BACILLARY DYSENTRY SHIGELLA SPECIES

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BACILLARY DYSENTRYSHIGELLA SPECIES

• Dr.Indumathi

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KLEBSIELLA

• GRAM NEGATIVE
• NON MOTILE
• CAPSULATED
• LACTOSE FERMENTING(MUCOID)
• IMViC --
• FORMS GUT AND RESPIRATORY FLORA IN 5 NORMAL
  INDIVIDUALS

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CLASSIFICATION

• 3 SPECIES
• K.pneumonia K.rhinoscleromatis and K.ozanae
• PATHOGENIC LESIONS
• HAEMORRHAGIC NECROTIZING CONSOLIDATION OF LUNG
  (1)
• UTI
• BACTEREMIA OTHER FOCAL INFECTION
• NOSOCOMIAL INFECTION

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PNEUMONIA

• FRIEDLANDERS PNEUMONIA CAP
• MIDDLE AGED AND OLD ALCOHOLICS
• SEVERE RAPID ONSET
• OFTEN FATAL
• HIGH FEVER, CHILLS, CURRENT JELLY SPUTUM
• ABSCESS, CAVITATION, EMPYEMA
• LOBAR PNEUMONIA WITH DESTRUCTIVE CHANGES
  USUALLY UPPER LOBE

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KLEBSIELLA PNEUMONIA
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RHINOSCLEROMA

• K.RHINOSCLEROMATIS
• AFRICA, ASIA, LATIN AMERICA
• DESTRUCTIVE GRANULOMA OF NOSE AND PHARYNX
• PURULENT NASAL DISCHARGE
• CRUSTING LESIONS WITH NODULE
• RESPIRATORY OBSTRUCTION
• DIAGNOSIS BY HPE AND POSITIVE BLOOD CULTURE

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RHINOSCLEROMA
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OZENA

• K.OZAENAE
• FETID PROGRESSIVE ATROPHY OF NASAL MUCOSA
• NASAL CONGESTION
• PRIMARY ATROPHIC RHINITIS IN ELDERLY
• NASAL BAD SMELL
• HEADACHE

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HISTORICAL REVIEW

• TERM DYSENTRY BY HIPPOCRATES
• FREQUENT PASSAGE OF STOOL WITH BLOOD AND MUCOUS
• STRAINING AND PAINFUL DEFECATION
• 19TH CENTRURY 2 FORMS OF DYSENTRY ACCURATELY
  SEPARATED
• EPIDEMICS DYSENTRY IN MILITARY CAMPS, ASYLUMS,
  JAILS BY SHIGELLA
• SPORADIC CASES OF DYSENTRY BY AMEOBA

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SHIGELLA

• GRAM NEGATIVE SHORT RODS
• NON MOTILE
• ANAEROGENIC
• NON CAPSULATED
• GIT PATHOGEN
• NON LACTOSE FERMENTER
• COMPLEX ANTIGENIC STRUCTURE
• NAMED AFTER SHIGA 1896

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CLASSIFICATION

• 4 SPECIES/SUBGROUPS BASED ON BIOCHEMICAL AND
  SEROLOGICAL CHARACTERS
• SHIGELLA DYSENTERIAE 12 Serotypes
• SHIGELLA FLEXNERI 6 serotypes
• SHIGELLA BOYDII 18
• SHIGELLA SONNEI 17 Colicine types

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EPIDEMIOLOGY BACILLARY DYSENTRY

• PREVALENT IN TROPICS/WORLD WIDE
• SUMMER MONTHS
• POOR SANITATION
• OVERCROWDING /POVERTY
• EPIDEMICS
• MAN IS THE ONLY HOST CASE/CARRIER RESERVOIR
• SHORT INCUBATION (48 HRS)

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EPIDEMIOLOGY

• CYCLIC PATTERN OF DISEASE
• EPIDEMICS DUE TO ONE SPECIES LASTING FOR
  20-30YRS.
• E.G. 20TH CENTURY S.DYSENTERIAE
• IN EUROPE
• 1926-38 S.FLEXNERI
• CURRENTLY S.SONNEI IN INDUSTRIALISED COUNTRIES

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EPIDEMIOLOGYINDIA

• ENDEMIC /HIGHLY COMMUNICABLE
• FOUND IN ALL AGE GROUPS
• ALL SPECIES S.FLEXNERI PREDOMINANT(50-85)
• S.DYSENTERIAE(8-25)
• S.SONNEI (2-24)
• S.BOYDII(0-8)
• EPIDEMICS AND SERVERAL OUTBREAKS FROM 1974
  KERALA AND WEST BENGAL
• MULTIPLE DRUG RESISTANT STRAINS CAUSING
  EPIDEMICS

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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

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PATHOGENESIS

• VIRULENCE FACTORS
• 1.INVASIVENESS ASSOCIATED WITH BACTERIAL
  PROTEIN CODED IN PLASMIDS OR CHROMOSOME.
• 2. TOXIN PRODUCTION EXOTOXIN THAT IS
  ENTERO,NEURO AND CYTOTOXIC SHIGA TOXIN

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PATHOGENESIS

• 
  INGESTED BACILLI
• ?
• TRANSIENTLY MULTIPLY IN SMALL INTESTINE
  CONCENTRATION OF 107 TO109 PER ML
• ?
• ENTER THE DISTAL COLON (MULTIPLY) INVADE THE
  MUCOSAL CELLS,
• ?
• MULTIPLY AND SPREAD TO ADJECENT
  CELLS(INTRACELLULAR SPREAD)
• ?
• ACUTE INFLAMMATION AND MICROABSCESS/CAP
  THROMOBOSIS
• SUPERFICIAL ULCERATION (SERPIGINOUS)
• ?
• ENDOTOXIN PRODUCTION TO PRODUCE BOWEL IRRITATION
  AND DIARRHOEA WITH BLOOD/MUCUS AND TOXEMIA

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PATHOGENESIS

• NO BLOOD STREAM INVASION
• BACTERIA RAPIDLY PHAGOCYTOSED BY MACROPHAGES
• ENTEROTOXIN LOCAL MUCOSAL DESTRUCTION
• CLINICALLY DYSENTRY LASTS FOR 1 TO 7 DAYS SELF
  LIMITING
• HIGH MORTALITY IN MALNOURISHED
• COMPLICATIONS HEMOLYTIC UREMIC SYNDROME SHIGA
  TOXIN RENAL FAILURE, TOXIC NEURITIS, ARTHRITIS
• RARELY IKARI SYNDROME MASSIVE INFECTION AND
  EARLY DEATH IN CHILDREN

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CLINICAL FEATURES

• FEVER HIGH GRADE
• TOXEMIA
• ABDOMINAL CRAMPS
• VOLUMINOUS WATERY DIARRHOEA
• FOLLOWED BY SMALL VOLUME FREQUENT PASSAGE OF
  BLOODY STOOLS.
• (OVER 10/DAY)
• ABDOMINAL TENDERNESS
• COMPLICATIONS FEBRILE SEIZURES, SEPSIS, PNEUMONIA

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LAB DIAGNOSIS

• SPECIMEN COLLECTION
• STOOL CONTAINING MUCOUS/BLOOD
• RECTAL SWAB
• RECTAL CATHETERIZATION
• RECOVERY IS BEST IN THE ACUTE STAGE WHERE BACILLI
  ARE SHED IN LARGE NUMBERS

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LAB DIAGNOSIS

• TRANSPORT MEDIUM
• BGS/CARY BLAIR
• ENRICHMENT SELENITE F
• METHODS OF DIAGNOSIS
• DIRECT MICROSCOPY
• CULTURE
• SLIDE AGGLUTINATION TEST

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LAB DIAGNOSIS

• MACROSCOPY
• BRIGHT RED STOOL
• ADHERENT TO CONTAINER
• ALKALINE
• ODOURLESS
• NO FAECAL MATTER
• SMALL QUANTITY

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LAB DIAGNOSIS

• MICROSCOPY
• NUMEROUS PUS CELLS STAINED FEACAL SMEARS WITH
  METHYLENE BLUE (SINGLE MOST IMPORTANT LAB TEST
  OTHER THAN STOOL CULTURE)
• NUMEROUS DISCRETE/ROULEUX RBCS
• NO BACTERIA SEEN
• PLENTY OF MACROPHAGES
• GHOST CELLS CELLS WITH NO NUCLEUS AND ONLY
  CYTOPLASMIC OUTLINE PRESENT

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LAB DIAGNOSIS

• CULTURE MEDIA USED
• FLUID SELENITE F ENRICHMENT
• SOLID MAC CONKEYS
• DCA
• SSA
• STEPS DIRECT PLATING ENRICHMENT CULTURE
• GROWTH FROM FLUID MEDIUM SUBCULTURED ONTO MA

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LAB DIAGNOSIS

• COLONIES ON MA/DCA NLF PALE AND TRANSLUCENT
• COLONIES PICKED UP FOR THE FOLLOWING TESTS
• HANGING DROP NON MOTILE
• GRAMS GNB
• BIOCHEMICAL TESTS IMVIC -- ANEROGENIC
  FERMENTERS
• SLIDE AGGLUTINATION WITH SPECIFIC HTS

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BIOCHEMICAL TESTS
SPECIES GLUCOSE LACTOSE MANNITOL INDOLE
S.DYS ACID - - V
S.FLEX ACID - V
S.BOYDI ACID - V
S.SONEI ACID - -
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TREATMENT AND PREVENTION

• ANTIBIOTICS TO BE GIVEN BECAUSE
• 1. PERSON TO PERSON TRANSMISSION INFECTED
  PERSON IS THE RESERVOIR IN ORDER TO PREVENT THE
  CHAIN OF TRANSMISSION
• GOOD SANITATION/SAFE DISPOSAL OF SEWAGE
• SAFE WATER SUPPLY
• SHIGELLA VACCINE (ORAL STREP DEP MUTANTLIVE
  ATTEN)4 DOSES PROTECTION 6 MONTHS. EXP IN
  HYPERENDEMIC AREAS.

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SALMONELLA GASTROENTERITIS

• FOOD POISONING
• ZOONOTIC INFECTION
• ANIMAL OR ANIMALPRODUCTS MEAT PRODUCTS, EGGS,
  CREAM, MILK (FOOD CONTAMINATION WITH RAT OR
  LIZARD DROPPINGS)
• S.TYPHIMURIUM/S.ENTERITIDIS, S.NEWPORT
• IP 24 HOURS DIARRHOEA, VOMITTING, PAIN ABDOMEN,
  FEVER