Granulomatous infections: tuberculosis, leprosy, actinomycosis, nocardiosis

Prof. dr hab. n. med. Beata M. Sobieszczańska Wrocław Medical University Dept. of Microbiology Granulomatous inflammation Chronic inflammatory reaction – protective response to chronic infection or foreign material preventing dissemination and restricting inflammation

Tuberculous M. tuberculosis M. africanum Typical M. bovis Noncultivable M. leprae Mycobacterium Skin ulcers M. ulcerans, M. balnei Atypical (MOTT) slow growers Saprophytic M. kansasii M. phlei, M. smegmatis M. scrofulaceum M. avium-intracellulare (MAI) Rapid growers: M. fortuitum, M. chelonei General characteristics: slender curved-rods nonmotile non-spore forming obligate aerobes fastidious (enriched special culture media) slow generation time (18-24 h) obligate facultative intracellular pathogens Acid fast = retains carbolfuchsin dye when decolorized with acid-alcohol Acid fast bacteria: Mycobacterium, Nocardia High concentration of lipids in the mycobacterial cell wall is associated with: • Cell wall impermeability • Antibiotic resistance • Resistance to killing by acids & alkalis • Resistance to osmotic lysis via complement deposition • Resistance to lethal oxidation • Survival inside of macrophages • Slow growth (lipids determine hydrophobic cell surface that causes mycobacteria to clump & inhibits nutrients access) – infection is an insidious, chronic process taking several weeks or months to become apparent Microscopy – acid fast

Ziehl-Neelsen = acid fast staining

Auramine staining - more sensitive than an acid fast stain requires fluorescence microscopy Virulence factors The ability to survive within macrophages (superoxide dismutase, catalase, mycolic acids)

Cord factor (wax C) = responsible for the growth as serpentine cords / present only in M. tuberculosis toxic to mammalian cells & inhibits PMNs migration

Mycobacteria do not produce toxins !!! Infects humans & wide Mycobacterium host range of animals africanum (cattle, nonhuman Humans primates, cats, goats, Airborne transmission dogs, pigs etc.) - East & West Africa worldwide • Ingestion of Mycobacterium tuberculosis MTB contaminated milk from infected cows Humans are the only reservoir for the bacterium Mycobacterium Airborne transmission bovis Optimal conditions for transmission include: overcrowding poor public hygiene Droplet nuclei

• IFNƔ activates macrophages making them capable of destroying MBT • The cell mediated immune response (delayed hypersensitivity) control the infection Primary tuberculosis • Caseous necrotic tissue • Most patients with primary tuberculosis are asymptomatic & the granulomas resolve

Caseation – a form of necrosis characteristic of tuberculosis in which diseased tissue form a firm, dry mass like cheese in appearance Primary infection • The patient will heal & a scar will appear in the infected loci • The bacteria at this time goes into a dormant state, as long as the person's immune system remains active & functions normally there is no disease symptoms • When a person's immune system is depressed a primary progressive tuberculosis will develop Primary Tuberculosis Primary tuberculosis: – Self limiting disease – no symptoms, recovery or mycobacteria remain in a dormant state

Primary progressive TB in 5% of infected – Miliary TB & TB meningitis – Common in malnourished children – 10% of adults (immunosuppressed individuals) Milliary lesions which are small granulomas, resemble, millet spread throughout the lung fields Patients are highly contagious

Milliary tuberculosis Secondary tuberculosis

• Reactivation (endogenous in 99% of cases) or reinfection (rare) • Tubercules liquefy & MBT starts to multiply extracellulary • Walls of nearby bronchi become necrotic & rupture = cavity formation and MBTspreading

Cavitary Secondary TB

Extensive cavitation of multiple granulomas of lung are typical for secondary tuberculosis Tuberculous spodylitis- Potts disease PRIMARY & POST-PRIMARY TB • Primary overt TB (5% infected) - single lesion or milliary TB (no immunity yet – still developing) • Post-primary/secondary TB - endogenous reactivation accompanied by a single (cavitary) lesion (strong immune cellular immunity) Haematogenous spread = miliary tuberculosis = secondary lesions at almost any anatomical location; may occur in a primary or secondary tuberculosis Reactivation is associated with deterioration of the cell-mediated immune response

Tuberculosis may affect any tissue, any organ, any system Most common disseminated disease: kidneys, bones, spleen, meninges Exposure to TB

Hypersensitivity Primary infection Immunosupression age under 5 y.o. 5% 95% Primary TB Latent TB 5% 90% Reactivation No disease

Pulmonary Extra-pulmonary

Dissemination New infections Diagnosis • Tuberculin skin test with PPD (purified protein derivate) intradermal injection • Measurement of skin lesion after 48-72 hours (delayed hypersensitivity) • <5 mm induration (bump) = negative • >5 mm induration = TB infection in people who are in a high-risk group (HIV infection) • ca. 10 mm induration = TB infection in people who are in a moderate-risk group • >15 mm induration = TB infection in people who are in low-risk group

Diagnosis

Interferon gamma – release assay (IGRA) BCG (Bacilli Calmet-Gengou) vaccine contains viable, attenuated M. bovis

Does not prevent the infection/tuberculosis

The vaccine prevents dissemination of the disease in the host organism (prevents hematogenous spread of tuberculosis) Treatment

First Line: Isoniazid (INH), Rifampin (RIF), pyrazinamide (PZA), Ethambutol (EMB), Rifabutin, Rifapentine

Second Line: p-amino salicylic acid (PASA), Streptomycin, Amikacin,/Kanamycin, Capreomycin, Cycloserine, Etionamide, Levofloxacin, Moxifloxacin TB resistance

Drug-resistant TB: resistant to at least one first-line anti-TB drug Multidrug-resistant (MDR TB): resistant to more than one anti-TB drug and at least INH and RIF Extensively drug-resistant TB (XDR TB): a rare type of MDR TB resistant to INH and RIF, plus any fluoroquinolone and at least one of the second-line drugs e.g. amikacin, kanamycin, caperomycin MOTT

M. kansasii - lung disease

M. scrofulaceum – cervical lymphadenitis in children

M. avium-intracellulare (MAI) - disseminated disease in immunocompromissed

M. mariunum - cutaneous disease Buruli ulcer - M. ulcerans • Contiguous disseminated • Clinical: small or large oedematous indurated plaque that may ulcerate late

• Photographs show disseminated edematous BU that has been widely excised MOTT summary Exist saprophytically in the soil or water Infection initiate inhalation or introduction into skin abrasions Crucial difference between M. tuberculosis & 'atypical' mycobacteria: lack of transmission from patients to patients Resistant to drugs used in the treatment of tuberculosis, but sensitive to antibiotics: macrolides, tetracyclines, quinolones Antibiotic regimen may require 5 or 6 drugs Mycobacterium leprae • Leprosy (Hansen disease) • Non-cultivated (mouse sole, armadillo) • Acid-fast (Ziehl-Neelsen staining) • Aerobic; grow at 30oC • Grow intracellulary in skin histiocytes, endothelial cells, nerves - Schwann cells) • Endemic: Asia, Pacific region, Americas, North Africa, China • Transmission: direct contact, air-borne route

Actinomyces israeli • Species: A. naeslundii • GP, anaerobic • Colonize upper respiratory tract, gastrointestinal tract, female genital tract • Low virulence potential –– natural barriers disruption (trauma, surgery, infection)

Actinomyces infections: ENDOGENOUS (polymicrobic, endodontic, odontogenic) Three types of actinomycosis • Cervicofacial • Thoracic/pulmonary • Abdominal Rarely: • Cerebral Actinomycosis

Sulfur granule characteristic granules consisting of bacterial colony (dense rosettes of filamentous bacteria) Nocardia asteroides • Strict aerobes • Branched filaments • Virulence factors: mycolic acids (cord factor) = replicate inside macrophages, catalase, superoxide dismutase • Ubiquitous in soil rich with organic matter • Worldwide distributed, but most common in tropical/subtropical Transmission: • Inhalation (person-to-person) • Direct introduction into tissues Nocardia asteroides • Inhalation=pulmonary / bronchopulmonary nocardiosis (bronchitis, pneumonia, lung abscesses) • Traumatic introduction = cutaneous nocardiosis - Mycetoma (Madura foot) - Lymphocutaneous infections - Chronic ulcerative lesions - Subcutaneous abscesses - Cellulitis

Secondary infections: meningitis, brain abscesses Thank you for your attention