October 06, 2012 Dra.

Quiles RICKETTSIA Structurally similar to Gram (-) bacilli Utilizes enzyme for the Krebs cycle Inhibited by tetracycline Have ribosomes for growth and synthesis Originally thought to be viruses because o Small size o Stain poorly with Gram stain o Grows only in cytoplasm of Eukaryotic cell o Obligate intracellular parasite except Coxiella o Sensitive and inhibited by Tetracycline and Chlorampenicol Contains both DNA and RNA( it is considered a virus if it has a 1 nucleic acid) Have Gram (-) cell wall that contains: o Peptidoglycan containing muramic acid and diaminopimelic acid o LPS have weak endotoxin activity (absent in Ehrlichia) o Cell wall protein OmpA and OmpB elicits humoral response Used as basis for serotyping in rickettsia Reservoirs: animals and arhthropods Accidental Host: Man Genera: o Rickettsia o Coxiella o Orientia o Rochalimea o Ehrlichia Stains weakly with Gram stain but is readily stained in: o Giemsa stain o Gimenez stain o Acridine orange o Other stains Easily destroyed by heat, drying and bactericidal agents except for Q fever(cause by Coxiella burnetticapable of producing endotxin that makes them more resistant) Grow readily in yolk sac of embryonated egg Growth enhanced by addition of sulfonamides o Sulfonamides also make rickettsial infxn more severe Intracellular Location: o Typhus group cytoplasm o Spotted fever group nucleus o Rochalimea surface of eukaryotic cell o Coxiella and Ehrlichia cytoplasmic vacuole Nonmotile, non sporeforming

PATHOLOGY Multiply in the endothelial cells of small blood vessels Vasculitis in many organs Disseminated Intavascular coagulopathy Vascular occlusion Swelling and necrosis of tissue Thrombosis of the vessels

Organism

Rocky mountain spotted fever 2 ticks: Wood: Dermacentor andersoni Dog ticks: Dermacentor variabilis

Rickettsialpox

Scrub typhus

Epidemic Typhus

Trench fever

Ehrlichiosis

Murine typhus

VECTORS

Alldermanyssus sanguinis

Trombiculid Mitis

Pediculus humanus (human body louse)

Pediculus humanus

Amblyoma americanus

Xenopxylla (rat flea)

RICKETTSIAL INFECTION Fever, headache, malaise, chills, prostration, skin rash (except Q fever) and hepatosplenomegaly Classified into groups: o Typhus Epidemic Endemic Scrub o Spotted fever Rocky Mountain Ricketttsialpox o Q fever o Trench fever o Ehrlichiosis

TYPHUS GROUP Generalized rash/Maculopapular rashes with the sparing of the palms and soles Centrifugal EPIDEMIC TYPHUS (Louse borne typhus) Rickettsia prowazeki VECTOR: Louse sever systemic infection and prostration; high fever that lasts for about 2 weeks Infection is more fatal in individuals over 40 years of age Brill-Zinsser Disease PRIMARY INFECTION (Recrudescent dse) -IgG -organism will remain dormant in LN without manifestation and given the chance to activate they will produce the SYMPTOMS SECONDARY INFECTION -IgM -Antibodies appear earlier and milder than Primary infection -Less fatal than Primary infection Endemic Typhus (Murine Typhus) Rickettsia typhi VECTOR: Rat flease Similar features with epidemic typhus Milder and rarely fatal except in elderly patients specially those beyond 60 years of age Scrub typhus Orientia tsutsugamushi VECTOR: Chiggers Resembles Epidemic typhus except for the ESCHAR (blackened scab) Generalized lymphadenopathy and lymphocytosis Cardiac and cerebral involvement may be severe Also has rash but will undergo ulceration Transmitted by mites

Organism Etiology Characteristics

SPOTTED FEVER GROUP Hash appears first on the extremities (Centripetal spread) with the involvement of the palms and soles Rocky Mountain Spotted Fever Rickettsia rickettsii Rickettsial Pox Q fever Trench Fever Ehrlichiosis Sennetsu Fever Human Ehrilichiosis

Etiolog y

Rickettsia akari VECTOR: GAMASID MITE

Coxiella burnetti

Rochalime a Quintana VECTOR: LOUSE Manifest: -headache exhaustio n -pain -Sweating -cold extremitie s and fever with roseola rash Relapse may occur

Neo rickettsia sennetsu (most common) VECTOR: TICKS Neorickettsi a sennetsu (common in japan) (Sennetsu fever_ -Human monocyte ehrlichiosis E. chaffenensis (common in Arkansas) -Human monocyte ehrlichiosis E. erwingii -Human granulocyte ehrlichiosis Anaplama phagocyte philium -Human granulocyte anaplasmosi s Leukocytic rickettsia -Parasitizes leuokocytes, neutrophils, lymphocytes granulocytes -Transmitted through tick vectors

Char

Most common rickettsial infection in the US Reservoirs: Wood ticks (Dermacentor andersoni) Dog ticks (Dermacentor variabilis) Maintained in the tick population by transovarian (tick to tick thru ovaries) (late of the couse of infection): During feeding the virulent adult rickettsia will be activated in salivary glands and because of clogging ti will spit out to the bite site.

Mild disease rsembling varicella Firm red papule at the bite site ESCHAR Resembl es lesion of the chickenpo x Lesion: Vesicular (if ruptured: Ulcerate) it is covered by blackened scumb (ESCHAR) *Chicken Pox(has no ESCHAR) *It is named as Rickettsial pox because of Vesicle)

5 UNIQUE FEATURES MOT: inhalation of dust containing the organism or inhalation of aerosols Excreted in the urine, feces and milk Individuals at risk: -Food handlers -Workers at slaughter houses -Ranchers -Veterinarian Not an obligate intracellular parasite; can survive the environment without the living cell for years

Fever, cervical Lympha denopathy Increased peripheral mononucle ar cells Formation of Atypical lymphocyte s

Similar to RMSF Leucopenia and thrombocytopen ia only 20% will present with skin rash

Effective transmission requires prolonged exposure (2448 hours) Incidence highest in children and teenagers Mortality is greatest among adults beyond the age over 40y.o

Highly resistant in drying heating and bactericidal agent because of endosporelike structure that they produce Not associated with skin rash/lesion Resembles influenza and non bacterial pneumonia,

N. sennetsu may be transmitted from TREMATOD E of infected FISH Ehrlichia infects circulating leukoocyte > multiply inside phagocytic vacuole -> forms cluster with inclusion like appearance (called MORULAE)

Rash develops later in the disease and not observed in about 10% of patient Complication s: -GI symptoms -Respiratory failure -Renal failure -Encephalitis Early diagnosis and early treatment significant.

hepatitis, encephalopat hy In chronic Q fever -> infective endocarditis occasionally develops from individuals with previously damaged or deformed heart valves

DIAGNOSIS Weil Felix Test o Not specific o Not a reliable tool o Old method Serological tests o Most sensitive and specific Complement Fixation Indirect Immunoflourescence nd o RMSF (done after 2 week of fever) Skin biopsy th o RMSF (between 4-8 day of illness) PCR

TREATMENT Tetracyclin o Orally but can be given IV in severe cases Doxycyclin Extend medication 3-4 days more even if patient is at defervescence phase If allergic chloramphenicol may be given Allergy to both drugs: o Erythromycin (but not Trimethoprim sulfamethoxasol) **Sulfonamides is contraindicated to the Rickettsial infection because it will enhance the growth of organism hence making the infection more severe.

CHLAMYDIA

October 06, 2012 Dr. Lim Chlamydia and Mycoplasma

CHLAMYDIA Obligate intracellular parasite (like rickettsia) Gram (-) 2 morphologically distinct forms o Elementary body (EB) Small, extracellular, infectious, inactive, rigid o Reticulate body (RB) Larger, intracellular, active, non infectious Unique developmental cycle Produces daughter cells that undergo morphologic reorganization Attachment of EB -> penetrate host cells -> remain within phagosome -> EB reorganizes into metabolically active RB -> binary fission -> RB reorganizes into EB -> cell ruptures -> infective EBs released 3 important specie o Chlamydia trachomatis o Chlamydophila psitacci o Chlamydophila pneumonia

Organism Characteristics

Chlamydia trachomatis Host range: human Serotypes: A-C Associated with trachoma(OCULAR INFECTION) MOT: Direct Contact D-K Associated with genitourinary tract infxn L1-L3 Associated with STD(LGV) MOT: Sexual Contact Human dse: Lymphogranuloma venereum (LGV) -Chronic form of STD -Manifested as genital ulcer accompanied by suppurative inguinal adenitis ( Buboes= enlarged inguinal LN because of ruptured genitalia. Acquired infection thru sexual contact inguinal LN draining the PUS) Trachoma -Chronic form of keratoconjunctivitis -Leading cause of blindness due to infection -Endemic in certain continents (DRY EYE INFECTION)

Chlamydia trachomatis pneumonia Incidence: primarily in infants approximately 1020% of infants born to infected mothers develop pneumonia Encounter: -Infected mother -Infection acquired during birth -Entry -Conjunctiva -Nasopharyngeal -Inclusion bodies > contain glycogen (iodine stain) Susceptible to sulfonamide(only C. trachomatis) Microscopic Exam -Halberstadler prowazek bodies (HP) (intracytoplasmic) Laboratory Diagnosis -Tissue culture( living cells as Culture medium -Cytology -Inclusion bodies -Frei testhistorical purposes (nonspecific, insensitive skin test) -McCoys cell line (CULTURE MEDIUM)

Chlamydophila psitacci Host range: primarily animal, occasionally human (psitaccosis/ornithosis) Parrot fever (bird fever) Microscopic exam: Levinthal Cole Lillie bodies Lab Diagnosis: Complement fixation MOT: inhalation of aerosolized bacteria found in dried feces of bird

Chlamydophila pneumoniae Host range: human Human dse: Pharyngitis, Bronchitis, Pneumonia, Sinusitis TWAR stain = Taiwan Acute Respiratory Agent

Non gonococcal urethritis (NGU) (Gonorrhea and Trachomatis occur together) -Ocular infection -GUT infection -PNEUMONIA -Urethritis id due to NGU thru sexual contact. Inclusion Conjunctivitis -pebbled appearance -Gritty consistency of conjunctiva

MYCOPLASMA Smallest free living bacteria Only bacteria with cholesterol in membrane PPLO Pleuropneumonia Like Organism New class: mollicutes (soft skin) Fried egg colonies No cell wall, hence, can resist penicillin Facultative anaerobes except M. pneumoniae Growth requirement: sterol Replication: binary fission Dse: o Mycoplasma pneumoniae Pneumonia Tracheobronchitis (most common) Pharyngitis o Mycoplasma hominis Pyelonephritis PID Postabortal fever Postpartum fever o Ureaplasma urealyticum NGU

Organism Characteristics

Mycoplasma pneumonia

Mycoplasma hominis

Ureaplama Urealyticum

Eatons agent, P1 adhesion and ciliostasis Virulent Factor: P1 adhesion factor/ P1 Antigen -allows the bacteria to adhere to lining of Respiratory tract as it adheres, it is capable in destroying the lining resulting CILIOSTASIS(destruction of Cilia; dysfunction of Mucociliary elevator) Metabolize glucose -Primary atypical pneumonia (walking pneumonia) -School children, young adults (5-20y.o) -Tracheobronchitis, pharyngitis Laboratory Diagnosis Complement fixation Cold Agglutinin test (Serologic, detects Abs against mycoplasma) Culture in PPLO Agar

Facultative anaerobe -Pyelonephritis, PID -Metabolizes arginine Treatment -Tetracyclin

Previously known as T. strain mycoplasma 45-75% of healthy sexually active women affected, assoc. with NGU Metabolizes or requires urea for growth Treatment -Tetracycline

Treatment Tetracyclin Doxycyclin Eryhtromycin Azithromycin