NEISSERIA

NEISSERIA

 Gram negative diplococci

 Catalase and Oxidase positive
 Non motile
 Aerobic
 Two species pathogenic to humans-
Neisseria meningitidis (meningococcus) and
Neisseria gonnorhea (gonococcus)
Meningococcal Meningitis
 Caused by Neisseria meningitidis
(or meningococcus) - capsulated
gram-negative diplococci with
adjacent sides flattened (lens-
shaped/half-moon shaped)

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Virulence Factors

Capsular Polysaccharide:
 13 serogroups - A, B, C, X, Y & W135 - account for the majority of
cases of invasive disease.
 Other capsular serogroups and noncapsulated meningococci -
commonly colonize the nasopharynx of asymptomatic carriers

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Virulence Factors (Cont..)

Other Virulence Factors:

 Outer membrane proteins

 LPS and endotoxin

 IgA proteases

 Transferrin binding proteins

 Adhesins
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Epidemiology
 Patterns of disease: Sporadic infection, to endemic,
hyperendemic and explosive epidemics
 High prevalence area: Sub-Saharan belt of Africa (from Ethiopia
to Senegal)
 Group A - leading cause of epidemic meningitis worldwide.

 Group B and C - currently the major serogroups causing invasive

disease worldwide
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Epidemiology (Cont..)
 Group W (formerly W 135) - cause outbreaks in mass gatherings.

 India: Sporadic cases - occurring every year, mainly from North

India with occasional outbreaks.
 Seasonality: Common in winter and spring.

 Age – 2 peaks – 3m-5yrs, 15-25 yrs

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Epidemiology (Cont..)
 Risk factors that promote colonization include:

 Overcrowding & semiclosed communities - schools, military and

refugee camps, Travelers (Hajj pilgrims)

 Smoking

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Epidemiology (Cont..)
 Risk factors that promote disease :

 Deficiency of terminal complement components (C5–C9)

 Eculizumab therapy-a terminal complement inhibitor

 Hypogammaglobulinemia and hyposplenism.

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Pathogenesis
 Source – Only Humans, nasopharyngeal carriers (mainly children) –
MC
 Mode of transmission- droplet inhalation

 portal of entry - nasopharynx

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Pathogenesis (Cont..)
 Spread of infection from nasopharynx to meninges

 Hematogenous route causing septicemia (most common)

 Direct spread along olfactory nerve through cribriform plate

 Through conjunctiva - rare

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Clinical Manifestations
 Rashes: A non-blanching rash (petechial or purpuric) – 80%

 Septicemia - endotoxin induced endothelial injury - increased

vascular permeability and intravascular thrombosis
 Waterhouse–Friderichsen syndrome - fulminant meningococcemia
- large purpuric rashes, shock, DIC, bilateral adrenal hemorrhage
and multiorgan failure
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Clinical Manifestations (Cont..)
 Pyogenic meningitis
 3–5 years of age - fever, vomiting, headache, neck stiffness

 Chronic meningococcemia – rare - repeated episodes of petechial

rash, fever, arthritis, and splenomegaly
 Postmeningococcal reactive disease - Immune complexes develop
4–10 days later - arthritis, rash, iritis, pericarditis, polyserositis,
and fever 13
LAB DIAGNOSIS
Specimen Collection and Transport
 CSF - most ideal specimen for pyogenic meningitis.

 Blood culture - another useful specimen for culture.

 CSF collection: Lumbar puncture under strict aseptic conditions.

 It is divided into three sterile containers; one each for cell count,
biochemical analysis and bacteriological examination

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Specimen Collection and Transport
(Cont..)
 CSF transport: Should be examined immediately

 When the bacteriological examination (culture) is required - CSF

should never be refrigerated - if a delay is expected - kept in an
incubator at 37°C.
 For molecular diagnosis - CSF can be kept inside the freezer.

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Cytological and Biochemical Analysis
Characteristics Normal individual Pyogenic meningitis Tuberculous Viral meningitis
meningitis
CSF pressure (mm of Normal (50–150) Highly elevated (>180) Moderately elevated Slightly
water) elevated/normal
Total leukocyte count 0–5 100–10,000 10–500 25–500
(per mm3)
Predominant cell type Lymphocytes Neutrophils Lymphocytes Lymphocytes

Glucose (mg%) 40–70 <40 mg/dL (decreased 20–40 mg/dL (slightly Normal
to absent) decreased)
Total proteins (mg%) 15–45 >45 mg/dL (usually 100–500 mg/dL 20–80 mg/dL (normal
>250; markedly (moderate to markedly or slightly elevated)
increased) increased)

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CSF Microscopy (Gram Staining)
Appearance in CSF gram stain Suggestive of

Gram-positive cocci in pair, capsulated, flame or Streptococcus pneumoniae

lanceolate-shaped
Gram-positive diplococci, flame or lanceolate-
shaped with clear halo (capsulated)
Gram-negative diplococci, capsulated, with Neisseria meningitidis
adjacent sides flattened (lens or half-moon shaped)
Pleomorphic gram-negative coccobacilli, capsulated Haemophilus influenzae

Gram-negative bacilli, arranged singly Escherichia coli or others

Gram-positive cocci in short chain Streptococcus agalactiae

Gram-positive short bacilli Listeria monocytogenes

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Direct Antigen Detection
 From CSF: After centrifugation – supernatant - used for antigen
detection. Latex agglutination test - performed using latex beads
coated with anti-capsular antibodies

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Culture
 Ideal media for bacteriological culture of CSF are enriched media
like chocolate agar and blood agar
 Enriching: As the bacterial load is very low - part of the CSF -
inoculated into enriched media - blood culture bottles at the bed
side (preferred) or brain heart infusion (BHI) broth in the
laboratory
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Culture (Cont..)
 Blood culture can be collected in conventional blood culture
bottles - BHI broth/agar or preferably in automated blood cultures
(e.g. BacT/ALERT)
 Culture plates (blood agar and chocolate agar) are incubated at
37°C, preferably in candle jar (provides 5% CO2) for 48 hours

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Culture and identification properties of
common
bacterial agents of pyogenic meningitis
Neisseria meningitidis
Blood agar-At 24 hrs- colonies are small (1 mm), round, convex,
gray, non hemolytic, translucent
-At 48 hrs- colonies become larger with opaque
raised centre and thin transparent margin
Biochemical identification: Meningococci are catalase and
oxidase positive. They ferment glucose and maltose but not
sucrose

Serogrouping: Slide agglutination serogrouping (SASG) test is

done to identify the serogroups of meningococci isolates by using
Essentials of Medical Microbiology

appropriate antisera 22
Treatment of Meningococcal meningitis
 Third-generation cephalosporins – DOC

 Penicillin can also be given; however, reduced sensitivity reported

from few countries
 Symptomatic treatment - aggressive fluid resuscitation (for
shock) and measures to decrease intracranial pressure.

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Chemoprophylaxis
 Indicated to the close contacts of primary cases.

 Close contacts - household contacts and others who are directly

exposed to patient’s oral secretions, in the 7 days before symptom
onset.
 Ceftriaxone (single dose, IM) - drug of choice

 Alternatively, rifampicin or ciprofloxacin can be given.

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Vaccine Prophylaxis
 Polysaccharide vaccine:

 Bivalent (A & C) or Quadrivalent (A,C,Y, & W135)

 Two doses - children of 3–18 months Single dose to > 2 yrs

 Efficacy >95%

 Duration of protection - 3–5 years

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Vaccine Prophylaxis (Cont..)
 Indication: Recommended for high-risk people
 (i) contacts of patients during outbreaks,
 (ii) splenic dysfunction,
 (iii) terminal complement component deficiency,
 (iv) taking eculizumab therapy,
 (v) laboratory staff at risk,
 (vi) international travellers
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Vaccine Prophylaxis (Cont..)
 Capsular vaccine is not available for serogroup B as:

 Capsule of serogroup B (made up of sialic acid) is less

immunogenic

 Encephalitogenic due to expression of similar cross reactive

antigens on neural cells.

 Not given below 3 years

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Vaccine Prophylaxis (Cont..)

Conjugated vaccine:
 Given to young children.

 Addition of a protein carrier (adjuvant) increases the

immunogenicity of the capsular vaccine.

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Vaccine for Group B (MenB Vaccine)
 Vaccine contains four recombinant proteins: Adhesin A, heparin
binding antigen, factor H binding protein and outer membrane
vesicles (OMV)
 Schedule: Two doses, given IM route 1 month apart

 Indication: 16–25 years age.

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GONOCOCCAL
URETHRITIS 30
GONOCOCCAL URETHRITIS
 Neisseria gonorrhoeae is noncapsulated, gram-negative kidney-
shaped diplococcus.
 Causes ‘gonorrhea’, a sexually transmitted infection (STI) -
commonly manifests as cervicitis, urethritis and conjunctivitis.

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Virulence Factors
 Pili or fimbriae - Adhesion to host cells & prevent phagocytosis

 Outer membrane proteins –

 Porin (protein I) - >50% of OMP

 PorB.1A strains - local and disseminated gonococcal infections

 PorB.1B strains- local genital infections only

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Virulence Factors (Cont..)
 Opacity-associated protein (Protein II) - adhesion to neutrophils
& other gonococci
 Transferrin-binding and lactoferrin-binding proteins

 IgA1 protease - protection from mucosal IgA

 Lipo-oligosaccharide (LOS)

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Clinical Manifestations
Gonorrhea: Produces various infections in males, females
 Males:
 Acute urethritis – Most common manifestation
 Purulent urethral discharge ( ‘gonorrhea’- flow of seed)
 Incubation period is 2–7 days
 Complications - epididymitis, prostatitis, balanitis & water-can
perineum
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Clinical Manifestations (Cont..)
 Females

 Infection is less severe – More asymptomatic carriage than

males

 Mucopurulent cervicitis – Most common presentation

 Vulvovaginitis – in prepubertal girls & postmenopausal women-

vagina mucosa thinned out & higher pH
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Clinical Manifestations (Cont..)
 Spread - Bartholin’s gland, endometrium and fallopian tube.
Salpingitis and pelvic inflammatory disease - sterility
 Fitz–Hugh–Curtis syndrome – Rare - peritonitis & perihepatic
inflammation.
 Both the sexes
 Anorectal gonorrhea
 Pharyngeal gonorrhea
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 Ocular gonorrhea
Clinical Manifestations (Cont..)
 Pregnant women

 Prolonged rupture of the membranes, premature delivery,

chorioamnionitis, and sepsis in the infant
 Neonates (Ophthalmia neonatorum)

 Purulent eye discharge within 2–5 days of birth

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Clinical Manifestations (Cont..)
 Disseminated gonococcal infection (DGI)

 Rarely following gonococcal bacteremia

 Polyarthritis and rarely dermatitis & endocarditis

 In HIV-infected persons

 Nonulcerative gonorrhea

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Epidemiology
 Incidence decreased in developed countries

 Under reporting due to stigma

 Host - exclusively human disease

 Source - asymptomatic female carriers or less often patient

 Transmission : sexual contact (venereal) and mother to baby

during birth.
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Laboratory Diagnosis - Specimen Collection

 Urethral swab in men and cervical swab in women

 Dacron or rayon swabs

 In chronic urethritis - secretion after prostatic massage or morning

drop of secretion

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Laboratory Diagnosis - Transport Media

 Charcoal-coated swabs kept in Stuart’s transport medium

 Amies medium

 JEMBEC or Gono-Pak system

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Laboratory Diagnosis - Microscopy

 Gram-negative intracellular kidney-shaped diplococci

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Laboratory Diagnosis - Culture
 Endocervical culture has a sensitivity of 80–90%

 Cervical swabs contain normal flora - selective media preferred

(Inhibit commensal Neisseria)
 Thayer Martin medium -

Es
se
Chocolate agar with antibiotics (Vancomycin, colistin,
nystatin)

 Modified New York City Medium- Lysed blood agar with lincomycin,
colistin,trimethoprim and amphotericin B

 Martin Lewis Medium

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Laboratory Diagnosis - Identification
 Gonococci - catalase and oxidase positive

 Ferment only glucose, but not maltose and sucrose

 Automated systems - MALDI-TOF can be used.

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Laboratory Diagnosis - Molecular
Method
 Nucleic acid amplification tests (NAATs) - PCR - detection of N.
gonorrhoeae from the clinical specimens targeting 16s or 23s rRNA
gene.

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Treatment of Gonorrhea
 Third generation cephalosporins – DOC for uncomplicated
gonococcal infection - both the sexual partners should be treated
 Ceftriaxone (250 mg given IM, single dose)
 Cefixime (400 mg given orally, single dose)

 If coexisting chlamydial infection – azithromycin or doxycycline

added.

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Prophylaxis
 No vaccination available for gonococci.

 Early detection of cases

 Treatment of both partners

 Tracing of contacts

 Health education about safe sex practices - use of condoms.

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Differences between Neisseria meningitidis
and
Neisseria gonorrhoeae
N. meningitidis N. gonorrhoeae

Capsulated Noncapsulated

Lens-shaped/half moon-shaped Kidney-shaped (diplococci with

(diplococci with adjacent sides adjacent sides concave)
flattened)
Ferments glucose and maltose Ferments only glucose

Rarely have plasmids Usually possess plasmids, coding

for drug-resistant genes
Exist in both intra- and Predominantly exist in
extracellular forms intracellular form
Habitat—nasopharynx Habitat—genital tract (urethra,
cervix), rarely pharynx
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