Margie S. Gayapa, M.D.

, DPSP

Genus Mycoplasma
Mycoplasma pneumoniae Mycoplasma hominis Ureaplasma urealyticum Mycoplasma genitalium

Mycoplasma
Smallest free-living bacteria (thus, they can pass through some filters used to remove bacteria) Smallest genome size (thus, they lack many metabolic pathways and require complex media for their isolation) Mycoplasmas are facultative anaerobes, except for M. pneumoniae, which is a strict aerobe Highly pleomorphic because they lack a rigid cell wall

Mycoplasma
Unlike bacteria: lack of cell wall Unlike viruses: contain both DNA and RNA and can replicate in cell-free media Unlike both bacteria and viruses: sterol-containing cell membranes

Mycoplasma
Characteristics (Jawetz)

Small, 125-250 nm in size Lack a rigid cell wall Resistant to penicillins, inhibited by tetracyclines or erythromycin Can reproduce in cell free media; on agar, the center of the whole colony is characteristically embedded beneath the surface Growth is inhibited by specific antibody Have an affinity to mammalian cell membranes

Mycoplasma
Morphology and Identification
Typical Organisms

Because of their small size, they cannot be studied by the usual bacteriologic methods Morphology appears different according to the method of examination

Culture
Culture requires a complex media with serum or ascitic fluid, growth factors (yeast extract) and metabolic substrate (glucose or urea), incubated for 3-10 days at 37C with 5% CO2 or a special broth

Mycoplasma
Morphology and Identification

Grow slowly by binary fission and produce "fried egg" colonies on agar plates M. pneumoniae colonies have a granular appearance Ureaplasma extremely small colonies called Tstrains (tiny strains)

Mycoplasma
Morphology and Identification
Growth characteristics

All require sterols for growth and for membrane synthesis Many utilize glucose for energy (except for Ureaplasma which require urea) The three species can be differentiated by their ability to metabolize glucose (M. pneumoniae), arginine (M. hominis) or urea (U. urealyticum) The fourth species M. genitalium is extremely difficult to culture

Mycoplasma
Antigenic Structure

Species are classified by biochemical and serologic features:

Complement fixation tests = Antigens are glycolipids Enzyme-linked immunosorbent assay (ELISA) tests = Antigens are proteins

Mycoplasma
Pathogenesis
Flask-like or filamentous shapes and specialized polar tip structures mediate adherence to host cells Adherence factors: interactive proteins, adhesins, adherenceaccessory proteins Toxic metabolic products: peroxides, superoxides

Mycoplasma
Pathogenesis (M. pneumoniae)
Adherence protein P1 Adhesin located at the tips of the bacterial cells binds to sialic acid residues on host epithelial cells
Colonization of the respiratory tract by M. pneumoniae results in the cessation of ciliary movement development of a dry cough

Association of the mycoplasma and the host cells:

- direct toxicity: toxic metabolic products of mycoplasma metabolism (hydrogen peroxide and superoxide) accumulate and damage host tissues - inhibition host cell catalase - cytolysis by Ag-Ab reaction or chemotaxis

Mycoplasma
Infection and Treatment

Extracellular pathogens to humans Host-specific Tetracyclines and erythromycin are effective

Mycoplasma
Mycoplasma Species considered as Human Pathogens
Organism M. pneumoniae
M. hominis M. genitalium U. urealyticum

Disease
Upper respiratory tract disease, tracheobronchitis, atypical pneumonia Pyelonephritis, pelvic inflammatory disease, postpartum fever Non-gonococcal urethritis Non-gonococcal urethritis

Mycoplasma pneumoniae
Causes atypical or walking pneumonia Common in ages 5-20 years old Causes majority of community-acquired pneumonia that do not require hospitalization Transmitted by means of respiratory secretions Incubation period: 1 to 3 weeks Generally, a mild disease characterized by patchy, sometimes bilateral infiltrates, prolonged cough and extra-pulmonary manifestations

Mycoplasma pneumoniae

Extrapulmonary manifestations may or may not involve respiratory symptoms and include the following:
Dermatologic manifestations e.g. erythematous macular and/or morbilliform rash, papulovesicular exanthem, erythema multiforme, Steven Johnsons Syndrome Cardiac manifestations e.g. arrhythmia and/or ECG abnormalities (conduction defects), congestive failure, pericarditis, myocarditis, endocarditis Neurologic manifestations e.g. encephalitis and meningoencephalitis, transverse myelitis, cerebral infarction Musculoskeletal manifestations e.g. polyarthralgias, acute arthritis (monoarticular or migratory) Hematologic manifestations e.g. immune hemolytic anemia, pancytopenia

Mycoplasma pneumoniae
Resolution of pulmonary infiltration and clinical improvement occur slowly over 1-4 weeks Most common pathologic findings are interstitial and peribronchial pnemonitis and necrotizing bronchiolitis

Mycoplasma pneumoniae
Laboratory Tests

Culture - gold standard but not widely available Serology

A. Complement Fixation good sensitivity and specificity, titers do not peak until 4-6 weeks after infection; detection of IgM in a titer >1:16 or a fourfold increase in IgG is suggestive of current infection B. Cold agglutinins - Approximately 34% - 68% of patients with M. pneumoniae infection develop cold agglutinins antiI. Cold agglutinins are antibodies that agglutinate human erythrocytes at 4C. These are not specific for M. pneumoniae infections, if present, a presumptive diagnosis can be made

Mycoplasma pneumoniae
Laboratory Tests

Mycoplasma pneumoniae
Laboratory Tests

C. Enzyme immunoassays (EIA) D. ELISA for IgM used for diagnosis of acute infection

Polymerase chain reaction (PCR) in reference laboratories

Mycoplasma hominis
Occasionally grows on blood agar Causes postpartum sepsis, salpingitis, tubo-ovarian abscess, wound infections

Ureaplasma urealyticum
Rapid urea hydrolysis in broth Causes nongonococcal urethritis in men, acute urethritis in women, neonatal pneumonia and chorioamnionitis

Mycoplasma genitalium
Mycoplasma species with the smallest genome Causes acute and chronic nongonococcal urethritis, cervicitis, endometritis, salpingitis and infertility in women

 L Phase Variants (L Forms)

L Phase Variants
Named after the Lister Institute in London where they were discovered, also lack cell walls Loss of cell wall maybe complete or partial (defective cell wall), the parent organism may be gram positive or negative Protoplasts usually derived from G(+) organisms, osmotically fragile, with external surfaces free of cell wall constituents Spheroplasts - usually derived from G(-) organisms, cell wall defective since they retain some outer membrane material

L Phase Variants
Like mycoplasmas, they are pleomorphic and continue to reproduce Can arise through spontaneous mutations or from treatments or effects of chemicals Some are stable, while others are unstable and revert back to bacterial parental forms Reversion is enhanced by growth in the presence of 15-30% gelatin or 2.5% agar; inhibited by inhibitors of protein synthesis

References
Brooks, GF et al. Jawetz Medical Microbiology. 25th ed. McGraw Hill-Co, 2004. Mais, D. Quick Compendium of Clinical Pathology. Second edition. American Society of Clinical Pathology Press. 2008. Jones, S. Clinical Laboratory Pearls. Lippincott Williams and Wilkins. 2001.