Shigella, Shigellosis

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Shigella, Shigellosis

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Shigella, Shigellosis

  1. 1. ShigellaDr.T.V.Rao MD Dr.T.V.Rao MD 1
  2. 2. Shigella a Highly Infectious Bacteria• Shigella is one of the most infectious of bacteria and ingestion of as few as 100- 200 organisms will cause disease.• Most individuals are infected with shigellae when they ingest food or water contaminated with human fecal material.• Shigella can survive up to 30 days in milk, eggs, cheese or shrimps. Dr.T.V.Rao MD 2
  3. 3. Definition• An enterobacteriaceae• Gram negative bacilli.• Readily growth O2 + An O2.• Metabolically active, fermenting a variety of substrates.• Mostly non-motile, non sporing, non acid fast, 2-4um x 0.4 -0.6um rounded ends. Dr.T.V.Rao MD 3
  4. 4. CLASSIFICATION• 4 SPECIES/SUBGROUPS BASED ON BIOCHEMICAL AND SEROLOGICAL CHARACTERS• SHIGELLA DYSENTERIAE : 12 Serotypes• SHIGELLA FLEXNERI : 6 serotypes• SHIGELLA BOYDII : 18• SHIGELLA SONNEI : 17 Colicins types Dr.T.V.Rao MD 4
  5. 5. Taxonomy Family Enterobacteriaceae1. Shigella dysenteriae: most serious form of bacillary dysentery2. Shigella flexneri: shigellosis in underdeveloped countries3. Shigella sonnei: shigellosis in developed countries4. Shigella boydii Dr.T.V.Rao MD 5
  6. 6. Morphology & Physiology• Small Gram-negative, facultatively anaerobic, coliform bacillus• Non-motile (no H antigen)• Possess capsule (K antigen) and O antigen• K antigen not useful in serologic typing, but can interfere with O antigen determination• O antigens: A, B, C, D correspond respectively to the four species• Non-lactose fermenting• Bile salts resistant: trait useful for selective mediaferment glucoseReduce nitrates (NO3 to NO2 or N2)are oxidase negative Dr.T.V.Rao MD 6
  7. 7. CLASSIFICATION on Basis of Mannitol Fermentation:• 1. Non-mannitol-fermenters• Shigella dysenteria• 2. Mannitol-fermenters• Shigella flexneri• Shigella boydii• Shigella sonnei Dr.T.V.Rao MD
  8. 8. MORPHOLOGY AND STAINING:• Short rods• - Non- encapsulated• - Non-motile• - Non-spore former• - Gram-negative Dr.T.V.Rao MD
  9. 9. Non-lactose fermenting non- motile organismsMannitol Mannitolnegative positive Shigella Non lactose Lactosedysenteria fermenter fermenter Indole negative Indole positive Shigella sonnei Shigella boydii Shigella flexneri Dr.T.V.Rao MD
  10. 10. CULTURAL CHARACTERISTICS•All members of Shigella are aerobic andfacultative anaerobes.•Grow readily in culture media at pH 6.4 to7.8 at 10 oC - 40 oC, with optimum of 37 oC.•After 24 hours incubation, Shigella coloniesreaches a diameter of about 2 mm.• The colonies are circular, convex, colorless,but moderately translucent with smoothsurface, and entire edges. Dr.T.V.Rao MD
  11. 11. Growth on Selective Medium• In XLD they appear pinkish to reddish colonies while in Heaktoen Enteric Agar (HEA), they give green to blue green colonies. Dr.T.V.Rao MD 11
  12. 12. HABITAT AND TRANSMISSION•Shigella species are found only in the humanintestinal tract.•Carriers of pathogenic strains can excrete theorganism up to two weeks after infection andoccasionally for longer periods.• Shigella are killed by drying. Shigella aretransmitted by the fecal-oral rout.• The highest incidence of Shigellosis occur in areasof poor sanitation and where water supplies arepolluted. Dr.T.V.Rao MD
  13. 13. Factors Contributing Spread• Spread is always from a human resource and generally involves one of the five f`s: – food, – fingers, – feces, – flies or – fomites.• This is in contrast to salmonellae, which are often spread to humans from infected animals.13 Dr.T.V.Rao MD
  14. 14. PATHOGENESIS• SOURCE : MAN: CASE OR CARRIER• MODE OF SPREAD: CONTAMINATED FINGERS, FOOD, FLIES, FOMITES• PERSON TO PERSON TRANSMISSION• INFECTIVE DOSE: 10-100 VIABLE BACILLI• HIGHEST CONCENTRATION IN STOOL DURING EARLY/ACUTE INFECTION 103 TO 109 VIABLE BACILLI PER GRAM OF STOOL• POST CONVALESCENT SHEDDING : LOW COUNTS 102 TO 103 Dr.T.V.Rao MD 14
  15. 15. Transmission• Faecal-oral transmission is the main path of Shigella infection. Other modes of transmission include ingestion of contaminated food or water, contact with infected objects, or sexual contact. Outbreaks of Shigella infection are common in places where sanitation is poor. Dr.T.V.Rao MD 15
  16. 16. Pathogenesis and Virulence Factors (cont.) Invasiveness in Shigella-Associated Dysentery Penetrate through mucosal surface of colon (colonic mucosa) and invade and multiply in the colonic epithelium but do not typically invade beyond the epithelium into the lamina propria (thin layer of fibrous connective tissue immediately beneath the surface epithelium of mucous membranes) Preferentially attach to and invade into M cells in Peyer’s patches (lymphoid tissue, i.e., lymphatic system) of small intestine Dr.T.V.Rao MD 16
  17. 17. PATHOGENIC DETERMINANTSO antigen: The ability to survive the passage through the host defenses may be due to O antigen.Invasiveness: Virulent Shigella penetrate the mucosa andepithelial cells of the colon in an uneven manner.Intracellular multiplication leads to invasion of adjacentcells, inflammation and cell death. Cell death is probablydue to cytotoxic properties of shiga toxin that interferewith protein synthesis. The cellular death and resultingphagocytosis response by the host accounts for thebloody discharge of mucus and pus and shallow ulcerscharacteristic of the disease.Other toxins: It has a protein toxin which may beneurotoxic, cytotoxic, and enterotoxic. The enterotoxicproperty is responsible for watery diarrhea. Dr.T.V.Rao MD
  18. 18. PATHOGENICITYShigella dysentery’s form a powerfulexotoxin, it is associated with epidemics ofbacillary dysentery. In man, shigellosis begins with symptomsof acute gastro-enteritis which isaccompanied by abdominal pain anddiarrhea.As it progresses, diarrhea becomes morefrequent and is usually accompanied Dr.T.V.Rao MDcolicky pain.
  19. 19. PATHOGENICITY• Later diarrhea losses its fecal characteristic and is followed by mucus with pus and blood.• The disease is usually accompanied by fever and marked prostration. It is also known that children are more frequently attacked than adult persons and the symptoms are more severe. Dr.T.V.Rao MD 19
  20. 20. Pathogenesis and Virulence Factors (cont.) Invasiveness in Shigella-Associated Dysentery Penetrate through mucosal surface of colon (colonic mucosa) and invade and multiply in the colonic epithelium but do not typically invade beyond the epithelium into the lamina propria (thin layer of fibrous connective tissue immediately beneath the surface epithelium of mucous membranes) Preferentially attach to and invade into M cells in Peyer’s patches (lymphoid tissue, i.e., lymphatic system) of small intestine Dr.T.V.Rao MD 20
  21. 21. Invasiveness in Shigella-Associated Dysentery(cont.) M cells typically transport foreign antigens from the intestine to underlying macrophages, but Shigella can lyse the phagocytic vacuole (phagosome) and replicate in the cytoplasm Note: This contrasts with Salmonella which multiplies in the phagocytic vacuole Actin filaments propel the bacteria through the cytoplasm and into adjacent epithelial cells with cell-to-cell passage, thereby effectively avoiding antibody-mediated humoral immunity (similar to Listeria monocytogenes) Dr.T.V.Rao MD 21
  22. 22. Pathogenesis & Immunity• Bacterial cells preferentially attach to and invade into M cells in Peyers patches of small intestine• M cells typically transport foreign antigens from the intestine to underlying macrophages,• Shigella can lyse the phagocytic vacuole (phagosome) and replicate in the cytoplasm Dr.T.V.Rao MD 22
  23. 23. Pathogenesis & Immunity• Exotoxin (Shiga toxin) is neurotoxic, cytotoxic, and enterotoxic, encoded by chromosomal genes,• Enterotoxic effect: Shiga toxin adheres to small intestine receptors• Blocks absorption (uptake) of electrolytes, glucose, and amino acids from the intestinal lumen Dr.T.V.Rao MD 23
  24. 24. Pathogenesis & Immunity• Cytotoxic effect: B subunit of Shiga toxin binds host cell glycolipid in large intestine,• Inactivate the 60S ribosomal subunit,• Inhibit protein synthesis, causing cell death, microvasculature damage to the intestine, and hemorrhage (blood and fecal leukocytes in stool)• Neurotoxic effect: Fever, abdominal cramping are considered signs of neurotoxicity Dr.T.V.Rao MD 24
  25. 25. Pathogenesis and Virulence Factors (cont.) Shiga Toxin Effects in ShigellosisEnterotoxic Effect:  Adheres to small intestine receptors  Blocks absorption (uptake) of electrolytes, glucose, and amino acids from the intestinal lumen Note: This contrasts with the effects of cholera toxin (Vibrio cholerae) and labile toxin (LT) of enterotoxigenic E. coli (ETEC) which act by blocking absorption of Na+, but also cause hypersecretion of water and ions of Cl-, K+ (low potassium = hypokalemia), and HCO3- (loss of bicarbonate buffering capacity leads to metabolic acidosis) out of the intestine and into the lumen Dr.T.V.Rao MD 25
  26. 26. Pathogenesis and Virulence Factors (cont.) Shiga Toxin Effects in Shigellosis (cont.)Cytotoxic Effect:  B subunit of Shiga toxin binds host cell glycolipid  A domain is internalized via receptor-mediated endocytosis (coated pits)  Causes irreversible inactivation of the 60S ribosomal subunit, thereby causing: Inhibition of protein synthesis Cell death Microvasculature damage to the intestine Hemorrhage (blood & fecal leukocytes in stool)Neurotoxic Effect: Fever, abdominal cramping are Dr.T.V.Rao MD 26 considered signs of neurotoxicity
  27. 27. Dr.T.V.Rao MD 27
  28. 28. Characteristics of Shiga Toxin Enterotoxic, neurotoxic and cytotoxic Encoded by chromosomal genes Two domain (A-5B) structure Similar to the Shiga-like toxin of enterohemorrhagic E. coli (EHEC) NOTE: except that Shiga-like toxin is encoded by lysogenic bacteriophage Dr.T.V.Rao MD 28
  29. 29. Clinical Syndromes (Shigellosis)• Ranges from asymptomatic infection to severe bacillary dysentery• Two-stage disease: watery diarrhea changing to dysentery with frequent small stools with blood and mucus, tenesmus, cramps, fever Early stage:• Watery diarrhea attributed to the enterotoxic activity of Shiga toxin• Fever attributed to neurotoxic activity of toxin Dr.T.V.Rao MD 29
  30. 30. Clinical SyndromesProcess involves: 1. Ingestion 2. Non-invasive colonization and cell multiplication• 3. Production of the enterotoxin by the pathogenic bacteria in the small intestine; Second stage:• Adherence to and tissue invasion of large intestine• Typical symptoms of dysentery• Cytotoxic activity of Shiga toxin increases severity Dr.T.V.Rao MD 30
  31. 31. Dr.T.V.Rao MD 31
  32. 32. Clinical Features• FEVER• BLOODY DIARRHOEA• ABDOMINAL CRAMPS• TENESMUS• MUCUS , PUS• CONVULSIONS• MILD INFECTION :WATERY STOOL• BACTEREMIA - RARE• REITER,S SYNDROME• HEMOLYTIC – UREMIC SYNDROME Dr.T.V.Rao MD 32
  33. 33. Epidemiology• Shigellosis is a major cause of diarrheal disease (developing nations)• Major cause of bacillary dysentery (severe second stage form of shigellosis)• Leading cause of infant diarrhea and mortality (death) in developing countries Dr.T.V.Rao MD 33
  34. 34. Epidemiology• Shigella occurs naturally in higher primates• Spread from human to human via the fecal-oral route• Less frequently, transmission by ingestion of contaminated food or water• Outbreaks usually occur in close communities;• Secondary transmission occurs frequently Dr.T.V.Rao MD 34
  35. 35. Epidemiology• Low infectious dose (102-104 CFU) with 1-3 day incubation period• Carriage of the organism persists for approximately one month following convalescence Dr.T.V.Rao MD 35
  36. 36. Epidemiology• HUMAN• FECAL – ORAL ROUTE• ( water ,, food ,, feces ,, flies )• PERSON – PERSON CONTACT• CHIILDHOOD• IID :: 10 - 100 ORGANIISMS• HIIGH IINFECTIIVIITY• IIP - 1– 4 DAYS• SOURCE - CASES ,, CARRIIERS• DAYCARE CENTERS,, MENTAL IINST..• TRAVEL ,, HOMOSEXEUAL Dr.T.V.Rao MD 36
  37. 37. LABORATORY DIAGNOSISThe only satisfactory method of laboratorydiagnosis is to cultivate the bacilli from thepatient.In the early stages of acute shigellosis,isolation of the causative organism from thefeces is usually accomplished withoutdifficulties by using the same special mediaand methods employed for salmonella Dr.T.V.Rao MD
  38. 38. Diagnosis of Shigella Infection• CULTUR• STOOL• RECTAL SWBS• –MacConkey AGAR NLF• –DCA ,, XLD• –SELENIITE F BROTH• 2-MIICROSCOPY :: LEUCOCYTES ,, RBC• 3- BIIOCHEMIICAL :: TSII - NO GAS,, H2S ,,• ACIID• 4-NON MOTIILE• 5- SEROLOGY TEST Dr.T.V.Rao MD :: SLIID 38
  39. 39. LAB DIAGNOSIS• COLONIES ON MA/DCA : NLF PALE AND TRANSLUCENT• COLONIES PICKED UP FOR THE FOLLOWING TESTS:• HANGING DROP : NON MOTILE• GRAM’S :GNB• BIOCHEMICAL TESTS : IMVIC ++-- ANEROGENIC FERMENTERS• SLIDE AGGLUTINATION WITH SPECIFIC HTS Dr.T.V.Rao MD 39
  40. 40. Methods to Diagnose Shigellosis• Shigellosis can be correctly diagnosed in most patients on the basis of fresh blood in the stool. Neutrophils in fecal smears is also a strongly suggestive sign. Nonetheless, watery, mucoid diarrhea may be the only symptom of many S sonnei infections, and any clinical diagnosis should be confirmed by cultivation of the etiologic agent from stools. Dr.T.V.Rao MD 40
  41. 41. Laboratory Identification:• Closely related to Escherichia• Species (serogrouping and biochemical analysis• Stool specimens and rectal swabs should be cultured soon after collection or placed in appropriate transport medium (Cary-Blair medium)• Readily isolated on selective/differential agar media (XLD, SS, and brilliant green agar)• Lactose nonfermenter Dr.T.V.Rao MD 41
  42. 42. Processing of Rectal Swabs• Rectal swabs may also be used to culture Shigella if the specimen is processed rapidly or is deposited in a buffered glycerol saline holding solution. Isolation of Shigella in the clinical laboratory typically involves an initial streaking for isolation on differential/selective media with aerobic incubation to inhibit the growth of the anaerobic normal flora. Dr.T.V.Rao MD 42
  43. 43. Culture Media for Identification• Commonly used primary isolation media include MacConkey, Hektoen Enteric Agar, and Salmonella-Shigella (SS) Agar. These media contain bile salts to inhibit the growth of other Gram-negative bacteria and pH indicators to differentiate lactose fermenters (Coliforms) from non-lactose fermenters such as Shigella Dr.T.V.Rao MD 43
  44. 44. Dr.T.V.Rao MD 44
  45. 45. Treating Cases of Shigellosis• MIILD IILLNESS REHYDRATIION• – SHORT ( 48 – 72 h)• – SH . SONNEI• BACIILLARY DYSENTERY• – ANTIMICROBIAL THERAPY ( SHORTEN• THE DURATION , PREVENT SPREAD)• AMPIICIILLIIN (PLASMIID RESIISTANCE)• COTRIIMOXAZOLE (RES..)• CIIPROFLOXACIIN• CEFTRIIAXONE Dr.T.V.Rao MD 45
  46. 46. Treatment, Prevention & Control:• Dehydration is problem to attend• Treat carriers, major source of organisms; Ciprofloxacin , Erythromycin• Antibiotic resistance is a major problem• Proper sewage disposal and water chlorination• Oral vaccines of Shigella: E. coli hybrids or Shigella mutants offers immunity for six months to one year – Need more studies Dr.T.V.Rao MD 46
  47. 47. Yet No Licenced Vaccine• Currently, no licensed vaccines targeting Shigella or ETEC exist; however, vaccines against both bacteria are in development. Dr.T.V.Rao MD 47
  48. 48. Prevention• SUPPLY OF PURE WATER• PERSONAL HYGIIENE ( HANDS)• SEWAGE DIISPOSAL• FOOD HYGIIENE• IINSECT CONTROL (FLIIES)• VACCIINE (ORAL) - 6 MONTHS Dr.T.V.Rao MD 48
  49. 49. Shigellosis and Endemicity• Shigellosis is endemic in developing countries were sanitation is poor. Typically 10 to 20 percent of enteric disease, and 50% of the bloody diarrhea or dysentery of young children, can be characterized as shigellosis, and the prevalence of these infections decreases significantly after five years of life. Dr.T.V.Rao MD 49
  50. 50. Developed countries too Suffer Shigella Infections• In developed countries, single- source, food or water-borne outbreaks occur sporadically, and pockets of endemic shigellosis can be found in institutions and in remote areas with substandard sanitary facilities. Dr.T.V.Rao MD 50
  51. 51. Hand Washing Can Still Save Many from Shigellosis Dr.T.V.Rao MD 51
  52. 52. • Programme Created by Dr.T.V.Rao MD for Medical and Paramedical Students in the Developing World • Email • doctortvrao@gmail.com Dr.T.V.Rao MD 52

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