Mycobacteria

Mycobacterium tuberculosis

A. Introduction
Mycobacteria are straight or slightly curved rods, non-motile, non-encapsulated, whose staining
properties are acid-fast. M. tuberculosis and M. bovis are facultative intracellular, obligate
aerobe, human pathogens that cause tuberculosis.

M. tuberculosis is normally found in humans (and perhaps primates), whereas M. bovis occurs in
humans and cattle as well as in a number of other reservoirs. Both species can cause disease in
other animals when experimentally infected (guinea pigs, mice and others). Transmission of M.
tuberculosis is via respiratory droplet nuclei emanating from the respiratory tract of an infected
individual. M. bovis may be transmitted through the ingestion of raw milk (or dairy products)
from infected cows. M. tuberculosis was first discovered by Robert Koch in 1882.

B. Tuberculosis (Consumption, Phthisis): Disease and Pathogenesis

1) Primary Tuberculosis.
After inhaling respiratory droplets containing M. tuberculosis, the initial infection is typically
located in a well aerated, peripheral zone of the lung. There is an early localized exudative
response by the host: PMN infiltration, edema, fluid within alveolar spaces. The bacteria are
phagocytized by PMNs but the phagolysosomal fusion is prevented and the bacteria multiply
within the cytoplasm. This is followed by a productive lesion which typically results in
granuloma formation, a reaction thought to be caused by the host's hypersensitivity to M.
tuberculosis antigens. Upon contact with M. tuberculosis, the macrophages form epitheloid
cells and some of these cells may fuse to build Langerhans giant cells (with dozens of nuclei in
the periphery and central bacilli). The granuloma also contains peripheral lymphocytes,
macrophages, and fibroblasts and is referred to as a tubercle. The center of the tubercle
undergoes a characteristic caseous necrosis (caseous=cheesy). Often the bacilli are carried to
the lymph vessels and draining lymph nodes and typically form a granulomatous lesion. The
pulmonary focus (infection site) and the granulomatous lesion in the hilar lymph node are called
the primary complex (Ghon complex). The caseous lesions may heal by fibrosis and
calcification and can be detected on chest X-rays for a lifetime. These calcified areas harbor
viable M. tuberculosis bacteria for life.

The host's defense of an M.tuberculosis infection rests entirely on cell mediated immunity
(CMI). Antigen-sensitized T cells are thought to stimulate alveolar macrophages (via -
interferon, macrophage activating factor), which phagocytize and digest the bacteria.
Occasionally, the host fails to mount an adequate immune response and the bacteria multiply
unrestricted in the lung and, by hematogenous dissemination, in every organ or tissue (miliary
tuberculosis).

2) Reactivation (Post-Primary) Tuberculosis

Most tuberculosis is secondary to reactivation of calcified lesions leftover from primary
tuberculosis. Endogenous reactivation can be caused by waning cell mediated immunity (CMI).
The caseous lesion undergoes liquefaction thereby forming a cavity and breaking into a
neighboring bronchus (cavern). Intra-pulmonary spread of the bacteria can be caused by
aspiration into other parts of the lung. Rupture of a caseous lesion into a pulmonary vessel may
cause both bleeding into the cavity (hemophtisis=blood coughing) and hematogenous spread of
the bacteria with miliary tuberculosis. Tuberculosis can manifest itself in every organ system
so that the symptoms and signs for disease vary correspondingly. The clinical onset of
tuberculosis is insidious with manifestations such as fever, cough, malaise, and weight loss.

3) Immune Response to Infection

Acquired Resistance (Koch phenomenon). Subcutaneous injection of guinea-pigs with M.
tuberculosis results in a nodule (after 10-14 days), which undergoes persistent ulceration. The
bacilli spread into the regional lymph nodes, which also undergo necrosis. A similar second
injection at another site results in a violent, faster but also more circumscript response. The
same response can be obtained when a culture filtrate (Tuberculin test) is used for the second
injection instead of viable M. tuberculosis. Although a humoral immune response to
mycobacteria is mounted by the host, these antibodies do not cause killing or complement
mediated lysis of the bacteria. In contrast, cell mediated immunity to reinfection can be
transferred to a non-immune individual with viable lymphoid cells. Cell mediated immunity
requires activated macrophages.

Mantoux (Tuberculin) test. Delayed-type hypersensitivity develops 1 month after human

infection with M. tuberculosis. The reactivity generally persists for many years, even life. A
positive reaction thus documents a previous infection, however, it does not reveal the state
of the disease. A negative reaction may be the result of anergy during disseminated or non-
disseminated disease. Since anergy is often temporary, one should repeat the tuberculin test at a
later time. Important clues as to the origin of anergy (age of the patient, other infections - HIV,
anergy to other CMI tests, steroid therapy) may come from the patients history and the clinical
condition of the patient.

Tuberculin
old tuberculin: autoclaved culture, 10 fold steam concentrated, filtered, glycerol preservative
purified protein derivative (PPD): repeated 50% ammonium sulfate precipitation of old
tuberculin (protein mixture).
- intradermal injection of 0.1 ml of PPD into the skin of the forearm (Mantoux test)
- average diameter of induration is measured after 48 h
positive: 10 mm or more induration
weak reactions: 4-9 mm induration (often infected with other pathogenic mycobacteria)
negative: induration smaller than 10 mm
standard or intermediate strength: 5 tuberculin units or 0.1 ug PPD
first strength: five fold lower (in case overreaction is suspected)
second strength: 20-50 times more than standard (in case anergy is suspected)

4) Tuberculosis and HIV Infection

A reason for the global resurgence of tuberculosis has been the incidence of HIV infection and
AIDS. Tuberculosis can manifest itself as primary but more often as post-primary disease. Of
particular importance is the development of mycobacteria with multiple drug resistance in HIV
patients, with most strains resistant to rifampin, isoniazid, and streptomycin.

C. Microbial Structure and Molecular Pathogenesis

Microbial Structure. M. tuberculosis typically appear as 2-4 µm long and 0.2-0.5 µm wide,
slightly bent rods. Often the bacteria appear irregularly shaped and they may grow in serpentine
cords. The fastes doubling time observed for M. tuberculosis is 12 h (compared to 20 min for E.
coli). Therefore, M. tuberculosis is a very slow grower in man and in culture. M. tuberculosis
cells have a single cytoplasmic membrane and are surrounded by four different surface layers
and an electrontransparent zone, each of which can be distinguished by electronmicroscopy and
by their molecular structure.

Peptidoglycan Layer. The mycobacterial peptidoglycan consists of the typical glycan

(GlucNac-MurNac units) and wall peptides (D-Ala-D-isoGlu-DAP-D-Ala), which contain
diaminopimelic acid (DAP) instead of lysine. The DAP undergoes crosslinking with the D-Ala
of neighboring wall peptides. In the peptidoglycan layer are also cell wall associated and cell
wall linked proteins, which cause humoral immune responses in infected individuals. Embedded
in the membrane and extending into the peptidoglycan layer are mannophosphoinosides, i.e.
membrane anchored glycolipids.

Arabinogalactan Layer (L3). The arabinogalactan is covalently linked to both the

peptidoglycan (phosphodiester linkage to MurNac) and the mycolic acid layer. It constitutes
approximately 35% of the cell wall mass of mycobacteria and is the most predominant
immunogen upon infection. Arabinogalactan is a polymer of D-arabinose and D-galactose with
all sugars in furanosyl configuration.

Mycolic Acid and Mycocerosidic Acid Layer (L2). This layer forms a second lipophilic
compartment in the cell wall of mycobacteria. Mycolic acids and mycocerosidic acids are
covalently linked to the arabinogalactan layer . They consist of -alkylated, -hydroxyl long-
chain saturated fatty acids. Several different classes of surface molecules are thought to be
anchored in this layer via hydrophobic interaction.

Surface Layer (L1)

1) Lipoarabinomannan. This group of molecules is anchored in the cytoplasmic membrane via
inositol phosphate membrane anchors similar to those occurring on the surface of eukaryotic
cells. The polysaccharide portion (D-arabinose-D-mannose) extends all the way to the surface
of the bacteria (through layers L1 and L2) and is immunogenic during infection.
2) Sulfolipids (Sulfatides). (Trehalose 2' sulfate esterified with long chain fatty acids) These
molecules are anchored via hydrophobic interaction in the mycolic acid layer (L2). They are
immunogenic during infection and are thought to be a virulence factor that prevents
phagolysosomal fusion.
3) Cord Factor. (6,6'-dimycolyltrehalose) The cord factor is also anchored in the L2 layer and
extends to the surface. It is thought to inhibit the migration of PMNs and is lethal upon injection
into mice. Cord factor is also thought to be responsible for the serpentine, cord like appearances
of mycobacteria.
4) Lipooligosaccharides (LOS). These are trehalose containing lipooligosaccharides which can
be decorated with a wide variety of different sugars resulting in strain specific antigenic diversity
of mycobacteria.
5) The Electrontransparent Zone: Glycopeptidolipids (GPL). These molecules have
originally been named C-mycosides and they consist of short peptides (D-alloThr-D-Ala-L-Ala)
which are acylated with fatty acids and anchored in the L2 layer. The peptides are also
glycosylated with a wide variety of different sugars chains. These structures represent the
electrontransparent zone that surrounds mycobacteria inside the phagosome and may be
instrumental in preventing phagolysosomal fusion.
Molecular Pathogenesis
M. tuberculosis often produces chronic asymptomatic infections. The bacteria enter and survive
indefinitely inside macrophages, thereby sustaining chronic infection. In response to poorly
understood cues, the bacteria proliferate and escape the macrophages, resulting in active
tuberculosis in a subset of infected individuals. The survival of M. tuberculosis inside
macrophages appears to result from:

- resistance to oxidative killing

- inhibition of phagosome-lysosome fusion
- resistance to lysosomal enzymes (mycobacterial surface structures)

Although numerous molecular structures of M. tuberculosis have been characterized it has so far
been impossible to identify their specific functions in bacterial virulence. The reason for this
slow progress is that bacterial genetics of mycobacteria is not as advanced as other systems.
Nevertheless, the common theme of mycobacterial virulence is that protein antigens, in contrast
to gram-negative and gram-positive bacteria, do not play a predominant role as virulence factors.
Glycolipid molecules, specific for this class of bacteria, may be responsible for their
characteristic survival inside of human macrophages.

Host Factors in Pathogenesis

Of all people infected with M. tuberculosis only some individuals develop disease. There appear
to be a number of unknown host factors promoting disease in the presence of bacteria, which can
be illustrated by the Lubeck accident. In 1930 a tragic accident occurred in Lubeck Germany:
251 children were inoculated with the same dose of virulent M. tuberculosis instead of BCG.
All children were tuberculin negative at the outset and

- 77 developed fatal disease

- 127 developed radiological primary complexes that healed
- 47 showed no sign of disease

Some ethnic groups appear to be more susceptible to tuberculosis than others. The prolonged
presence of the disease in some groups (e.g. Caucasians) seems to correlate with their increased
resistance. In the United States, the most susceptible groups are American Indians, Blacks, and
Eskimos. Socioeconomic factors, however, play a role as well, since they contribute to
malnutrition, lack of health care, and the prevention of bacterial spread. As a rule of thumb,
malnutrition (reduced protein), overcrowding, stress, age (infants and elderly),
immundeficiency, and silicosis are all factors that promote the disease.

D. Laboratory Diagnosis
The diagnosis generally results from clinical evaluation, chest X-ray, tuberculin test, and
laboratory findings. A definitive diagnosis, however, can only be made by culturing the
organism from a specimen. Specimen are therefore inoculated onto media and stained for acid-
fast bacilli at the same time.

The stain of Ziehl-Neelsen is generally used. The specimen is steamed in Carbolfuchsin for 3
min and subsequently washed in ethanol-3% HCl, which decolorizes other bacterial species.
Mycobacteria resist the destaining and are considered Ziehl-Neelsen positive, acid-fast (red).
Specimens like sputum, urine, gastric washings, and cerebrospinal fluid may be stained for acid-
fast bacilli. The same specimen can also be investigated by immunofluorescence with specific
antibodies, although this technique is not as reliable.

Specimens are inoculated onto specific media. This requires prior treatment with 2% NaOH
and N-acetyl-L-cysteine (liquefaction) to decontaminate the specimen. Lowenstein-Jensen or
7H10 agar (egg yolk-potato or albumin-oleic acid combined with malachite green) promote
growth over 2-8 weeks at 37oC incubated aerobically. The colonies appear dry, wrinkled,
cream-colored (reminiscent of fungi-mycobacteria). In contrast to M. bovis, M. tuberculosis is
niacin positive.

MLST and genome sequencing is used for epidemiological analysis of M.tb..

Lowenstein-Jensen Biochemical Reactions Pathogenic for

Culture

Species Time* Colony Niacin Pyrazin- Nitrate

morpholog amide reduction
y

M. 3-4 weeks dry, cauli- positive sensitive positive man,primate,

tuberculosis lower like guinea-pig
M. bovis 3-4 weeks smooth, negative resistant negative cattle,man, primate,
flat, wet, guinea-pig, rabbit
shiny

Time* required for the appearance of macroscopic colonies

Niacin test: presence of niacin in the culture

Several rapid test are available to aid in the diagnosis. These include serological and molecular
biological techniques (PCR), which can demonstrate the presence of characteristic antigens or
DNA sequences in a given sample.

E. Treatment. The principal strategy for controlling tuberculosis is prevention! New cases
must be identified quickly and sufficiently treated. The contacts of infected individuals must be
identified and tested by Chest X-ray and skin test. Infected individuals without disease
symptoms (latent disease) are treated INH & rifapentine.
Screening tests for infection and disease: 1) Chest X-ray 2) tuberculin test 3) blood test
(IFN-gamma release assay)
Chemoprophylaxis is performed with isoniazid (INH) for 9-12 months

Drug Therapy:
first line oral drugs: isoniazid (INH), rifampicin (RIF), pyrazinamide (PZA), ethambutol
(EMB)
injectable drugs: streptomycin, amikacin, kanamycin, capreomycin
second line oral drugs: ofloxacin, ciprofloxacin, ethionamide (ETH), aminosalicylic acid,
cycloserine

Standard drug therapy is a multiple drug therapy and employs isoniazid (300 mg/diem) and
rifampicin (600 mg/diem) for 9 months. During the first two months pyrazinamide (PZA) and
ethambutol (EMB) are added. Successful therapy results in negative sputum test (sputum
conversion) after three weeks and a cure rate of 95% can be accomplished.

The reason for multiple drug resistance (MDR) in M. tuberculosis inadequate treatment!
(e.g. monotherapy, insufficient dose, omission of drugs, insufficient number). MDR occurs first
in patients with previous insufficient treatment and subsequently spreads to contacts.
Retreatment or treatment of patients with MDR tuberculosis should be carried out in specific
programs that are equipped to monitor resistance, treatment, and progress of the disease.
Typically, a regimen with 7 drugs is applied and a long term cure rate of 56% can be
accomplished. In patients with AIDS who are infected with MDR M. tuberculosis, the disease
may be lethal before effective therapy can be implemented. Resectional surgery can aid in the
therapy of MDR tuberculosis.

Streptomycin was the first drug to be found effective against tuberculosis. It was discovered by
Schatz and Waksman at Rutgers University in cultures of Streptomyces griseus. PAS
(paraaminosalicylic acid) was discovered by Lehmann in Sweden and it was designed to inhibit
the growth promoting effect of aspirin on M. tuberculosis. Isoniazid was found in several
laboratories independently, but these investigations were based on previous work on the anti-
mycobacterial effect of thiosemicarbazones (Domagk in Germany).

Streptomycin inhibits ribosomal protein synthesis of mycobacteria; bacterial resistance occurs

very frequently. RIF inhibits mycobacterial RNA polymerases. INH, ETH, PZA and EMB
inhibit mycolic acid synthesis. Resistance mechanism for INH, ETH and PZA involve recessive
mutations in the genes for enzymes that activate these antibiotics or mutations in the gene for the
enzymatic target.

Drug Activity
isoniazid bactericidal for intra- and extracellular bacteria
rifampicin bactericidal for intra- and extracellular bacteria
pyrazinamide bactericidal only for intracellular organisms
streptomycin bactericidal only for extracellular organisms
ethambutol bacteriostatic for intra- and extracellular organisms

F) M. bovis
Tuberculosis in cattle is caused by M. bovis, which is also virulent for man. The infection
occurs by the ingestion of contaminated milk and diary products. Pasteurization of all milk and
the slaughter of all tuberculin positive cattle has eradicated the disease in the United States.
 Typically, the bacteria penetrate the oropharynx or intestine and the first lesions appeared in
lymph nodes of the neck or mesenterium. The lesion of cervical lymph nodes (scrofula) was
characteristic. The disease would progress to predominantly infect bones and joints. Infection
of vertebrae results in their collapse and the development of a hunchback (Pott's disease).

G) Vaccination
A bovine isolate was passaged several hundred times on bile-containing media resulting in an
attenuated strain (Bacille Calmette-Guerin BCG). This strain has been extensively used for
vaccination and resulted in 70% protection for 5-10 years against severe tuberculosis (meningitis
and military tuberculosis) without affecting infection rates and lung tuberculosis. Only
tuberculin-negative individuals are vaccinated, which generally results in a conversion of the
skin test (this is a disadvantage because it does not indicate infection). The widespread BCG
vaccination has been abandoned in the United States.

Mycobacterium leprae – Leprosy

Worldwide, there are an estimated 2 million persons with leprosy. Leprosy is endemic in Asia,
Africa, Latin America, and the Pacific; Africa has the highest disease prevalence, and Asia has
the greatest number of cases. Except as imported cases, leprosy is virtually absent from Canada,
northern and western Europe, and the United States. In the United States, there were 219 cases in
2009, mostly immigrants from Mexico, Southeast Asia, the Philippines, and the Caribbean.

Distribution of leprosy within endemic countries is very nonhomogeneous, and even adjacent
villages may have striking differences in disease prevalence. Likely genetic factors play a role in
disease expression, as HLA-DR-3 has been associated with tuberculoid disease, HLA-MTI with
lepromatous leprosy, and a concordance between disease prevalence and type has been
demonstrated in monozygotic twins but not in dizygotic twins. Residence in an endemic country
imposes a greater risk of disease than that posed to household contacts in nonendemic locales.
The disproportion of the polar forms of leprosy varies widely in different populations: In India
and Africa, 90% of patients are tuberculoid, and in Southeast Asia 50% are lepromatous and
50% tuberculoid, whereas in Mexico 90% are lepromatous. It is entirely unclear whether these
differences are a result of hereditary predisposition, prior mycobacterial contact and consequent
immunity, or even route of transmission. The mode of transmission of leprosy remains
uncertain. The most commonly held view is that it is spread from human to human, primarily as
a nasal droplet infection. The incubation period for leprosy is uniquely long among bacterial
diseases, a minimum of 2 to 3 years, averaging 5 to 7 years, and can be as long as 40 years or
more.

Tuberculoid, Borderline and Lepromatous Leprosy

The form of leprosy is important in predicting disease complications, reaction states likely to be
encountered, and intensity and duration of required chemotherapy. Clinical manifestations of
leprosy are largely confined to the skin, upper respiratory system, eyes, testes, and peripheral
nerves. Most of the serious sequelae are a result of M. leprae's having unique tropism for
peripheral nerves. Small nerve fibers are most commonly functionally impaired, resulting in loss
of fine touch, pain, and hot and cold sensation; position and vibration sense are generally
maintained. Both major nerve trunks and microscopic dermal nerves may be affected in leprosy
patients, the most common nerve trunk impairment being the ulnar nerve at the elbow, leading to
clawing of the fourth and fifth fingers, loss of dorsal interosseous musculature, and loss of
sensation of the hand in the ulnar distribution. Nerve damage appears to result from either
bacterial multiplication within Schwann cells or granulomatous damage to the perineurium. Loss
of protective sensation in the feet may result in troublesome, recurrent plantar ulceration.

On one pole of the leprosy spectrum is the patient with lepromatous leprosy. These patients have
symmetric skin nodules, plaques, and a thickened dermis. Because M. leprae grows best at low
temperatures, the cool areas of the body, such as the ear lobes, are commonly affected. The
warmer areas—the scalp, axilla, groin, and midline of the back—are generally spared.
Lepromatous leprosy patients may have loss of eyebrows, especially the lateral portions, and at
times eyelashes and body hair. In untreated lepromatous leprosy, organisms can be detected in
sputum, and a high-level afebrile continuous bacteremia is frequently found, which may be so
profuse that organisms are found in stained smears of peripheral blood “buffy” coats. In
lepromatous patients, the upper respiratory system, particularly the nasal mucosa, are infiltrated
with organisms, leading to chronic nasal congestion. In the preantibiotic era and occasionally
even today, this process may extend to the nasal cartilage, leading to septal collapse and a
“saddle nose” deformity. Peripheral neuropathy in lepromatous patients, when present, is often
generalized and symmetric and frequently is associated with distal anesthesia of the hands and
feet.

Tuberculoid leprosy represents the other pole of the leprosy spectrum. Patients with tuberculoid
leprosy have one or a few hypopigmented anesthetic plaques with distinct, often elevated and
erythematous borders. Skin lesions are often dry, scaly, and anhydrotic. Lesions may vary in size
from a few to many centimeters in diameter. At times, lesions may not manifest hypoesthesia.
Large and pathologic asymmetric peripheral nerve trunk involvement, often spatially associated
with skin lesions, is found in tuberculoid leprosy. At times, patients may have large and
functionally impaired nerve trunks (generally only one) without skin lesions, as the sole
manifestation of tuberculoid leprosy. Tuberculoid leprosy, unlike lepromatous leprosy, does not
result in upper respiratory signs and symptoms. At times, tuberculoid leprosy heals
spontaneously.

The majority of leprosy patients have manifestations intermediate between the two polar forms
of leprosy, a condition termed borderline leprosy, which does not heal spontaneously.
Depending on whether these manifestations are closer to the tuberculoid pole or lepromatous
pole, they are classified borderline lepromatous (BL) or borderline tuberculoid (BT).

Eye Involvement
In lepromatous leprosy, the anterior chamber of the eye is invaded by M. leprae, causing an
uveitis. These may result in glaucoma and cataract formation. Eye involvement in leprosy is also
a consequence of corneal insensitivity, resulting in “beaded” corneal nerves, which leads to
trauma (trichiasis), secondary infection, and scarring. In addition, lepromatous leprosy is
associated with loss of eyebrows and eyelashes.

Diagnosis
Clinical symptoms and signs as well as histologic picture (acid fast bacilli) of tissue samples or
blood smears. M. leprae can be grown in vivo in the nine banded Armadillo, but not in
laboratory media. Thus, there is no clinical microbiological diagnosis.
Therapy
Between 1943 and 1970, sulfone monotherapy, particularly dapsone, was the only treatment
employed to treat all forms of leprosy. Currently established agents used to treat leprosy include
dapsone, clofazimine, and rifampin. Also, ethionamide and prothionamide, as well as certain
aminoglycosides (streptomycin, kanamycin, amikacin, but not gentamicin and tobramycin) have
been used. Unfortunately, the requirement of aminoglycosides for intramuscular administration
and the long-term therapy required for leprosy make them impractical for most developing
countries where leprosy is endemic. Very recently, antimicrobials from three classes of
antibiotics, each of which appears more bactericidal than dapsone and clofazimine, have been
found promising for the treatment of leprosy. Minocycline is consistently bactericidal for M.
leprae in a clinical trial in lepromatous leprosy, 100 mg daily resulted in very rapid and
consistent clinical improvement as well as rapid clearance of viable M. leprae from the dermis.
Clarithromycin appears bactericidal for M. leprae and effective in clinical trials. Finally,
fluoroquinolones appear bactericidal for M. leprae.

ACTINOMYCES AND NOCARDIA

General
Actinomyces and Nocardia can appear as beaded Gram positive rods that may resemble fungi.
Therefore, they are sometimes referred to as “actinomycetes” (used here as a descriptive term).
The term Actinomycetes is also used as taxonomic order and includes Corynebacterium and
Nocardia , but not Actinomyces. Actinomyces belongs to the taxonomic order of anaerobic
Gram positive rods. Genera of the Actinomycetes group like Corynebacterium and Nocardia
contain mycolic acid in their cell wall, whereas Actinomyces does not.

The medically most important species are Actinomyces israeli, the cause of actinomycosis, and
Nocardia asteroides and brasiliensis, the causes of nocardiosis.

Actinomycosis
Definition
A chronic, suppurative disease caused by A. israeli that spreads mainly by direct extension to
form draining sinuses. Three main forms are recognized: (i) cervicofacial, (ii) thoracic, and (iii)
abdominal/pelvic.

Microbiology
1. Most A. israeli are anaerobic. They may be microaerophilic.
2. Can be recovered from saliva, dental surfaces and tonsillar crypts as saprophytes.
3. In infected tissue, colonies often form dense masses known as "sulfur granules"; sulfur
granules may be discharged through draining sinuses.

Pathogenesis
Infection often follows traumatic or surgical disruption of a mucosal barrier (e.g., tooth
extraction, perforated appendix).
Thoracic actinomycosis follows aspiration of infected oral debris in patients with gingival
disease.
Pelvic actinomycosis occurred in women using IUD's.
 Actinomyces

mucous membranes etc.

host tissue

associated bacteria: abscess

Fusobacterium, Eikanellaodens,
corr
Capnocytophaga, Actinobacillus,
Prevotella, Porphyr
omonas,
Pathogenesis of Actinomycosis

Clinical Picture
Cervicofacial - usually slow, growing, painless fluctuant mass in lower mandible.
Thoracic
Constitutional symptoms such as fever, weight loss, cough.
X-rays reveal chronic, necrotizing infiltrate that spreads across anatomic boundaries; can
simulate cancer.
Diagnosis may be delayed until obvious extrapulmonary extension has occurred.

Abdominal and Pelvic

Preceding abdominal perforation (may be subclinical), surgery, or both.
Abdominal most common in ileocecal area.
Mass created by bowel trapped within inflammation can simulate cancer; eventually may drain
through abdominal wall or retroperitoneally.
Diagnosis Biopsy. Methylene blue or gram stain of pus; identification of sulfur granules.
 Sulfur granules
Culture for at least 2 weeks anaerobically.
Cultural confirmation may be difficult and require multiple attempts.
Treatment
Prolonged antibiotic therapy with penicillin (doxycycline and clindamycin are alternatives).
Surgical drainage and excision also are important.

Nocardiosis
Introduction
In the United States, nocardiosis is primarily a disease of immunocompromised patients which
presents as a pulmonary infection with a propensity for dissemination, particularly to the central
nervous system. In tropical countries, nocardiosis usually presents as a chronic, cutaneous
infection resulting from skin inoculation (mycetoma).
Microbiology
Nocardia are aerobic, weakly gram-positive, partially acid-fast, filamentous bacteria.
They grow poorly on antibiotic-containing media usually used for fungi; must alert the clinical
lab to the possibility of Nocardia so that specimens are cultured on bacteriologic media and held
for an appropriate period.
Recovery from clinical specimens may require up to 4 weeks. Subcultures grow quickly.
Pathogenesis
Pulmonary - Nocardia asteroides
Occurs via inhalation; majority of patients are immuno-compromised with defects in cell
mediated immunity (e.g., systemic lupus erythematosus patient taking corticosteroids).
Systemic dissemination often follows pulmonary infection with cerebral involvement
characteristic.
Cutaneous - Nocardia brasiliensis
Cutaneous inoculation of soil containing organisms. No immune defect required.

Clinical Disease
Pulmonary nocardiosis
An acute, subacute, or chronic necrotizing lung infection.
X-rays often show nodules which go on to cavitate.
May extend into contiguous structures or disseminate to virtually any organ; involvement
usually takes the form of one or more abscesses.
Cutaneous usually presents as a chronic skin infection characterized either by slow extension
along lymphatics or by destruction of deeper tissues ("Madura foot").

Diagnosis: Aggressive specimen collection. Gram and modified acid fast strains of pus or biopsy
specimens. Must communicate suspicion to clinical laboratory.

Therapy
Improve patient's immune status, if possible (e.g., taper steroids). Prolonged antibiotic therapy.
Sulfonamides are the drugs of choice. Surgery may be an important adjunct.