REVIEW OF SPECIAL BACTERIOLOGY

BY: MUHAMMAD TALHA ANWAR

Batch 18’ ( PUNJAB MEDICAL COLLEGE )

CONTENTS
1-Gram +ve Cocci
2-Gram -ve Cocci
3-Gram +ve Rods
4-Mycobacteria
5- Gram +ve Rods resembling Fungi
6-Spirochetes
7-Gram -ve Respiratory Rods
8-Rickettsia
9-Chlamydia
10-Mycoplasma Pneumoniae
11-Gram -ve Enteric Rods
 GRAM POSITIVE COCCI
Bacteria Include
1-Staphylococcus
2-Streptococcus

STAPHYLOCOCCUS
Staphylococcus a Gram +ve bacteria .
EXAMPLES
1-S.Aureus
2-S.Epidermidis
3-S.saprophyticus

1-S.AUREUS
DISEASES
It causes Toxic Shock Syndrome ,Endocarditis,Food poisoning,Scalded skin syndrome and
Impetigo.
Kawasaki's syndrome(Vasculitis involving medium and small sized arteries especially Coronary
artery and thus a leading cause of heart disease in children with age under 5yrs.)

CHARACTERISTIC
It is catalase positive and Coagulase positive and shows Beta Hemolysis.
Contain Protein A(Virulence Factor which shuts down Complement system), and is Resistant to
Beta lactam Drugs .
It Contains Staphyloxanthin ,substance Giving Golden colour to Colonies.
Also show resistance to Methicillin and Nafcillin hence known as Methicillin and Nafcillin
resistant (MRSA and NRSA ) S.Aureus respectively.

TRANSMISSION
Main site of Colonization is Nose(30%).

PATHOGENESIS
Produce disease by producing toxins and inducing pyogenic inflammation.
Toxins included are Enterotoxins(Cause Food poisoning),Toxic Shock Syndrome Toxin(Cause
Toxic Shock Syndrome),Exfoliation(Cause Scalded skin syndrome) and Leukocyte Killing Toxin
like Alpha toxin and P-V leukocidin .

CLINICAL FINDINGS
Clinical manifestations falls into two groups
Pyogenic are Cellulitis,hidradenitis,Conjunctivitis, lymphangitis
,Carbuncles,Sepsis,Endocarditis,Osteomyelitis,Hospital acquired pneumonia and Metastatic
Abscesses
While Toxic mediated are Toxic shock and scalded skin syndrome and Food Poisoning .

LABORATORY DIAGNOSIS
Gram staining smears shows gram +ve.
Golden Colonies
Grape like Clusters
Coagulase positive
Beta hemolytic.

2-S.EPIDERMIDIS AND S.SAPROPHYTICUS

Both are coagulase Negative and have white colonies.

DISEASES
S.epidermidis cause endocarditis and Prosthetic joint infection while S.saprophyticus causes
UTI .

TRANSMISSION
S.epidermidis is member of normal skin flora
While S.saprophyticus is found in Genital Tract.

LABORATORY DIAGNOSIS
S.epidermidis is Novobiocin Sensitive
While S.saprophyticus is Novobiocin Resistant.

STREPTOCOCCI
SPECIES
Five Species are included in this Type.
1-S.pyogenes. 2-S.agalactiae
3-Enterococci 4-S.pneumoniae
5-Viridans Groups (It includes S.sanguinis,S.mitis,S.mutans,S.salvarius,S.anginosus)

PROPERTIES
1-These are Gram +ve Bacteria That are Catalase -ve and found in Chains .
2-In addition two antigens are present in them:-
i-One is C carbohydrate located in Cell Wall.
ii-Other is M protein which is Virulence Factor .Streptococcus has 80 serotypes based on M
protein .
Some strains Producing M protein Cause Rheumatic Fever and Other Cause Acute
Glomerulonephritis.No antibodies is made against M protein as it is normal component of
human tissue and human are tolerant to it.
3-They are Capsulated (An other Virilulence Factor)

CLASSIFICATION
They can be Classified in two ways.
1-Based on Hemolysis they Cause
2-Lancefield Classification

1-CLASSIFICATION BASED ON TYPE OF HEMOLYSIS

They are of 3 types
1-Alpha Hemolytic
2-Beta Hemolytic
3-Gamma Hemolytic

ALPHA HEMOLYTIC
1-They cause incomplete hemolysis thus have green Colonies Because of incomplete conversion
of Hemoglobin to Biliverdin.
2-Example are S.pneumoniae and Viridans Group.

BETA HEMOLYTIC
1-They cause Complete Hemolysis because of presencw of Streptolysin O and S.
2-Examples are S.Pyogenes ,S.agalactiae and Enterococci.

GAMMA HEMOLYTIC
1-They show no Hemolysis.
2-Examples are some species of Enterococci and Non Enterococci.

2-CLASSIFICATION BASED ON C CARBOHYDRATE (LANCFIELD CLASSIFICATION)

They are Classified into A to U groups.

GROUP A
1-It include S.pyogenes
2-It consist of Pilli(Lipoteichoic acid +M protein) and Capsule (Hyaluronic acid).

GROUP B
1-It Includes S.agalactiae.
2-It is normally Found in genital tract of women.

GROUP D
1-It includes Two species .
1-Enterococci 2-Non-enterococci
Enterococci------->
1-It includes E.Fascalis and E.faecium.
2-Not Killed by Pencillin G.
3-Much Hardy Organism than Non-enterococci.
Non-Enterococci------->
1-It includes S.bovis.
2-Show variable hemolysis.
Other Groups are Less Frequent.

TRANSMISSION:-
Normal Flora of Skin (S.pyogenes), Vagina and Colon (S.agalactiae) and Colon (Enterococci and
Anaerobic Streptococci).

PATHOGENESIS

PATHOGENESIS BY GROUP A
S.pyogenes cause disease by three mechanism
i-Pyogenic Inflammation
ii-Exotoxin Production
iii-Immunologic Reactions

PYOGENIC INFLAMMATION
Inflammation caused by S.pyogenes is because of formation of 3 enzymes
i-Hyaluronidase. ii-DNase
iii-Streptokinase
Hyaluronidase is spreading factor and cause breakdown of Hyaluronic acid present in
subcutaneous tissue.
Streptokinase is Anti-thrombotic.
DNase breaks DNA in necrotic tissues.

TOXIN PRODUCTION
It produces 5 toxins.
i-Erythrogenic Toxin. ii-Streptolysin O
iii-Streptolysin S. iv-Exotoxin B
v-Pyrogenic exotoxin A

Erythrogenic Toxin------>It cause Scarlet fever in person lacking Antitoxin .It is

Superantigenic.Its mechanism of action is Similar to TSST of S.aureus.
Streptolysin O ------->It cause Beta hemolysis and is antigen.It is Oxygen Sensitive
Streptolysin S-------->It also causes Beta hemolysis but it is not antigenic.It is oxygen stable
Exotoxin A------>It is Protease found in S.pyogenes hence they are also known as Flesh eating.
Pyrogenic Exotoxin A------->It cause Toxic Shock Syndrome and is Super antigenic.

PATHOGENESIS BY GROUP B
Produce no toxin and no immunologic induced diseases.
Capsule is Virulence Factor.

PATHOGENESIS BY VIRIDANS
Produce no toxin and destructive enzymes.
They Contain Glycocalyx.
Capsule is Virulence factor.

CLINICAL FINDINGS
CLINICAL FINDINGS OF GROUP A
S.pyogenes causes three types of diseases.
i-Pyogenic ii-Toxigenic
iii-Immunologic

Pyogenic Diseases------->
1-It includes Cellulitis ,impetigo ,pharyngitis,lymphangitis and endometritis.
2-Features of Pharyngitis are Throat pain and fever,inflammed tonsils with yellowish exudate.
3-If untreated cause otitia media,sinusitis ,meningitis and peritonaillar abscess.

Toxigenic Disease---------->1-It includes scarlet fever and Toxic shock syndrome.

2-Feature of scarlet fever is Strawberry Tongue.
3-Feature of Toxic shock syndrome is pyogenic inflammation and positive blood culture.

Immunologic Disease--------->
It includes Acute Glomerulnephitis(AGN) and Acute Rheumatic Fever.

i)AGN
1-Features of AGN are hypertension, Face and ankle edema and Smoky urine (Because of
Presence of red cells in urine).
2-Cause of AGN is Antigen-Antibody Complex on Glomerular basement membrane.
3-AGN occurs 2-3 weeks after skin infection.

ii)ACUTE RHEUMATIC FEVER

1-Feature are fever ,migratory polyarthritis and Carditis(Can cause Damage to heart) .Chorea
may occurs. ASO titers and ESR are elevated .
2-Cause is Immunologic reaction between Cross-reacting antibody to M protein and antigens
of joint,heart and brain tissues. ARF occurs 2 weeks after Pharyngitis.

CLINICAL FINDINGS OF GROUP B

1-They cause penumonia,Spesis and meningitis in neonates particularly in those having
gestation period less than 37 weeks.
2-In adults they cause ostomyelitis,endocarditis,arthritis and cellulitis particularly in diabetic
patients.

CLINICAL FINDINGS OF VIRIDANS GROUP

1-Some species like S.mutans,S.sanguinis ,S.salvarius and S.mitis cause endocarditis following
dental surgery.
2-While other species like S.anginosus,S.milleri and S.intermedius cause Brain abscesses. Dental
Surgery is Predisposing factor for brain abscess.
3-S.mutans produce dextran and is involve in dental caries.
4-They also cause Mixed aerobic-anaerobic infection like lung and abdominal abscess.

CLINICAL FINDINGS OF GROUP D

1-Enterococci hospital acquired UTI and Endocarditis particularly in patients who have
undergone G.I or Urinary tract surgery.
2-Non-enterococci cause Endocarditis in patient with Colon Carcinoma .

LABORATORY DIAGNOSIS
LABORATORY DIAGNOSIS OF GROUP A
1-Gram stained smears in pharyngitis are useless as Viridans group also found there(Normal
flora) and
hence can not be distinguished. However stained smears from wound infection arr diagnostic.
2-Beta hemolytic Colonies appear on Cultures of Swabs from the pharynx (with in 18-48 hours).
3-They are Bacitracin Sensitive.

LABORATORY DIAGNOSIS OF GROUP B

1-Bacitracin Resistant.
2-They hydrolyze Hippurate.
3-They produce a protein that enchances hemolysis on sheep blood agar when combined with
Beta Hemolysin of S.Aureus(CAMP test)

LABORATORY DIAGNOSIS OF GROUP D

Enterococci grow in Hypertonic 6.5 NaCl solution while Non-enterococci do not.
LABORATORY DIAGNOSE OF VIRIDANS GROUP
1-Show alpha Hemolysis.
2-They are optochin Resistant .
3-They are resistant to lysis by Bile.

PNEUMOCOCCI
DISEASES
1-Pneumonia. 2-Conjunctivitis
3-Meningitis. 4-Bacteremia
5-Sinusitis. 6-Otitis Media

IMPORTANT PROPERTIES
1-They are Gram +ve Cocci with lancet shaped(oval +pointed at ends)
2-They are Capsulated (85 distinct types distinguished by Quellung Reaction)
3-They are Catalase Negative Organism.
4-They Cause Alpha Hemolysis .
5-They are Bile Soluble
6-There Growth is Inhibited By Optochin.
7-They Contain C substance that reacts with C-Reactive protein (An acute phase beta globulin
raised during acute inflammation)

PATHOGENESIS
1-Capsule is main Virulence Factor.
2-Lipoteichoic acid play roles in pathogenesis.
3-Pneumolysin contribute to Pathogenesis by causing alpha hemolysis .
4-IgA Protease Helps in Colonization in Upper Respiratory Tract.

FACTORS THAT PREDISPOSE PERSON TO INFECTION

1-Alcohol and Drug intoxication.
2-Splenectomy
3-Abnormal Circulatory Dynamics (Heart Failure)
4-Abnormality of Respiratory Tract
5-Sickle cell anemia (may cause asplenic)
6-Trauma to Head (Leakage of Fluid Through Nose Leading to Meningitis

CLINICAL FINDINGS
Pneumonia starts with Chill ,Fever,Cough and Pleuratic pain with sputum having Red or
brown rusty Color.

LABORATORY DIAGNOSIS
Gram stained smears show Gram positive lancet shaped Diplococci.
Alpha hemolysis on Blood Agar Plate.
Bile Soluble.
Optochin Sensitive.
CSF culture positive in meningitis

GRAM -VE COCCI

BACTERIA INCLUDED:-
Nesseria Gonorrhea (Gonococci)
Nesseria Meningitidis (MeningoCocci)

GENERAL FEATURES :-
1-They are Gram Negative Diplococci .
2-They metabolize Glucose.
3-They Contain LOS which has strong Endotoxin like Activity.(Note endo Toxin Induces Shock
by producing TNF and IL1.)
5-Produce IgA protease that Cleave the mucus layer and Help in the Colonization of Bacteria.
4-Nesseria Gonorrhea is Found in Neutrophils.

GONOCOCCI VS MENINGOCOCCI

1-SPECIFIC STRUCTURAL FEATURES:-

Gonococci lack Polysaccharide Capsule While Meningococci have Polysaccharide Capsule.

2-METABOLISM:-
Gonococci Cannot Metabolize Maltose But Meningococci can Metabolize Maltose.

3-VACCINE AVAILABILITY:-
Gonococci Has pilus protein that undergo antigenic Variation so there is no Vaccine for
Gonococci But we do have Vaccine Against Meningococci.

4-TRANSMISSION:-
Gonococci is Transmitted Sexually or perinatally while Meningococci is Transmitted via
Respiratory and Oral Secretions.

5-CLINICAL FINDINGS:-
Gonococci Causes Gonorrhea ,Septic Arthritis ,Neonatal Conjunctivitis (2-5 days after Birth)
,PID and Fitz-Hugh-Curtis Syndrome(complication of pelvic inflammatory disease (PID)
involving liver capsule inflammation leading to the creation of adhesions).

While Meningococci Causes Meningococcemia with Peticheal Hemorrhages and Gangerene of

Toes ,Meningitis ,Water House-Friderichsen Syndrome (Adrenal insufficiency ,Fever ,DIC and
Shock )

6-LAB DIAGNOSIS:-
Gram Staining ----->Gram Negative Diplococci
Sugar Fermentation Test------>Meningococci Ferment Maltose But Gonococci can not.
Isolation in Thayer-Martin Agar.It selectively Favours Growth of Nesseria by Inhibiting
growth of Gram +ve Organisms with Vancomycin,gram -ve Organism except Nesseria with
Trimethoprim and Colistin and Fungi With Nystatin.
 GRAM POSITIVE RODS
BACTERIA INVOLVED:
1-Bacillus (anthracis and Cereus)
2-Clostridia(tetani,perfringens,botulinum and difficile
3-Corynebacterium(diphtheriae)
4-Listeria (Monocytogenes)

1-BACILLUS
It includes Bacillus anthracis and Bacillus Cereus

1-BACILLUS ANTHRACIS
General Features:-
1-Gram positive Rod.
2-Produce anthrax toxin
3-Only Bacteria With D-Glutamate Capsule.
4-Colonies Show Medusa head Appearance

PATHOGENESIS:-
EDEMA toxin has A and B component with B component enable binding and triggering the
reuptake of active A component. The Active Component increases cAMP leading to edema .

Clinical Findings :-
1-Cutaneous Anthrax------> painless papule surrounded by vesicles----->Ulcer with black
eschar---->If untreated leads to bacteremia and death.
2-Pulmonary Anthrax(Wool sorter disease)----->Inhalation of Spores----->Flu like symptoms-
---->Then progress to Fever ,Pulmonary Hemorrhage,Mediastinitis(Mediastinal Widening) and
shock
3-Gasterointestinal Anthrax----->Vomiting and Bloody Diarrhea.

Diagnosis:-
1-Smear shows Gram +ve Rods
2-Non hemolytic Colonies on Blood Agar
3-PCR
4-ELISA

2-BACILLUS CEREUS

General features:-
1-Gram +ve Rod.
2-spores Survive Cooking rice (Enterotoxin formation)---->Reheated Rice syndrome

Clinical Findings:-
Emetic Type------>Cereulide toxin----->Nausea and Vomiting within 1-5 hours
Diarrheal Type---->Watery, non bloody diarrhea and G.I pain within 8-18 hours

2-CLOSTRIADIA
1-CLOSTRIDIUM TETANI
Pathogenesis:-
Tetanospasmin(Tetanus Toxin)----->Cleave SNARE PROTEINS for Neurotransmitters--------
>Inhibit Renshaw Cell in spinal Cord------>Inhibit release of GABA and Glycin3

Clinical Findings:-
Spastic paralysis
Trismus(lock jaw)
Risus Sardonicus(raised eyebrows and open grin)
Opisthotonos (Spasm of Spinal Extensors)

2-CLOSTRIDIUM BOTULINUM
General Features:-
1-Local Botox injection used to treat dystonia ,achalasia , muscle spasm and Cosmetic reduction
of Facial wrinkles.
2-Transmitted from bad bottles of food ,juice and Honey .

Pathogenesis:-
Produce Heat Labile Toxin----->Inhibit Release of Acetylcholine at NM junction ---->Botulism

Clinical Findings :-
1-Diplopia
2-Dyspnea
3-Dysphagia
4-Dysarthria
5-Desecending flaccid Paralysis
6-Floppy Baby Syndrome

DIAGNOSIS:-
Mice inoculation Test.
3-CLOSTRIDIUM PERFRINGENS
Pathogenesis:-
Produce Alpha Toxin (Lecithinase,a Phospholipase)------->Leads to Myonecrosis (Gas gengrene)
and Hemolysis .

Spores survive in Undercooked food------>Release of Heat labile enterotoxin when ingested-----

-->Food Poisoning

Diagnosis:-
1-Smear of tissue and exudate----->Gram
positive rods
2-Anaerobic Culture
3-Sugar Fermentation Test
4-Double Zone of hemolysis on Blood Agar
5-Egg Yolk Agar---->Lecithinase +ve

4-CLOSTRIDIUM DIFFICILE
Pathogenesis:-
Produce 2 toxins.
Toxin A------>An enterotoxin------>Binds to Brush border of gut and Alters Fluid Secretion -----
> Diarrhea
Toxin B------>a cytotoxin--------> Disrupts cytoskeleton via actin depolymerization ------->
Diarrhea (Pseudomembranous Colitis)

Risk Factor :-
Use of drugs like Clindamycin , PPI and ampicillin.

Diagnosis:-
1-Exotoxin detection in infiltrate of a patient's specimen
2-ELISA
3-Cytotoxicity test

3-CORYNEBACTERIUM DIPHTHERIAE
General Features:-
1-Gram +ve Rod (Club shaped) with Metachromatic Granules
2-Transmission via Respiratory Droplets.
3-Produce Exotoxin (encoded by beta prophage)

Pathogenesis:-
Exotoxin----->Inhibit Protein synthesis via ADP-ribosylation of EF2
Clinical findings:-
Pseudomembranous pharyngitis(grayish-white membrane) with lymphadenopathy.

Complications include Neuritis, Myocarditis and arrhythmias.

Diagnosis:-
1-Culture on Loffler’s Medium, Tellurite plate or Blood Agar
2- On Tellurite Plate---->Tellurium form from Tellurium salt------>Gray BlackColor-----
>Diagnostic
3-Gram Staining and Methylene blue staining on Throat Swab. Methylene blue reveal
Metachromatic(blue and Red)
Granules
4-PCR
5- Elek Test positive for Toxin.

4-LISTERIA MONOCYTOGENES
General features:-
1-Gram +ve Rod.
2-Facultative intracellular Organism
3-Transmitted by ingestion of unpasteurized Dairy product and Cold deli meats ,via
Transplacental Transmission or via vaginal Transmission during Birth.
4-Grow well at 4-10°C (Cold enrichment)
5-Forms Rocket Tails via actin Polymerization----->This allows intracellular transmission and
CELL-CELL spread across Cell membrane ----->Thus avoiding Antibody
5-Characteristic Tumbling Movement in broth

Clinical Findings:-
1-Amnionitis
2-Septicemia
3-Spontaneous abortion
4-Granulomatosis infantiseptica
5-Neonatal meningitis (3rd most common Cause of Meningitis in neonates after S.agalactiae
and E.coli)
6-Meningitis in Immunocompromised patients
7-Mild and Self-limited Gastroenteritis in healthy individuals.

Diagnosis:-
1-Gram Staining
2-Culture
3-Narrow zone of beta Hemolysis on bloodagar
4-Sugar Fermentation Test +ve
 MYCOBACTERIA
1-MYCOBACTERIUM TUBERCULOSIS
FEATURES:
1-Facultative intracellular
2-Immune system itself causes damage
3-Contains NO endotoxins or exotoxins
4-CORD FACTOR which inhibits WBC migration ,
causes characteristic serpentine growth pattern and
induces TNF-α release
5-TUBERCULIN which triggers cell-mediated immunity → caseation and granulomas and
triggers delayed hypersensitivity reaction
6-SULFATID which prevent phagosome-lysosome fusion

PATHOGENESIS:-

Primary tuberculosis:
1-Organisms replicate in naïve alveolar macrophages within phagosomes.
2-Body eventually mounts T-cell response, activating macrophages to fight the infection
3-Activated macrophages destroy lung tissue as they try to fight the infection → caseous
necrosis
4-If immune intact, organisms are walled-off in Ghon focus (middle or lower lung) or Ghon
complex (Area of Necrosis+Draining Lymho node)
5-If immune compromised or otherwise unable to fight the infection, symptomatic TB develops

Secondary (reactivation) tuberculosis:-

Weakening of immune system → body can no longer contain latent infection
Infection can then disseminate to multiple organ systems e.g. Pott disease(lumbar vertebrae)
or Miliary Tuberculosis . May Cause Meningitis (Base of Brain) , Sterile pyuria (Kidney) and
osteomyelitis caused by M. tuberculosis.
TRANSMISSION
respiratory droplets

PREDISPOSING FACTORS FOR INFECTION

1-HIV+
2-poverty
3-IV drug abuser

SYMPTOMS:-
Fever
Weight loss
Night sweats
Cough (productive or non productive)
Hemoptysis

DIAGNOSIS:-
1-Acid Fast Staining of Sputum
2-Auramine Stain For Rapid Screening ----- Visualized By Fluorescence Microscopy
3-Culture on Lowenstein-Jensen agar after Concentrating the specimen with NaOH by
Centrifugation
4-Liquid BACTEC MEDIA(Radioactive substance Containing Medium) ------Release
Radioactive CO2 ----->Indication of Growth of Bacteria
5-BIOCHEMICAL TEST----->Niacin +ve and Catalase +ve
6-NAAT (Nucleic Acid amplification Test)
7- FOR DRUG RESISTANCE :-
Luciferase Test------Normal Lightening of Luciferase if Resistant present (Because
enzyme is not consumed)
8-LATENT INFECTION:-
PPD test +ve------if current infection or Past Exposure
PPD test -ve --------if no infection , Sarcoidosis or HIV infection (because of Low CD4+ cell count)
PPD TEST(Pure Protein Derivative Test)---Now Replaced by Interferon Gamma Release
Assay --------Blood Cells Mixed with Patient’s Serum -------Amount of Gamma Interferon
released is measured .

Direct Observe Therapy(DOT) prevent development of Resistance .

2-MYCOBACTERIA OTHER THAN TUBERCULOSIS (MOOT)

i) M.avium-intracellulare -------Cause disseminated non-TB disease in AIDS .Prophylaxis with
Azithromycin when CD4+ count is less than 50 cells /mm3
ii)M.scrofulaceum ------- Cervical Lymphadenitis in children
iii)M.marinum------Hand infection in aquarium handlers

3-MYCOBACTERIA LEPRAE
Disease:-
Leprosy (Hansen Disease)

FORMS OF DISEASE :-
There are Two forms of Disease .
i)Lepromatous------Presents Diffusely ove the Skin with leonine facies and is Communicable.It
is Characterized by low cell mediated immunity with a humoral Th2 response.It is Lethal.

ii)Tuberculoid---- It is limited to few hypoesthetics and causes hairless skin plaques.It is

charaterized by high Cell mediated immunity with largely Th1 type immune response.

FEATURES:-
Bacteria Loves Cool temperature so infects Skin and Superficial Nerves 'Glove and Stocking 'loss
of sensation.It can not be grown in vitro.Reservoir in USA is Armadillos.

DIAGNOSIS:-
LEPROMATOUS LEPROSY:-
1-Acid Fast stain of Nasal scrapings or Skin lesions
2-Serology------IgM against Glycolipid 1

TUBERCULOID LEPROSY:-
Typical Granuloma Formation is Diagnostic
Not Grown on Artificial Media.

GRAM +ve RESEMBLING FUNGI

NOCARDIA VS ACTINOMYCES
1-GENERAL FEATURES:-
i)-Both are Gram Positive Rods and form Long ,branching filaments Resembling Fungi.
ii)-Nocardia is Aerobe While Actinomyces is Anaerobe
iii)-Nocardia is weakly acid fast while Actinomyces is not Acid Fast.

2-SITE:-
Nocardia is Found in Soil while Actinomyces is Normal Oral ,reproductive and GI flora.

3-CLINICAL FINDINGs:-
Norcardia Causes Pulmonary infections in immunocompromised Patients (It Can mimic TB but
Negative PPD test),It also causes cutaneous infections after trauma in Immunocompetent
Patients .It ca Spread to CNS.

While Actinomyces Causes Oral/Facial Abscesses that drain through Sinus Tracts .It is
associated with Dental Caries/Extraction. It forms yellow Sulphur granules and can also cause
PID with IUDs.

4-LAB. DIAGNOSIS:-
NOCARDIA:-
1-Gram Staining------> gram +ve Branching
Rods or Filaments
2-Weak Acid

ACTINOMYCES :-
1-Gram Staining .
2-Yellow Sulphur granules are Characteristics.

SPIROCHETES
Bacteria Involved
1-Leptospira interrogans
2-Borrelia (Big size)
3-Treponema

General Features:-
1-Spiral shaped
2-Only Borrelia Can be Visualized by Aniline Dyes(Wright or Giemsa Stain) in LM due to size.
3-Treponema is visualized by DFA or Dark-Field Microscopy.

1-TREPONEMA PALLIDUM
Disease:-
Syphilis

EXPLANATION:-
Primary Syphilis------>Localized disease with painless Chancre.
Secondary Syphilis------>Disseminator Disease with constitutional Symptoms,Maculopapular
Rash on palms and soles ,Condylomata Lata (Smooth ,Moist,painless,wart-like lesions on
Genitals) ,Lymphadenopathy and Patchy Hair Loss.
May lead to Latent Syphilis(Positive serology without symptoms)

Tertiary Syphilis------>Mainly CVS and Neurological Symptoms . Gummas (Chronic

Granulomas) ,Aortitis(Vasa Vasorum Destruction) ,Neurosyphilis (Tabes Dorsalis ,general
Paralysis) ,arygyll Robertson pupil (Also Known as Prostitute's pupil as it accomodates by does
not react).Signs include Broad-based ataxia , +ve Romberg ,Charcot joint and stroke without
HTN.

Congenital Syphilis-------> Presents with Facial abnormalities such as Rhagades (Linear scars
at angle of mouth ) ,Snuffles (Nasal Discharge) ,Saddle Nose ,Notched ( Hutchinson) teeth
,Mulberry Molars and Short Maxilla ,Saber shins and CN VIII Deafness. This occurs after 1st
Trimester.

Diagnosis:-
MICROSCOPY:-
1° and 2° Syphilis------>Dark field Microscopy
3° syphilis---------->Silver Stain

SPECIFIC SEROLOGIC TEST:-

Immunofluorescence
Hem agglutination

NON-SPECIFIC TEST:-
Cardiolipin from Beef Heart react with Reagin Antibody(IgG+IgM)----->Flocculation Test.
False +ve------->Viral Infection,Leprosy, Drugs and Rheumatic Fever
False -ve ------->Prozone Phenomena(High Antibody Titer----->No Flocculation. So Dilute
the serum to make Test Positive)

CONGENITAL SYPHILIS:-
IgG Test------>Higher Titer in Child than mother give +ve Test

JARISCH-HERXHEIMER REACTIONS:-
Flue like syndrome (Fever ,Chills ,Headache and myalgia) after antibiotics are started .This is
due to killed virus (usually spirochetes) releasing toxins.

2-BORRELIA BURGDORFERI
Disease:-
Lyme Disease

Transmission :-
Ixodes deer Tick .
Natural Reservoir is the mouse.

EXPLANATION :-
Stage 1-----> Early Localized: Erythema Migrans(Bulls-eye configurations ) and flu like
symptoms

Stage 2 -----> Early disseminated : secondary lesions , Carditis ,AV Block and bilateral VII nerve
Palsy (Bell palsy ) , migratory myalgia / transient arthritis.

Stage 3 -----> Late disseminated :Encephalopathies ,Chronic Arthritis.

Diagnosis :-
ELISA (Detects antibody to Borrelia)

3-LEPTOSPIRA INTERROGANS
Diseases :-
Leptospirosis
Weil Disease

General Feature of Bacteria:-

1-Spirochete with hook-shaped ends found in water Contaminated with Animal urine.

EXPLANATIONS :-
Leptospirosis--------> flu like symptoms ,myalgia (classically of calves) ,jaundice ,photophobia
with conjunctival suffusion (erythema without Exudate).

Weil Disease-----> Also known as icterohemorrhagic leptospirosis .Severe form with

Jaundice and Azotemia(Build up of nitrogenous Compound in the blood ) from Liver and Kidney
dysfunction respectively. Other Features are Fever ,Hemorrhage and Anemia.

Diagnosis :-
1-Microscopic agglutination testing for serologic identification of leptospirosis
2-PCR of blood, urine, CSF, tissue.

GRAM -VE RESPIRATORY RODS

BACTERIA :-
1-Hemophilus Influenzae
2-Bordetella Pertussis
3-Legionella pneumophila

1-HEMOPHILUS INFLUENZAE
GENERAL FEATURES:-
1-Gram Negative Rod (Coccobacilli)
2-Require Factor V ( NAD) and X ( Hematin) for Growth.
3-Produce IgA Protease
4-Cultured on Chocolate Agar
5-Can be Grown with S.Aureus which provide Factor V through hemolysis of RBCs

PATHOGENESIS
IgA Protease production breaks mucus layer of Respiratory tract which helps in colonization of
Bacteria and its dissemination through blood to other organs .Encapsulated Strains are more
Dangerous than unEncapsulated.

CLINICAL FINDINGS
Mnemonic :- its haEMOPilus.

1-Epiglottidis (thumb sign of X ray ,Cherry red Epiglottis)

2-Meningitis
3-Otitis media
4-Pneumonia

DIAGNOSIS
1-Isolation on Chocolate Agar(Contain Hematin and NAD)
2-Definitive Identification-----> Biochemical Test or Capsular Swelling(Quellung Reaction)
3-Latex Agglutination Test

2-LEGIONELLA PNEUMOPHILA
GENERAL FEATURES:-
1-Gram -ve Rod.
2-Stains Poorly (Increasing Counter staining time may visualize it)
3-Requires Iron and Cysteine for Growth .

TRANSMISSION:-
Aerosal Transmission from environmental water source .

CLINICAL FINDINGS:-
1-Legionnaires' disease------> Severe pneumonia (unilateral and lobar ) ,Fever
,Hyponatremia ,G.i.T and CNS symptoms .Common in Smokers and Chronic Lungs disease.
2-Pontiac Fever-----> Mild flu like symptoms.

LAB DIAGNOSIS :-
1-Culture on Charcoal Yeast Agar(Contain
Iron and Cysteine)
2-Gram Stain Reveals Many Neutrophils But
no Organism
3-Significant Rise in Antibody Titer in
Convalescent phase by Indirect
immunofluorescence Assay is Diagnostic.

3-BORDETELLA PERTUSSIS
GENERAL FEATURES
1-Gram -ve Coccobacillus
2-Contain filamentous hæmagglutinin , Pertussis Toxin and Tracheal Toxin .

PATHOGENESIS :-
1-The filamentous hæmagglutinin adhesin(FHA) ------> serves as a dominant attachment factor
for adherence to host ciliated epithelial cells of the respiratory tract
2-Pertussis Toxin -----> Disables Gi ------>Increases cAMP------->Edema
3-Tracheal Toxin-------> causes damage and eventual extrusion of ciliated cells
4-Produce Lymphocytosis Promoting Factor. (Because of This feature may be mistaken as viral
infection)

CLINICAL FINDINGS
Three Clinical stages:-
1-Catarrhal Stage -------> low grade Fever ,Coryza
2-Paroxysmal ----------> Paroxysms of intense cough followed by inspiratory Whoop (Whooping
Cough) , Posttussive Vomiting .
3-Convalescent -------> Gradual Recovery of Chronic Cough .

DIAGNOSIS:-
1-Isolation from Nasopharyngeal Swab on Bordet-Gengou Media
2-Fluorescence Antibody Staining on Isolated Organism
3-PCR

RICKETTSIA
GENERAL FEATURES
1-Small aeorbic gram -ve Bacteria.
2-Lives Intracellularly so can not be Gram stained.
 RICKETSSIAL NOTES CLINICAL FINDINGS
DISEASES

ROCKY MOUNTAIN Caused by R.rickettsii. Classical triad of fever ,Rash

SPOTTED FEVER Vector is Tick. (vasculitis) and Headache.
Rash starts at wrist and
ankles and then spreads to
trunk ,palms and Soles
TYPHUS Endemic(fleas) ---> R.Typhi Rash starts centrally and
Epidemic (Human body spread out sparing palm and
louse)- R.prowazekii soles.

ERLICHIOSIS Caused by Ehrlichia. Monocytes with

Vector is Tick. morulae(mulberry like
inclusions) in cytoplasm.

ANAPLASMOSIS Caused by Anaplasma. Granulocytes with morulae

Vector is tick.

Q FEVER Caused by Coxiella burnetii. Pneumonia.

No arthropod Vector. Culture Negative
Spores inhaled as aerosols Endocarditis.
from cattle/sheep amniotic
fluid.

DIAGNOSIS:-
BASED ON SEROLOGY ANALYSIS
1-Weil-F elix Test:-Antigen in Rickettsia Cross Reacts With O-antigen polysaccharide
of Proteus resulting in agglutination of proteus
2-ELSIA
3-Indirect Immunofluorescence
4- 4 Fold Rise in Antibody Titer Between Acute and convalescent Phase is Diagnostic .Acute
Phase Titer 1:128 is Presumptive.
 CHLAMYDIA
GENERAL FEATURES
1-Can not make their own ATP.
2-They are obligate intracellular that cause mucosal Infections.
3-Cell Wall lack classic peptidoglycan (Due to reduced muramic acid)

LIFE CYCLE
Elementary body(small and dense)---- enters cell via endocytosis ---Transform into
reticulate body------Reticulate Body(Cytoplasmic Inclusions) replicate in cell by fission------
 Reticulate body Reorganize into Elementary body and released from Cell .

SPECIES :-
1-Chlamydia trachomatis
2-Chlamydophila pneumoniae
3-Chlamydophila psittaci

1-CHLAMYDIA TRACOMATIS
SEROTYPES :-
1-A,B,C-------- Cause blindness due to follicular conjunctivitis .
2-D-- K -------- Causes Urethritis/PID ,ectopic pregnancy ,Neonatal Pneumonia with
eosinophilia and neonatal conjunctivitis (1-2 weeks after birth)
3- L1 ,L2 and L3 ---- Lymphogranuloma venereum (Small painless ulcers on Genitals)

REITER SYNDROME(Reactive arthritis) ------- Autoimmune Disease in which antibodies

against chlamydia cross reacts with body tissues. Classical triad of symptoms -Conjunctivitis
,Urethritis and Arthritis (Mnemonic -- You cannot see ,You cannot pee and you cannot climb
up a tree)

2-CHLAMYDOPHILA PNEMUMONIAE AND CHLAMYDOPHILA

PSITTACI
Atypical Pneumonia (low grade Fever and Little cough with sputum.

NOTE------------TYPICAL PNEUMONIA presents with High Grade fever with Red (bloody)
or Yellow green Sputum(pus) and is caused by S.aureus ,S.pneumoniae ,P.aeruginosa
,Klebsiella ,H.Influenza )

DIAGNOSIS
1-Detection of Inclusion bodies by Giemsa Staining.
2-DNA probe ---->Detection In Exudate,Within epithelial cells.
3-ELISA------>Antigen Detection
4-Inclusion body of C.Trachomatis have Glycogen so Iodine test Can visualize Them.
5-Serologic is Diagnostic Only for C.pneumoniae and C.psittaci.
6-Nucleic acid Amplification Test.

MYCOPLASMA PNEUMONIAE
GENERAL FEATURES
1-Lack Cell wall. Hence Not seen on Gram stain. Grown on Eaton agar.
2-Pleomorphic
3-Contain Sterol in Cell Membrane for stability
4-Produce H2O2 and Cold Agglutinins(IgM) which help in pathogenesis and diagnosis.

CLINICAL FINDINGS
Atypical Pneumonia (Walking pneumonia) ------- Insidious onset ,Headache , non
productive cough and patchy or diffuse interstitial infiltrate. More Common in patient < 30
years old.

DIAGNOSIS
1-SEROLOGY:-
Cold Agglutinins (IgM autoantibody against type O RBCs which agglutinate RBCs at 0-4°C
temperature and leads to hemolysis ) titer of 1:128 or Higher Is indicative of recent Infection.
2-CONFIRMATION is made by 4 fold or greater Rise in specific antibody titer in Complement
Fixation Test.

GRAM -VE ENTERIC BACTERIA

They are divided into 3 main types based on their ability to ferment lactose.
1-Lactose Fermenting (Klebsiella , E.coli and Enterobacter )
2-Non-Lactose Fermenting (Pseudomonas ,Salmonella ,Shigella )
3-Slow Fermenter (Vibrio , Serratia )

IMPORTANT LAB TESTS FOR GRAM -ve ENTERIC BACTERIA

1-LACTOSE FERMENTATION---- Fermentation of lactose---- Pink colonies on MacConkey
Agar.
2-EMB AGAR------- Lactose Fermenters grow as Purple/ black Colonies. E.Coli grows with a
green sheen.
3-TRIPLE SUGAR IRON TEST (TSI) -------
The Triple Sugar Iron (TSI) test is a roughly named for its ability to test microorganism's
ability to ferment sugars and to produce Hydrogen sulfide.
COMPOSITION
The TSI slant is a test tube that contains agar, a pH-sensitive dye (phenol red), 1% lactose, 1%
sucrose, 0.1% glucose,as well as sodium thiosulfate and ferrous sulfate orferrous ammonium
sulfate.

INTERPRETAION :-
Bacteria that ferment any of the three sugars in the medium will produce byproducts.These
byproducts are usually acids, which will change the color of the red pH-sensitive dye (phenol
red) to a yellow color. Position of the color change distinguishes the acid production associated
with glucose fermentation from the acidic byproducts of lactose or sucrose fermentation. Many
bacteria that can ferment sugars in the anaerobic butt of the tube are enterobacteria.

Some bacteria utilize thiosulfate anion as a terminal electron acceptor, reducing it to sulfide. If
this occurs, the newly formed hydrogen sulfide (H2S) reacts with ferrous sulfate in the medium
to form ferrous sulfide, which is visible as a black precipitate. Examples of sulfide-producing
bacteria include Salmonella, Proteus, Citrobacter and Edwardsiella species. The blackening of
the medium is almost always observed in the butt (bottom) of the medium.

A bacterium that is a non-lactose fermenter and ferments glucose, initially causes a yellow
slant/yellow bottom (acid/acid reaction) after 8 hours but then converts to a red slant/yellow
bottom after 24 hours (alkali/acid reaction). Whereas if it ferments both lactose and glucose,
it results in a yellow/yellow tube and remains that way due to the large amount of acid
produced in the reaction. Blackening of the bottom due to H2S production may mask the acid
reaction (yellow) in the bottom of the tube. Salmonella Typhi may result in blackening of the
medium at the interface of bottom and the slant.

1-LACTOSE FERMENTERS

1-ESCHERICHIA COLI
GENERAL FEATURES
1-Gram Negative Rod
2-Virulence Factors include Fimbriae (cystitis and pyelonephritis (P-pili) , K capsule
(pneumonia ,neonatal meningitis) and LPS endotoxin (Septic Shock).
LAB DIAGNOSIS
1-Ferment Lactose----->Form Pink Colonies
2-Culture on Blood Agar and Differential Medium Like EBM agar and MacConkey Agar
3-Green Sheen on EMB agar

2-KLEBSIELLA -ENTEROBACTER
GENERAL FEATURES OF KLEBSIELLA :-
1-Gram negative Rod.
2-Member of normal flora of Intestine
3-Contain Abundant Polysaccharide Capsule thus form mucoid colonies.

CLINICAL FINDINGS
Aspiration Pneumonia in Alcoholics and Diabetics.
Abscesses in lungs and Liver.
Dark red “currant jelly “ sputum (blood/mucus)

DIAGNOSIS :-
1-Lactose Fermentation on EMB or MacConkey medium.
2-Biochemical Test
 2-LACTOSE NON-FERMENTERS

1-SALMONELLA AND SHIGELLA

GENERAL FEATURES OF SALMONELLA AND SHIGELLA

1-Both are gram negative rods
2-Both are Non-lactose Fermenter
3-Both are Oxidase negative
4-They can invade the G.I tract via M cells of Peyer patches.

LAB DIAGNOSIS OF SALMONELLA:-

1-Stool and Bone Marrow Cultures are +ve in Enteric Fevers
2-No lactose Fermentation on EMB or MacConkey medium
3-Alkaline Slant and Acid Butt on TSI with Gas and H2S production except S.typhi which form
only H2S not Gas.
4-Slide Agglutination
5-Widal Test ----->Serology test----->an agglutination testwhich detects the presence of serum
agglutinins (H and O) in patients serum with typhoid and paratyphoid fever

DIAGNOSIS OF SHIGELLA
1-No Lactose Fermentation on EMB agar or MacConkey medium
2-On TSI------>Alkaline Slant and Acid Butt with No gas and No H2S
3-Slide Agglutination----->Confirmatory
SALMONELLA VS SHIGELLA
2-PSEUDOMONAS AERUGINOSA
GENERAL FEATURES
1-Gram negative aeorbic, motile opportunistic rod.
2-Does not Ferment Lactose
3-Oxidase Positive
4-Produce pyocyanin (blue Green Pigment) and Pyoverdin.
5-Has Grape Like Odor.
6-Has Injectosome (Third Secretion system)
7-Mucoid Polysaccharide capsule (Biofilm formation) -- Cause of pneumonia in Cystic fibrosis
patients.

PATHOGENESIS
1-Produce Endotoxin-----Shock and Fever
2-Produce Exotoxin A-----It inactivates EF-2 thus inhibit protein synthesis
3-Produces Phospholipase C ----- Degrades Cell membrane
4-Produce Pyocyanin ----Generates ROS.

ASSOCIATIONS OF PSEUDOMONAS

Can be Remembered by word PSEUDOMONAS

1-Pneumonia (Ventilator associated ) and Pigments like Pyocyanin
2-Sepsis
3-Ecthyma gangrenosum (Rapidly Progressive necrotic cutaneous lesions in
immunocompromised patients)
4-UTIs
5-Diabetes ,Drug use
6-Osteomyelitis (puncture wounds)
7-Mucoid Polysaccharide Capsule
8-Otitis Externa (Swimmer’s ear)
9-Nosocomial Infections (Catheters)
10-Exotoxin A
11-Skin Infections (Hot tub folliculitis )

It Can cause Corneal ulcers/Keratitis in Contact Lens Wearers /Minor eye Trauma.
LAB DIAGNOSIS
1-Non-lactose fermenting on EMB agar or MacConkey's medium
2-Oxidase +ve
3-On TSI agar------->Metallic sheen of growth ,coupled with blue-green pigment on nutrient
medium and a fruity aroma ===>Presumptive Diagnosis
4-Biochemical Test------>Confirmatory
 3-SLOW FERMENTER
VIBRIO
GENERAL FEATURES:-
1-Gram -ve flagellated comma Shaped .
2-Oxidase +ve
3-Grows in alkaline media
4-Sensitive to Stomach acid (Acid Labile)
5-Requires large inoculum (High ID 50) unless host has decrease gastric activity.

TRANSMISSION
Ingestion of contaminated water and uncooked food (raw shellfish).

PATHOGENESIS:-
Cholera toxin , an Enterotoxin---------Permanently activate Gs------Increase cAMP------
Massive Diarrhea

CLINICAL FINDINGS
Profuse diarrhea (Rice-Water Stool) .Thus patient Requires prompt oral rehydration.

LAB DIAGNOSIS
1-Oxidase Test +ve----->Distinguish it from Enterobacteriaceae
2-Non lactose Fermenting of EMB agar and MacConkey's Medium (Culture on Diarrheal stool)
3-Ferment Fructose
4-On TSI------>An Acid Slant and An acid Butt
5-Agglutination by polyvalent O1 or Non-O1 antiserum------>Confirmatory

OTHER IMPORTANT GRAM -ve ENTERIC BACTERIA

1-Helicobacter Pylori
2-Campylovactor Jejuni
3-Yersia enterocolitica
4- PROTEUS-PROVIDENCIA-MORGANELLA GROUP
1-HELICOBACTER PYLORI
GENERAL FEATURES
1-Curved Gram -ve Rod.
2-Flagellated (Motile)
3-Triple Positive i.e Oxidase +ve , catalase +ve and Urease +ve

PATHOGENESIS :-
Colonizes gastric antrum ---- Produces urease which converts urea to ammonia thus
neutralizing Acidic gastric environment----- Produce proteases------Duodenal ulcer and
Gastritis.
It is a risk factor for Peptic Ulcer Disease ,Gastric adenocarcinoma and MALT lymphoma.
Rarely found in blood.

LAB DIAGNOSIS
1-Gram Stained Smears of Biopsy specimen of Gastric Mucosa.
2-Urea Breath Test----->Radiolabeled urea is ingested------->Release of Radioactive CO2 reveal
Organism is present (Urea----->Ammonia +CO2)
3-Detection of H.Pylori antigen in stool

2-CAMPYLOBACTER JEJUNI
GENERAL FEATURES
1-Gram -ve Comma or S shaped (With Polar Flagella) Rod.
2-Oxidase Positive
3-Grows at 42°C temperature

TRANSMISSION:-
Fecal-Oral route.
Contact with infected animals

CLINICAL FINDINGS
Bloody diarrhea especially in Children.
May Cause GBS and Reactive Arthritis (Autoimmune Reactions)

LAB DIAGNOSIS
1-Stool specimen Culture on blood agar containing antibiotics----->Incubation at 42°C in
microaerophilic atm. Containing 5% O2 and 10% CO2 ------>C.jejuni will not grow at 25°C ,and
Is Oxidase +ve and Sensitive to Nalidixic Acid
2-Blood Culture----->Comma or S shaped motile Gram Negative Rod.
3-C.intestinalis ----->Grow at 25°and is Resistant to Nalidixic Acid.
4-Urease Test -ve

3-YERSINIA ENTEROCOLITICA
GENERAL FEATURES:-
1-Gram Negative rod.

TRANSMISSION
1-Pet feaces ,Contaminated Milk and Pork.

CLINICAL FINDINGS:-
Acute Diarrhea
Pseudoappendicitis (Right Lower abdominal pain due to mesenteric adenitis and / or termial
ileitis)

4-PROTEUS-PROVIDENCIA-MORGANELLA
GENERAL FEATURES:-
1-Gram negative Rod.
2-Motile

DISEASES :-
Pneumonia and UTIs

DIAGNOSIS:-
1-Swarming overgrowth on Blood Agar---->Makes Isolation Difficult------->Add Phenylethyl
Alcohol to Inhibit Swarming
2-Non-lactose fermenting on EMB agar or MacConkey agar.
3-P.Vulgaris and P.mirabilis Produce H2S which blanks Butt on TSI. But not byP.morganii and
P.rettgeri
4-P.mirabilis---->Indole -ve while All other are indole +ve

GRAM VARIABLE ROD

BACTERIA:-
Gardnerella Vaginalis

GENERAL FEATURES:-
1-Pleomorphic
2-Gram variable Rod

CLINICAL FINDINGS
Bacterial Vaginosis------Gray vaginal discharge with a fishy smell which is non painful.This js
associated with sexual activity .It is also characterized by Overgrowth of anaerobic bacteria in
the vagina .

LAB DIAGNOSIS:-
1-AMINE WHIFF TEST ---mixing discharge with 10% KOH enhances fishy odor
2-Clue Cell----Vaginal Epithelial cells covered with Gardnerella ---Stippled Appearance
along outer margin.