MD-2021 | Manila Central University S.Y.

2018-2019

MICROBIOLOGY
ATYPICAL BACTERIA:
CHLAMYDIA, MYCOPLASMS, LEGIONELLA
PROPERTIES of MYCOPLASMA and UREAPLASMA
Based on the lecture of Dr. Malabanan | January 24, 2019
SIZE 0.2 to 0.8 um
CELL WALL Absent
GROWTH Sterols; metabolize glucose
Four main groups of bacteria (according to sensitivity): REQUIREMENTS
1. Gram-positive
ATMOSPHERE Facultatively anaerobic
2. Gram-negative
REQUIREMENTS
3. Anaerobes
REPLICATION Binary fission
4. Atypical
GENERATION 1 to 6 hours
TIME
ATYPICAL BACTERIA
- Chlamydia ANTIBIOTICS Penicillin – R
o Intracellular pathogen (difficult to culture) SUSCEPTIBILITY Cephalosporins – R
- Mycoplasma and Ureaplasma Tetracycline - S
o Small bacteria that lack a cell wall
- Legionella Mycoplasma pneumoniae
o Gram-ve but concentrate intracellularly - PRIMARY ATYPICAL PNEUMONIA
o Common in 5 to 20 years old
***Atypical bacteria are generally found in the chest and the o MOT: nasal secretion
genitourinary system o 15 to 20% community acquired pneumonia
Pneumonia, Urethritis, PID o Maybe complicated with CNS, cardiac or
hematological problems
- ‘Walking pneumonia’ (milder symptoms)
EPIDEMIOLOGY - Tracheobronchitis – 70 to 80% infections
➢ It is thought that the 3 main atypical pathogens might - Pharyngitis
be implicated in up to 40% of CAP (community-
acquired pneumonia)
➢ The precise incidence is not known
➢ Often not identified in clinical practice due to lack of
readily available, reliable standardized tests of
confirmatory diagnosis
➢ By age 20, 50% of people in the USA have detectable
levels of antibodies to Chlamydia pneumonia

Risk Factors:
- Mycoplasma + Chlamydia spread by person to person
contact
o Spread most common in closed populations
e.g. schools, offices + military barracks

- Legionella found most commonly in the fresh water +

man-made H20 systems

Mycoplasma hominis
MYCOPLASMA and UREAPLASMA - Facultative anaerobes
- Metabolize arginine, “fried-egg appearance” in media
➢ 1st clearly proven association with human disease in
culture
1962
- Frequently isolated from urogenital tract
➢ Referred as pleuropneumonia-like organism
o Pyelonephritis
➢ Smaller gram negative pleomorphic organism capable
o Pelvic inflammatory disease
of self-replication
o Postpartum fever
➢ Bulbous enlargement at one end
o Portabortal fever
➢ >2x size of large viruses; gliding movement
TREATMENT
- Tetracycline
- Doxycycline
***Uniformly resistant to erythromycin

©icacomedian 1
 MD-2021 | Manila Central University S.Y. 2018-2019

Ureaplasma urealytica
- a.k.a. T-strain mycoplasma
- metabolized urea with production of ammonia
- 60% of apparently healthy sexually experienced
women harbor this organism in the vagina
- Has been associated with non-gonococcal urethritis

Mycoplasma genitalium
- Sexually-transmitted pathogen
- NGU in males
- Cervicitis and PID in females

DIAGNOSIS
- PCR amplification

TREATMENT
- Azithromycin NOT doxycycline

CHLAMYDIA
Antigenic Structure
➢ Obligate intracellular bacteria ➢ Lipopolysaccharide (LPS)
➢ Contains both DNA and RNA ➢ Surface protein antigens
➢ Possess prokaryotic ribosome and synthesize their ➢ 3 major group antigens:
own proteins, nucleic acid and lipids o Genus-specific antigens
➢ Lack peptidoglycan o Species-specific antigens
➢ Can undergo a unique cycle o Serotype-specific antigens

MORPHOLOGICALLY DISTINCT FORMS DIFFERENTIATION OF CHLAMYDIA SPECIES

1. Elementary body – infectious form (300 to 400 nm) Property C. trachomatis C. psittasi C.
is rigid resistant to disruption as result of disulfide pneumonia
linkages and never replicates Human human Animal (birds,
Range parrots)
2. Reticulate body- noninfectious from (800-1000nm), Human,
is the metabolically active, replicating chlamydial occasional
form, are osmotically fragile because of the paucity of Human LGV psittacosis Pharyngitis,
Disease (Lymphogranuloma Bronchitis
cross-linked membrane proteins
venereum),
trachoma inclusion
and conjunctivitis

GROWTH CYCLE Sinusitis, neonatal

pneumonitis,
Susceptible cell urethritis, cervicitis
↓ salpingitis,
proctitis,
Ingestion of bacteria
epididymitis
↓ Elementary Round, narrow Round, Pear-
Reorganization into reticulate body inside phagosome Body narrow shaped,
↓ Periplasmic space large-body
Growth by binary fission (24 hrs) Periplasmic
↓ space Periplasmic
Reorganized into elementary bodies space
↓ Inclusion Round, vacuololar Variable, Round,
Inclusion contains EBs and RBs Body dense dense
Glycogen YES NO NO
↓
inclusion
Continued reorganization body with
↓ iodine stain
Extrusion of mass of EBs by reverse endocytosis Susceptibility YES NO NO
to
sulfonamide
Plasmid YES YES NO
DNA

©icacomedian 2
 MD-2021 | Manila Central University S.Y. 2018-2019

Chlamydia trachomatis LEGIONELLA PNEUMOPHILIA

Chlamydia trachomatis (Iodine-stained inclusions in McCoy)
➢ produces mild flu-like illness to severe pneumonia
with systemic involvement
➢ PONTIAC FEVER

MORPHOLOGY
- Gram (-) rod-shaped
→ if safranin is left on extended period of time or if
carbol fuschin is used as counter stain
- (-) AFB, motile, containing pili
- Can be visualized in tissues: Dieterle’s silver
impregnation stain and Direct fluorescent AB
- Surrounded by 2 triple layer unit membrane,
separated by periplasmic space; lipid vacuoles
present

Clinical Spectrum of Chlamydia trachomatis Infections BIOCHEMICAL and CULTURAL CHARACTERISTICS

Serovars Host Infection Complication - Utilizes artificial agar medium (MH)
A, B, Ba, C Females, trachoma Blindness - Supplemented with hemoglobin and IsoVitalex in 5%
Males, C02 exceeded concentration inhibit growth
children - Slow growth (3 to 5 days) at 37 deg C
B, D-K females Cervicitis, Salpingitis, - Uses amino acid as major source of energy
urethritis, endometritis,
- Requires cysteine in artificial medium
proctitis, perihepatitis,
conjunctivitis ectopic - Hydrolyses starch, gelatin and hippurate
pregnancy, - (+) catalase, weakly (+) oxidase
infertility, - Brown pigment when grown with tyrosine
postpartum - Contains FA comp. – to protect organism in
endometritis thermophilic environment
B, D-K males Urethritis, Epididymitis, - With ubiquinones and Lipid A in LPS
postgonococal Reiter’s syndrome
urethritis, RESISTANCE
proctitis,
conjunctivitis
- May survive 139 days at room temperature in DW and
B, D-K infants Conjunctivitis, 1 year in tap water
pneumonia, - Can survive in aerosols
asymptomatic - Killed at 60 deg C or disinfectants (chlorinated
pharyngeal and phenolic ether)
gastric infections
CLINICAL INFECTION
1. Legionaire’s Disease – widespread and worldwride
LYMPHOGRANULOMA VENEREUM (LGV) 2. Risk factors: smoker, alcoholic, immunosuppressed or
- Also known as climatic bubo or tropical bubo with pulmonary disease
- Serotypes L1,L2, L3 3. Pneumonia – history of exposure to air
- Should NOT be confused with Granuloma Inguinale conditioner/water aerosols
caused by Calymmatobacterium granulomatis
(Donovan bodies) A. Pontiac Fever – 1968
- FREI Test – intradermal skin test Epidemic Pontiac, Michigan
o Abrupt onset of fever, chills, headache,
myalgia
Chlamydia pneumoniae o Cough in 50 to 60% of patients
- First isolated in Taiwan in patients with respiratory
infections – associated with “TWAR” (TaiWan Acute B. Legionaire’s Disease or Pneumonia
Respiratory Agent) o Varies from mild pneumonia to Acute
- Transmitted from man to man Respiratory Distress Syndrome
- More in young adults o Inc. period of 2 to 10 days
o High fever, non-productive cough, chills and
TREATMENT delirium 1/3 cases
- Erythromycin or Tetracycline o Diarrhea 30%
o After 3 to 4 days cough becomes productive
with non-purulent sputum
o Empyema, pneumothorax, and respiratory
failure

©icacomedian 3
 MD-2021 | Manila Central University S.Y. 2018-2019

o Hyponatremia in ½ of cases FEATURES of BACTERIAL, VIRAL and ATYPICAL

o Mortality rate 10 to 20% PNEUMONIA
Features Bacteria Viral Mycoplasma
PATHOGENESIS Age Any Any Any
Organism Season cold cold All year
- Intracellular (facultative) thru phagocytic by neutrophil Onset Abrupt Variable Insidious
and macrophage (cellular immunity) Fever High Variable Low-grade
- Multiplication → cell death → lysis → release of Tachypnea Common Common Uncommon
Cough Productive Non-prod Non-prod
cellular enzymes and factors → damage to lung tissue
Associated Coryza; Coryza Myringitis;
Symptoms Abdominal Pharyngitis
LABORATORY DIAGNOSIS Pain
- Direct demonstration of organism in tissues – dieterle PE crackles variable Wheezing;
- AB detection crackles
o ELISA 4x increase 1:128 titer = recent Leukocytosis common Variable Uncommon
infection noted 6 to 8 weeks XRAY Consolidation Diffuse Variable
- Cultural/isolation Pleural Common Rare 10 to 20%
o Buffered CYE media (70%) Effusion

TREATMENT
- Erythromycin and Azithromycin
- Doc: Levofloxacin
- Cephlalosporin and PCN = not effective
o Presence of Beta-lactamase

CONTROL
- Elimination of organism -END-
o Hyperchlorination
o Disinfectants
- High heating of water

DIAGNOSIS
Case:
A 38 yr old patient with M. pneumonia. CXR shows a vague, ill-
defined opacity in the left lower lobe.

➢ CXR findings are usually non-specific and difficult to

distinguish from other pneumonias
➢ Chest signs on examination minimal
➢ Rx of suspected atypical pneumonias should be
empirical
➢ Cultures + serologic tests are not routinely available in
laboratories

MANAGEMENT
- Severe cases should be admitted
- Atypical pneumonias usually Rx as for other CAP, at
least initially
- No evidence that routinely giving antibiotics active
against atypical organisms leads to better outcomes
in non-severe CAP
- Macrolides, such as Erythromycin, Clarithromycin +
Azithromycin have been shown to be effective in the
Rx of all 3 organisms
- Erythromycin tends to be less well-tolerated + only
few trails demonstrates its efficacy in the Rx of
Legionella
- Severe Legionella infections may require rifampicin +
a macrolide
- Tetracycline, doxycycline + fluoroquinolones are also
effective
- Recommended duration of therapy: ___________

©icacomedian 4