By DR.
UMAIR Subject-MICROBIOLOGY
ZAMAN Theme-Gram Negative
Subtheme-Cocci
MBBS-CHPE-MPHIL
(Microbiology)
KMSMC- Sialkot
Learning objectives
Morphology
Pathogenesis /Virulence
Clinical manifestation /Symptoms
Diagnosis/Investigations
Treatment & Prevention
Case study 1
A 25 yrs old male presented to clinic with H/O
urethral discharge and sensation of burning on
urination. Clinician suspected UTI and advised
urine culture. Which was cultured on routine
Cultrure media ______________agar. No growth was
obtained.
What is Your Diagnosis?
What will be possibility of no growth on Media.
Case study 1
Further history Reveals Ureteral Discharge
Also positive sexual contact history
Gram staining of the urine sediment was done
which shows many pus cells neutrophil like with
Gram negative diplococcic both intra cellular and
extra cellular
What is Your Diagnosis?
Which Media Will you Use ?
What treatment you will start?
NEISSERIA
Introduction
The Neisseria are Gram Negative-ve
diplococcic (kidney bean shaped)
Pathogens are:- N. meningitides
N. gonorrhoeae
Special growth requirements (Fastidious)
OXIDASE POSITIVE
N. gonorrhoeae
Obligate parasite & Reservoir human urogenital
tract.
Culture:
Chocolate agar enriched media (lysed
RBCs),aerobic atmos +5% CO2.
Thayer-Martin medium contains vancomycin,
Colistin, nystatin & trimethoprim-Colonies: 48hrs
incubation.
Carbohydrate utilization: N. gonorrhea ferment
glucose only.
Selective media
Virulence factors / Pathogenicity
Pili
Attachment
Inhibit phagocytic uptake
antigenic
Endotoxin (Lipooligosaccharide)
Outer membrane protein
IgA protease –Aids in colonization and cellular uptake
Have no capsule
Invade mucosal surfaces and casue inflammation
Diseases & Complications
Causes Gonorrhoeae
Male
Urethritis, Epididymitis, Proctitis, Arthritis
Urethral stricture in males.
Female
Endocervicitis, PID-Pelvic inflammatory disease,
Salpingitis , infertility in females
INFANTS
Neonatal Ophthalmia - leads to blindness
Treatment -Silver Nitrate drops
Gonorrhoea
Acute pyogenic infection of urethra and (in
females) cervix.
Acute purulent urethral & vaginal discharge
Leukorrhea
Painful Urination Dysuria
Sexually active patients
Reiter’s Syndrome
Triad symptoms
Arthritis
Urethritis
Conjunctivitis
Diagnosis
Specimen: Urethral, cervical
smears & swabs (transport
medium).
Gram film: Intracellular Gram -
ve diplococcic in PMNs
neutrophils from urethral smear
Culture: Chocolate & Thayer
Martin medium
Treatment & Prevention
One curative dose Blind treatment of Ceftriaxone
Also Test for Chlamydia trachomatis or treat with
Doxycycline
Penicillin: resistance due to production of B-
Lactamases
TRASMISSION Sexual Contact & during Birth#
Prevention- Use of Condoms
SEQ
A 5 yrs old boy presented in emergency department
with H/O of high grade fever for three days, nausea,
neck stiffness.
Name the causative agent
Route of transmission
Pathogenesis and diagnosis
SEQ
On Investigation there is no growth on routine culture
media, but CSF Examination reveal Gram negative
diplococcic
Name the causative agent
Route of transmission
Pathogenesis and diagnosis
N. meningitides
Similar to N. gonorrhea but less fastidious can
grow on blood agar?
CHO utilization: Acid from glucose &
maltose.
Reservoir: human nasopharynx (10-25%)
Trasmsmiision- oropharangeal colonization
spreads to meninges via blood stream
Features N Meningitides N Gonorrheae
Portal of entry/Reservoir Resp tract Genital tract
capsule present absent
Fermentation Maltose+ glucose Glucose only
Beta lactamase production Some None
Vaccine Available Not available
Gram stain of Neisseria meningitis
Virulence factors
Polysaccharide capsule---antiphagocytic &
Antigenic
Endotoxin (Lipooligosaccharide)---- causes fever,
shock and features of meningococcemia
IgA protease--- helps attachment in oropharaxnx
Pilli and outer membrane help to colonize & invade
Factor H binding protein-act on complement
system C3b, immunogenic for group B meningococcal
Antigenic structure
Polysaccharide antigens
Three main groups A,B,C
Other groups Y,W135.
Grouping: slide agglutination with specific
antisera
Pathogenicity
Meningococcal meningitis, as a spread from
nasopharynx blood stream
meninges
in susceptible hosts.
Direct spread to meninges
Deficiency in late complements C5-C8
predispose to bacteremia
Clinical features
Meningitis
Meningococcemia(Fever, shock and petechial
rash)
(Waterhouse-Friderchsen syndrome)-Severe
form of meningococcemia (Ecchymosis, DIC, shock,
thrombocytopenia & adrenal insufficiency leads to
death.
Death from Waterhouse-Friderichsen syndrome
Diagnosis
Clinically: rapid deterioration of flu like illness,
Headache, neck stiffness, +ve kerning’s sign, fever,..
…
Culture- CSF + blood
CSF Gram Stain: WBC mainly PMNs , RBCs
Oxidase Positive
Latex particle agglutination test for capsule OR
CIE (Counter Immunoelectrophoresis)to identify
[Link] capsular antigen in CSF
Ferment Glucose & Maltose both
PCR
Neck rigidity
Treatment & Prevention
Start blind treatment Parenteral antibiotics
Ampicillin & Ceftriaxone with or without
Vancomycin.
Prevention
Capsular polyshacarides Vaccine
Unconjugated vaccine & Conjugated vaccine
Vaccine against Group B…. Containing factor H
binding protein
Prophylaxis of close contact rifampin or
ciprofloxacin
Commensal Neisseria
[Link], [Link], [Link],..
In mucous mem. Of mouth,nose, pharynx, less common in genital tract.
Differ. From pathogenic one:
grow in ordinary media( no CO2)
at room temp.
rough, pigmented
acid from a number of CHOs
Other causes of meningitis
Bacterial causes:
Three primary pathogens:
N. meningitidis, HI, [Link]
[Link] all ages
Haemophilus Influenza 2m-5y
[Link] all ages but more common in
adult with underlying illnesses.
Neonatal meningitis causing
bacteria
[Link] & other coliforms
Listeria
[Link] B
OTHER BACTERIASL CAUSES
After surgery or trauma
[Link]
[Link]
AFB chronic meningitis
Spirochaetes
Other Causes
Viral :EnteroVirus, Paramyxovirus, Herpes
viruses, adenoviruses, arboviruses.
Fungi: yeasts (Candida, Cryptococcus spp.)
Aspergillus spp.
Free living amoeba: Naegleria fowleri,
Acanthamoeba
Findings in CSF
Normal CSF:
Clear , colorless
0-5 lymphocytes
Sterile
150-450 mg /l protein
2.8-3.9mmol/l glucose
BACTERIAL TB VIRAL
Turbid Clear or slightly turbid Clear or slightly turbid
500-20,000 cells mainly 10-500 cells, mainly 10-500 cells mainly
polymorph Neutrophils , few lymphocytes( polys early) lymphocytes
lymphocytes
Bacteria in Gram stain AFB in Z-N stain Stool culture, or serology
Grow in LJ medium +ve
Markedly raised protein Moderately raised protein Normal or slightly raised
protein
Reduced or absent glucose Sugar reduced Normal glucose
Cerebral abscess
Clear or slightly turbid
Bacteria: S. milleri, Bacteroides, [Link].
Proteus(Causative bacteria)
0-500 mainly polymorphs
Often no organisms in CSF
Normal or raised protein
Normal glucose
Complication of meningitis
Death ( 30% with pneumococci,10% HI &
[Link].
Ventriculitis
hydrocephalus
Paralysis
Cerebral abscess..
Treatment of meningitis
Depends on age ,causal bacteria
Urgent, parenteral
Ceftriaxone
Neonates: amp+ gm (or ceftriaxone)
Sensitivity testing
Anti TB