Transcriptionist: Bunny Fril Editor: in Chief Pages: 5

Outline: I. Mycobacterium Leprae a. History b. Diagnostic Features c. Epidemiology d. Clinical Manifestation e. Types f. Lepromin test g. Laboratory Diagnosis h. Treatment i. Prevention and Control II. Mycobacterium Marinum a. Diagnostic Features b. Clinical Manifestations c. Clinical Diagnosis d. Treatment III. Mycobacterium Ulcerans a. Diagnostic Features b. Epidemiology c. Clinical Manifestations d. Treatment

Take note: nasal scrapings contain a very high number of the organisms because they prefer to stay in the cooler part of the body, and the nasal septum temp is lower than any other part of the body.

I. MYCOBACTERIUM LEPRAE A. History Discovered in 1873 by G.A. Hansen Causes Hansens Disease or Leprosy (no effective therapy until 1940) In Spain: Lepers- Legally dead, a social stigma (marker for isolation) B. Diagnostic Features An obligate Intracellular parasites that needs a host to replicate Prefers to attack Macrophages and Schwann cells Acid-fast staining straight or slightly curved rods, arranged singly, in parallel bundles or globular masses Red Stain (seen in smears) Gram Variable - more gram(+) than gram(-) not really useful for identification Regularly found in scrapings from the skin or mucous membrane (nasal septum- has lower temp. Bacilli from ground tissue nasal scrapings: 1. Inoculated into footpads of mice--> development of local granulomatous lesions with limited bacterial multiplication 2. Inoculated into armadillos development of extensive lepromatous/leprosy

Bacilli are often found within endothelial cells of blood vessels or in mononuclear cells Humans and Nine-banded armadillos are the only known natural hosts Has mycolic acid which gives it a thin waxy coating Mycolic acid- large fatty acid; dense, large lipid outer capsule outside the cell wall (phenolic glycolipid 1 or PGL-1) which has served as the antigen for serologic test for leprosy CANNOT be grown in cell-free media or tissue culture Grows best at below 37C in humans and mice (predilection for cooler areas of body) Grows luxuriously in cold blooded armadillos Gram(+) bacillus under Ziehl-Neelsen staining method

Fig.1: A tissue section: Red- mycobacterium acid-fast

C. Epidemiology -estimated 6 million with leprosy (3 million untreated) - Endemic: Asia (greatest number cases), Africa, Latin America, and Pacific - Associated with: poverty, rural residence, armadillo contact (N. America) - Transmission is due to overcrowding and poor hygiene - Modes of Transmission: 1. Majority - nasal droplet infection 2. Skin-to-skin contact - not the general route because organisms are not found histologically in the epidermis nor the dermis 3. Contact with lepromatous leprosy patients (shedding of organisms in nasal secretions or ulcer exudates)

SY 2011-2012
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Subject: Microbiology Topic: Mycobacterial Skin Infections Lecturer: Dr. Teresa Barzaga MD Date of Lecture: 07-20-2011

4. Insect vectorsbed bugs and mosquitoes in areas of leprosaria community harbor M. Leprae 5. Transmitted by soil: a.) M. Leprae specific PGL-1 has been found in soil b.)Leprosy is primarily a rural and not an urban disease c.) Direct dermal inoculation such as in tattoo parlors has been associated with disease transmission Incubation period: minimum of 2-3 years; can be as long as 40 years Long Incubation period: M. Leprae multiplies very slowly (doubling every 14 days in mice) The number of bacilli harbored by lepromatous patient on initial diagnosis if far greater than that of any human bacterial disease D. Clinical Manifestations Largely confined to the skin, Upper respiratory tract, testes, and peripheral nerves Most serous sequelae: small nerve fibers are functionally impaired (loss og touch, pain, hot and cold sensation- result of topism for peripheral nerves) E. Major Types CATEGORY Course Skin lesions Acid Fast Organisms (AFB) in skin Nerve Involvement Lepromin skin test Cellmediated immunity Skin infiltrates TUBERCULOID LEPROMATOUS Nonprogressive; benign Macular Few Severe, sudden, asymmetric Positive Intact Helper T-cell Progressive; malignant Nodular Abundant

Fig.2: Tuberculoid leprosy

Fig.3 Tuberculoid type of leprosy

Fig. 4 Leonine Facies- Lepromatous Leprosy

Slow symmetric Negative Deficient Suppressor TCells

Fig. 5 Leonine Fascie- lepromatous type of leprosy

F. Lepromin Test - Intradermal skin test using heat killed human or armadillo derived M. Leprae - Not diagnostic - Test lacks specificity

- Can be induced in normal healthy individuals by vaccination with BCG G. Laboratory Diagnosis 1. Demonstration of AFB (acid-fast bacilli) in smears of: a. Nasal scrapings b. Skin lesions c. Ear lobes- lower temp; organisms can be taken from here 2. Tissue sections 3. Biopsy of Skin or thickened nerve 4. Culture in footpads of mice

Fig.6 Section of the skin, showing abundant organisms (acid-fast bacilli)

- Slow growing - Grow optimally at low temp. (32C) - Shares other antigens with other mycobacteria - Inhibits water and marine organism - Incubation period: 2-3 weeks - Infection follows: o After minor trauma in infected swimming pools, aquariums or natural bodies of water o Trauma from fish spines or nips by crustaceans *Infection is common among fish handlers and swimmers - Disease almost always confined to superficial cooler body tissues, most often on the extremities - Typical presentation: Single inflammatory nodule that is seen in the elbows, knees or on the feet of swimmers, or hands of fish handlers begin as small papulesenlarges acquire a blue purple hue suppuration progress to ulceration Take note: lesions are called swimming pool granulomas or fish-tank granulomas B. Diagnosis 1. Culture of skin lesions (definitive diagnosis) Organisms grow best at 30C35C 2. Histologic exam Presence of granuloma + clinical history (suggestive of the diagnosis) *most strains are resistant to IMH, para-amino-salicylic acid and streptomycin C. Treatment *most strains are resistant to INH, PAS and SM 1. good results with Rifampicin and EMB 2. Tetracyclines 3. TMP- SMX

Fig. 7 Section of the Skin, Acid fast bacilli, underneath the dermis

H. Treatment - Sulfones - Rifampicin - Clofazimine *take note: treatment should be continued until skin smears become negative I. Prevention and Control 1. Identification and treatment of case 2. Children of presumably contagious parents has rendered them noninfectious

---------------------------------------------------------------II. MYCOBACTERIUM MARINUM A. Diagnostic Features - From salt water dead fish - Can cause tuberculosis

Fig. 8

- Prevalent in Australia (median age group 50-66) and Africa (peak age 515) Take note: (worldwide infection) *1st most common: mycobacterium tuberculosis *2nd most common: mycobacterium leprae *3rd most common: mycobacterium ulcerans B. Transmission - not fully understood - linked in contaminated water 1. abraded skin 2. probably via skin trauma (contaminated with water, soil or vegetation) 3. insects play an important role - ONLY mycobacterium to cause disease by the production of TOXINS - Toxins produced are called Mycolactum - lipid molecule, it diffuses at the side of infection and at the surrounding skin to kill the surrounding cells and suppresses the immune response of the patient - lesion begins as a nodule ulcerates over 4-6 weeks Centers of ulcer necrotic without ceasation Organisms are located at the periphery, adjacent to normal tissue C. Treatment Success has been reported with: 1. Local heat, excision and skin grafting 2. Combination of either INHStreptomycin or diaminodiphenylsulfone plus oxytetracycline 3. Combination of SMX, RMP and minocycline Supposed to be red acid-fast bacterium (but the picture given was black and white) ---------------------------------------------------------------III. MYOBACTERIUM ULCERANS A. Diagnostic Features - Slow growing, belongs to a large group of environmental Mycobacteria - Inhabits water where it can colonize aquatic plants, herbivorous animals and aquatic insects - Endemic in countries with tropical rainforest - Causes chronic, painless, cutaneous ulcers (Buruli ulcers- Uganda; Bairnsdale ulcers- Australia) - Prefer cooler temperatures (30C35C) seen at the extensors of the body (hands and feet) - Ulcers: seen in extensor surface of extremities

Fig. 9 lesions on the hand

Lesion seen in the arm with hemorrhage and ulceration

Note the location of the lesion. Mycobacterium likes to stay at cooler temp part of the body

Caused by Mycobacterium ulcerans

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