆ cure „ Reservoir: rodent, cattle, cat, dog „ inhalational anthrax „ Bacteria secrete in animal urination and - inhaled spores Æ hemorrhagic contamination in environment mediastinitis Æ sudden dead „ Transmitted by abrasion wound „ gastrointestinal anthrax (rare) - eating spores contaminated meat ÆGI symptomÆhigh mortality rate

Leptospirosis Leptospirosis

„ Composed of 2 symptom 2. Severe leptospirosis (Weil syndrome) 1.Anicteric leptospirosis - severe jaundice, hepatosplenomegaly - leptospiremic phase: fever, headache, - acute renal failure (dead) myalgia, hepatosplenomegaly - bleeding in GI, skin, brain - leptospiruric phase: aseptic meninigitis

Cat-scratch disease Bacterial infection with „ Bartonella henselae (gram negative bacilli) immunocompromised „ Transmitted by scratch or bite of cat host „ s/s : red papule or pustule skin, enlarged LN (axilla, neck) „ Microscopic: granulomatous inflammation and abscess

15 Bacterial infection with Pseudomonas infection immunocompromised host „ Pseudomonas aeruginosa (gram negative „ Pseudomonas infection bacilli) „ Legionnaires infection „ Nosocomial infection „ Common in severe burn, cystic fibrosis, leukopenia

Pseudomonas aeruginosa Legionnaires infection

„ Legionella pneumophila (gram negative „ Necrotizing pneumonia bacilli) „ Keratitis (contact lens) „ Reservoir: water source, air condition „ Vulvular disease (IVDU) „ 2 symptom „ Otitis externa (swimming) - pontiac fever (URI, fever Æ cure) „ Ecthyma gangrenosum (severe burn) - legionnaires disease (severe pneumonia)

Legionnaires infection

„ legionnaires disease (severe pneumonia) Filamentous bacteria - scattered lung lesions, particularly bronchiole and alveoli - microscopic : mixed inflammatory cells, vasculitis, thrombosis

16 Order Actinomycetales Filamentous bacteria (Actinomycetes)

„ Aerobic actinomycetes „ Actinomycosis - cell wall with mycolic acid „ Nocardiosis Nocardia, Mycobacterium, Corynebacterium - cell wall without mycolic acid „ Mycetoma (actinomycotic mycetoma) Actinomadura, Streptomyces „ Anaerobic actinomycetes - cell wall without mycolic acid Actinomyces, Propionibacterium, Lactobacillus

* เชื้อที่ cell wall มี mycolic acid จะยอมติด AFB และ modified AFB

Actinomycosis

„ Actinomycosis เกิดจากเชื้อ - Actinomyces spp. „ Actinomyces israelii „ Nocardiosis เกดจากเชิ ื้อ „ Flora in oral, pharynx, GI, vagina - Nocardia spp. „ Caused by lump jaw, osteomyelitis, intra- „ Actinomycotic mycetoma เกิดจากเชื้อ abdominal infection, pelvic inflammatory disease (IUD) - Actinomadura, Streptomyces, Nocardia spp. - organism pass the wound

Actinomycosis Actinomycosis

„ Gross: sulfur granules (grains) „ Microscopic: organisms surrounded by neutrophils, histiocytes, giant cells „ Special stains (GMS): filamentous shaped bacteria

sulfur granules

17 Actinomycosis Nocardiosis

„ Oppotunistic infection in immunocompromised host „ Nocardia asteroides - lobar pneumonia or abscess - organisms found in soil - transmitted by inhaled organisms - s/s : fever, cough, dyspnea

Cluster of filamentous bacteria Filamentous bacteria by GMS

Nocardiosis Nocardia spp. (Modified AFB stain)

„ Microscopic : neutrophil, macrophage, necrosis, organisms and may be giant cells „ Special stains : modified acid fast stain (red filament or branching)

Mycetoma Actinomycotic mycetoma

„ Actinomycotic mycetoma : caused by „ Localized multiple nodules with sinuses and - Actinomadura spp. swelling lesions - Streptomyces spp. „ Involving cutaneous and subcutaneous - Nocardia spp. tissues, fascia and bone „ Eumycotic mycetoma : caused by „ Occurs on foot or hand - fungi e.g. Pseudallescheria spp., „ Results from traumatic implantation of soil Madurella spp. organisms into the tissues

18 Actinomycotic mycetoma Actinomycotic mycetoma

„ Lesions are composed of suppurating abscesses and sulfur granules (grains) „ Microscopic : organisms surrounded by neutrophils, histiocytes, giant cells „ Special stains (GMS): filamentous shaped bacteria

Actinomycotic mycetoma

Mycobacterial infection

Cluster of filamentous bacteria Filamentous bacteria by GMS

Mycobacterium spp. Pulmonary tuberculosis

„ Mycobacterium tuberculosis complex „ Caused by M. tuberculosis - M. tuberculosis, M. bovis, M. africanum, M. microti „ Classified 2 types - causes pulmonary and extrapulmonary - Primary pulmonary tuberculosis tuberculosis „ Nontuberculous mycobacteria (NTM) - Secondary pulmonary tuberculosis - Mycobacterium avium complex (MAC) (M. avium, M. intracellare) „ Mycobacterium causes leprosy - M. leprae

19 Primary pulmonary tuberculosis Primary pulmonary tuberculosis

„ Primary infection at lungs composed of “Ghon complex” - Lung infection Æ Ghon focus - Infection of hila node „ Most of infected personsÆ healed scar „ Clinical : non specific

Secondary pulmonary tuberculosis Secondary pulmonary tuberculosis

„ Clinical course „ reactivation or reinfection of primary TB - chronic cough, low grade fever, weigh loss, with asymptomatic anorexia „ Common infection at high O2 (apex of - recovery if normal immune or treatment lung) - lymphatic or hematogenous spread to „ Severe lung damage and produces cavity other organs eg, liver, spleen, pancreas Æ miliary TB

Secondary pulmonary tuberculosis Miliary TB

20 Caseous granulomas Pulmonary TB

AFB stain

Extrapulmonary tuberculosis

„ TB at any organs eg. LN, GI, skin, meninges, bone, liver spleen etc. „ Transmitted by TB lung spreading or direct invasion to any organs „ Gross and microscopic similar to TB lung

Diagnostic test for TB Nontuberculous mycobacteria

„ Special stains „ Common in immunocompromised host eg. - AFB : reddish bacilli AIDS, leukemia - Gram stain : indistinct gram positive bacilli „ Organisms contain in soil and water „ Culture „ M. avium complex (MAC) „ PCR „ Infection in any organs eg. lung, GI, bone „ s/s : depend on location

21 Nontuberculous mycobacteria MAC

„ Gross: non-specific „ Microscopic: clusters of macrophages contain many organisms (AFB stain)

AFB stain

Leprosy Tuberculoid leprosy

„ Mycobacterium leprae „ Asymmetry erythematous plaque with sharp „ Transmitted by respiration outer margins fading centrally to a flattened clear zone of healing that is rough, anhidrotic, „ Causes skin lesion hairless, hypopigmented, and anesthetic - tuberculoid leprosy „ Muscle atrophy, ulcer, contracture - lepromatous leprosy „ Slow progressive „ Micro: granulomatous inflammation, rare organisms

Tuberculoid leprosy Lepromatous leprosy

„ More severe „ The early lesions of lepromatous leprosy are multiple, symmetrically distributed, erythematous ill-defined macules and papules „ Muscle atrophy „ Micro: clusters of macrophages containing organisms (AFB stain)

22 Lepromatous leprosy Chlamydia infection

Chlamydia infection Chlamydia trachomatis

„ Chlamydia trachomatis „ trachoma „ Chlamydia psittaci „ acute inclusion conjunctivitis „ Chlamydia pneumoniae „ urogenital infection „ lymphogranuloma venereum

Chlamydia psittaci Chlamydia pneumoniae

„ Caused by animal disease „ Transmitted by respiration „ Human infected by respiration of secretion of „ Caused by atypical pneumonia affected animal „ Micro : lymphocytes infiltration in „ Clinical features: upper respiratory tract interstitium infection, atypical pneumonia

23 M. pneumoniae

„ No cell wall Æ no Gram staining Mycoplasma infection „ Transmitted by respiration „ Common in child, young adult „ Caused by - pharyngitis - sinusitis - laryngotrachebronchitis - atypical pneumonia

Rickettsia infection Rickettsia infection „ Animal resurviors: tick, mite, flea, louse „ 3 groups: - spotted fever group - typhus group - scrub typhus group

spotted fever group typhus group

„ Rocky Mountain spotted fever „ Epidermic typhusBrill-Zinsser disease - R. rickettsii - R. prowazekii - Tick bite - Louse feces „ Rickettsiapox „ Murine typhus - R. akari - R. typhi - Mite bite - Rat flea feces

24 scrub typhus group Rickettsia infection

„ Pathology „ Scrub typhus - destroy arteriole and capillary - Orientia tsutsugamushi - necrotizing vasculitis - Chigger bite „ spotted fever and scrub typhus groups : eschar „ typhus group: no eschar

eschar THE END

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