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Molecular pathogenesis

of infection

Andriansjah, Anis Karuniawati, T. Mirawati Sudiro

Departemen Mikrobiologi FKUI
Microbes and humans
Very few microbes are
always pathogenic

Many microbes are

potentially pathogenic

Most microbes are

never pathogenic
Kochs Postulates (1890) by Robert Koch

The microbe must be present in every case of

the disease

The microbe must be isolated from the diseased

host and grown in pure culture

The disease must be reproduced when a pure

culture is introduced into a non-diseased
susceptible host

The microbe must be recoverable from an

experimentally infected host
Exception to Kochs Postulates
The microbes could not always be grown in the

Cofactors or genetic and immunologic factors in

the host may play a vital part

Ethical considerations prevent applying Kochs

postulates to diseases and pathogens that occur
in human only

The disease do not appear until many years

after a specific infection
Guidelines for establishing the causes of infectious diseases
Koch`s postulat Moleculer Koch`s Molecular guidelines for
postulat establishing microbial
disease causation
1. The microbe must 1. The phenotype or 1. The nucleic acid sequence of
be present in every property under a putative pathogen should be
case of the disease investigation should present in most cases of an
be significantly infectious disease
associated with
pathogenic strains of a
species and not with
nonpathogenic strains
2. The microbe must 2. Specific inactivation 2. The nucleic acid sequence of a
be isolated from the of the gene or genes putative pathogen should be
diseased host and associated with the absent from most healthy
grown in pure culture suspected virulence controls. If the sequence is
trait should lead to a detected in healthy control, it
measurable decrease should be present with a lower
in pathogenicity or prevalence as compared with
virulence patient with disease, and in lower
copy number
Koch`s postulat Moleculer Koch`s Molecular guidelines for
postulat establishing microbial
disease causation
3. The disease must 3. Reversion or 3. The copy number of a
be reproduced when replacement of the pathogen-associated nucleic
a pure culture is mutated gene with acid sequence should decrease or
the wild-type gene become undetectable with
introduced into a
should lead to resolution of the disease and
restoration of should increase with relapse or
susceptible host pathogenicity or recurrence of disease
4. The microbe must - 4. The presence of a pathogen-
be recoverable from associated nucleic acid
an experimentally sequence in healthy subjects
should help predict the
infected host
subsequent development disease
5. Disease tissue should have
higher copy number than normal
6. These sequence-based findings
should be reproducible
The infectious process
Entry of agents

colonization, adhesion and


pathogenic action The iceberg concept of

infectious disease
poliomyelitis in a child- clinical disease
0.1-1% are clinicall less severe
Rubella asymptomatic 50%

Rabies: 100% aparent

Spectrum of
Microbe and host factors influencing outcome of infection

Virulence Infectious dose Correct portal

of entry

No infection

Outcome Infection, No disease

Host Infection causes disease

Genetic (non- Previous exposure General level of

specific immunity) (specific immunity Health
The infectious process

Entry of agents

colonization, adhesion and invasion

pathogenic action
Portals of Entry

Mucous membrane
Respiratory, gastrointestinal, urinary,
reproductive tracts
Conjunctiva, the thin membrane covering
the surface of the eyeball and the
underside of each eyelid


(Parenteral route)
Is not a portal entry, but instead a means
by which the portals of entry can be
To colonize a site populated by normal flora,
the new arrival must compete successfully
established organisms for space and
nutrients (siderophores)
overcome their toxic product
counter the bodys defenses aimed at
protecting the surfaces (IgA proteases)
Adhesion / Attachment
The process by which microorganisms
attach themselves to cells

Adhesion factors:
Specialized structures
Adhesion disk (protozoa), suckers, hooks
Ligands: Surface lipoprotein and
glycoprotein (bacteria, viruses)
Adhesin (bacteria): found on fimbrae,
flagella, glycocalyses
Attachment protein (viruses)
Adherence mechanism
factors support the adherence mechanism

Pili and fimbriae mediate attachment

Pili constanly lost and reform allow some bacteria

avoid host defenses

Adhesins protein, eg. nonfibrillar adhesins of

Streptococcus pyogenes mediates attachment to
fibronectin, a protein found on many host cell surface

Signal transduction signal which affect to activate or

repress the expression of some gene
Binding of adhesins to receptor on host cell may activate or
repress virulence genes of bacterial cells
Lost the ability to make ligands:
Genetic change or mutation
Exposure to certain physical or chemical agent
harmless or avirulent

Some bacterial pathogens do not attach to host

cells directly, but instead interact with each other
to form a sticky web of bacteria and
polysaccharides called a biofilm, which adheres
to a surface within a host (example: dental
Receptor molecule on Host Cells
typically glycoprotein containing sugar molecule
such as mannose and galactose

Not present for the benefit of the infectious

agents; they have specific functions in the life of
the cells

Present only in certain cells, which are then

uniquely susceptible to infection (specificity of
pathogens for particular hosts):
N.gonorrhoeae has adhesin on its fimbrae that
adhere to cells lining the urethra and vagina of human
The ability a of microorganism to cause disease

Degree of pathogenicity

Virulence factors
A variety of traits that interact with a host and enable
the pathogen to enter a host, adhere to host cells,
gain access to nutrients, and escape detection or
removal by the immune system
Virulence Factors
Extracellular Enzymes (Hyaluronidase and
collagenase, Coagulase, Kinase)
Toxin (Exotoxin, endotoxin)
Antiphagocytic factor (capsule, antiphagocytic
Invasion factor
Virulence Factors
Extracellular Enzymes
Hyaluronidase and
collagenase degrade specific
molecules to enable bacteria
to invade deeper tissue
Coagulase --- coagulate blood
protein --- form clot --
providing a hiding place for
bacteria within a clot
Kinase such as
staphylokinase and
streptokinase digest blood
Virulence Factors
Cytotoxins: kills host cells in
general or affect their function
Neurotoxins: specifically
interfere with nerve cell function
Enterotoxins: affects cell lining
the gastrointestinal tract
Lipid A, lipid portion of the
membranes lypopolysaccharide
Toxin Nomenclatur : has no systematic basis

Indicate what type of host cells they attack

Cytotoxin, neurotoxin, leukotoxin, hepatotoxin
Bacterial species that produces them
Cholera, shiga, diphtheria, tetanus toxin
The activities
Adenylate cyclase, lechitinase
Letter designations
Exotoxin A of Pseudomonas aeruginosa
Some toxins have more than one name
E.Coli O157:H7 : shiga toxin and verotoxin
Enterotoksin : term denoting protein toxin that
cause diarrhea or vomiting (i.e., enteric symptoms)
Eksotoksin Endotoksin
Dieksresi oleh sel hidup Bagian integral dinding sel
bakteri negatif Gram. Dilepaskan
pada saat bakteri mati dan
sebagian selama pertumbuhan
Diproduksi oleh bakteri postif Bakteri negatif Gram saja
dan negatif Gram
Polipeptida Lipopolisakarida (LPS)
Relatif tak stabil pada Stabil
pemanasan> 600C
Sangat antigenik Imunogenik lemah
Dapat diubah menjadi toksoid Tidak dapat
Sangat toksik Sedang
Biasanya terikat pada reseptor Tidak
Tidak menimbulkan demam Demam
Sering dikontrol oleh gen Disintesis langsung oleh gen
ekstrakromosomal (plasmid) kromosomal
Mechanism of Action

Help bacteria spread in


Lyses cells

Block protein synthesis

Elevate Cyclic AMP

Block nerve function


Normally : antigen presenting cells

(APCs) process protein antigen by
cleaving them into peptides and
displaying one of the resulting
peptides in a complex with MHC
class II on the APC surface

Only a few helper T cells will have

receptor that recognize this complex,
so only a few T cells will be

Superantigens form a bridge

between the MHC class II of
macrophages or other APCs and
receptor on T cells that interact
with the class II MHC

Many APCs will have

superantigens molecules bound
to their surface

Superantigen also bind T cell

receptor indiscriminately
forms many more APC-T
helper cell pairs than would
normally form

Normal response to antigen : APC stimulation 1

in 10,000 T cells
Superantigen : APC stimulation 1 in 5 T cells
Result : excessively high levels of IL-2 to be
released bloodstream symptoms :
nausea, vomiting, malaise, and fever
Excess production of other cytokines,
which leads to shock
E.g. staphylococcal toxin
Septic shock
The form of shock associated with
bacterial infection, e.g. :
Endotoxin (e.g. E.coli or N.meningitidis)
Toxic shock syndrome toxin (TSST1),
superantigen produced by Staphylococcus
Lipoarabinomannan in Mycobacterium sp.
Food poisoning

Disease without colonization (ability of a bacterium to remain

at a particular site and multiply)
Occurs after consumption of food containing toxins, which
may :
Chemical (e.g. heavy metals)
Bacterial in origin
The bacteria multiply and produce toxin within contaminated
The bacteria may be destroyed during food preparation, but
the toxin is unaffected, consumed, and act within hours
Toxin produced by
Clostridium botulinum, Staphylococcus aureus,
Bacillus cereus,
Clostridium perfringens (ingested in contaminated food and produces
an exotoxin while undergoing sporulation in the intestine)
Food-associated toxin

Food may simply act as vehicle for the pathogen

e.g. Campylobacter jejuni

Provide conditions in which the pathogen can

multiply to produce numbers large enough to
cause diseases
Organisms multiply and toxin produced but infection
remains localized in gastrointestinal tract (e.g. E.coli,
Vibrio cholerae)
Organisms invade or toxin absorbed, disseminated,
cause symptoms of systemic infection (e.g.
Salmonella typhi)
Virulence Factors
Antiphagocytic factors

Composed of chemicals that are normally
found in the body (including
polysaccharides) do not stimulate a
hosts immune response
Protect the bacteria from the host
inflammatory response (complement
activation and phagocyte mediated killing)
Capsules prevent formation of C3

Antiphagocytic chemicals
Prevent the fusion of lysosomes with
phagocytic vesicles, which allows the
bacteria to survive inside of phagocytes
S.pyogenes produces a protein on its cells
wall and fimbrae (M protein), that resist
phagocytosis and thus increases virulence
Virulence Factors
Invasion factors

Mechanisms that enable a bacterium to invade

eukaryotic cells facilitate entry at mucosal

Some are obligate intracellular, most are

facultative intracellular pathogens

The specific bacterial surface factors that

mediate invasion are not known in most instance
Virulence Factors

Organisms require iron for metabolism and growth

In blood : iron is bound either to Hb or transferrin

In milk or other solution (tears, saliva, etc.) iron is
bound to lactoferrin

Siderophores : substances produced by many

bacteria to capture iron from the host

The binding constants of the siderophores for iron

are so high that even iron bound to transferrin or
lactoferrin is confiscated and taken up by the
bacterial cells
Competition between host cells and bacterial pathogens for iron
Virulence Factors
Lipopolisaccharide (LPS) is site for attachment of C3b
Modification of LPS affect to the interaction of this

Evading the host antibody response

Change the surface antigens that are recognized
by the antibody so that antibody no longer bind
Hide from immune system by coating themselves
with host protein such as fibronectin
Protein A of Staphylococcus aureus bind to Fc
portion of antibodies thus coating the bacteria with
antibodies not lead opsonization of the bacteria
Pathogenesis of Viral Diseases
Maintain a reservoir
Enter a host
Contact and enter susceptible cells
Replicate within the cells
Release from the host cells
Virus-host interactions engender host immune
Be either cleared from the body of the host,
establish a persistent infection, or kill the host
Be shed back into the environment
Contact, entry, and primary replication
Entrance: one of the body surfaces; needle
sticks, blood transfusions, organ transplants,
insect vectors
Adsorption or attachment: process of
penetrates a host cells to gain access to the
cells replicative machinery
Adsorption occurs because of specific protein
Enveloped virus use spikes (viral protein that
protrude from their membrane)
Naked virus: their ligands as part of their capsid
Important principles
1. Many viral infections are subclinical
2. Same diseases variety of viruses
3. Same virus variety of diseases
4. Diseases viral morphology
5. Genetics of host & virus interaction
outcome of individual case
Determinants of Viral diseases

Nature of the disease

Target tissue
Portal of entry of virus
Access of virus to target tissue
Tissue tropism of virus
Permissiveness of cells to viral replication
Viral pathogen (strain)
Determinants of Viral diseases

Severity of disease
Cytopathic ability of virus
Immune status
Competence of immune system
Prior immunity to the virus
Virus inoculum size
Length of time before resolution of infection
General health of the person
Other diseases influencing immune status
Host genetic makeup
Tahap-tahap dalam patogenesis infeksi
1. Masuknya virus dan replikasi primer
2. Tropisma dan penyebaran virus dalam tubuh
3. Kerusakan sel/ jaringan dan manifestasi
4. Pemulihan dari infeksi dan tipe infeksi
5. Penyebaran virus ke luar tubuh/ lingkungan
Virus spread in human body
Tahap-tahap dalam patogenesis infeksi
1. Masuknya virus dan replikasi primer
- Jalan masuk
- replikasi primer pada tempat masuk
- masa inkubasi
2. Tropisma dan penyebaran virus dalam tubuh
- Mekanisme penyebaran dalam tubuh
bervariasi: aliran darah, limfatik, saraf
perifer, antar sel
- spesifik jaringan/ sel
- Faktor-faktor sel/ jaringan dan faktor-
faktor virus yang mempengaruhi tropisma
- reseptor spesifik
- ekspresi gen virus
- enzim yg diperlukan untuk replikasi virus
Receptor & co-receptor Hemaglutinin dan neuraminidase of
Of HIV influenza virus
Binding of a virus to its receptor on the host cell
surface result in penetration of the cell or the delivery
of virus nucleic acid to the cytoplasm of the cell

Nucleic acid enters the host cell by:

1. Direct entry of just the nucleic acid, as with poliovirus
2. Fusion of the viral envelope with the cell membrane and
subsequent uncoating, as with influenza virus
3. Endocytosis and the release of nucleic acid from the capsid
(uncoating), as with Poxviruses
of entry of
at the site of entry and cause disease at the same site, or
spread to sites distant from the point of entry and replicate
at these site

2 release mechanisms from the host:

Very dramatic and results in relatively large numbers of

virions leaving the host cell at the same time and host cell

Budding or blebbing: a newly formes nucleocapsid

pushes against the host cell membrane until the
membrane evaginates and pinches off behind the virus.
The released virus is coated with host cell membrane,
called the viral envelope. The release is slower process
than lysis
The process of Budding in Enveloped Viruses
Virus-host interaction

Cytopathic viruses
Ultimately kill the host cell, the result is often local necrosis
Can trigger apoptosis or programmed cell death

Noncytopathic viruses
Do not immediately produce cell death and result in latent or
persistent infections
Productive: virus produce persistent infection with the release of
only a few new viral particles at a time
Non-productive: viruses do not actively make virus at detectable
levels for a period of time (latent infection)
3. Kerusakan sel/ jaringan dan manifestasi klinis
- Iceberg concept of infection : tipe
respons sel/ pejamu terhadap infeksi
- Lokal, sistemik
- Jaringan tertentu lebih tahan thd
kerusakan dibandingkan lainnya (misal
jar.usus vs otak)
- Mekanisme pertahanan tubuh dan proses
Syncytia in paramyxovirus infection

Transformed cells in oncogenic virus infection

Mekanisme pertahanan tubuh :
- Spesifik dan non-spesifik
- Kekebalan seluler dan humoral
- Proses imunopatologis
misal flu-like sistemic symptoms
(interferon), DHF
Usaha virus dalam mengatasi sistem imun
- Menginfeksi sel-sel yang berperan pada sistem imun
- Menginfeksi sel neuron yg sedikit atau tidak
mengekspresi MHC class I (virus herpes)
- Menghasilkan protein imunomodulator yang
menghambat MHC (adenovirus)
- Bermutasi antigen berubah (virus influenza, HIV)
- Ekspresi protein permukaan ditekan (virus herpes)
4. Pemulihan dari infeksi dan tipe infeksi
- Berbagai tipe infeksi: infeksi akut, kronik,
laten; infeksi subklinis, rekuren, slow
- Pada infeksi akut pemulihan sejalan dengan
musnahnya virus dari tubuh
The Role of Viruses in Cancer
Normal conditions:
Division of cells in a mature multicellular animal is under
strict genetic control

The phenomenon of uncontrolled cell division
Cell undergoing neoplasia are said to be neoplastic, and
a mass of neoplastic cells is a tumor
Tumor: benign and malignant
Protooncogenes: genes
that play a role in cell

Factors contribute to the

inhibition of oncogene
repressor and the
activation of
oncogenes (UV,
radiation, carcinogens
and viruses)
(Virus menyebabkan 20-25% kanker pada manusia)

Virus RNA
Virus Hepatitis C Karsinoma hepatoseluler
Virus DNA
Virus hepatitis B Karsinoma hepatoseluler
Virus papilloma manusia Papilloma dan karsinoma
Herpes virus 8 Sarkoma Kaposi
Virus Epstein Barr Limfoma Burkitt,
ca nasofaring
Oncogenic viruses :
- Establish persistent infection
- Stimulate uncontrolled cell growth transformation and

Usually the first step but not sufficient to cause oncogenesis / tumor
Immortalization accumulation of mutations/
chromosomal rearrngement tumor
Immortalization more susceptible to co-factors tumor
Adenovirus E1A,
SV40-LT, HPV16&18 E7
-- bind to Rb-related proteins

Contoh : Inaktivasi tumor supresor oleh protein virus