Mycobacteria

Prof. Julius T. Capili RMT,MPH,PhD,DPASMAP | December 23, 2020

Trans by: Baguingan, Bangayan, Llapitan,Pacamalan, Simangan

OUTLINE
I. Mycobacteria: Gen. C. Decontamination and
Characteristics Digestion
II. M. Tuberculosis D. Factors Affecting the
Complex Action of Decontamination
A. Components of MTC Agent
B. Pathogenesis E. Acid Fast Staining
III. Nontuberculous F. Culture Media
Mycobacteria V. Review Questions
IV. Laboratory Diagnosis VI. References
A. Specimen
Collection and Transport
B. Grading of Sputum
Specimens Fig 1. Mycobacterium tuberculosis (arrows) in a processed sputum
specimen stained by Ziehl Neelsen stain. The Mycobacterium tuberculosis
I. MYCOBACTERIA: GENERAL CHARACTERISTICS is red against a blue background.

• Aerobic(some may grow in reduced oxygen concentrations) ,

very thin, slightly curved or straight rods (0.2 to 0.6 × 1 to 10 μm).
• Non–spore forming (except for M. marinum), nonmotile, and non-
encapsuated
• Catalase (+) and produce Much’s granules
• Genera that are closely related to Mycobacterium include
Nocardia, Rhodococcus, Tsukamurella and Gordonia
• Cell wall contains N-glycolylmuramic acid and has very high lipid
content
• Most species associated with disease grow slowly, but rapidly
growing species grow in 2-3 days
Fig 2. The fluorescent dye Auramine O was used to stain a sputum
• Some species require 5-10% CO2; resistant to heat, cold and sample. It shows two fluorescent Mycobacterium tuberculosis. x1000.
drying
• Cell wall resist decolorization with acid-alcohol
• Incomplete staining may show “beaded appearance” • Culture: slow growing, buff in color raised and dry- “cauliflower
• Microscopy: slender, slightly curved or straight Gram-positive colonies”
rod • Rough colonies exhibit “cording” (curved strands of bacilli)
• Have tendency to clump • Biochemical Tests: (+) niacin and nitrate reduction
• “Gram-neutral” or “Gram-ghost” appearance • With growth in thiopene-2-carboxylic acid hydrazide (T2H)
• Culture: smooth and soft or a rough and friable appearance (egg • Virulence factor: cord factor (trehalose- 6, 6’- dimycolate
based media) • Specific gravity: 0.79-1.07
• pH requirement: 6.5- 6.8 (culture media) a. Niacin Accumulation
• Generation time: >12 hours- grow slowly because of their - most commonly for MTB
hydrophobic cell surface - accumulation of niacin (nicotinic acid), result of lack of an enzyme
• Two Groups of Mycobacteria that converts niacin to niacin ribonucleotide in the coenzyme
→ Mycobacterium tuberculosis complex (MTC) pathway
→ Nontuberculous Mycobacteria (NTM) - Nicotinic acid reacts with cyanogen bromide in the presence of
amine to form a yellow-pigmented compound
II. MYCOBACTERIUM TUBERCULOSIS COMPLEX
- performed only from cultures on L-J medium that are at least 3
Mycobacterium tuberculosis, weeks old and at least 50 colonies
Mycobacterium bovis, Reagent: Cyanogen Bromide and Aniline
M. bovis [BCG] (+) result: Yellow
Mycobacterium africanum, (+) = M. tuberculosis
Mycobacterium microtii
Mycobacterium canettii b. Nitrate Reduction
A. COMPONENTS OF MTC - NITROREDUCTASE catalyzes reduction of nitrate to nitrite
- incubated in 2 mL of sodium nitrate at 37° C for 2 hours
Mycobacterium tuberculosis - differentiates MTB from the scotochromogens
• Also known as the Koch bacillus or human tubercle bacilli Reagent: Hydrochloric acid (50 mL HCl in 50 mL of water),
• Doubling time of tubercle bacilli is about 18 hours Sulfanilamide, and N-1naphthylenediamine dihydrochloride
• Inhibited by nitroimidazopyran (NAP) Indicator: Zinc
• Microscopy: thin straight rods measuring about 0.4 x 3 um with (+) result: Red color
X, Y, V and L formation (+) M. kansasii, M. szulgai, M. fortuitum, and M. tuberculosis

Trans # 09 Mycobacteria 1 of 7
• patients with cavitary disease are primary reservoir • Methods of administration:
• Primary route of transmission: Person to person by inhalation → Standard dose: 0.1 ml of PPD
of droplet nuclei: (infectious aerosols, 1 to 5 μm) → Mantoux test- intracutaneous injection; most accurate
• infectious aerosols may also be produced by manipulation of → Von pirquet- scratching the tuberculin in the skin
lesions or processing of clinical specimens in the laboratory → Vollmer patch test- piece of cloth soaked in OT/PPD and
Mycobacterium bovis placed over skin; for infants
• Produces TB in cattle, dogs, cats, swine, parrots and humans → Moro percutaneous test- OT/PPD + lanolin-ointment rubbed
• Primary route of transmission: Ingestion of contaminated milk onto skin
from infected cows or by exposure to animals and their → Tuberculin tine test- multiple puncture technique
carcasses; airborne transmission • Result interpretation
• Attenuated strain is used for vaccination of newborns → After 48 to 72 hours, an infected individual shows a delayed
• Culture: slow growing, small, granular, rounded white colonies hypersensitivity reaction to the PPD, characterized by
and nonpigmented erythema and, most important, induration
− Glycerol selectively inhibits growth
• Biochemical tests: (-) niacin and nitrate
− Susceptible to thiopene-2-carboxylic acid hydrazide
(T2H)
− (-) 68C catalase test
Mycobacterium africanum
• Associated with cases of human TB in tropical Africa
• Detection requires used of spoligotyping
• Inactive biochemically but urease (+); variable (+) in T2H growth
Mycobacterium canettii Fig.3 A positive tuberculin skin test on an arm.
• Is the smooth strain of M. tuberculosis
• Grows more rapidly than M. tuberculosis (6 days on solid media) → The diameter of induration is measured and then interpreted:
• Natural reservoir has not been clearly defined; rarely infects → > 10 mm- indicates infection with M. tuberculosis
humans → > 5mm but < 10 mm- indicates doubtful result; may be due to
• First human isolate was from a cervical lymph node (Somalic other mycobacteria
child); also isolated from AIDS patient with mesenteric TB → < 5mm- negative; repeat test with 250 TU
• Biochemical test: (+) niacin and reduced nitrate to nitrite Pott’s Disease
Mycobacterium microti • Also known as tuberculosis spondylitis or skeletal TB of the spine
• Has been isolated from TB patients in both immunocompetent • Grave form of tuberculosis caused by the invasion of M.
and immunocompromised individuals tuberculosis into the spinal vertebrae
• Habitat: Humans rarely; small animals (e.g., voles and other wild
Miliary Tuberculosis
rodents)
• An extrapulmonary tuberculosis which refers to the speeding of
B. PATHOGENESIS many organs outside the pulmonary tree with AFB through
Tuberculosis hematogenous spread
• A disease of the respiratory tract that may mimic other diseases • Occurs shortly after primary pulmonary disease but can take
such as pneumonia, neoplasm or fungal infections place anywhere in the course of acute or chronic TB
• Chronic granulomatous infection which is transmitted by • Common sites of spread: spleen, liver, lungs, bone marrow,
inhalation of infected droplets by means of coughing, sneezing or kidney, adrenal glands and eyes
talking Multidrug-resistant Mycobacterium tuberculosis (MDR-TB)
• Signs and symptoms: low-grade fever, night sweats, fatigue, • Defined as without previous history of TB disease and resistance
anorexia, weight loss to at least isoniazid and rifampicin (anti-TB drugs)
• Reactivation occurs when there is an alteration or a diminution of • Usually acquired by spontaneous mutation as a result of the
the cellular immune system inappropriate use of antimicrobial agents to treat M. tuberculosis
• Clinical diagnosis: usually limited to detection of positive and the lack of patient compliance
tuberculin test using PPD • Types of MDR-TB
→ Primary MDR-TB
Tuberculin Test - defined as without previous history of TB disease and
• Detects patient’s cell-mediated immune response to the bacterial resistance to at least isoniazid and rifampicin (anti-TB
antigens in type IV hypersensitivity reaction drugs)
• Does not detect active disease from hypersensitivity resulting → Extensively drug resistant TB (XDR- TB)
from a previous infection or vaccination - defined as resistance to rifampcin +fluoroquinolone + at
• A reactive (positive) result indicates past exposure to M. leastone of three injectable second line anti-TB drugs
tuberculosis (aminoglycosides, amikacin, kanamycin, or
• Types of reagent: capreomycin)
→ Old tuberculin (OT)
• the original test reagent for tuberculin test III. NONTUBERCULOUS MYCOBACTERIA
• Prepared from 6-week old broth cultures, from which • Currently, has approximately 130 species
organisms were filtered and concentrated by steaming • Present in the environment and sometimes colonize the skin and
• Active component of the filtrate is a heat-stable protein respiratory and GIT of healthy individuals
→ Purified Protein Derivative (PPD) • Mode of transmission: trauma, inhalation of infectious aerosols
• Partially purified preparation of OT prepared by and ingestion
ammonium sulfate fractionation • Few disease are nosocomial or are acquired as an iatrogenic
• Product consists of a mixture of small tuberculoproteins infection
• The test reagent use for tuberculin skin testing

Trans # 09 Mycobacteria 2 of 7
• Other names used to designate the NTMs: anonymous, • Biochemical tests-
atypical, unclassified, unknown, tuberculoid, environmental, → (+) Tween 80 hydrolysis (rapid)
opportunistic, mycobactera other than tubercle bacili (MOTT) → (+) pyrazinamidase; strong nitrate reducer
• Runyon classification: slow growing NTMs (Runyon groups I to Mycobacterium marinum
III), and rapid growers (Runyon group IV)
• Causes diseases of the fish and has been isolated from aquarium
• Causative agent of “swimming pool granuloma” – red or blue red
Table 1. Non-tuberculous Mycobacteria (TNM)
subcutaneous nodule on the elbow, knee, toe ,finger
Natural reservoir: fresh water and salt water
Microscopy: moderate to long rods with cross-barring
Culture: smooth to rough and wrinkled blue colonies
(photochomogenic)
Biochemical tests:
(+) Tween 80 hydrolysis
(+)urease, pyrazinamidase

Mycobacterium ulcerans
• 3rd most common species
• Rare cause of Buruli ulcer- painless nodule under skin
after previous trauma

Growth temp.: 30-33C and usually none at 37C

Microscopy: moderately long rods without beading
Culture: smooth & rough nonpigmented colonies (6-12
weeks incubation)
Biochemical tests:
Mycobacterium avium Complex (+) heat-stable catalase
• Often called the MAC or MAI (M. avium intracellulare) complex
→ comprises M. avium, M. intracellulare, M. avium subsp. avium, Mycobacterium gordonae
M. avium subsp. paratuberculosis, M. Avium subsp. silvaticum • Culture: have a transparent (more virulent; more drug resistant),
(wood pigeon bacillus), M. vulneris, M. marseillense, M. opaque, or a translucent, colony morphology
bouchedurhonense, and M. timonense • Biochemical test: (+) heat-stable catalase; with growth in T2H
• Grow optimally at 41°C and produce smooth, soft, nonpigmented • M. avium- cause of infection in poultry and swine
colonies • Also known as “tap water bacillus”
• Ubiquitous in the environment and can persist well over a year in • Contaminates tap water used by patients in rinsing mouths prior
tap water, and tolerates temperature extremes. to the aerosolized saline procedure for sputum collection
• Major reservoir: natural waters • Rarely causes human infection
• Portal of entry: GIT and respiratory tract
• Associated with respiratory disease clinically similar to Growth temperature: 22 to 37C
tuberculosis in adults, lymphadenitis in children, and Culture: smooth yellow orange colonies
disseminated infection in patients with HIV (scotochromogens)
Biochemical tests-
• Can infect and replicate in protozoa- more invasive toward
(+) heat-stable catalase;
human epithelial and macrophage cells
Tween 80 hydrolysis
• Other manifestations: synovitis, genitourinary tract disease,
(-) nitrate reduction
cutaneous lesions, deep infection of the hand, osteomyelitis,
meningitis, ulcer of the colon, and pericarditis Mycobacterium xenopi
• Significant laboratory abnormalities: anemia and elevated • Microscopy: long rods with distinct cross-banding (shepherd’s
ALP crook); some cording
• Microscopy: pleomorphic, short, cocobacillary without beading; • Culture: MB 7H10- smooth to rough colonies with dark centers
stain with PAS and waxy edges
• Culture: have a transparent (more virulent; more drug resistant), • Recovered from hot and cold watertaps, especially water storage
opaque, or a translucent, colony morphology tanks of hospitals, and from birds
• Biochemical test: (+) heat-stable catalase; with growth in T2H • First isolated from an African toad
• M. avium- cause of infection in poultry and swine • Causes pulmonary infection in adults; a potential pathogen
• M. avium subsp. paratuberculosis- causative agent of
inflammatory bowel disease (Johne’s disease) in cattle, sheep, Growth temperature: 42C
and goats Microscopy: long and filamentous rods
→ isolated from the bowel mucosa of patients with Crohn’s Culture:
disease MBH710- small colonies with dense
→ require mycobactin (produced M. phlei and other spp.) which centers and filamentous edges
is an iron-binding hydroxymate compound Cornmeal glycerol agar- round colonies
with branching filaments
→ May take as long as 6 to 18 months for primary isolation
“bird’s nest” appearance with sticklike
Mycobacterium kansasii projections (young colonies)
• Microscopy: long rods with distinct cross-banding (shepherd’s Can be nonphotochromogen and
crook); some cording scotochromogen (bright yellow colonies)
• Culture: MB 7H10- smooth to rough colonies with dark centers Biochemical tests-
and waxy edges (+) heat-stable catalase;
→ Photochromogenic colonies- “dark red crystals of 10-beta- pyrazinamidase;
carotene” arylsulfatase
Trans # 09 Mycobacteria 3 of 7
 Recovery of mycobacteria is improved with blood collection
IV. LABORATORY DIAGNOSIS in either a broth or the Isolator lysis-centrifugation system
A. SPECIMEN COLLECTION AND TRANSPORT In patients with AIDS, quantitation of such organisms can be
used to monitor therapy and determine the prognosis
• Successful isolation of these organisms depends on the quality
of the specimen obtained and the use of appropriate processing 6. Wounds, Skin Lesions, and Aspirates
and culture techniques by the mycobacteriology laboratory Best type of specimen for culturing of a skin lesion or
• Specimens: respiratory samples, such as sputum, tracheal or wound: aspirates
bronchial aspirates, specimens obtained by bronchial alveolar If the volume is insufficient for aspiration, pus and exudates
lavage, urine, gastric, aspirates, tissue (biopsy) specimens, may be obtained on a swab and then placed in a transport
cerebrospinal fluid (CSF), and pleural and pericardial fluid medium, such as Amie’s or Stuart’s medium (dry swabs are
• Blood or fecal specimens- immunocompromised patients unacceptable)
• Specimens should be collected in sterile, leakproof, disposable, If specimens cannot be processed immediately, 10-15 ml
saline is added immediately
and appropriately labelled containers without fixatives and
placed in bags to contain leakage. B. SUBGRADING OF SPUTUM SPECIMENS
• If transport and processing will be delayed specimens should be • Bartlett’s criteria- for scoring sputum
refrigerated at 4°C until processed- except blood
• Murray-Washington method- for contamination
1. Pulmonary Specimens assessment
Methods for obtaining pulmonary secretions: • Heineman’s method- emphasizes the ratio between
spontaneously produced or induced sputum, gastric squamous epithelial cells and PMNs
lavage, transtracheal aspiration, bronchoscopy, and
C. DECONTAMINATION AND DIGESTION
laryngeal swabbing
Most commonly submitted specimen: sputum, aerosol- • These procedures are performed to kill all contaminating
induced sputum, bronchoscopic aspirations, or gastric organisms and to dissolve mucous substances
lavage samples • Dissolving the mucin prior to inoculation onto culture
Specimen of choice: Spontaneously produced sputum medium enables the mycobacteria to use the nutrients of the
Saliva and nasal secretions should not be collected medium
No use of oral antiseptics during the collection period • The high lipid content in the cell wall of mycobacteria makes
Sputum specimens must be free of food particles, them less susceptible to the killing action of various
residues, and other extraneous matter chemicals
Sputum collection guidelines recommend collection of an • The optimal decontamination procedure requires an agent
early morning specimen for 3 consecutive days that is mild and yields growth of mycobacteria while
2. Urine Specimens controlling contaminants
The clinical manifestations of urinary tuberculosis, which
Factors Affecting the Action of Decontamination Agent:
are variable, include frequency of urination (most
Concentration of the chemical agent
common), dysuria, hematuria, and flank pain. Definitive Exposure/ contact time and temperature
diagnosis requires recovery of acid-fast bacilli from the
urine.
Early morning voided urine specimens (40 mL minimum) Specimens that Require Decontamination:
in sterile containers should be submitted daily for at least Sputum
3 days Voided urine
The collection procedure is the same as for collecting a Autopsy tissue
clean-catch midstream urine specimen Abdominal fluid
24-hour urine specimen is undesirable Any contaminated fluid
Catheterization should be used only if a midstream voided
specimen cannot be collected Specimens that Require Both Decontamination and
3. Fecal Specimens Digestion:
AFB staining or culture of stool (or both) from patients with Sputum
AIDS has been used to identify patients who may be at risk Gastric washing
for developing disseminated M. avium complex disease Bronchoalveolar lavage
Bronchial washing
Should be submitted in a clean, dry, wax-free container
Transtracheal aspirate
without preservative or diluent
Contamination with urine should be avoided
4. Tissue and Body Fluid Specimens Specimens that Do Not Require Decontamination:
Crucial for isolation of AFB from CSF CSF
At least 10 mL of CSF is recommended for recovery of Synovial fluid
mycobacteria Biopsy tissue from deep organs
10-15 mL minimum- for other body fluids such as pleural,
Reagents for Decontamination and Digestion of Specimens:
peritoneal, and pericardial fluids, should be collected in a
sterile container or syringe with a Luer-tip cap 1. 2%-4% NaOH
Tissues may be immersed in saline or wrapped in gauze Most common decontamination agent (2:2)
Swabs are discouraged Both a decontaminant and digestant
5. Blood 2. 5%-6% oxalic acid
Collected to diagnose individuals with AIDS For decontamination of sputum specimens containing Gram-
Culture medium: BACTEC 13A vial negative rods like Pseudomonas

Trans # 09 Mycobacteria 4 of 7
3. 1% cetyl-pyridium chloride
To prolong the shelf-life of sputum, up to 8 days (ideal for
transport of specimen)
4. Zephiran-trisodium phosphate
• Decontamination-digestion reagent
• An effective decontaminant with little bactericidal effect
on tubercle bacilli
• Liquefies sputum rapidly but requires a long exposure
time to decontaminate the specimen
• Phosphate buffer- results in greater isolation of
mycobacteria
• Advantage: for specimens containing large numbers of
bacteria
5. N-acetyl- L- cysteine (NALC)- NaOH
Both a decontaminant and a digestion agent
NALC is also known as dithiothreitol; a digestion agent

D. ACID-FAST STAINS

• Acid-fastness is affected by age of colonies, medium on which

growth occurs, and exposure to UV
• AFS require at least 104AFB/mL for detection from
concentrated specimens

• 5,000 to 10,000 AFB/mL is needed to obtain (+) AFB staining

E. CULTURE MEDIA
• Methods:
a. Ziehl-Neelsen/Hot Stain Procedure
b. Kinyoun stains/Cold Stain Procedure → Incubated at 35°C in the dark with 5% to 10% CO2 with
c. Auramine-rhodamine fluorochrome stains (more humidity
sensitive) 1. Tubed media
incubated at slanted position with the screw caps loose for
Primary Stain: Auramine-rhodamine 1 week to allow evaporation of excess fluid and entry of
Decolorizer: Acid Alcohol CO2
Counter stain: Potassium permanganate 2. Plated media
**Examined at 250x to 400x magnification placed in CO2-permeable plastic bag or wrapped with
**Positive: bright, yellow-orange bacilli against dark background CO2-permeable tape
All positive fluorescent smears are confirmed with Examined weekly for growth
Ziehl-Neelsen on the same smear **Rapid Growers: 2-3 days
• Precautions during AFB Staining and Microscopy: **Pathogenic: 2-6 weeks
Smears should not come in contact with one another MALACHITE GREEN is inhibitory agent for nonmycobacteria
during staining ** M. Marinum or M. ulcerans: 25° to 30° C
Staining jars should not be used a. Egg-Based Media
Wipe the OIO before reading the next smear slide - composed of fresh whole eggs, potato flour, and glycerol,
with slight variations in defined salts, milk, and potato flour
Cause of False(+) AFS: Malachite green: suppress gram(+) bacteria
1. Changes in the cell wall Egg yolk: lipid source, promotes growth of mycobacteria
2. Insufficient decolorization Nonselective egg-based media: shelf life of 1 year
3. Laboratory contamination
4. Delayed processing and overgrowth of other Löwenstein-Jensen (L-J): most commonly used
bacteria medium; M. Genovense fails to grow
Malachite green (0.025%)
Gruft (Modification of LJ): +RNA; Malachite Green,
Cause of False(-) AFS: Penicillin and Nalidixic acid
1. Overzealous decontamination
2. Loss fro concentration technique b. American Thoracic Society
3. Organism obscured by a very thick smear - - Malachite green (0.02%)
4. Over-decolorization of the smear - Wallenstein Medium for isolation of M. avium complex
5. Poor counter staining
6. Lack of observer proficiency in reading stains c. Agar-based media
- Composed of defined salts, vitamins, cofactors, glycerol,
malachite green, and agar combined with an enrichment
consisting of oleic acid, bovine albumin, glucose, and
beef catalase
Middlebrook:
2% glycerol; enhances the growth of MAC
Middlebrook 7H10:
Malachite green (0.00025%)

Trans # 09 Mycobacteria 5 of 7
 **Middlebrook 7H10 selective:
- carbenicillin (inhibition of pseudomonads), polymyxin
B, trimethoprim lactate, and amphotericin B
Middlebrook 7H11
- Malachite green (0.0001%), 0.1% casein hydrolysate:
isolation of isoniazid-resistant M. tuberculosis
**Middlebrook 7H11 supplemented with mycobactin J
for isolation of M. genovense
Mitchison’s selective 7H11
- casein hydrolysate, Carbenicillin,
Amphotericin B, Polymyxin
B, Trimethoprim lactate
Dubos Oleic Acid Albumin
Note: Good for AST although Middlebrook 7H10 is
preferred
3. Liquid media
a. BACTEC128 medium(MB7H12) and BACTEC 13A
(MB7H13)

- Part of BACTEC system

- Requires daily agitation to enhance growth and read within
4 days of inoculation
- Antimicrobial agents: polymyxin B, amphotericin B,
nalidixic acid, trimethoprim, and azlocillin (PANTA)
b. Middlebrook 7H11
- Malachite green (0.0001%), 0.1% casein hydrolysate;
isoniazid-resistant M. tuberculosis
- **Middlebrook 7H11 supplemented with mycobactin J àM.
Genovense
c. Mitchison’s selective 7H11
- casein hydrolysate,
- Carbenicillin,
- Amphotericin B,
- Polymyxin
- B,Trimethoprim lactate
d. Dubos Oleic Acid Albumin
- Note: Good for AST; Middlebrook 7H10 is
preferred
- Liquid Media a. BACTEC 12B medium (MB 7H12)
and BACTEC 13A (MB 7H13)
- Part of BACTEC system
- Requires daily agitation to enhance growth and read
within 4 days of inoculation
- Antimicrobial agents: polymyxin B,
amphotericin B, nalidixic acid, trimethoprim, and
azlocillin (PANTA)

Growth enhancer:
polyoxyethylene stearate
14C-labeled substrate (palmitic acid): metabolized by
mycobacteria, liberating radioactive CO2 (14CO2)à
detected by BACTEC 460TB
Growth indicator: release of CO2
- M. tuberculosis = 9 to 14 days;
- NTM = <7 days

e. Middlebrook 7H9 broth and Dubos Tween albumin

- Nonselective liquid media used for subculturing stock
strains
f. Septi-Chek AFB
- Biphasic Media: 20 mL Middlebrook 7H9 broth ,20%
CO2; solid phase contains three media: modified
L-J, Middlebrook 7H11, and a chocolate agar slab
g. BBL Mycobacteria Growth Indicator Tubes

Trans # 09 Mycobacteria 6 of 7
 V. REVIEW QUESTIONS 7. There are millions of cases of leprosy (Hansen’s disease)
worldwide,but predominately in Asia and Africa. The clinical
1. A 34-year-old immigrant from Africa has patchy areas of skin spectrum of Hansen’s disease is best characterized by
anesthesia and hypopigmentation on his upper extremities. Nerve a. Immunologic anergy
biopsy evaluated under light microscopy shows many bacteria b. Chronic pneumonitis
invading Schwann cells. This patient's disease is most likely caused c. Peripheral neuritis
by: d. Bacilli in lesions that digest tissues
a. Borrelia burgdorferi e. Erythematous lesions resembling concentric circles
b. Treponema pallidium 8. Pathogenic mechanisms involved in tuberculosis can be
c. Corynebacteria diphtheriae primarily attributed to which of the following?
a. Toxin production by the mycobacteria
d. Mycobacteria leprae
b. Specific cell adhesion sites
e. Campylobacter fetus c. Cell-mediated hypersensitivity
2. Bacteria isolated from the lung tissue of a 32-year-old d. Humoral immunity
Caucasian male fail to decolorize with hydrochloric acid and e. Clogging of alveoli by large numbers of acid-fast
alcohol after staining carbolfuchsin. Which of the following cell mycobacteria
wall components is most likely responsible for this staining 9. Mycobacterium avium is a major opportunistic pathogen in AIDS
phenomenon? patients. M. avium from AIDS patients can be best characterized
a. N-acetylmuramic acid by which one of the following statements?
b. Teichoic acid a. The majority of M. avium isolates from AIDS patients
c. Lipopolysaccharide are nonpigmented
b. M. avium isolates from AIDS patients are of multiple
d. Mycolic acid serovars
e. Ergosterol. c. Few isolates from AIDS patients are acid-fast
3. A 52-year-old Asian male presents to your office with cough, d. Most isolates from AIDS patients are sensitive to
night sweats and occasional hemoptysis. Sputum cultures isoniazid and streptomycin
placed on a selective medium grow mycobacteria e. M. avium can be isolated from the blood of AIDS
microscopically observed to grow in parallel chains ("serpentine patients
cords"). This observed bacterial growth pattern most strongly VI.REFERENCES
correlates with:
• Dean Capili’s Lecture
a. Acid-fastness
b. Growth rates
c. Virulence
d. Pigmentation
e. Survival in macrophages
4. The treatment of tuberculosis
a. is initiated with a single "first-line" drug.
b. is initiated after the results of sensitivity testing is
available.
c. is most effective in patients with chronic or arrested
tubercles.
d. may last 2 to 3 weeks.
e. should be directly observed whenever possible.
5. A homeless man who is known to be HIV positive unexpectedly
dies in a dormitory of a congregate nighttime shelter. A
roommate states that during the night, he complained of periods
of shaking chills and fever and appeared to be coughing up
blood. An acid-fast stain slide of tissue from the lungs is shown
in the photograph. Which statement best describes the disease
process that is visible in the stained slide?
a. Cytoplasmic inclusions associated with Chlamydia
b. Legionella within alveoli indicating atypical pneumonia
c. Mycobacteria overwhelming alveolar macrophages
d. Pseudomonas microcolonies within lung parenchyma
e. Signs of consolidation linked to typical pneumonia.
6. Which of the Following is GOLD STANDARD for active TB test?
a. Sputum smear for acid-fast bacilli
b. Sputum culture
c. Nucleic acid amplification test
d. Chest X-ray
e. Tuberculin skin test
f. Interferon gamma release assay (IGRA)

Trans # 09 Mycobacteria 7 of 7