Gram + Bacilli of Medical Importance

Bacillus
Characteristic
• Gram-positive, endospore-forming, motile rods
• Mostly saprobic (environmental organism)
• Aerobic and catalase positive
• Versatile in degrading complex macromolecules.
• Source of antibiotics (produced antibiotic) by Bacillus subtilis
• Primary habitat is soil.

2 species of medical importance:

• Bacillus anthracis cause anthrax
• Bacillus cereus cause food poisoning

Robert Koch & Bacillus anthrax

• Robert Koch worked with for his postulates and used to prove germ theory – germs are the
cause of many diseases.

Virulence factors –
• Encapsulated for protection.
• Exotoxins production
• spore-forming (Except in living body)
• facultative anaerobe (can grow with/without oxygen)

Bacillus anthracis – bacteria responsible for anthrax

Occurrence:
• Most case occur in herbivores from Africa, Asia, Haiti, and Middle Eastern countries.
• Products from these animals may contain spores.
• 20k-100k human cases:
o In U.S., less than 10 human cases/year due to effective control measures but epizootic outbreaks occur
regularly.
• Vaccination of workers involved in the industrial processing of imported animal products and the decline in using
fibers of animal origin à has helped prevent exposure to spores.

Control and Treatment –

• Antibiotics:
o treated with penicillin, tetracycline, or ciprofloxacin.
• Vaccination:
o given live spores and toxoid vaccines to protect livestock against anthrax.
o given purified toxoid vaccine consisting of six inoculations over 1.5yrs + annual boosters to maintain immunity
for high-risk occupations and military personnel.

Clinical forms of anthrax

There are three clinical manifestations dependent on portal of entry:
1. Cutaneous Anthrax – spores enter through skin.
2. Pulmonary Anthrax – inhalation of spores.
3. Gastrointestinal Anthrax – ingested spores.
1) Cutaneous Anthrax:
o Spores enter skin through small cuts when handling animal hides or hair.
o SX: growth of microbe in skin causes a small papule that progresses to a black, swollen, crusty ulcer = eschar
o Can be fetal with toxemia and septicemia.

2) Pulmonary Anthrax – “Woolsorter’s disease”

o Inhaled spores germinate in the lungs.
à Vegetative cells grow and produce exotoxins.
à Resulting toxemia causing capillary thrombosis and cardiovascular shock
à Septicemia causes death within a few hours.
o Symptoms:
à Early symptoms: fatigue, malaise, fever, aches, and cough.
à Late symptoms: high fever, labored breathing, and shock.
o Diagnosis:
à Source of infection: cultured from soil, cutaneous lesions, respiratory tract, or blood (+/- of exotoxin)
à Antibiotic treatment: Ciprofloxacin – effective antibiotic against bacillus anthracis but does not counteract
the toxin (not neutralize the exotoxin produced by the bacteria)
à Vaccination: Toxoid (biothrax) administered to humans
à Preventative measures:
¨ Sterilization of hides, hair, and bone products of herbivorous livestock
¨ burn carcasses of livestock that die from anthrax to prevent environment spread.
¨ Administer immunization to susceptible hosts.

3) Gastrointestinal Anthrax
o Rarest form (Not been reported in U.S.
o Occurs in underdeveloped countries when food (milk, cheese, or meat) contaminated with spores is ingested.
o Exotoxins produced in the digestive tract causes necrotic lesion of ileum and/or large intestine.
o Fetal septicemia occurs within hours after the bacterium reaches the lymph and/or bloodstream.

Bacillus cereus – bacteria responsible for food poisoning

Type of bacteria:
• large, spore-forming bacterium
• gram-positive (thick cell wall, appears purple)
• A saprobe that lives in the soil (organism feeds on dead or decaying organic matter)

Characteristic:
• Cause of food poisoning due to contamination of food
• Bacillus cereus is a common airborne and dust-borne contaminant (easily spread through air or dust particles and
contaminate surface of food)
• This bacterium preferred cooked foods such as rice, potato, and meat dishes, where it can grow and produce
enterotoxin.

Symptoms: vomiting and diarrhea

Other infections it can also cause:

• Nosocomial infections
• Can be serious and leads to progressive pneumonia, fulminant sepsis, and central nervous system in the
immunosuppressed, IV drug users, and neonate.
 Clostridium
Characteristic:
• Common soil inhabitants
• Strict Anaerobe
• Catalase negative
• 120 species
• Oval or spherical spores produced only under anaerobic conditions
• Synthesize organic acids, alcohols, and exotoxins
• Cause wound infections, tissue infections, and food intoxications

Most common pathogenic species

¨ Clostridium perfringens
¨ Clostridium tetani
¨ Clostridium botulinum
¨ Clostridium difficile

Clostridial Food poisoning

¨ Clostridium botulinum – rare but severe intoxication usually from home canned food
¨ Clostridium perfringens – mild intestinal illness; second most common form of food
poisoning worldwide

Clostridium perfringens- Bacterium responsible for Clostridium gastroenteritis

• Cause Gas gangrene – bacteria invade tissue and produce gas as a byproduct of metabolism.
• Spores can be found in various environments: soil, human skin, intestine, vagina.

Acquisition/Predisposing factors:
• Wound types that can lead to infection include:
o surgical incision, puncture, gunshot wound, crushing trauma or a compound fracture, diabetic sore,
frostbite.

Two forms of infection:

• Anaerobic cellulitis – remains localized to a specific area.
• Myonecrosis –
o progresses into healthy tissue.
o endospores germinate in anaerobic environments, leading to intense pain with swelling and tissue death.

Virulence Factors:
• Toxins: Alpha toxin – causes RBC rupture, edema, and tissue destruction.
• Exoenzymes:
o Lecithinase dissolves cell membranes and releases toxic cellular enzymes.
o Collagenase breaks down collagen in connective tissue.
o Hyaluronidase degrades hyaluronic acid, helping bacteria spread through tissues.

Pathology:
• Vegetative cells produce virulence factors that kill & digest host tissues.
• Bacteria ferment CHO in necrotic tissues resulting in gases produced as result of fermentation.
(= CO2 + H2) may rip & tear tissues.
• Stench associated with gas gangrene is caused by the production of butyric acid.

Prevention and Treatment:

• Immediate cleansing of dirty wounds, deep wounds, compound fractures, and infected incisions
• Debridement of disease tissue to remove infected areas.
 • Administration of Large doses of cephalosporin or penicillin
• Hyperbaric oxygen therapy (provide oxygen in an anaerobic environment to enhance recovery)
• No vaccines available for prevention

Clostridial Gastroenteritis –
• Cause:
o Spores contaminate food that has not been cooked thoroughly enough to destroy spores.
o Spores germinate and multiply (especially if unrefrigerated)
• Symptom:
o When consumed, toxin is produced in the intestine, acts on epithelial cells, acute abdominal pain,
diarrhea, and nausea.
• Recovery: Rapid recovery following symptom onset.

Clostridium tetani – Bacterium responsible for Tetanus

• Common resident of soil and intestines of animals

• Not very invasive so doesn't get thru gut wall.
• Soil contaminated with feces (rarely human)
• Causes tetanus (lockjaw) – a neuromuscular disease.
• Most commonly among geriatric patients (old patient) and IV drug abusers; neonates in developing countries.

Mode of transmission:
• Introduction of spores usually through wounds or opening in the skin:
o puncture wounds
o I.V. drug use
o burn or frostbite
o crushed body part
o umbilical stump (in neonates).
o trivial injuries at risk (rarely)
• bacterium required anaerobic environment for grow and release toxin.

Pathology:
• Spore germination:
o Spores germinate in anaerobic wounds into vegetative cells.
• Toxin production:
o Vegetative cells produce TETANOSPASMIN (exotoxin - neurotoxin)
• Effect of Tetanospasmin:
o Tetanospasmin absorbed into motor neurons à migrates thru nerves to CNS à binds to neurons blocking
the release of inhibitory neurotransmitters like GABA (gamma-aminobutyric acid) and Glycine.
o This blockage leads to uncontrolled contractions of muscles, esp. affecting Masseter muscle (jaw) causing
lockjaw.

Treatment – aimed at deterring degree of toxemia and infection and maintaining homeostasis.
• Antitoxin therapy:
o Tetanus immune globulin is administered in human à inactivates circulating toxin but does not
counteract that which is already bound to nerve cells.
• Antibiotic:
o penicillin or tetracycline to control infection.
• Muscle relaxants: administered to reduce muscle spasms and contraction.

Prevention:
• Vaccine available (DTaP) is given at 2,4,6,15 months, booster needed every 10 years.
C. difficile – bacterium responsible for Clostridium Difficile-Associated Disease (CDAD)

Characteristic
• Normal resident of colon, in low numbers
• Causes antibiotic-associated colitis.
o Relatively non-invasive; treatment with broad-spectrum antibiotics kills the other bacteria, allowing C.
difficile to overgrow (superinfection)
• Produces enterotoxins that damage intestines.

Symptoms:
• diarrhea,
• Abdominal cramps
• Fever
• Patches of colon lining sloughs off (in severe case)

Risk Factors:
• It is a nosocomial disease (hospital-acquired)
• May be rise due to the use of gastric acid inhibitors (e.g., proton pump inhibitors) – to reducing stomach acidity
allow the bacteria to thrive.

Treatment:
• Mild uncomplicated cases respond to fluid and electrolyte replacement and withdrawal of antimicrobials.
• Severe infections treated with oral vancomycin or metronidazole and replacement cultures (replacement of normal
gut flora, for example, probiotics or fecal transplants).

Prevention:
• Increased precautions to prevent spread.
o Ex: hand hygiene, proper cleaning protocols, and the cautious use of antibiotics.

Clostridium botulinum- bacterium responsible for Botulism

Three manifestations of botulism

1. Foodborne botulism
o Death can result from asphyxiation.
2. Infant botulism
o Results from the ingestion of endospores
3. Wound botulism
o Contamination of a wound by endospores

Where? Found in soil, intestinal tract of herbivores and fish.

1. Foodborne botulism:
• Occurrence:
o Often associated with Poor canning processes or food not cooked sufficiently to kill spores.
o Vegetative cells can then produce neurotoxin (botulin) under anaerobic conditions.
o Commercial canning cases rare (< 100 cases in US annually).
o More common in low acid or alkaline foods.
o Toxin is destroyed by boiling (vigorously for at least 3 minutes).
• Pathology:
o Affects nervous system primarily ... specifically the NMJ (neuromuscular junction)
 o Usually an intoxication (caused by ingestion of the toxin) & NOT AN INFECTION which affects the
treatment approach.
o Absorbed neurotoxin blocks the release of ACETYLCHOLINE at NMJ
à Prevent muscle contraction, leading to Progressive flaccid paralysis.
à Can cause including respiratory and/or cardiac paralysis.
• Symptom (early sign):
o ptosis (drooping eyelids), blurred/double vision, difficulty in chewing/swallowing, dry mouth first SX.

2. Wound Botulism:
• C. botulinum spores contaminate anaerobic wound (e.g., puncture) and germinate.
• Vegetative cells produce exotoxin & cause wound botulism.
• May occur in neonate if cord is cut w/ unsterile instrument.

3. Infant Botulism:
• 1st recognized in 1976.
• BACTERIAL INFECTION.
• Spores from foods (raw honey) are ingested, germinate, and produce toxins (Neurotoxin) in the infant’s gut.
o Spores can germinate in infant’s intestines and the vegetative cells produce the neurotoxin.
• SX (symptom):
o 1st = inability of the baby to hold its head erect ("floppy baby syndrome")
o trouble suckling and swallowing.
o child's limbs become paralyzed.
o death can result from respiratory paralysis.

Treatment for Botulism:

o Determine presence of toxin in food, intestinal contents, or feces
o Administer antitoxin (to neutralize circulating toxins in the bloodstream) and provide cardiac and
respiratory support as needed.
o Infectious botulism treatment – treat with penicillin.
o Practice proper methods of preserving and handling canned foods; addition of preservatives.

Botox (Botulinum Toxin):

• Initial Medical uses:
o Initially used for crossed eyes and uncontrollable muscle spasms in neck
• Cosmetic use:
o Became “lunch hour face” lift before FDA approval.
• Surprising side effect: helped with headaches and migraines.
• Causes temporary paralysis in facial muscles to prevent wrinkles.
• Frequency of treatment: Repeat every 4-6 months
 Listeria monocytogenes – bacterium responsible for listeriosis
Characteristic
• Unencapsulated
• Locomotive structure: 1-4 Flagella
• It is not fastidious – can grow in a variety of condition.
• Resistant: tolerates cold, heat, salt, pH extremes and bile

Virulence Factors:
• Ability to replicate in the cytoplasm of cells after inducing phagocytosis; avoids being targeted
by humoral immune system.

Reservoir and Transmission:

• Primary reservoir is soil and water, animal intestines.
• Can contaminate foods and grow during refrigeration.

Disease (Listeriosis) –
• most cases associated with dairy products, processed meats, fresh produce is new.
• Often mild or subclinical in normal adults but can cause severe illness in:
o Immunocompromised patients
o Pregnant women
o fetuses and neonates
• affects brain and meninges.
o 20% death rate
• Acquired by eating contaminated food.

Symptoms appear up to 2 months:

• Fever
• muscle aches
• diarrhea
• other gastrointestinal symptoms

The disease can become “invasive,” spreading beyond the gastrointestinal system.

Listeria and pregnancy

• High risk groups: older adults, pregnant women, newborns, those with weakened immune system
o Pregnant women have mild flu-like symptoms; bacteria pass the placenta and causes:
à Miscarriage
à stillbirth, premature delivery
à or life-threatening disease in newborn
o Other than pregnant women have flu-like with headache, septicemia, meningitis.

Diagnosis:
• Identification of gram-positive bacillus in blood, CSF, amniotic fluid

Treatment:
• First-choice drugs for treatment: Ampicillin and trimethoprim-sulfamethoxazole (TMP-SMX)
• Follow-up treatment may include erythromycin.

The disease seems to be related to a suppressed immune system, occurring most often in the very young and elderly.

Prevention:
• Pasteurization of food product
• Cooking food thoroughly to kill the bacteria.
 Corynebacterium diphtheriae
Reservoir and Transmission
• Reservoir of healthy carriers; potential for diphtheria is always present (individuals who carry
the bacteria without showing symptoms, making them reservoir for the disease)
• At-risk Groups: Most cases occur in non-immunized children living in crowded, unsanitary
conditions.
• Transmission: bacteria are acquired via respiratory droplets from carriers or actively infected
individuals

2 stages of disease:
1. Local infection – upper respiratory tract inflammation
• Symptoms include:
o Sore throat
o Nausea
o Vomiting
o swollen lymph nodes
o Formation of pseudomembrane (thick layer of dead cells, bacteria WBC) can cause
asphyxiation.

2. Diptherotoxin production and toxemia

• Target organs – primarily affect heart and nerves.
• Function:
o The toxin inhibits protein synthesis (causing the signs and symptoms).
o The toxin is produced by bacteria in the throat, absorbed by mucous membranes
and distributed to other organs via the circulatory system.

Treatment:
• Antibiotic: Penicillin (PCN) or erythromycin
• Antitoxin (administering antitoxin can neutralize the diptherotoxin)
• Surgically open blocked airway or perform tracheostomy (In severe cases, surgery to open a
blocked airway may be require)

Prevention:
• DTaP vaccine, booster
 Mycobacterium
Characteristic
• Gram-positive irregular bacilli
• Acid-fast staining due to the presence of mycolic acids in their cell wall.
• Strict aerobes that require oxygen to survive
• Produce catalase (enzyme breaks down hydrogen peroxide
• Possess mycolic acids and a unique type of peptidoglycan
• Do not form capsules, flagella, or spores
• Grow slowly.

Important species:
¨ Mycobacterium tuberculosis
¨ Mycobacterium leprae

Mycobacterium tuberculosis – bacterium responsible for tuberculosis (TB)

• Commonly known as Tubercle bacillus

• Produces no exotoxins or enzymes that contribute to infectiousness.

Virulence factors:
• contain complex waxes and cord factor that prevent destruction by lysosomes or macrophages (allow it to evade
immune response).

Epidemiology:
• Predisposing factors include:
• inadequate nutrition, debilitation of the immune system, poor access to medical care, lung damage, and
genetics
• Bacillus very resistant; transmitted by airborne respiratory droplets.
• Global presence: an estimate 1/3rd of world population and 15 million in U.S. carry tubercle bacillus; highest
rate in U.S. occurring in recent immigrants.
• 5% to 10% of infected people develop clinical disease.
o Without treatment, the disease progresses slowly.
o Majority (85%) of TB cases contained in lungs.
• Can be asymptomatic or symptomatic.

Tubercle Formation:
• Granulomas (form in the lungs) with a central core of TB bacilli and enlarged macrophages surrounded by an
outer wall of fibroblasts, lymphocytes, and neutrophils.
• Can arrest the disease.
• Centers of the cores can break down and become necrotic, caseous lesions that gradually heal by calcification of
normal lung tissue.

Clinical tuberculosis divisions:

• Primary TB
• Secondary TB
• Extrapulmonary TB (disseminated)

Primary TB:
• Asymptomatic or run a mild fever for ~3-4 wks
• Infectious dose: as low as 10 cells!!!
• Once inhaled, TB Bacilli enter lungs, where neutrophils and macrophages attempt to phagocytize it.
 • Continue to live in phagocytes, reproduce and eventually kill them (the bacilli can survive within phagocytes,
reproduce, and eventually kill them)
• Tuberculin test = positive (+) if individual exposed to the bacilli, indicate infection.
• Many patients recover more or less completely from the primary episode of TB.
• Can lead to caseous lesions (cheese-like in appearance – a characteristic feature of TB infection).

Secondary TB
• Bacilli become dormant. (if primary TB is untreated, can lead to secondary TB)
o reactivated weeks, months, or years later
o Persons with weakened immune systems high risk
• Tubercles fill with masses of bacilli, expand and drain into the bronchial tubes and upper respiratory tract
• Gradually the patient experiences more severe symptoms:
o Violent coughing, greenish or bloody sputum, fever, anorexia, weight loss, fatigue.
• Untreated – 60% mortality rate

Extrapulmonary TB
• During Secondary TB, bacilli disseminate to regional lymph nodes, kidneys, long bones, genital tract, brain, and
meninges.
• Spreads to areas other than the lungs
• Untreated tubercular meningitis is invariably fatal, and even treated cases can have a 30% to 50% mortality
rate.

Diagnosis:
• Chest X –Ray
• TB Skin Test: Mantoux test
• PPD (= Purified tuberculin Protein Derivative) injected into skin à intense inflammatory response within 24-
72 hrs if positive.
• Type IV (Delayed) rxn if:
o Have
o been vaccinated against
o Have had TB.
• Not good in first 3-7 weeks of the disease

Management and Prevention

• 6-24 months of at least 2 drugs from a list of 11
• One pill regimen called Rifater (isoniazid (only target mycolic acid), rifampin, pyrazinamide)
• Vaccine based on attenuated bacilli Calmet-Guerin strain of M. bovis used in other countries
• MDR – TB – multidrug-resistant tuberculosis
• XDR-TB – extremely drug-resistant tuberculosis
o Resistant to isoniazid and rifampin

Mycobacterium leprae – responsible for leprosy (Hansen’s disease)

Characteristic:
• Gram (+) bacillus, slightly curved in shape.
• Aerobic and slow-growing
• Strict parasite (does not grow on artificial media)
o Globi – large packets of bacteria.
• Contains mycolic acid, contributing to its durability.

Leprosy – a chronic disease that begins in the skin and mucous membranes and progresses into nerves.
• Endemic regions throughout the world
• Mechanism of transmission is not fully verified, although it may involve:
o skin contact, vehicles, droplet nuclei
Virulence
• Not highly virulent (doesn’t easily cause disease), though factors like health and living conditions influence
susceptibility and the cause of the disease.
• May be associated with specific genetic marker.
• Macrophages phagocytize the bacilli, but a weakened macrophage or slow T cell response may not kill bacillus.
• Incubation period can range from 2-5 years (long); if untreated, bacilli grow slowly in the skin macrophages and
Schwann cells of peripheral nerves.

Leprosy occurs in two major forms:

• Tuberculoid leprosy (most common form)
• Lepromatous leprosy (Most severe and extensive but less common)

Tuberculoid:
• Discolored lesions
o skin = lighter than normal in dark-skinned persons
o Skin= reddish patches appearing in light-skinned individuals
• Shallow lesions, damage nerves resulting in local loss of pain reception.
• Relatively few bacilli and lepra cells (infected epithelial cells) are seen.
• Fewer complications and is more easily treated.

Lepromatous:
• Severe and extensive
o a deeply nodular infection that causes severe disfigurement of the face and extremities, widespread
dissemination
• Bacterium prefers less than body temperature (30ºC).
o Lesions occur on hands, ears, nose, face, and unclothed regions.
o Advanced cases have loss of feeling and tissues waste away in hand and feet due to loss of nerve
function.

Diagnosing:
• Combination of symptomology, microscopic examination of lesions, and patient history
• Numbness in hands and feet, loss of heat and cold sensitivity, muscle weakness, thickened earlobes, chronic
stuffy nose
• Detection of acid-fast bacilli in skin lesions, nasal discharges, and tissue samples

Treatment & Prevention:

• Treatment by long-term combined therapy
• Prevention requires constant surveillance of high-risk populations.
• WHO sponsoring a trial vaccine.

Historic Leper Colonies in US

• Hawaii – kalaupapa (on island of Moloka)
o Found in 1866 with isolation law, redacted in 1969.
• Cavalia – LA