microbiology - fundamentals of immunology infection

Fundamentals of Immunology Infection & Host ResistanceMaria Mirasol L. Tuano, MD, DPPSMicrobiology

Pathogenesis of Bacterial Infection: Introduction

The pathogenesis of bacterial infection includes:

– initiation of the infectious process

– the mechanisms that lead to the development of signs & symptoms of disease

Characteristics of bacteria that are pathogens include:

– transmissibility – adherence to host cells – invasion of host cells and

tissues – Toxigenicity– ability to evade the host's

immune system Many infections caused by bacteria

that are commonly considered to be pathogens are inapparent or asymptomatic .

Disease occurs if the bacteria or immunologic reactions to their presence cause sufficient harm to the person.

Definition of Terms Adherence (adhesion, attachment) - The process by which bacteria stick to the surfaces of host cells.

o Once bacteria have entered the body, adherence is a major initial step in the infection process.

Carrier - A person or animal with asymptomatic infection that can be transmitted to another susceptible person or animal. Infection - Multiplication of an infectious agent within the body.

o Multiplication of the bacteria that are part of the normal flora of the gastrointestinal tract, skin, etc, is generally not considered an infection;

o on the other hand, multiplication of pathogenic bacteria (eg, Salmonella species) even if the person is asymptomatic is deemed an infection.

Invasion - The process whereby bacteria, animal parasites, fungi & viruses

enter host cells or tissues and spread in the body. Non-pathogen – A microorganism that does not cause disease; may be part of the normal flora. Opportunistic pathogen - An agent capable of causing disease only when the host's resistance is impaired (ie, when the patient is "immunocompromised"). Pathogen - A microorganism capable of causing disease. Pathogenicity - The ability of an infectious agent to cause disease. Toxigenicity - The ability of a microorganism to produce a toxin that contributes to the development of disease. Virulence - The quantitative ability of an agent to cause disease.

o Virulent agents cause disease when introduced into the host in small numbers.

o Virulence involves invasion and toxigenicity

Identifying Bacteria That Cause Disease

Humans & animals have abundant normal flora that usually do not produce disease (but achieve a balance that ensures the survival, growth & propagation of both the bacteria & the host.

Some bacteria that are important causes of disease are cultured commonly with the normal flora

o eg, Streptococcus pneumoniae, Staphylococcus aureus

Sometimes bacteria that are clearly pathogens (eg, Salmonella Typhi) are present, but infection remains latent or subclinical & the host is a "carrier" of the bacteria.

It can be difficult to show that a specific bacterial species is the cause of a particular disease.

In 1884, Robert Koch proposed a series of postulates that have been applied broadly to link many specific bacterial species with particular diseases.

Koch's postulates: have remained a mainstay of microbiology; however, since the late 19th century, many microorganisms that do not meet the criteria of the postulates have been shown to cause disease.

Microbiology: Fundamentals of Immunology Infection & Host Resistance of 19

o Example: Treponema pallidum (syphilis) & Mycobacterium leprae (leprosy) cannot be grown in vitro

Koch's postulateso however, there are animal

models of infection with these agents.

o In another example, Neisseria gonorrhoeae (gonorrhea), there is no animal model of infection even though the bacteria can readily be cultured in vitro;

o Neisseria gonorrhoeae (gonorrhea) - experimental infection in humans has been produced, which substitutes for an animal model.

In other instances, Koch's postulates have been at least partially satisfied by showing bacterial pathogenicity in an in vitro model of infection rather than in an animal model.

Example: some forms of E coli- induced diarrhea have been defined by the interaction of the E coli with host cells in culture.

The host's immune responses also should be considered when an organism is being investigated as the possible cause of a disease.

Thus, development of a rise in specific antibody during recovery from disease is an important adjunct to Koch's postulates.

Modern-day microbial genetics has opened new frontiers to study pathogenic bacteria & differentiate them from nonpathogens.

Molecular cloning has allowed investigators to isolate & modify specific virulence genes & study them with models of infection.

The ability to study genes associated with virulence has led to a proposed form of molecular Koch's postulates.

Some pathogens are difficult or impossible to grow in culture, and for that reason it is not possible with Koch's postulates or the molecular Koch's postulates to establish the cause of their associated diseases.

The polymerase chain reaction is used to amplify microorganism-

specific nucleic acid sequences from host tissues or fluids.

The sequences are used to identify the infecting organisms.

Table 9–1. Guidelines for Establishing the Causes of Infectious DiseasesKoch's Postulates

Molecular Koch's Postulates

Molecular Guidelines for Establishing Microbial Disease Causation

1. The microorganism should be found in all cases of the disease in question, and its distribution in the body should be in accordance with the lesions observed.

1. The phenotype or property under investigation should be significantly associated with pathogenic strains of a species and not with nonpathogenic strains.

1. The nucleic acid sequence of a putative pathogen should be present in most cases of an infectious disease, and preferentially in anatomic sites where pathology is evident.

2. The microorganism should be grown in pure culture in vitro (or outside the body of the host) for several generations.

2. Specific inactivation of the gene or genes associated with the suspected virulence trait should lead to a measurable decrease in pathogenicity or virulence.

2. The nucleic acid sequence of a putative pathogen should be absent from most healthy controls. If the sequence is detected in healthy controls, it should be present with a lower prevalence as compared with patients with disease, and in lower copy numbers.

3. When such a pure culture is inoculated into susceptible animal species, the typical disease must result.

3. Reversion or replacement of the mutated gene with the wild-type gene should lead to restoration of pathogenicity or virulence.

3. The copy number of a pathogen-associated nucleic acid sequence should decrease or become undetectable with resolution of the disease (eg, with effective treatment) and should increase with relapse or recurrence of disease.

4. The 4. The presence of


microorganism must again be isolated from the lesions of such experimentally produced disease.

a pathogen-associated nucleic acid sequence in healthy subjects should help predict the subsequent development of disease. 5. The nature of the pathogen inferred from phylogenetic analysis of its nucleic acid sequence should be consistent with the known biologic characteristics of closely related organisms and the nature of the disease. The significance of a detected microbial sequence is increased when microbial genotype (phylogeny) predicts microbial phenotype and host response (eg, microbial morphology, serology, pathology, clinical features of disease).6. A dose-response relationship between pathogen-associated nucleic acid sequence and pathology should be evident. Diseased tissue should have higher copy numbers of sequence than normal tissues. Patients with severe illness should have a higher burden of microbial sequences than patients with mild disease. In situ hybridization or

PCR should localize the pathogen-associated sequence to areas of visible pathology and sites of suspected infection.

This approach has been used to establish the causes of several diseases, including:

o Whipple's disease (Tropheryma whipplei)

o Bacillary angiomatosis (Bartonella henselae)

o Human monocytic ehrlichiosis (Ehrlichia chaffeensis)

o Hantavirus pulmonary syndrome (Sin Nombre virus)

o Kaposi's sarcoma (human herpesvirus 8)

Analysis of infection and disease through the application of principles such as Koch's postulates leads to classification of bacteria as pathogens, opportunistic pathogens, or nonpathogens.

Some bacterial species are always considered to be pathogens, and their presence is abnormal

o Examples: Mycobacterium tuberculosis (tuberculosis) & Yersinia pestis (plague).

o Such bacteria readily meet the criteria of Koch's postulates.

Other species are commonly part of the normal flora of humans (and animals) but also can frequently cause disease

o Example: Escherichia coli is part of the gastrointestinal flora of normal humans but is also a common cause of urinary tract infections, traveler's diarrhea & other diseases.

Strains of E coli that cause disease are differentiated from those that do not by determining:

1. whether they are virulent in animals or in vitro models of infection &

2. whether they have a genetic makeup that is significantly


associated with production of disease.

Other bacteria: eg, Pseudomonas species, Stenotrophomonas maltophilia & many yeasts & moldso only cause disease in

immunosuppressed & debilitated persons & are opportunistic pathogens.

Transmission of Infection Bacteria (and other microorganisms)

adapt to the environment, including animals & humans, where they normally reside & subsist.

In doing so, the bacteria ensure their survival & enhance the possibility of transmission.

By producing asymptomatic infection or mild disease, rather than death of the host, microorganisms that normally live in people enhance the possibility of transmission from one person to another.

Some bacteria that commonly cause disease in humans exist primarily in animals and incidentally infect humans.

o Example: Salmonella & Campylobacter species typically infect animals & are transmitted in food products to humans.

Other bacteria produce infection of humans that is inadvertent, a mistake in the normal life cycle of the organism; the organisms have not adapted to humans & the disease they produce may be severe.

o Example: Yersinia pestis (plague) has a well-established life cycle in rodents & rodent fleas, and transmission by the fleas to humans is inadvertent;

Other bacteria produce infection of humans that is inadvertent, a mistake in the normal life cycle of the organism; the organisms have not adapted to humans & the disease they produce may be severe.

o Example: Bacillus anthracis (anthrax) lives in the environment, occasionally infects animals, and is transmitted to humans by

products such as raw hair from infected animals.

Other bacteria produce infection of humans that is inadvertent, a mistake in the normal life cycle of the organism; the organisms have not adapted to humans, and the disease they produce may be severe.

o Example: when wounds are contaminated by soil – C. perfringens [Gas gangrene] & Clostridium tetani [Tetanus]).

The clinical manifestations of diseases (eg, diarrhea, cough, genital discharge) produced by microorganisms often promote transmission of the agents.

o Examples of clinical syndromes and how they enhance transmission of the causative bacteria are as follows: Vibrio cholerae can cause voluminous diarrhea which may contaminate salt and fresh water


o Examples: drinking water or seafood such as oysters and crabs may be contaminated

ingestion of contaminated water or seafood can produce infection & disease.


o Examples: Similarly, contamination of food products with sewage containing E coli that cause diarrhea results in transmission of the bacteria.


o Examples: Mycobacterium tuberculosis (tuberculosis) naturally infects only humans;


It produces respiratory disease with cough & production of aerosols, resulting in transmission of the bacteria from one person to another.

Many bacteria are transmitted from one person to another on hands .

o A person with S. aureus carriage in the anterior nares may rub his nose, pick up the staphylococci on the hands, and spread the bacteria to other parts of the body or to another person, where infection results.

o Many bacteria are transmitted from one person to another on hands.

o Many opportunistic pathogens that cause nosocomial infections are transmitted from one patient to another on the hands of hospital personnel.

o Hand washing is thus an important component of infection control.

The most frequent portals of entry of pathogenic bacteria into the body are the sites where mucous membranes meet with the skin:

o respiratory (upper and lower airways)

o gastrointestinal (primarily mouth)

o genitalo urinary tracts

Abnormal areas of mucous membranes & skin:

o eg, cuts, burns, and other injuries

o are also frequent sites of entry.

Normal skin and mucous membranes provide the primary defense against infection.

o To cause disease, pathogens must overcome these barriers

Once in the body, bacteria must attach or adhere to host cells, usually epithelial cells.

After the bacteria have established a primary site of infection, they multiply & spread directly through

tissues or via the lymphatic system to the bloodstream.

This infection (bacteremia) can be transient or persistent.

Bacteremia allows bacteria to spread widely in the body & permits them to reach tissues particularly suitable for their multiplication.

Pneumococcal pneumonia is an example of the infectious process.

S. pneumoniae can be cultured from the nasopharynx of 5–40% of healthy people.

Occasionally, Pneumococci from the nasopharynx are aspirated into the lungs

o aspiration occurs most commonly in debilitated people & in settings such as coma when normal gag & cough reflexes are diminished .

Infection develops in the terminal air spaces of the lungs in persons who do not have protective antibodies against that capsular polysaccharide type of Pneumococci.

Multiplication of the Pneumococci & resultant inflammation lead to Pneumonia.

The Pneumococci enter the lymphatics of the lung & move to the bloodstream.

o Between 10% and 20% of persons with Pneumococcal pneumonia have bacteremia at the time the diagnosis of pneumonia is made.

Once bacteremia occurs, the Pneumococci can spread to secondary sites of infection

o eg, cerebrospinal fluido heart valveso joint spaces

The major complications of Pneumococcal pneumonia are:

o Meningitiso Endocarditiso Septic arthritis

The infectious process in Cholera involves:

o ingestion of Vibrio cholerae,o chemotactic attraction of the

bacteria o to the gut epithelium, o motility of the bacteria by a

single polar flagellum


o penetration of the mucous layer on the intestinal surface.

The V. cholerae adherence to the epithelial cell surface is mediated by pili & possibly other adhesins.

Production of cholera toxin results in flow of chloride & water into the lumen of the gut, causing diarrhea & electrolyte imbalance .

The Clonal Nature of Bacterial Pathogens

Bacteria are haploid & limit genetic interactions that might change their chromosomes & potentially disrupt their adaptation & survival in specific environmental niches.

The primary mechanism for exchange of genetic information between bacteria is transfer of extrachromosomal mobile genetic elements: plasmids or phages.

The genes that code for many bacterial virulence factors commonly are on plasmids or are carried by phages.

Transfer of these mobile genetic elements between members of one species or, less commonly, between species can result in transfer of virulence factors.

Sometimes the genetic elements are part of highly mobile DNA (transposons) & there is recombination between the extrachromosomal DNA &chromosome (illegitimate or nonhomologous recombination.

If this recombination occurs, the genes coding for virulence factors may become chromosomal .

One important result of the conservation of chromosomal genes in bacteria is that the organisms are clonal.

For most pathogens there are only one or a few clonal types that are spread in the world during a period of time.

o Example: epidemic serogroup A Meningococcal meningitis occurs in Asia, Middle East & Africa, and occasionally spreads into Northern Europe & Americas.

o Example: On several occasions, over a period of

decades, single clonal types of serogroup A Neisseria meningitides have been observed to appear in one geographic area & subsequently spread to others with resultant epidemic disease.

o Example: There are many types of H influenzae, but only clonal H influenzae type b is commonly associated with disease.

o Example: There are two clonal types of Bordetella pertussis, both associated with disease.

o Similarly, Salmonella Typhi (typhoid fever) from patients is of 2 clonal types.

Regulation of Bacterial Virulence Factors

Pathogenic bacteria (and other pathogens) have adapted both to saprophytic or free-living states, possibly environments outside of the body & to the human host.

In the adaptive process, pathogens husband their metabolic needs & products.

They have evolved complex signal transduction systems to regulate the genes important for virulence.

Environmental signals often control the expression of the virulence genes.

Common signals include:o Temperatureo iron availabilityo osmolality o growth phase o pH o specific ions (eg, Ca2+) or

nutrient factors The gene for diphtheria toxin from

Corynebacterium diphtheriae is carried on temperate bacteriophages.

o Toxin is produced only by strains lysogenized by the phages.

o Toxin production is greatly enhanced when C. diphtheriae is grown in a medium with low iron.

Expression of virulence genes of Bordetella pertussis is enhanced when the bacteria are grown at 37


°C & suppressed when they are grown at lower temperatures or in the presence of high concentrations of Magnesium sulfate or Nicotinic acid .

The virulence factors of Vibrio cholerae are regulated on multiple levels and by many environmental factors.

o Expression of the cholera toxin is higher at pH 6.0 than at pH 8.5 & higher also at 30 °C than at 37 °C.

o Osmolality & amino acid composition also are important.

o As many as 20 other genes of V cholerae are similarly regulated.

Yops are a series of yersinia virulence plasmid-encoded proteins that result in antiphagocytic function.

o Yops are expressed maximally at 37 °C in the absence of Calcium.

o When calcium is present, the production of Yops still is higher than at 25 °C.

o Thus, production of the antiphagocytic virulence factors is highest at the body temperatures of animals & humans rather than at the ambient temperature of rodent fleas, where antiphagocytic factors are not important to the bacteria.

o The regulation of other virulence factors in Yersinia species also is influenced by environmental factors.

Motility of bacteria enables them to spread and multiply in their environmental niches or in patients.

o Yersinia enterocolitica & Listeria monocytogenes are ubiquitous in the environment where motility is important to them.

o Presumably, motility is not important in the pathogenesis of the diseases caused by these bacteria.

o Y. enterocolitica is motile when grown at 25 °C but not when grown at 37 °C.

o Similarly, Listeria is motile when grown at 25 °C & not motile or minimally motile when grown at 37 °C.

Bacterial Virulence Factors: Adherence Factors

Once bacteria enter the body of the host, they must adhere to cells of a tissue surface.

If they did not adhere, they would be swept away by mucus & other fluids that bathe the tissue surface.

Adherence, which is only one step in the infectious process, is followed by development of microcolonies & subsequent steps in the pathogenesis of infection.

The interactions between bacteria & tissue cell surfaces in the adhesion process are complex.

Several factors play important roles:o surface hydrophobicity and

net surface chargeo binding molecules on bacteria

(ligands) o host cell receptor interactions.

Bacteria and host cells commonly have net negative surface charges & therefore, repulsive electrostatic forces.

These forces are overcome by hydrophobic & other more specific interactions between bacteria & host cells.

In general, the more hydrophobic the bacterial cell surface, the greater the adherence to the host cell.

Different strains of bacteria within a species may vary widely in their hydrophobic surface properties & ability to adhere to host cells.

Bacteria also have specific surface molecules that interact with host cells.

Many bacteria have pili, hair-like appendages that extend from the bacterial cell surface & help mediate adherence of the bacteria to host cell surfaces.

Example: some E coli strains have type 1 pili, which adhere to epithelial cell receptors containing D-mannose


o adherence can be blocked in vitro by addition of D-mannose to the medium.

E. coli organisms that cause urinary tract infections commonly do not have D- mannose-mediated adherence but have P-pili, which attach to a portion of the P blood group antigen

o the minimal recognition structure is the disaccharide α-D- galactopyranosyl-(1–4)- β -D- galactopyranoside (GAL-GAL binding adhesion).

The E coli that cause diarrheal diseases have pilus-mediated adherence to intestinal epithelial cells, though the pili & specific molecular mechanisms of adherence appear to be different depending upon the form of the E coli that induce the diarrhea.

Other specific ligand-receptor mechanisms have evolved to promote bacterial adherence to host cells, illustrating the diverse mechanisms employed by bacteria.

Group A streptococci (Streptococcus pyogenes) also have hair-like appendages, termed fimbriae, that extend from the cell surface.

Lipoteichoic acid, protein F & M protein are found on the fimbriae.

The lipoteichoic acid & protein F - cause adherence of the streptococci to buccal epithelial cells

o this adherence is mediated by fibronectin, which acts as the host cell receptor molecule

M protein - acts as an antiphagocytic molecule.

Antibodies that act against the specific bacterial ligands that promote adherence (eg, pili & lipoteichoic acid) can block adherence to host cells & protect the host from infection.

Bacterial Virulence Factors: Invasion of Host Cells & Tissues

For many disease-causing bacteria, invasion of the host's epithelium is central to the infectious process.

o Some bacteria: eg. Salmonella species invade tissues

through the junctions between epithelial cells.

o Other bacteria: eg. Yersinia species, N. gonorrhoeae, Chlamydia trachomatis

o invade specific types of the host's epithelial cells & may subsequently enter the tissue.

Once inside the host cell, bacteria may remain enclosed in a vacuole composed of the host cell membrane, or the vacuole membrane may be dissolved & bacteria may be dispersed in the cytoplasm.

Some bacteria – eg, Shigella species multiply within host cells whereas other bacteria do not.

"Invasion" - is the term commonly used to describe the entry of bacteria into host cells, implying an active role for the organisms & a passive role for the host cells.

In many infections, the bacteria produce virulence factors that influence the host cells, causing them to engulf (ingest) the bacteria.

The host cells play a very active role in the process.

Toxin production and other virulence properties are generally independent of the ability of bacteria to invade cells & tissues.

o Example: Corynebacterium diphtheriae is able to invade the epithelium of the nasopharynx & cause symptomatic sore throat even when the C. diphtheriae strains are nontoxigenic.

In vitro studies with cells in tissue culture have helped characterize the mechanisms of invasion for some pathogens; however, the in vitro models have not necessarily provided a complete picture of the invasion process.

Full understanding of the invasion process, as it occurs in naturally acquired infection, has required study of genetically engineered mutants & their ability to infect susceptible animals humans.

Thus, understanding of eukaryotic cell invasion by bacteria requires satisfying much of Koch's postulates & the molecular Koch's postulates.


Examples of bacterial invasion of host cells as part of the infectious process.

o Shigella species adhere to host cells in vitro.

Commonly, HeLa cells are used o these undifferentiated

unpolarized cells were derived from a Cervical carcinoma.

The adherence causes actin polymerization in the nearby portion of the HeLa cell, which induces the formation of pseudopods by the HeLa cells & engulfment of the bacteria.

Adherence & invasion are mediated at least in part by products of genes located on a large plasmid common to many Shigellae .

At least 3 proteins (invasion plasmid antigens, Ipa)

o IpaB, IpaC, and IpaD, contribute to the process.

Once inside the HeLa cells, the shigellae either are released or escape from the phagocytic vesicle, where they multiply in the cytoplasm.

Actin polymerization propels the Shigellae within an HeLa cell & from one cell into another.

The pathogenesis of Shigellae adherence & invasion in vivo appears to be somewhat different & less well understood at the molecular level.

The Shigellae adhere to integrins on the surface of M cells in Peyer's patches & not to the polarized absorptive cells of the mucosa.

M cells normally sample antigens & present them to macrophages in the submucosa.

Shigellae are phagocytosed by the M cells, pass through the M cells & escape killing by macrophages.

The Shigellae are thought to adhere to integrins on the basal surfaces of nearby mucosal cells followed by engulfment by the mucosal cells & spread to adjacent cells in a manner similar to the in vitro cell invasion model.

From studies using cells in vitro, it appears that the adherence-invasion process with Y enterocolitica is similar to that of Shigella.

Yersiniae adhere to the host cell membrane & cause it to extrude protoplasmic projections.

The bacteria are then engulfed by the host cell with vacuole formation; the vacuole membrane later dissolves.

Invasion is enhanced when the bacteria are grown at 22 °C rather than at 37 °C.

Once Yersiniae have entered the cell, the vacuolar membrane dissolves & the bacteria are released into the cytoplasm.

In vivo, the Yersiniae are thought to adhere to & invade the M cells of Peyer's patches rather than the polarized absorptive mucosal cells, much like Shigellae.

Listeria monocytogenes from the environment is ingested in food.

Presumably, the bacteria adhere to & invade the intestinal mucosa, reach the bloodstream & disseminate.

The pathogenesis of this process has been studied in vitro.

o Listeriamonocytogenes adheresto & readily invades macrophages & cultured undifferentiated intestinal cells.

o The listeriae induce engulfment by the host cells.

Two proteins, the internalins, appear to have a primary role in this process.

The engulfment process, movement within a cell & movement between cells, requires actin polymerization to propel the bacteria, as with Shigellae.

Legionella pneumophila infects pulmonary macrophages & causes pneumonia.

Adherence of the Legionellae to the macrophage induces formation of a long, thin pseudopod which then coils around the bacteria, forming a vesicle (Coiling phagocytosis).

Coiling phagocytosis o The vesicle remains intact,

phagolysosome fusion is inhibited & the bacteria multiply within the vesicle.

Neisseria gonorrhoeae o uses pili as primary adhesins

&


o opacity associated proteins (Opa) as secondary adhesins to host cells.

Certain Opa proteins mediate adherence to polymorphonuclear cells.

Some gonococci survive after phagocytosis by these cells.

Pili & Opa together enhance the invasion of cells cultured in vitro.

In uterine (fallopian) tube organ cultures,

o the Gonococci adhere to the microvilli of nonciliated cells & appear to induce engulfment by these cells.

The Gonococci multiply intracellularly & migrate to the subepithelial space by an unknown mechanism.

Bacterial Virulence Factors: Toxins Toxins produced by bacteria are

generally classified into 2 groups: o Exotoxinso endotoxins

EXOTOXINS Many gram (+) & gram (-) bacteria

produce exotoxins of considerable medical importance.

Some of these toxins have had major roles in world history.

o Example: Tetanus caused by the toxin of Clostridium tetani killed as many as 50,000 soldiers of the Axis powers in World War II

the Allied forces, however, immunized military personnel against tetanus & very few died of that disease

Vaccines have been developed for some of the exotoxin-mediated diseases & continue to be important in the prevention of disease.

These vaccines called Toxoids - are made from exotoxins, which are modified so that they are no longer toxic.

Many exotoxins consist of A & B subunits.

o The B subunit - generally mediates adherence of the toxin complex to a host cell & aids entrance of the exotoxin into the host cell.

o The A subunit - provides the toxic activity.

Corynebacterium diphtheriae - is a gram(+) rod that can grow on the mucous membranes of the upper respiratory tract or in minor skin wounds.

o Strains of C. diphtheriae that carry a temperate bacteriophage with the structural gene for the toxin are toxigenic & produce diphtheria toxin & cause Diphtheria.

Many factors regulate toxin production; when the availability of inorganic iron is the factor limiting the growth rate, then maximal toxin production occurs.

The toxin molecule is secreted as a single polypeptide molecule (MW 62,000).

This native toxin is enzymatically degraded into 2 fragments:

o A & Bo linked together by a disulfide

bond. Fragment B (MW 40,700) - binds

to specific host cell receptors & facilitates the entry of Fragment A (MW 21,150) into the cytoplasm.

Fragment A - inhibits peptide chain elongation factor EF-2 by catalyzing a reaction that yields free nicotinamide plus an inactive adenosine diphosphate- ribose-EF-2 complex.

Arrest of protein synthesis disrupts normal cellular physiologic functions.

Diphtheria toxin is very potent . Clostridium tetani - is an

anaerobic gram(+) rod that causes tetanus.

o C. tetani from the environment contaminates wounds & the spores germinate in the anaerobic environment of the devitalized tissue.

o Infection often is minor and not clinically apparent

Clostridium tetani o The vegetative forms of C.

tetani produce the toxin tetanospasmin (MW 150,000) that is cleaved by a bacterial protease into 2


peptides (MW 50,000 & MW 100,000) linked by a disulfide bond.

o The toxin initially binds to receptors on the presynaptic membranes of motor neurons.

o It then migrates by the retrograde axonal transport system to the cell bodies of these neurons to the spinal cord & brain stem.

o The toxin diffuses to terminals of inhibitory cells including both glycinergic interneurons & γ -aminobutyric acid- secreting neurons from the brain stem.

o The toxin degrades synaptobrevin, a protein required for docking of neurotransmitter vesicles on the presynaptic membrane.

o Release of the inhibitory glycine and γ - aminobutyric is blocked & the motor neurons are not inhibited.

o Spastic paralysis results.o Extremely small amounts of

toxin can be lethal for humans.

o Tetanus is totally preventable in immunologically normal people by immunization with tetanus toxoid.

Clostridium botulinum - causes botulism.

o It is found in soil or water & may grow in foods (canned, vacuum-packed, etc) if the environment is appropriately anaerobic.

o An exceedingly potent toxin (the most potent toxin known) is produced.

o It is heat-labile & is destroyed by sufficient heating.

o There are multiple distinct serologic types of toxin.

o Types A, B & E are most commonly associated with human disease.

o The toxin is very similar to tetanus toxin, with a 150,000 MW protein that is cleaved into 100,000 MW & 50,000 MW proteins linked by a disulfide bond.

o the release of acetylcholine at the synapse, resulting in lack of muscle contraction & paralysis.

o Botulinum toxin is absorbed from the gut & binds to receptors of presynaptic membranes of motor neurons of the peripheral nervous system & cranial nerves.

o Proteolysis, by the light chain of botulinum toxin, of target proteins in the neurons inhibits the release of acetylcholine at the synapse, resulting in lack of muscle contraction & paralysis.

Spores of Clostridium perfringens are introduced into wounds by contamination with soil or feces.

In the presence of necrotic tissue (an anaerobic environment), spores germinate & vegetative cells can produce several different toxins.

Many of these are necrotizing & hemolytic & together with distention of tissue by gas formed from carbohydrates & interference with blood supply favor the spread of gas gangrene.

The alpha toxin of C. perfringens is a lecithinase that damages cell membranes by splitting lecithin to phosphorylcholine & diglyceride.

Theta toxin also has a necrotizing effect.

Collagenases & DNAses are produced by clostridiae as well.

Some Staphylococcus aureus strains growing on mucous membranes

o eg, the vagina in association with menstruation or in wounds

o elaborate Toxic Shock Syndrome Toxin-1 (TSST-1), which causes Toxic Shock Syndrome .

Toxic Shock Syndrome Toxin-1 (TSST- 1), which causes toxic shock syndrome.

o The illness is characterized by:

Shock High fever a diffuse red rash that

later desquamates


multiple other organ systems are involved as well.

o TSST-1 is a super antigen and stimulates lymphocytes to produce large amounts of IL-1 & TNF.

o The major clinical manifestations of the disease appear to be secondary to the effects of the cytokines.

o TSST-1 may act synergistically with low levels of lipopolysaccharide to yield the toxic effect.

o Many of the systemic effects of TSST-1 are similar to those of toxicity due to lipopolysaccharide.

Some strains of group A beta- hemolytic streptococci produce pyrogenic exotoxin A that is similar to or the same as streptococcal erythrogenic toxin, which results in Scarlet Fever.

Rapidly progressive soft tissue infection by streptococci that produce the pyrogenic exotoxin A has many clinical manifestations similar to those of staphylococcal toxic shock syndrome.

The pyrogenic exotoxin A - also is a super antigen that acts in a manner similar to TSST-1.

Table 9–2. Characteristics of Exotoxins and Endotoxins (Lipopolysaccharides)EXOTOXINS ENDOTOXINSExcreted by living cell; high concentrations in liquid medium.

Integral part of the cell wall of gram- negative bacteria. Released on bacterial death and in part during growth. May not need to be released to have biologic activity.

Produced by both gram-positive and gram-negative bacteria.

Found only in gram-negative bacteria.

Polypeptides with a molecular weight of 10,000–900,000.

Lipopolysaccharide complexes. Lipid A portion probably responsible for toxicity.

Relatively unstable; toxicity often destroyed rapidly by heating at temperatures above 60°C.

Relatively stable; withstand heating at temperatures above 60°C for hours without loss of toxicity.

Highly antigenic; stimulate formation of high-titer antitoxin. Antitoxin neutralizes toxin.

Weakly immunogenic; antibodies are antitoxic and protective. Relationship between antibody titers and protection from disease is less clear than with exotoxins.

Converted to antigenic, nontoxic toxoids by formalin, acid, heat, etc. Toxoids are used to immunize (eg, tetanus toxoid).

Not converted to toxoids

Highly toxic; fatal to animals in microgram quantities or less.

Moderately toxic; fatal for animals in tens to hundreds of micrograms.

Usually bind to specific receptors on cells.

Specific receptors not found on cells.

Usually do not produce fever in the host.

Usually produce fever in the host by release of interleukin-1 and other mediators.

Frequently controlled by extrachromosomal genes (eg, plasmids).

Synthesis directed by chromosomal genes.

Bacterial Virulence Factors Toxins: Exotoxins Associated with Diarrheal Diseases and Food Poisoning

Exotoxins associated with diarrheal diseases are frequently called enterotoxins.

Vibrio cholera o has produced epidemic

diarrheal disease (cholera) in many parts of the world & is another toxin-produced disease of historical & current importance.

o After entering the host via contaminated food or drink, V. cholerae penetrates the intestinal mucosa and attaches to microvilli of the brush border of gut epithelial cells.

o V. cholerae, usually of the serotype O1 (and O139), can produce an enterotoxin with a molecular weight of 84,000.

o The toxin consists of 2 subunits:

A - which is split into two peptides, and A1 &


A2, linked by a disulfide bond

Bo Subunit B - has 5 identical

peptides & rapidly binds the toxin to cell membrane ganglioside molecules.

o Subunit A - enters the cell membrane & causes a large increase in adenylyl cyclase activity & in the concentration of cAMP .

o The net effect is rapid secretion of electrolytes into the small bowel lumen, with impairment of sodium & chloride absorption & loss of bicarbonate.

o Life-threatening massive diarrhea

eg, 20–30 L/d can occur & acidosis develops

o The deleterious effects of cholera are:

due to fluid loss acid-base imbalance

o Treatment, therefore, is by electrolyte & fluid replacement.

Some strains of Staphylococcus aureus produce enterotoxins while growing in meat, dairy products, or other foods.

o In typical cases, the food has been recently prepared but not properly refrigerated.

There are at least 6 distinct types of the staphylococcal enterotoxin.

After the preformed toxin is ingested, it is absorbed in the gut, where it stimulates neural receptors.

The stimulus is transmitted to the vomiting center in the central nervous system.

o Vomiting, often projectile, results within hours.

Diarrhea is less frequent. Staphylococcal food poisoning - is

the most common form of food poisoning.

S aureus enterotoxins - are super antigens.

Enterotoxins are also produced by some strains of :

o Y enterocolitica o Vibrio parahaemolyticus

o Aeromonas species & other bacteria

o but the role of these toxins in pathogenesis is not defined.

Bacterial Virulence Factors Toxins: Lipopolysaccharides of Gram(-) Bacteria

The lipopolysaccharides (LPS, endotoxin) of gram-negative bacteria are derived from cell walls and are often liberated when the bacteria lyse.

The substances are heat-stable, have molecular weights between 3000 and 5000 (lipooligosaccharides, LOS) & several million (lipopolysaccharides), & can be extracted - eg, with phenol-water

Table 9–3. Composition of Lipopolysaccharide "Endotoxins" in the Cell Walls of Gram-Negative BacteriaCHEMISTRY COMMON NAME(a) Repeating oligosaccharide (eg, man-rha-gal) combinations make up type-specific haptenic determinants (outermost in cell wall).

(a) O-specific polysaccharide. Induces specific immunity

(b) (N-Acetylglucosamine, glucose, galactose, heptose). Same in all gram- negative bacteria.

(b) Common core polysaccharide

(c) Backbone of alternating heptose and phosphate groups linked through KDO (2-keto-3-deoxyoctonic acid) to lipid. Lipid is linked to peptidoglycan (by glycoside bonds).

(c) Lipid A with KDO responsible for primary toxicity

The pathophysiologic effects of LPS

are similar regardless of their bacterial origin except for those of bacteroides species, which have a different structure & are less toxic.

LPS in the bloodstream is initially bound to circulating proteins which then interact with receptors on macrophages & monocytes & other cells of the reticuloendothelial system.

IL-1, TNF, & other cytokines are released, & the complement & coagulation cascades are activated.

The following can be observed clinically or experimentally:


o fever, leukopenia & hypoglycemia

o hypotension & shock resulting in impaired perfusion of essential organs (eg, brain, heart, kidney)

o intravascular coagulation o & death from massive organ

dysfunction. Injection of LPS produces fever after

60–90 minutes, the time needed for the body to release IL-1.

Injection of IL-1 produces fever within 30 minutes.

Repeated injection of IL-1 produces the same fever response each time, but repeated injection of LPS causes a steadily diminishing fever response because of tolerance due in part to reticuloendothelial blockade & in part to IgM antibodies to LPS.

Injection of LPS produces early leukopenia, as does bacteremia with gram-negative organisms.

Secondary leukocytosis occurs later. The early leukopenia coincides with

the onset of fever due to liberation of IL-1.

LPS enhances glycolysis in many cell types and can lead to hypoglycemia.

Hypotension - occurs early in gram- negative bacteremia or following injection of LPS.

There may be: o widespread arteriolar and

venular constriction followed by peripheral vascular dilatation

o increased vascular permeability

Hypotension – There may be: o decrease in venous return o lowered cardiac output,

stagnation in the microcirculation

o peripheral vasoconstriction, shock,

o & impaired organ perfusion and its consequences.

Disseminated intravascular coagulation also contributes to these vascular changes.

LPS is among the many different agents that can:

o activate the alternative pathway of the Complement

cascade, precipitating a variety of complement-mediated reactions (anaphylatoxins, chemotactic responses, membrane damage, etc)

o & a drop in serum levels of complement components (C3, C5–9).

Disseminated intravascular coagulation (DIC) - is a frequent complication of gram (-) bacteremia & can also occur in other infections.

o LPS activates factor XII (Hageman factor)— the first step of the intrinsic clotting system & sets into motion the coagulation cascade, which culminates in the conversion of fibrinogen to fibrin.

o At the same time, plasminogen can be activated by LPS to plasmin (a proteolytic enzyme), which can attack fibrin with the formation of fibrin split products.

o Reduction in platelet and fibrinogen levels and detection of fibrin split products are evidence of DIC.

o Heparin can sometimes prevent the lesions associated with DIC.

LPS causes platelets to adhere to vascular endothelium and occlusion of small blood vessels, causing ischemic or hemorrhagic necrosis in various organs.

Endotoxin levels can be assayed by the limulus test: A lysate of amebocytes from the horseshoe crab (limulus) gels or coagulates in the presence of 0.0001 μg/mL of endotoxin.

Bacterial Virulence Factors Toxins: Peptidoglycan of Gram(+) Bacteria

The peptidoglycan of gram-positive bacteria is made up of cross-linked macromolecules that surround the bacterial.

Vascular changes leading to shock may also occur in infections due to gram-positive bacteria that contain no LPS.

Gram (+) bacteria have considerably more cell wall-associated


peptidoglycan than do gram-negative bacteria.

Peptidoglycan released during infection may yield many of the same biologic activities as LPS, though peptidoglycan is invariably much less potent than LPS.

Bacterial Virulence Factors Enzymes:

Many species of bacteria produce enzymes that are not intrinsically toxic but do play important roles in the infectious process.

Bacterial Virulence Factors Enzymes: Tissue-Degrading Enzymes

Many bacteria produce tissue – degrading enzymes.

The best-characterized are enzymes from C, S aureus, group A streptococci and, to a lesser extent, anaerobic.

The roles of tissue-degrading enzymes in the pathogenesis of infections appear obvious but have been difficult to prove, especially those of individual enzymes.

o Example: antibodies against the tissue-degrading enzymes of streptococci do not modify the features of streptococcal disease.

In addition to lecithinase, C. perfringens produces the proteolytic enzyme collagenase, which degrades collagen, the major protein of fibrous connective tissue & promotes spread of infection in tissue.

S aureus produces coagulase, which works in conjunction with serum factors to coagulate plasma.

Coagulase contributes to the formation of fibrin walls around staphylococcal lesions, which helps them persist in tissues.

Coagulase also causes deposition of fibrin on the surfaces of individual staphylococci, which may help protect them from phagocytosis or from destruction within phagocytic cells.

Hyaluronidases - are enzymes that hydrolyze hyaluronic acid, a constituent of the ground substance of connective tissue.

o They are produced by many bacteria (eg, staphylococci, streptococci & anaerobes) & aid in their spread through tissues.

Many hemolytic streptococci produce streptokinase (fibrinolysin), a substance that activates a proteolytic enzyme of plasma.

o This enzyme is then able to dissolve coagulated plasma and probably aids in the rapid spread of streptococci through tissues.

Streptokinase (fibrinolysin) o Streptokinase has been used

in treatment of Acute Myocardial Infarction to dissolve fibrin clots.

Many bacteria produce substances that are cytolysins ie, they dissolve red blood cells (hemolysins) or kill tissue cells or leukocytes (leukocidins).

o Example: Streptolysin O, is produced by group A streptococci & is lethal for mice & hemolytic for red blood cells from many animals.

Streptolysin O - is oxygen-labile and can therefore be oxidized and inactivated, but it is reactivated by reducing agents.

o It is antigenic. Streptolysin S - The same

streptococci also produce oxygen-stable, serum- inducible, which is not antigenic.

Clostridia produce various hemolysins, including the lecithinase.

Hemolysins are produced by most strains of S. aureus; staphylococci also produce leukocidins.

Most gram(-) rods isolated from sites of disease produce hemolysins.

o Example: E coli strains that cause urinary tract infections typically produce hemolysins, whereas those strains that are part of the normal gastrointestinal flora may or may not produce hemolysins.

Immunoglobulin A - is the secretory antibody on mucosal surfaces.

o It has two primary forms: IgA1 and IgA2


that differ near the center, or hinge, region of the heavy chains of the molecules.

Bacterial Virulence Factors Enzymes: IgA1 Proteases

IgA1 - has a series of amino acids in the hinge region that are not present in IgA2.

Some bacteria that cause disease produce enzymes, IgA1 proteases, that split IgA1 at specific proline-threonine or proline-serine bonds in the hinge region & inactivate its antibody activity.

IgA1 protease is an important virulence factor of the pathogens:

o Neisseria gonorrhoeaeo Neisseria meningitideso Hemophilus influenza &o Staphylococcus pneumoniae.

The enzymes are also produced by some strains of Prevotella melaninogenica, some Streptococci associated with dental disease & a few strains of other species that occasionally cause disease.

Nonpathogenic species of the same genera do not have genes coding for the enzyme & do not produce it.

Production of IgA1 protease allows pathogens to inactivate the primary antibody found on mucosal surfaces & thereby eliminate protection of the host by the antibody.

Bacterial Virulence Factors Antiphagocytic Factors:

Many bacterial pathogens are rapidly killed once they are ingested by polymorphonuclear cells or macrophages.

Some pathogens evade phagocytosis or leukocyte microbicidal mechanisms by adsorbing normal host components to their surfaces.

o Example: S. aureus has surface protein A, which binds to the Fc portion of IgG.

Other pathogens have surface factors that impede phagocytosis

o Example: S. pneumoniae, N. meningitidis

o many other bacteria have polysaccharide capsules. S

pyogenes (group A streptococci) has M protein.

N. gonorrhoeae (gonococci) has pili. Most of these antiphagocytic surface

structures show much antigenic heterogeneity.

o Example: there are more than 90 Pneumococcal capsular polysaccharide types and more than 80 M protein types of group A streptococci.

Antibodies against one type of the antiphagocytic factor

o eg, Capsular polysaccharide, M protein

o protect the host from disease caused by bacteria of that type but not from those with other antigenic types of the same factor.

A few bacteriao eg, Capnocytophaga &

Bordetella o produce soluble factors or

toxins that inhibit chemotaxis by leukocytes & thus evade phagocytosis by a different mechanism.

Bacterial Virulence Factors Intracellular Pathogenicity:

Some bacteriao eg, M tuberculosis, Brucella

species & Legionella species o live and grow in the hostile

environment within polymorphonuclear cells, macrophages, or monocytes.

The bacteria accomplish this feat by several mechanisms:

– They may avoid entry into phagolysosomes & live within the cytosol of the phagocyte

– they may prevent phagosome-lysosome fusion & live within the phagosome

– or they may be resistant to lysosomal enzymes & survive within the phagolysosome.

Many bacteria can live within nonphagocytic cells

Bacterial Virulence Factors Antigenic Heterogeneity:

The surface structures of bacteria (and of many other microorganisms) have considerable antigenic heterogeneity.


Often these antigens are used as part of a serologic classification system for the bacteria.

The classification of the 2000 or so different salmonellae is based principally on the types of the:

o O (lipopolysaccharide side chain)

o H (flagellar) antigens Similarly, there are more than 100 E

coli O types & more than 100 E coli K (capsule) types.

The antigenic type of the bacteria may be a marker for virulence, related to the clonal nature of pathogens, though it may not actually be the virulence factor (or factors).

V cholerae O antigen type 1 and O antigen type 139 - typically produce cholera toxin, whereas very few of the many other O types produce the toxin.

Only some of the 80 or more group A streptococcal M protein types are associated with a high incidence of Poststreptococcal glomerulonephritis.

N meningitidis capsular polysaccharide types A and C are associated with epidemic meningitis.

o In the examples cited above & in other typing systems that use surface antigens in serologic classification, antigenic types for a given isolate of the species remain constant during infection & on subculture of the bacteria.

Some bacteria and other microorganisms have the ability to make frequent shifts in the antigenic form of their surface structures in vitro and presumably in vivo.

o Example: 1) Borrelia recurrentis, which causes relapsing fever.

o 2) N. gonorrhoeae The Gonococcus has three surface-

exposed antigens that switch forms at very high rates of about one in every 1000:

o lipooligosaccharide, 6–8 types o pili, innumerable types & o Opa (protein II), 10–12 types

for each strain. The number of antigenic forms is so

large that each strain of N

gonorrhoeae appears to be antigenically distinct from every other strain.

Switching of forms for each of the 3 antigens appears to be under the control of different genetic mechanisms.

It is presumed that frequent switching of antigenic forms allows gonococci to evade the host's immune system;

o gonococci that are not attacked by the immune system survive & cause disease.

Bacterial Virulence Factors The Requirement for Iron:

Pathogenic bacteria must be able to compete successfully for nutrients with nonpathogenic bacteria & with host cells, or they must alter the environment to suit their needs.

Iron - is the most thoroughly studied nutrient essential to the infectious process.

o Iron has a wide oxidation-reduction potential which makes it important in a variety of metabolic functions.

Like other cells, bacteria require 0.4– 4 μ mol/L of iron in order to grow.

Humans and animals have an abundant amount of iron; however, most of it is located intracellularly (ie, in hemoglobin and myoglobin) & is not accessible to bacteria.

Free iron in its ferric form (Fe3+) occurs primarily as highly insoluble hydroxides, carbonates & phosphates.

The concentration of free ionic iron in blood, lymph, extracellular tissue fluid & external secretions is very


low, on the order of 10 -18

mol/L Fe 3+

This low concentration of free ionic iron is due to the host's iron-binding & transport proteins, transferrin in blood & lymph, & lactoferrin in external secretions.

Transferrin and lactoferrin have high association constants for Fe3+ and are only partially saturated under conditions of normal iron metabolism.

Ferritin and hemoglobin also bind iron.

Thus, the host's iron metabolism denies pathogenic bacteria an adequate source of iron for growth.

Bacteria have developed several methods to obtain sufficient iron for essential metabolism.

Most bacteria have a low-affinity iron assimilation system, which permits them to use the polymeric forms of iron in spite of the low solubility of the ferric compounds.

Some bacteria have evolved high- affinity iron assimilation systems.

Part of these high-affinity systems involves siderophores, which are small (MW 500–1000) ligands that are specific for ferric iron & thus supply iron to the bacterial cell.

Much variation exists among the siderophores that have been characterized, but most fall into 2 categories:

o Catechols (phenolates), of which enterobactin is the best-characterized,

o Hydroxamates, of which ferrichrome is the best-characterized.

Enterobactin is produced by E coli and some other Enterobacteriaceae.

Hydroxamates are commonly found in fungi.

Siderophore production is genetically responsive to the concentration of iron in the medium.

o Example: Enterobactin is produced only under low-iron conditions.

Siderophores function to capture iron; enterobactin can remove iron from transferrin.

Once the siderophore captures the iron, it is internalized into the cell through the action of specific outer membrane protein receptors, which also are synthesized under conditions of low iron.

Some bacteria do not have demonstrable siderophores.

Yersinia pestis can utilize iron from hemin & may be able to initiate infection using iron from hemin in the gut of the biting flea.

N. gonorrhoeae makes a series of iron- regulated outer membrane proteins, but the mechanism by which these proteins function to capture & internalize iron is not well understood.

Other bacteriao eg, Legionella pneumophila,

listeria species, salmonella species, & other bacteria

o can obtain iron from the host's intracellular iron pools.

The availability of iron affects the virulence of pathogens.

o Example: the virulence of N meningitidis for mice is increased 1000-fold or more when the bacteria are grown under iron-limited conditions.

Bacterial Virulence Factors The Role of Bacterial Biofilms:

Similar effects of iron on virulence have been shown for other species of bacteria.

Some plasmids that have genes for virulence also encode for iron- sequestering systems.

A biofilm - is an aggregate of interactive bacteria attached to a solid surface or to each other & encased in an exopolysaccharide matrix.

o This is distinct from planktonic or free- living bacterial


growth, in which interactions of the microorganisms do not occur.

Biofilms form a slimy coat on solid surfaces and occur throughout nature.

A single species of bacteria may be involved, or more than one species may coaggregate to form a biofilm.

Fungi including yeasts are occasionally involved.

Biofilms are important in human infections that are persistent and difficult to treat.

o Examples: Staphylococcus epidermidis & Staphylococcus aureus infections of central venous catheters, eye infections such as occur with contact lenses & intraocular lenses, in dental plaque

o Pseudomonas aeruginosa airway infections in cystic fibrosis patients.

The initial step in biofilm formation is colonization of the surface.

Bacteria may use flagella to move on a surface and initiate colonization.

Some bacteria may use pili to pull themselves together into clumps while others rely on cell division to initiate colony formation.

Bacteria continuously secrete low levels of molecules called quorum- sensing signals

o eg, Acylhomoserine lactone signals

As the number of bacteria increase, the concentrations of these signals increase.

When a threshold is reached, the bacteria respond & change their behavior by changing activation of genes.

Many genes may be involved, & this varies from one species of bacteria to another.

The extracellular polysaccharide is produced; P aeruginosa produces alginate.

Genes may be activated that influence metabolic pathways & the production of virulence factors.

Bacteria deep within the matrix tend to have decreased metabolism.

The bacteria in the exopolysaccharide matrix may be

protected from the host's immune mechanisms.

The matrix also presents a diffusion barrier for some antimicrobials, while other antimicrobials may bind to it.

Some of the bacteria within the biofilm show marked resistance to antimicrobials in contrast to the same strain of bacteria grown free-living in broth, which helps to explain why it is so difficult to treat infections associated with biofilms.

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Natapos din.


microbiology - fundamentals of immunology infection

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