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Legionella+Mycoplasma+Atypical Pneumonia

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  • 1. LEGIONELLA MYCOPLASMA ATYPICAL PNEUMONIA Dr Kamran Afzal Classified Microbiologist
  • 2. LEGIONELLA
  • 3. TAXONOMY
    • Domain : Eubacteria
    • Division : Proteobacteria
    • Family : Legionellaceae
    • Genus : Legionella
    • Species : L. pneumophila L. pasculeii
    • L. fraseri
      • 41 species, 3 sub-species and 60 serogroups
  • 4. Legionella pneumophila
    • Gram – rods (weak)
    • 0.3 - 0.9 μm X 1- 50 μm with pointed ends, wrinkled surface
    • Motile with polar / sub-polar flagella, pili, fimbriae
    • Strict aerobe
    • Nutritionally fastidious
      • L-cysteine and ferric salts required
    • Non-sporing, motile
  • 5. EPIDEMIOLOGY
    • 1-4 % of all Pneumonias
    • Male preponderance
    • High summer incidence
    • Can cause community outbreak at large scale
    • Predisposing factors
      • Smoking / Alcohol
      • Increased age
      • Underlying disease
        • Lymphoma, leukemia, CCF, pulmonary disease
      • Immuno-compromised status
        • AIDS, T Cell dysfunctions
  • 6. HISTORICAL PERSPECTIVE
    • July 1976, American Legion Convention in Philadelphia, Pennsylvania
    • 184 Legionnaires’ developed pneumonia
    • 29 Legionnaires’ and 5 others staying in the same hotel died of illness
  • 7. HABITAT
    • Do not occur as commensal flora in man
    • No man to man transmission
    • Thermally heated bodies of water
      • Hotels and hospitals
    • Gain entry into cooling towers of large buildings and evaporative condensers of
      • A/Cs, humidifiers, nebulizers
  • 8.  
  • 9.  
  • 10.  
  • 11. LEGIONNAIRES’ DISEASE
    • Incubation period : 2-10 days
    • Case fatality ratio : 0-20 %
    • Clinical syndrome : Pneumonia
    • Local Symptoms : High fever, cough, headache, chest pain, nausea, malaise, dyspnea and haemoptysis
    • Systemic Symptoms: Disorientation, confusion, nausea, vomiting, diarrhea and renal insufficiency
    • PONTIAC FEVER : A brief and slow febrile flu-like illness, does not cause death
  • 12.  
  • 13.  
  • 14. LABORATORY DIAGNOSIS
    • Samples
      • Sputum
      • Lung biopsy material
      • Pleural fluid
      • Bronchial washings
      • Blood
      • Environmental samples (water)
      • Samples can be incubated at 60 0 C x 30 min
    • Inoculated on BCYE Agar
  • 15. CULTURAL CHARACTERISTICS
    • Strict aerobe
    • 37 0 C (30 – 60 0 C) X 10-14 days
    • L-cysteine and Iron required
    • Does not grow on ordinary culture media
    • Grows on
      • Buffered Charcoal Yeast Extract Agar (BCYE)
      • Tyrosine BYE Agar
      • Feeley Gorman Agar
  • 16. COLONY APPEARANCE
    • BCYE Agar
      • Circular, low convex, smooth glistening surface, crenated edge, soft consistency, gray or gray/blue colour
    • Fluorescence under UV light
      • L. pneumophila colony does not produce fluorescence
    • FG Agar
      • Produce diffusible brown pigment
    • Produce opacity around colonies on Egg Yolk medium with clearing beyond the zone of opacity
  • 17. BIOCHEMICAL REACTIONS
    • Does not ferment routine sugars
    • Hydrolyze
      • starch
      • hippurate
      • gelatin
    • Catalase +
    • Oxidase +
  • 18.
    • Immunoassays
      • ELISA
      • RIA
      • Latex agglutination
    • Direct detection
      • DFAT
      • Silver impregnation
    • Serology
      • IFAT
    • PCR
  • 19. TREATMENT
    • Erythromycin High dose I/V Macrolides
    • Azithromycin
    • Rifampicin
    • Fluoroquinolones
    • Supportive therapy
      • Ventilation, renal dialysis, re-hydration, correction of electrolyte imbalance
    • Control measures
      • Chlorination of water with intermittent temperature increase to 60 0 C
  • 20. MYCOPLASMA
  • 21.  
  • 22. DISEASES
  • 23. Differentiation of Species
    • M. pneumoniae - glucose
    • M. hominis - arginine
    • U. urealyticum - urea
    • M. genitalium - difficult to culture
  • 24. MORPHOLOGY
    • Smallest free-living bacteria (0.2 - 0.8 µ m)
    • Small genome size
    • Strict aerobe
    • Lack a cell wall
    • Grow slowly by binary fission
    • “ Fried egg” colonies
  • 25. “ Fried Egg” Colonies of Mycoplasma M. pneumoniae colonies have a granular appearance
  • 26.  
  • 27. Can be part of normal flora
    • They reside extracellularly in the respiratory and urogenital tracts and rarely penetrate the sub-mucosa, except in the case of immunosuppression or instrumentation, when they may invade the bloodstream and disseminate to numerous organs and tissues
  • 28. Mycoplasma are cell wall deficient
    • Cross-section of Mycoplasma bacteria
  • 29. PATHOGENESIS
    • Adherence
      • P1 pili
      • Movement of cilia ceases
      • Clearance mechanism stops
    • Toxic metabolic products
      • Peroxide and superoxide
    • Immuno-pathogenesis
      • Activate macrophages
      • Stimulate cytokine production
  • 30.  
  • 31. CLINICAL MANIFESTATIONS
    • Tracheo-bronchitis
      • 70-80% of infections
    • Pneumonia
      • Approximately 10% of all atypical pneumonias
        • “ Primary atypical pneumonia”
        • Mild disease but long duration
  • 32.
    • Incubation 2-3 weeks
    • Persistent non-productive cough
    • Radiological signs precede symptoms
    • Slow resolution
      • Rarely fatal
  • 33. LABORATORY DIAGNOSIS
    • Microscopy
      • Difficult to stain
    • Immunochromatography
    • Immunofluorescence
    • Culture (definitive diagnosis)
      • Sputum (usually scant) or throat washings
        • May take 2-3 weeks
    • Molecular diagnosis
      • PCR-based tests
        • Rapid, sensitive and specific
  • 34.
    • Serology
      • ELISA
      • Complement fixation
        • May take 4-6 weeks
        • Fourfold rise in titer
      • Cold agglutinins (4 0 C)
        • 1/3 - 2/3 of patients
        • Appear earlier
        • Non-specific
        • Presumptive diagnosis
  • 35. Culturing Mycoplasma
    • Mycoplasma can be cultured on liquid or solid media
      • PPLO Broth enriched with 20% horse or human serum
    • Grows optimally at 35 - 37 0 C up to 3 weeks
    • The colonies appear as fried egg
  • 36.  
  • 37. TREATMENT AND PREVENTION
    • Treatment
      • Tetracycline or erythromycin
      • Newer fluoroquinolones
      • They are relatively resistant to pencillins and Cephalosporins
    • Prevention
      • Avoid close contact
      • No vaccine
  • 38. ATYPICAL PNEUMONIA
  • 39. DEFINITION
    • Pneumonia is defined as inflammation of lung parenchyma
      • During the process of inflammation of alveoli there occurs inflammatory exudate that fill up air spaces and result in consolidation of lung
  • 40. GROSS MANIFESTATIONS LOBAR PNEUMONIA BRONCHOPNEUMONIA INTERSTITIAL
  • 41. ATYPICAL PNEUMONIA
    • Atypical pneumonia is caused by atypical bacteria that do not stain with Gram stain or do not fit in any category like in virus or bacteria
    • The inflammation is confined to interstitial spaces between alveoli
    • Radiologically gives appearance of reticulonodular pattern
    • Linear thread like opacities in lungs
  • 42.  
  • 43. Not prominent Prominent (myalgia, fatigue, N/V, diarrhea) Extra-pulmonary symptoms Purulent Scanty Sputum Productive cough Dry cough Cough Abrupt Gradual Onset S. pneumoniae , H. influenzae , K. pneumoniae , mixed aerobic and anaerobic oral flora M. pneumoniae , L. pneumophilia, C. pneumophilla, viruses, protozoa and fungi Etiology TYPICAL PNEUMONIA ATYPICAL PNEUMONIA
  • 44. ROUTES OF INFECTION
    • Microaspiration
    • Gross Aspiration
    • Aerosolization / inhalation
    • Hematogenous route
    • Contiguous spread
  • 45. INVESTIGATIONS
    • Total and differential blood count
    • Blood, urine, sputum -> Culture/sensitivity
    • Gram staining/ZN stain for AFB
    • CRP
    • Serological investigations
    • Antigen detection in sputum or urine by
      • Fluorescent methods, Immunoelectrophoresis, Latex agglutination, ELISA
    • Radiology -> CXR, MRI and CT scan
    • Fiberoptic bronchoscopy with bronchial washing/ brushing /biopsy -> Histopathology
    • Molecular techniques
  • 46. Serology
    • By serological methods using acute and convalescent sera
    • Significantly raised titer or rising titer of antibodies give clues to diagnosis
  • 47. Specific Serological Tests
    • Legionella pneumophila
      • Rapid microagglutination test
      • Test for Legionella antigen in the urine
    • Mycoplasma pneumoniae
      • Complement fixation test
      • IgM by latex agglutination or ELISA
      • Cold agglutinin test
  • 48.
    • Chlamydia
      • Microimmunofluorescence
      • ELISA
    • Coxiella burnetii
      • Complement fixation test
    • Serologic tests
      • A four fold or greater rise in titer is confirmatory of an acute infection
  • 49. Histopathology
    • White spaces are alveolar spaces and are empty and clear
    • But surrounded by swollen interstitial tissue infiltrated with inflammatory cells, typical of interstitial pneumonia
  • 50.
    • Thread like linear striations extending in the lungs forming sort of a network
    • Very small patchy spots or nodules over or along these lines giving reticulo-nodular appearance -> Atypical or viral pneumonias
    Radiology
  • 51. COMPLICATIONS
    • Parapneumonic effusions
    • Septic arthritis
    • Endocarditis
    • Pericarditis
    • Respiratory failure
    • Mental symptoms