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Bacteriology in ENT

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Ramesh Parajuli

This document discusses various anaerobic organisms and infections they can cause in the head and neck region. It describes key anaerobes like Bacteroides, Prevotella, Peptostreptococcus, Fusobacterium, Clostridium, Actinomyces and infections associated with them such as peritonsillar abscess, actinomycosis, acute necrotizing ulcerative gingivitis. It also discusses complications of anaerobic head and neck infections that can spread locally or hematogenously. The approach to patients involves considering proximity of infection to colonized mucosal sites and polymicrobial nature of infections that often involve both aerobic and anaerobic organisms.

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ANAEROBIC ORGANISMS,ANAEROBIC ORGANISMS, DIPHTHERIA, MYCOBACTERIADIPHTHERIA, MYCOBACTERIA & TREPONEMA IN ENT& TREPONEMA IN ENT Dr. Ramesh Parajuli, MSDr. Ramesh Parajuli, MS Otorhinolaryngology, Head & Neck Surgery Chitwan Medical College Teaching Hospital, Bharatpur-10, Chitwan, Nepal
Corynebacterium DiphtheriaeCorynebacterium Diphtheriae Aerobic, Gram-positive rod,Aerobic, Gram-positive rod, non spore forming, non motilenon spore forming, non motile Club shaped, palisades (v or lClub shaped, palisades (v or l shaped) or ā€œshaped) or ā€œChinese letterā€-Chinese letterā€- tellurite medium(D)tellurite medium(D) Granules-loefflerā€™s medium(SGranules-loefflerā€™s medium(S))
2 phenotypes- toxigenic(tox+ ve) and non2 phenotypes- toxigenic(tox+ ve) and non toxigenic(tox-ve)toxigenic(tox-ve) Diphtheria-nasopharyngeal & skin infection causedDiphtheria-nasopharyngeal & skin infection caused by c.diphtheriaeby c.diphtheriae Toxigenic:pharyngeal diphtheriaToxigenic:pharyngeal diphtheria Non-toxigenic:cutaneous diphtheriaNon-toxigenic:cutaneous diphtheria Lysogenic conversion by bacteriophage ā€˜toxā€™ geneLysogenic conversion by bacteriophage ā€˜toxā€™ gene
3 strains: Gravis ,3 strains: Gravis , Intermedius & MitisIntermedius & Mitis Gravis and intermediusGravis and intermedius types-higher mortalitytypes-higher mortality CornebacteriumCornebacterium ulcerans:- infected byulcerans:- infected by bacteriophagebacteriophageļƒ ļƒ  diphtheria likediphtheria like presentationpresentation
Mechanism of action of DiphtheriaMechanism of action of Diphtheria ToxinToxin
PathologyPathology Tonsil Necrosis - initialTonsil Necrosis - initial lesionlesion CharactersticCharacterstic pseudomembranepseudomembrane formation: (necrotic tissue +formation: (necrotic tissue + bacteria+ fibrinous exudate)bacteria+ fibrinous exudate) Early removal - Bleeding,Early removal - Bleeding, easy separation latereasy separation later Bull neck: Cellulitis &Bull neck: Cellulitis & Cervical lymphadenopathyCervical lymphadenopathy
Bull-neck appearance
Transmission:Transmission: aerosol(resp.droplet)aerosol(resp.droplet) Incubation period:3-4 daysIncubation period:3-4 days ToxemiaToxemia Mechanical complications:Mechanical complications: pseudomembranepseudomembrane Systemic effects:Systemic effects: toxintoxin
Clinical FeaturesClinical Features Age : Rare over 10 yearsAge : Rare over 10 years Malaise ,Sore throat andMalaise ,Sore throat and PyrexiaPyrexia Membrane over theMembrane over the Faucial pillarsFaucial pillars Progressive DysphagiaProgressive Dysphagia and Toxemiaand Toxemia Inspiratory Stridor andInspiratory Stridor and Barking coughBarking cough Cough ā€“ Paroxysmal andCough ā€“ Paroxysmal and ExhaustingExhausting
Bacteriology in ENT
DeathDeath -Acute airway obstruction-Acute airway obstruction -circulatory failure-circulatory failure Acute Toxic MyocarditisAcute Toxic Myocarditisļƒ ļƒ cardiaccardiac dysfunctiondysfunction -2-2ndnd weekweek Peripheral NeuropathyPeripheral Neuropathy --Recurrent laryngeal nerve palsyRecurrent laryngeal nerve palsy -Palatal Paralysis most common-Palatal Paralysis most common -Presents with nasal regurgitation-Presents with nasal regurgitation & hyper nasal speech& hyper nasal speech
Bacteriology in ENT
Differential DiagnosisDifferential Diagnosis Foreign bodyForeign body Infectious MononucleosisInfectious Mononucleosis Peritonsillar AbscessPeritonsillar Abscess Retropharyngeal AbscessRetropharyngeal Abscess
Differential DiagnosisDifferential Diagnosis cont.cont. StreptococcalStreptococcal pharyngitispharyngitis Vincentā€™s anginaVincentā€™s angina ThrushThrush Post-tonsillectomyPost-tonsillectomy faucial membranesfaucial membranes Leukemia andLeukemia and agranulocytosisagranulocytosis
ManagementManagement Airway :Airway : -Removal of Laryngeal-Removal of Laryngeal MembraneMembrane -Humidification-Humidification -0xygen therapy-0xygen therapy - ET intubation or- ET intubation or TracheostomyTracheostomy -Systemic Steroids : Reduce need-Systemic Steroids : Reduce need for airway interventionfor airway intervention
ManagementManagement Benzyl Penicillin :Benzyl Penicillin : 600mgx i.v.x 6 hourly600mgx i.v.x 6 hourly Diptheria AntitoxinDiptheria Antitoxin 10,000-1,00,000 units10,000-1,00,000 units (Depending upon(Depending upon severity)severity)
Bed rest ā€“ 2 toBed rest ā€“ 2 to 4 weeks until4 weeks until danger ofdanger of myocarditis ismyocarditis is overover Vaccination:Vaccination: DPTDPT
Diptheroids (Coryneforms)Diptheroids (Coryneforms) Nondiphtherial corynebacteriaNondiphtherial corynebacteria Colonisers or contaminants ā€“invasiveColonisers or contaminants ā€“invasive disease in immunocompromiseddisease in immunocompromised C.pseudodipthericum ā€“pharynx ,skinC.pseudodipthericum ā€“pharynx ,skin -C.xerosis ā€“ skin ,nasopharynx & conjunctiva-C.xerosis ā€“ skin ,nasopharynx & conjunctiva C.Auris ā€“ EAC, C.striatum ā€“ ant.Nares ,skinC.Auris ā€“ EAC, C.striatum ā€“ ant.Nares ,skin
Anaerobic OrganismsAnaerobic Organisms Most are commensals-Most are commensals- harmlessharmless eg saliva,gingival scrappingeg saliva,gingival scrapping Sites- skin, mouth,Sites- skin, mouth, nasopharynx, uppernasopharynx, upper respiratory tractrespiratory tract Conditions favored-Conditions favored- Decreased oxidation-Decreased oxidation- reduction potential eg.reduction potential eg. Trauma, Tissue destruction,Trauma, Tissue destruction, foreign body, malnutrition.foreign body, malnutrition.
ClassificationClassification Gram-negative rods:Gram-negative rods: BacteroidesBacteroides [e.g.[e.g. B.B. fragilisfragilis],],Fusobacterium, prevotella,Fusobacterium, prevotella, porphyromonasporphyromonas Gram-positive rods:Gram-positive rods: ActinomycesActinomyces,clostridium,,clostridium,EubacteriumEubacterium,, BifidobacteriumBifidobacterium,,PropionibacteriumPropionibacterium Gram-positive cocci:Gram-positive cocci: PeptostreptococcusPeptostreptococcus andand PeptococcusPeptococcus Gram-negative cocci:Gram-negative cocci: VeillonellaVeillonella
IMPORTANT ANAEROBESIMPORTANT ANAEROBES Bacteroides-Bacteroides- B. fragilis- most frequently isolatedB. fragilis- most frequently isolated Resistant to beta lactamsResistant to beta lactams Prevotella: newly named & previously BacteroidesPrevotella: newly named & previously Bacteroides B. melaninogenicus (Recently PrevotellaB. melaninogenicus (Recently Prevotella melaninogenicus )- black, brown colonies Majormelaninogenicus )- black, brown colonies Major group in oral flora.group in oral flora. Peptostreptococcus-Peptostreptococcus- -Normal flora of skin ,mucus membrane-Normal flora of skin ,mucus membrane Species- P. micros, P. anaerobius P. magnusSpecies- P. micros, P. anaerobius P. magnus (abscess)(abscess)
PeptococcusPeptococcus FusobacteriumFusobacterium Clostridium - spore formingClostridium - spore forming Gas gangrene, food poisoning, tetanus, colitisGas gangrene, food poisoning, tetanus, colitis Cl. Perfringens- Toxin- hemolytic- dermonecrotic,Cl. Perfringens- Toxin- hemolytic- dermonecrotic, Phospholipase c, LecithinasePhospholipase c, Lecithinase Wound contamination- cellulitis- myositisWound contamination- cellulitis- myositisļƒ ļƒ  gasgas gangrene.gangrene.
Infection due to anaerobes- mostly polymicrobialInfection due to anaerobes- mostly polymicrobial Abscess cavity or necrotic tissueAbscess cavity or necrotic tissue Failure of abscess to yield organism on routineFailure of abscess to yield organism on routine culturecultureļƒ ļƒ  clue for anaerobic organismclue for anaerobic organism Abscess in deeper body tissueAbscess in deeper body tissue Putrid smelling infection site or dischargePutrid smelling infection site or discharge
Acute Necrotizing UlcerativeAcute Necrotizing Ulcerative Gingivitis(ANUG)/ Trench Mouth/Vincentā€™sGingivitis(ANUG)/ Trench Mouth/Vincentā€™s StomatitisStomatitis -Etiology. :Fusobacterium-Etiology. :Fusobacterium Nucleatum, BorreliaNucleatum, Borrelia VincentiVincenti - Tender bleeding gums,- Tender bleeding gums, foul breathe &bad tastefoul breathe &bad taste -Gingival mucosa esp.-Gingival mucosa esp. papilla-ulcerated&papilla-ulcerated& covered with greycovered with grey exudateexudate -Fever, Cervical-Fever, Cervical lymphadenopathy &lymphadenopathy & leucocytosisleucocytosis
Acute Necrotizing UlcerativeAcute Necrotizing Ulcerative Mucositis / Noma/Cancrum OrisMucositis / Noma/Cancrum Oris Usually a/w ulcerativeUsually a/w ulcerative gingivitisgingivitis Anaerobes esp.Anaerobes esp. B.porphyromonasB.porphyromonas Rapid tissueRapid tissue destructiondestructionļƒ ļƒ teeth fallteeth fall outoutļƒ ļƒ bone/wholebone/whole mandible sloughmandible slough Heal leaving disfiguringHeal leaving disfiguring defectdefect
Acute Necrotizing infection of PharynxAcute Necrotizing infection of Pharynx Usu.a/w ulcerativeUsu.a/w ulcerative gingivitisgingivitis C/F:fever,sore throat,foulC/F:fever,sore throat,foul breath,badbreath,bad taste,sensation of chokingtaste,sensation of choking O/E: Greyish membraneO/E: Greyish membrane over Tonsillar pillars thatover Tonsillar pillars that peel easilypeel easily Lymphadenopathy &Lymphadenopathy & LeucocytosisLeucocytosis May spread to larynxMay spread to larynx
PeriPharyngeal spacePeriPharyngeal space infectioninfection Peritonsillar abscessPeritonsillar abscess - Complication of Tonsillitis orComplication of Tonsillitis or De novoDe novo - Mixed flora containing bothMixed flora containing both Anaerobes & GABHSAnaerobes & GABHS - Association betweenAssociation between Periodontal disease (sourcePeriodontal disease (source of anaerobic organism) andof anaerobic organism) and PTA.PTA. - Ludwigā€™s AnginaLudwigā€™s Angina
ActinomycosisActinomycosis Member of normal oral flora-Member of normal oral flora- gingival crevicesgingival crevices G+ve, anaerobic,branchingG+ve, anaerobic,branching rodsrods A.israelii-most common.A.israelii-most common. A.naeslundii,A.naeslundii, A.odontolyticus,A.viscous etcA.odontolyticus,A.viscous etc
Disruption of mucosalDisruption of mucosal barrierbarrierļƒ ļƒ local infectionlocal infectionļƒ ļƒ slowlyslowly progressiveprogressiveļƒ ļƒ chronic phasechronic phase with single or multiple induratedwith single or multiple indurated lesionslesions Trauma, F.B. poor oral hygieneTrauma, F.B. poor oral hygiene Chronic granulomatousChronic granulomatous infectioninfection
Firm indurated mass- central necrosis withFirm indurated mass- central necrosis with fibrotic ā€˜wooden wallā€™(neutrophils & sulfurfibrotic ā€˜wooden wallā€™(neutrophils & sulfur granules)granules) Multiple sinus tract which discharge pusMultiple sinus tract which discharge pus Usu. angle of jaw involvedUsu. angle of jaw involved
Bacteriology in ENT
Sulphur granules-characteristicSulphur granules-characteristic D/D- Malignancy or GranulomatousD/D- Malignancy or Granulomatous diseasedisease Any mass lesion or relapsing infection inAny mass lesion or relapsing infection in head & neck regionhead & neck regionļƒ ļƒ rule outrule out actinomycosisactinomycosis
Sinusitis &OtitisSinusitis &Otitis Anaerobes implicated in (0-88)% of CRSAnaerobes implicated in (0-88)% of CRS (Doyle, Ramadan, Brook)(Doyle, Ramadan, Brook) anaerobes in CRS (0 to 52%)(Harrison 17anaerobes in CRS (0 to 52%)(Harrison 17thth edn.)edn.) Peptostreptococcus, Fusobacterium & P.Peptostreptococcus, Fusobacterium & P. acnesacnes COMCOM - Anaerobes in Upto 50% casesAnaerobes in Upto 50% cases - B.fragilis in upto 28% cases of COMB.fragilis in upto 28% cases of COM
Complications of AnaerobicComplications of Anaerobic Head & Neck InfectionHead & Neck Infection Continuous spreadContinuous spread - Craniad: Osteomyelitis of skull /mandible orCraniad: Osteomyelitis of skull /mandible or intracranial complications(brainintracranial complications(brain abscess,subdural empyema)abscess,subdural empyema) - Caudal :Mediastinitis or PleuropulmonaryCaudal :Mediastinitis or Pleuropulmonary infectioninfection - Hematogenous disseminationHematogenous dissemination - Lemierreā€™s Syndrome-Lemierreā€™s Syndrome- Fusobacterium necrophorumFusobacterium necrophorum
Approach to the patientsApproach to the patients Harmless commensals, disease proximityHarmless commensals, disease proximity to mucosal site colonisedto mucosal site colonised Site of lower oxidation-reduction potentialSite of lower oxidation-reduction potential Polymicrobial naturePolymicrobial nature Negative cultureNegative culture ļƒ ļƒ ā€˜clueā€™ā€˜clueā€™ Foul or putrid infection site or dischargeFoul or putrid infection site or discharge diagnosticdiagnostic
DiagnosisDiagnosis 3 critical steps3 critical steps 1.1. Proper specimenProper specimen collectioncollection 2.2. Rapid transportRapid transport preferably in anaerobicpreferably in anaerobic mediamedia 3.3. Proper handling ofProper handling of specimen by the labspecimen by the lab
Specimen collectionSpecimen collection Sterile body fluid ā€“ blood,Sterile body fluid ā€“ blood, pleural, peritoneal fluid,CSFpleural, peritoneal fluid,CSF and aspirates or biopsies fromand aspirates or biopsies from normally sterile sitesnormally sterile sites Specimen unacceptable:Specimen unacceptable: expectorated sputum ,nasalexpectorated sputum ,nasal tracheal suction, bronchoscopytracheal suction, bronchoscopy specimen,voided urine &specimen,voided urine & faecesfaeces
Ways of eliminating oxygen gasWays of eliminating oxygen gas Gas pac jarGas pac jar : -: - Contains aContains a packet of sodiumpacket of sodium borohydride, sodiumborohydride, sodium bicarbonate & citric acid.bicarbonate & citric acid. - Addition of water causes- Addition of water causes production of H2, CO2 gas &production of H2, CO2 gas & displaces air (and thusdisplaces air (and thus oxygen).oxygen).
Gas exchange jar : Air in theGas exchange jar : Air in the jar is replaced with O2-freejar is replaced with O2-free gas (from a tank).gas (from a tank). Glove box:Glove box: Box is filled withBox is filled with anaerobic (O2-free) gasanaerobic (O2-free) gas ,usually a mixture of H2 and,usually a mixture of H2 and CO2.CO2. -Positive pressure-Positive pressure keeps O2 outkeeps O2 out
Bacteriology in ENT
TreatmentTreatment Surgical drainage (mostSurgical drainage (most circumstances) + antimicrobialscircumstances) + antimicrobials DOC: Penicillin GDOC: Penicillin G For Beta ā€“lactamase producingFor Beta ā€“lactamase producing Bacteroides and PrevotellaBacteroides and Prevotella -Clindamycin (DOC infections above-Clindamycin (DOC infections above diaphragm) & Metronidazolediaphragm) & Metronidazole
Mycobacterium TuberculosisMycobacterium Tuberculosis Rod shaped, obligateRod shaped, obligate aerobes ,slow growingaerobes ,slow growing Acid-fast ā€“ high contentAcid-fast ā€“ high content of mycolic acidof mycolic acid Low cell wallLow cell wall permeability topermeability to antibioticsantibiotics
No exotoxin norNo exotoxin nor endotoxinendotoxin Damage done byDamage done by immune system (CMI)immune system (CMI) Tuberculin(surfaceTuberculin(surface protein) along withprotein) along with mycolic acidmycolic acidļƒ ļƒ delayeddelayed type hypersensitivity &type hypersensitivity & CMICMI
Nasal TuberculosisNasal Tuberculosis ROUTES OFROUTES OF SPREADSPREAD - Direct inoculation:- Direct inoculation: Nose Pricking orNose Pricking or Finger nail TraumaFinger nail Trauma - Droplet Spread:- Droplet Spread: Coughing, SneezingCoughing, Sneezing - Haematogenous- Haematogenous disseminationdissemination
3 FORMS3 FORMS 1. Nodular1. Nodular 2.Ulcerative2.Ulcerative 3.Sinus Granuloma3.Sinus Granuloma
1.Nodular1.Nodular Begins in VestibuleBegins in Vestibule APPLE JELLY NODULEAPPLE JELLY NODULE Untreated-scar and deformityUntreated-scar and deformity 2.Ulcerative form2.Ulcerative form Usually cartilaginous septum or inferior TurbinateUsually cartilaginous septum or inferior Turbinate Septal PerforationSeptal Perforation 3.Sinus granuloma3.Sinus granuloma Isolated sinus involvement without any sign and symptomsIsolated sinus involvement without any sign and symptoms in the nose.in the nose. Unilateral , Maxillary Sinus- usuallyUnilateral , Maxillary Sinus- usually
Tuberculous Otitis MediaTuberculous Otitis Media Incidence < 1% COMIncidence < 1% COM Spread: Insuffalation via E.tube,Spread: Insuffalation via E.tube, Hematogenous, contiguousHematogenous, contiguous Presentation:Presentation: -Chronic Otorrhoea-Chronic Otorrhoea -Hearing loss (moderate to severe-Hearing loss (moderate to severe CHL, mixed)CHL, mixed) -Dizziness-Dizziness
O/EO/E Multiple perforations (hall mark)-Multiple perforations (hall mark)- later coalesce into a single largelater coalesce into a single large perforationperforation AbundantAbundant pale granulationpale granulation tissue - characteristictissue - characteristic Handle of Malleus- denudedHandle of Malleus- denuded Middle ear mucosa- paleMiddle ear mucosa- pale Complications:Complications: -Profound SNHL-Profound SNHL -Facial n. palsy-Facial n. palsy
Diagnosis-HPEDiagnosis-HPE - ME Mucosal biopsy & Aural polpectomy- ME Mucosal biopsy & Aural polpectomy specimen positive in 30% & 35%specimen positive in 30% & 35% respectivelyrespectively - Management:Management: - ATT- ATT - Mastoidectomy- Mastoidectomy
Tuberculous Cervical AdenitisTuberculous Cervical Adenitis Most common Cause of LNMost common Cause of LN swelling in neckswelling in neck Children & young adultsChildren & young adults Primary foci ā€“ usually tonsilsPrimary foci ā€“ usually tonsils 90% single LN group usually90% single LN group usually Deep Jugular chainDeep Jugular chain Stages:Stages: Stage of LymphadenitisStage of Lymphadenitis Stage of Periadenitis includingStage of Periadenitis including ā€œcollar studā€ā€œcollar studā€ abscessabscess Stage of sinus formationStage of sinus formation
Differential diagnosisDifferential diagnosis 1.Persistent Generalised Lymphadenopathy(PGL)1.Persistent Generalised Lymphadenopathy(PGL) 2.Lymphoma2.Lymphoma 3.Kaposiā€™s Sarcoma3.Kaposiā€™s Sarcoma 4.Carcinomatious Metastasis4.Carcinomatious Metastasis 5.Sarcoidosis5.Sarcoidosis 6.Drug Reaction(eg.Phenytoin)6.Drug Reaction(eg.Phenytoin)
Diagnosis:Diagnosis: - Tuberculin skin test,Tuberculin skin test, - FNAC-70%sensitivityFNAC-70%sensitivity - LN excisional biopsy-LN excisional biopsy- 80% sensitivity80% sensitivity - Treatment: ATT+Treatment: ATT+ excision of LNexcision of LN
Oropharyngeal TuberculosisOropharyngeal Tuberculosis Secondary to coughingSecondary to coughing heavily of infected sputumheavily of infected sputum Oral lesion ā€“ not commonOral lesion ā€“ not common -Ulceration :dorsum of tongue-Ulceration :dorsum of tongue -Painless , irregular-Painless , irregular ,granulating floor,granulating floor Pharynx-not commonPharynx-not common - Site of primary infectionSite of primary infection (Tonsils, Adenoids)(Tonsils, Adenoids)
Mycobacterial infection of theMycobacterial infection of the Salivary glandsSalivary glands Etiology.: atypical or NTMEtiology.: atypical or NTM Parotid, submandibular glandsParotid, submandibular glands Presentation :Presentation : -Children age group 3 ā€“ 4 years-Children age group 3 ā€“ 4 years -Painless mass in neck or face-Painless mass in neck or face -Skin breakdown &sinus-Skin breakdown &sinus formationformation
TB Esophagitis:TB Esophagitis: -swallowed sputum or direct-swallowed sputum or direct spread from adjacent LNspread from adjacent LN -stricture,fistula, mucosal-stricture,fistula, mucosal irregularitiesirregularities GranulomatousGranulomatous cheilitis-cheilitis- rarerare
TB LarynxTB Larynx Nearly always aNearly always a complication of advancecomplication of advance cavitatory PTBcavitatory PTB C/F:C/F: -Dysphonia-Dysphonia -Pain on swallowing &-Pain on swallowing & speakingspeaking -Otalgia-Otalgia
O/EO/E -Predominantly posterior-Predominantly posterior 1/31/3rdrd of glottisof glottis -Diffuse redness &-Diffuse redness & edemaedema -Ulcerations-Ulcerations Diagnosis:Diagnosis: -Biopsy of laryngeal-Biopsy of laryngeal tissuetissue
TreatmentTreatment -Securing airway-Securing airway -ATT-ATT ComplicationsComplications - Stenosis- Stenosis - Vocal cord fixation- Vocal cord fixation
DIAGNOSISDIAGNOSIS SpecimenSpecimen 1.1.Sputum- 3 early morning specimenSputum- 3 early morning specimen 2.2.Swab- larynx / gastric aspirateSwab- larynx / gastric aspirate 3.3.Tissue biopsy :Tissue biopsy : AFB Microscopy: -Low sensitivity (40 -60)%AFB Microscopy: -Low sensitivity (40 -60)% Culture- definite diagnosisCulture- definite diagnosis - Lowenstein- Jensen medium: 4 to 8- Lowenstein- Jensen medium: 4 to 8 weeksweeks BACTEC media ā€“growth 2 weeksBACTEC media ā€“growth 2 weeks DNA amplification/ PCR : allows diagnosis inDNA amplification/ PCR : allows diagnosis in several hoursseveral hours
RadiologyRadiology Tuberculin skin test-Tuberculin skin test- Mantoux test, zone of induration after 48- 72 hrMantoux test, zone of induration after 48- 72 hr
TB Skin TestTB Skin Test
Bacteriology in ENT
Mycobacterium tuberculosisMycobacterium tuberculosis bacteria usingbacteria using acid-fastacid-fast Ziehl-Neelsen stainZiehl-Neelsen stain..
Colonies ofColonies of M. tuberculosisM. tuberculosis growing on mediagrowing on media
Histopathologic appearanceHistopathologic appearance
TB on AFB smearTB on AFB smear
TREATMENT & PREVENTIONTREATMENT & PREVENTION BCG vaccinationBCG vaccination ChemotherapyChemotherapy
11STST Line TreatmentLine Treatment Rifampicin ā€“ Dose- 10mg/kg body wt.Rifampicin ā€“ Dose- 10mg/kg body wt. Isoniazid ā€“ Dose-5mg/kg,Administer vitamin B6Isoniazid ā€“ Dose-5mg/kg,Administer vitamin B6 Pyrazinamide ā€“25mg/kgPyrazinamide ā€“25mg/kg Ethambutol ā€“ 15mg/kgEthambutol ā€“ 15mg/kg Streptomycin -15mg/kgStreptomycin -15mg/kg
22NDND LINE TREATMENT OR NEWER DRUGSLINE TREATMENT OR NEWER DRUGS AMINOGLYCOSIDES: Capreomycin,amikacin,kanamicinAMINOGLYCOSIDES: Capreomycin,amikacin,kanamicin THIOAMIDES: Ethionamide,prothionamideTHIOAMIDES: Ethionamide,prothionamide PAS(Para-Aminosalicyclic acid)PAS(Para-Aminosalicyclic acid) CYCLOSERINE (or trizidone)CYCLOSERINE (or trizidone) FLUOROQUINOLONES-FLUOROQUINOLONES- ofloxacin,ciprofloxacin,sparfloxacinofloxacin,ciprofloxacin,sparfloxacin &Gatifloxacin,Sparfloxacin-latest(improved activity)&Gatifloxacin,Sparfloxacin-latest(improved activity) Rifabutin, RifamycinRifabutin, Rifamycin ThiocetazoneThiocetazone Rifapentine- latest one 600mg/weeklyRifapentine- latest one 600mg/weekly Macrolide- clarithromycin.Macrolide- clarithromycin. Linezolide :Oxazolidinone antibioticLinezolide :Oxazolidinone antibiotic
MDR-MDR- TBTB MDR suspected :MDR suspected : -History of irregular multi-drug therapy and sputum-History of irregular multi-drug therapy and sputum remaining positiveremaining positive -No good response in a smear positive case put-No good response in a smear positive case put on standard re-treatment regimen.on standard re-treatment regimen. - Sputum- Sputum C/S testC/S test Causes:Causes: - inappropriate regimen ,non compliance,interruption of drug- inappropriate regimen ,non compliance,interruption of drug supply,lack of diagnosis and free treatmentsupply,lack of diagnosis and free treatment
XDR-TBXDR-TB Extensively drug resistant TB:TB that has developedExtensively drug resistant TB:TB that has developed resistance to at least rifampicin & isoniazid as well as toresistance to at least rifampicin & isoniazid as well as to any member of the quinolone family & at least one of theany member of the quinolone family & at least one of the following 2following 2ndnd line anti-TB injectable drugs:line anti-TB injectable drugs: kanamycin,capreomycin or amikacinkanamycin,capreomycin or amikacin (Global Task Force on XDR-(Global Task Force on XDR- TB,WHO,2006)TB,WHO,2006) 11STST line drug misused, mismanagedline drug misused, mismanagedļƒ ļƒ  MDR- TBMDR- TB 22NDND line drug misused, mismanagedline drug misused, mismanagedļƒ ļƒ  XDR-TBXDR-TB
POTENTIAL NEWER THERAPIES FORPOTENTIAL NEWER THERAPIES FOR TUBERCULOSISTUBERCULOSIS Protein kinase inhibitors: pyridomycin, RifadineProtein kinase inhibitors: pyridomycin, Rifadine Pyridine analogues like NAD (NicotinamidePyridine analogues like NAD (Nicotinamide adenine dinucleotide) and Streptolydigin whichadenine dinucleotide) and Streptolydigin which inhibits initiation of RNA synthesis.inhibits initiation of RNA synthesis. Cytokine Immunotherapy: IL-2- subcutaneous lowCytokine Immunotherapy: IL-2- subcutaneous low dose for patients with active tuberculosis todose for patients with active tuberculosis to augment the immune cell response.augment the immune cell response. IFN Gammatherapy by aerosol toIFN Gammatherapy by aerosol to accelerateaccelerate M.tuberculosisM.tuberculosis killing.killing. Interleukin-12: for restoring impaired cellularInterleukin-12: for restoring impaired cellular immune function in AIDS and tuberculosis.immune function in AIDS and tuberculosis.
Recent Advances in theRecent Advances in the Diagnosis & Management ofDiagnosis & Management of Tuberculosis:Tuberculosis: 1.BACTEC TM 460-liquid culture method1.BACTEC TM 460-liquid culture methodļƒ ļƒ detectsdetects radiolabeled CO2 releasedradiolabeled CO2 released 2.MGIT(mycobacterial growth indicator tube)2.MGIT(mycobacterial growth indicator tube) 3.PCR3.PCR 4.PA-824 :a nitroimidazopyran compound related to4.PA-824 :a nitroimidazopyran compound related to metronidazole activity against both slow &rapidlymetronidazole activity against both slow &rapidly dividing mycobact.dividing mycobact.ļƒ ļƒ may enter human testingmay enter human testing soonsoon
5.Rifacinna5.Rifacinna 6.Benzofuro(2,3-b) quinolone derivative6.Benzofuro(2,3-b) quinolone derivative 7.Interferon gamma release assay(IGRAs)-mtb-7.Interferon gamma release assay(IGRAs)-mtb- specific antigens,ESAT-6 & CFP-10specific antigens,ESAT-6 & CFP-10 8.Dipiperidines8.Dipiperidines 9.Multiplex SNaphot technique-identification of9.Multiplex SNaphot technique-identification of diff.species of mycobacteriadiff.species of mycobacteria 10.R207910(TMC207)-a lead compound10.R207910(TMC207)-a lead compound
Atypical MycobacteriaAtypical Mycobacteria Mycobacteria other than M.tuberculosis & M.bovisMycobacteria other than M.tuberculosis & M.bovis Mycobacteria Other Than Tuberculosis(MOTTS)=NonMycobacteria Other Than Tuberculosis(MOTTS)=Non Tuberculous MycobacteriaTuberculous Mycobacteria Oppurtunistic infection in human beingsOppurtunistic infection in human beings Non contagiousNon contagious 4 groups-based on pigment production & rate of growth4 groups-based on pigment production & rate of growth 1.1. Photochromogens ā€“ yellow orange colonies in lightPhotochromogens ā€“ yellow orange colonies in light eg.M.kansasii , M. marinumeg.M.kansasii , M. marinum 2. Scotochromogens ā€“pigment in dark eg. M scrofulaceum2. Scotochromogens ā€“pigment in dark eg. M scrofulaceum 3. Nonchromogens ā€“no pigments,eg.MAC3. Nonchromogens ā€“no pigments,eg.MAC 4. Rapid growers ā€“eg M.Fortuitum ,M. chelonei4. Rapid growers ā€“eg M.Fortuitum ,M. chelonei
Mycobacterium LepraeMycobacterium Leprae Hansen (1868)-first bacterial pathogen ofHansen (1868)-first bacterial pathogen of humans to be describedhumans to be described Acid fast rodAcid fast rod Obligate intracellular-canā€™t be cultured inObligate intracellular-canā€™t be cultured in vitro, but in mouse footpadvitro, but in mouse footpad Optimum temp.growth-less than bodyOptimum temp.growth-less than body temptempļƒ ļƒ  preference for skin, mucosa &preference for skin, mucosa & superficial nervesuperficial nerve
Transmission- nasal dischargeTransmission- nasal discharge Both Humoral & cellularBoth Humoral & cellular immune responseimmune response Clinically- ChronicClinically- Chronic granulomatous diseasegranulomatous diseaseļƒ ļƒ skin,skin, peripheral nerve & nasalperipheral nerve & nasal mucosamucosa
Bacteriology in ENT
ENT PRESENTATIONENT PRESENTATION Early involvement of nasal mucosaEarly involvement of nasal mucosa Nasal obstruction ,crust formation & blood stainedNasal obstruction ,crust formation & blood stained discharge.discharge. Atrophic rhinitis, Cartilaginous perforation & DorsalAtrophic rhinitis, Cartilaginous perforation & Dorsal saddling ā€“latesaddling ā€“late Nasopharynx to oropharynx- Granulomatous lesion,Nasopharynx to oropharynx- Granulomatous lesion, ulcers, healing with fibrosisulcers, healing with fibrosis Larynx- lesion like TB & SyphilisLarynx- lesion like TB & Syphilis - Supraglottic- mainly epiglottis, aryepiglottic folds- Supraglottic- mainly epiglottis, aryepiglottic folds -Epiglottis : hollow rod, mucosa studded with tiny-Epiglottis : hollow rod, mucosa studded with tiny nodules- laryngeal stenosis & airway obstructionnodules- laryngeal stenosis & airway obstruction..
TuberculoidTuberculoid LepromatousLepromatous Cell mediatedCell mediated immuneimmune systemsystem Strong CMIStrong CMI Weak CMIWeak CMI LepromineLepromine skin testskin test ++ __ No. ofNo. of organismorganism LowLow HighHigh No. of lesion &No. of lesion & symptomssymptoms Fewer lesions,Fewer lesions, Macular, nerveMacular, nerve enlargement,enlargement, paresthesiaparesthesia Numerous lesions- nodular,Numerous lesions- nodular, loss of eyebrows,loss of eyebrows, destruction of nasal septum,destruction of nasal septum, parasthesia, Leonine faciesparasthesia, Leonine facies
Diagnosis:Diagnosis: Punch biopsy,Punch biopsy, nasal scrapings,nasal scrapings, skin lesionsskin lesions & ear lobules& ear lobules
FormForm ofof LeprosLepros yy WHO Recommended RegimenWHO Recommended Regimen (1982)(1982) TubercTuberc uloiduloid (paucib(paucib acillary)acillary) Dapsone-100 mg/d,Dapsone-100 mg/d, unsupervised)unsupervised) ++ Rifampin-600 mg/month,Rifampin-600 mg/month, supervised for 6 monthssupervised for 6 months LepromLeprom atousatous (multiba(multiba cillary)cillary) Dapsone-100 mg/d+Dapsone-100 mg/d+ clofazimine -50mg/d, unsupervised;clofazimine -50mg/d, unsupervised; rifampin-rifampin-600 mg +600 mg + clofazimine-clofazimine-300300 mg monthly (supervised)mg monthly (supervised) for 1ā€“2 yearsfor 1ā€“2 years
TREPONEMATREPONEMA trepos=turn, nema= threadtrepos=turn, nema= thread Spiral, round or pointed endsSpiral, round or pointed ends Member of genera SpirochetesMember of genera Spirochetes subspecies:subspecies: 1.Pallidum- venereal Syphilis1.Pallidum- venereal Syphilis 2.Endemicum - endemic Syphilis2.Endemicum - endemic Syphilis (bejel)(bejel) 3.Pertenue- Yaws3.Pertenue- Yaws 4.Carateum-4.Carateum- PintaPinta
Treponema PallidumTreponema Pallidum Thin walled spiral organismThin walled spiral organism Motile : endoflagella(axialMotile : endoflagella(axial filaments)filaments) Thin not reliably seen in gramThin not reliably seen in gram stain,stain, darkfield microscopy ordarkfield microscopy or immunofluorescenceimmunofluorescence Not grown on bacteriologic mediaNot grown on bacteriologic media or cell cultureor cell culture
Stages of syphilisStages of syphilis
Nasal SyphilisNasal Syphilis Primary SyphilisPrimary Syphilis - External nose or Vestibule- External nose or Vestibule -chancre-rare-chancre-rare -Self limiting disappears in-Self limiting disappears in 6-10 weeks6-10 weeks -contagious-contagious
Secondary SyphilisSecondary Syphilis Most infectiousMost infectious MUCOUS PATCHES ON THE TONGUE OF A PATIENT WITH SECONDARY SYPHILIS
Tertiary SyphilisTertiary Syphilis Most common stage ofMost common stage of nasal syphilisnasal syphilis Bony portion of NasalBony portion of Nasal SeptumSeptum Gumma ā€“pathognomicGumma ā€“pathognomic punched out ulcerpunched out ulcer
Bacteriology in ENT
Congenital SyphilisCongenital Syphilis EARLY:EARLY: first 3mos of life,manifestfirst 3mos of life,manifest as snufflesas snufflesļƒ ļƒ nasalnasal discharge purulentdischarge purulent LATE:manifest at pubertyLATE:manifest at puberty gummatous lesiongummatous lesion destroys nasal structure,destroys nasal structure, Keratitis,deafness,hutchisoKeratitis,deafness,hutchiso nā€™s teethnā€™s teeth
Syphilitic PharyngitisSyphilitic Pharyngitis May be congenital or acquired by sexualMay be congenital or acquired by sexual intercourseintercourse Secondary stage most likelySecondary stage most likely incidence risingā€“ Mainly in HIV positiveincidence risingā€“ Mainly in HIV positive
Primary SyphilisPrimary Syphilis Extragenital sites : lips,Extragenital sites : lips, tongue, buccal mucosatongue, buccal mucosa and tonsilsand tonsils Begins as a Papule,Begins as a Papule, breaks down to form abreaks down to form a painless ulcer withpainless ulcer with indurated marginindurated margin (chancre)(chancre) Non tender cervicalNon tender cervical lymphadenopathylymphadenopathy Spontaneous healingSpontaneous healing
Secondary SyphilisSecondary Syphilis -is infectious-is infectious Hyperemia and inflammation ofHyperemia and inflammation of pharynx and soft palatepharynx and soft palate Snail Track ulcer :-OralSnail Track ulcer :-Oral cavity and oropharnyxcavity and oropharnyx -Ulcerated leison covered with-Ulcerated leison covered with greyish white membranegreyish white membrane which when scraped haswhich when scraped has pink basepink base with no bleeding.with no bleeding.
Tertiary SyphilisTertiary Syphilis Typically painless .Typically painless . No lymphadenopathy unless secondaryNo lymphadenopathy unless secondary infection.infection. GUMMA are characterstic.GUMMA are characterstic. - Seen in Hard palate, Nasal septum- Seen in Hard palate, Nasal septum ,Tonsil ,PPW or larynx.,Tonsil ,PPW or larynx. VDRL may be negativeVDRL may be negative
EAREAR- TM perforation, granular- TM perforation, granular middle ear, COM- if super infection.middle ear, COM- if super infection. -Infection mimic TB.-Infection mimic TB. -Inner ear: Hennebertā€™s sign ,-Inner ear: Hennebertā€™s sign , Tullioā€™signTullioā€™sign -SNHL, Vertigo, Endolymphatic-SNHL, Vertigo, Endolymphatic hydrops- Fibrous adhesion bet.hydrops- Fibrous adhesion bet. Stapes foot-plate & Labyrinth.Stapes foot-plate & Labyrinth.
Syphilis LarynxSyphilis Larynx Rarely involvedRarely involved Secondary & Tertiary more commonSecondary & Tertiary more common Hoarseness & Dysphagia ā€“ commonHoarseness & Dysphagia ā€“ common O/EO/E - Epiglottis & Aryepiglottic folds- Epiglottis & Aryepiglottic folds principally involvedprincipally involved
DiagnosisDiagnosis 1.Immunoflurorescence or dark field microscopy1.Immunoflurorescence or dark field microscopy 2. Biopsy:2. Biopsy: 3.Serology:3.Serology: Non-treponemal antibody tests:VDRL,RPR,ARTNon-treponemal antibody tests:VDRL,RPR,ART For screening and treatment follow upFor screening and treatment follow up Treponema specific antibody tests:forTreponema specific antibody tests:for confirmation,usu.remains positive for life,confirmation,usu.remains positive for life, FTA-ABS test,TPHAFTA-ABS test,TPHA
Stage of SyphilisStage of Syphilis TreatmentTreatment Primary, secondary, or earlyPrimary, secondary, or early latentlatent Penicillin G benzathine (singlePenicillin G benzathine (single dose of 2.4 mU IM)dose of 2.4 mU IM) Late latent (or latent ofLate latent (or latent of uncertainuncertain duration), cardiovascular, orduration), cardiovascular, or benign tertiarybenign tertiary benzathine Penicillin Gbenzathine Penicillin G (2.4 mU IM weekly for 3 weeks)(2.4 mU IM weekly for 3 weeks) Procain penicillin- 1.2mu for 20Procain penicillin- 1.2mu for 20 days.days. Alternative drugsAlternative drugs Doxycycline- 100mg bd/ 15 daysDoxycycline- 100mg bd/ 15 days Erythromycin- 500mg qid for 15Erythromycin- 500mg qid for 15 days.days. Ceftriaxone1gm/ im/ 7-15 daysCeftriaxone1gm/ im/ 7-15 days
THANK YOUTHANK YOU

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Bacteriology in ENT

  • 1. ANAEROBIC ORGANISMS,ANAEROBIC ORGANISMS, DIPHTHERIA, MYCOBACTERIADIPHTHERIA, MYCOBACTERIA & TREPONEMA IN ENT& TREPONEMA IN ENT Dr. Ramesh Parajuli, MSDr. Ramesh Parajuli, MS Otorhinolaryngology, Head & Neck Surgery Chitwan Medical College Teaching Hospital, Bharatpur-10, Chitwan, Nepal
  • 2. Corynebacterium DiphtheriaeCorynebacterium Diphtheriae Aerobic, Gram-positive rod,Aerobic, Gram-positive rod, non spore forming, non motilenon spore forming, non motile Club shaped, palisades (v or lClub shaped, palisades (v or l shaped) or ā€œshaped) or ā€œChinese letterā€-Chinese letterā€- tellurite medium(D)tellurite medium(D) Granules-loefflerā€™s medium(SGranules-loefflerā€™s medium(S))
  • 3. 2 phenotypes- toxigenic(tox+ ve) and non2 phenotypes- toxigenic(tox+ ve) and non toxigenic(tox-ve)toxigenic(tox-ve) Diphtheria-nasopharyngeal & skin infection causedDiphtheria-nasopharyngeal & skin infection caused by c.diphtheriaeby c.diphtheriae Toxigenic:pharyngeal diphtheriaToxigenic:pharyngeal diphtheria Non-toxigenic:cutaneous diphtheriaNon-toxigenic:cutaneous diphtheria Lysogenic conversion by bacteriophage ā€˜toxā€™ geneLysogenic conversion by bacteriophage ā€˜toxā€™ gene
  • 4. 3 strains: Gravis ,3 strains: Gravis , Intermedius & MitisIntermedius & Mitis Gravis and intermediusGravis and intermedius types-higher mortalitytypes-higher mortality CornebacteriumCornebacterium ulcerans:- infected byulcerans:- infected by bacteriophagebacteriophageļƒ ļƒ  diphtheria likediphtheria like presentationpresentation
  • 5. Mechanism of action of DiphtheriaMechanism of action of Diphtheria ToxinToxin
  • 6. PathologyPathology Tonsil Necrosis - initialTonsil Necrosis - initial lesionlesion CharactersticCharacterstic pseudomembranepseudomembrane formation: (necrotic tissue +formation: (necrotic tissue + bacteria+ fibrinous exudate)bacteria+ fibrinous exudate) Early removal - Bleeding,Early removal - Bleeding, easy separation latereasy separation later Bull neck: Cellulitis &Bull neck: Cellulitis & Cervical lymphadenopathyCervical lymphadenopathy
  • 8. Transmission:Transmission: aerosol(resp.droplet)aerosol(resp.droplet) Incubation period:3-4 daysIncubation period:3-4 days ToxemiaToxemia Mechanical complications:Mechanical complications: pseudomembranepseudomembrane Systemic effects:Systemic effects: toxintoxin
  • 9. Clinical FeaturesClinical Features Age : Rare over 10 yearsAge : Rare over 10 years Malaise ,Sore throat andMalaise ,Sore throat and PyrexiaPyrexia Membrane over theMembrane over the Faucial pillarsFaucial pillars Progressive DysphagiaProgressive Dysphagia and Toxemiaand Toxemia Inspiratory Stridor andInspiratory Stridor and Barking coughBarking cough Cough ā€“ Paroxysmal andCough ā€“ Paroxysmal and ExhaustingExhausting
  • 11. DeathDeath -Acute airway obstruction-Acute airway obstruction -circulatory failure-circulatory failure Acute Toxic MyocarditisAcute Toxic Myocarditisļƒ ļƒ cardiaccardiac dysfunctiondysfunction -2-2ndnd weekweek Peripheral NeuropathyPeripheral Neuropathy --Recurrent laryngeal nerve palsyRecurrent laryngeal nerve palsy -Palatal Paralysis most common-Palatal Paralysis most common -Presents with nasal regurgitation-Presents with nasal regurgitation & hyper nasal speech& hyper nasal speech
  • 13. Differential DiagnosisDifferential Diagnosis Foreign bodyForeign body Infectious MononucleosisInfectious Mononucleosis Peritonsillar AbscessPeritonsillar Abscess Retropharyngeal AbscessRetropharyngeal Abscess
  • 14. Differential DiagnosisDifferential Diagnosis cont.cont. StreptococcalStreptococcal pharyngitispharyngitis Vincentā€™s anginaVincentā€™s angina ThrushThrush Post-tonsillectomyPost-tonsillectomy faucial membranesfaucial membranes Leukemia andLeukemia and agranulocytosisagranulocytosis
  • 15. ManagementManagement Airway :Airway : -Removal of Laryngeal-Removal of Laryngeal MembraneMembrane -Humidification-Humidification -0xygen therapy-0xygen therapy - ET intubation or- ET intubation or TracheostomyTracheostomy -Systemic Steroids : Reduce need-Systemic Steroids : Reduce need for airway interventionfor airway intervention
  • 16. ManagementManagement Benzyl Penicillin :Benzyl Penicillin : 600mgx i.v.x 6 hourly600mgx i.v.x 6 hourly Diptheria AntitoxinDiptheria Antitoxin 10,000-1,00,000 units10,000-1,00,000 units (Depending upon(Depending upon severity)severity)
  • 17. Bed rest ā€“ 2 toBed rest ā€“ 2 to 4 weeks until4 weeks until danger ofdanger of myocarditis ismyocarditis is overover Vaccination:Vaccination: DPTDPT
  • 18. Diptheroids (Coryneforms)Diptheroids (Coryneforms) Nondiphtherial corynebacteriaNondiphtherial corynebacteria Colonisers or contaminants ā€“invasiveColonisers or contaminants ā€“invasive disease in immunocompromiseddisease in immunocompromised C.pseudodipthericum ā€“pharynx ,skinC.pseudodipthericum ā€“pharynx ,skin -C.xerosis ā€“ skin ,nasopharynx & conjunctiva-C.xerosis ā€“ skin ,nasopharynx & conjunctiva C.Auris ā€“ EAC, C.striatum ā€“ ant.Nares ,skinC.Auris ā€“ EAC, C.striatum ā€“ ant.Nares ,skin
  • 19. Anaerobic OrganismsAnaerobic Organisms Most are commensals-Most are commensals- harmlessharmless eg saliva,gingival scrappingeg saliva,gingival scrapping Sites- skin, mouth,Sites- skin, mouth, nasopharynx, uppernasopharynx, upper respiratory tractrespiratory tract Conditions favored-Conditions favored- Decreased oxidation-Decreased oxidation- reduction potential eg.reduction potential eg. Trauma, Tissue destruction,Trauma, Tissue destruction, foreign body, malnutrition.foreign body, malnutrition.
  • 20. ClassificationClassification Gram-negative rods:Gram-negative rods: BacteroidesBacteroides [e.g.[e.g. B.B. fragilisfragilis],],Fusobacterium, prevotella,Fusobacterium, prevotella, porphyromonasporphyromonas Gram-positive rods:Gram-positive rods: ActinomycesActinomyces,clostridium,,clostridium,EubacteriumEubacterium,, BifidobacteriumBifidobacterium,,PropionibacteriumPropionibacterium Gram-positive cocci:Gram-positive cocci: PeptostreptococcusPeptostreptococcus andand PeptococcusPeptococcus Gram-negative cocci:Gram-negative cocci: VeillonellaVeillonella
  • 21. IMPORTANT ANAEROBESIMPORTANT ANAEROBES Bacteroides-Bacteroides- B. fragilis- most frequently isolatedB. fragilis- most frequently isolated Resistant to beta lactamsResistant to beta lactams Prevotella: newly named & previously BacteroidesPrevotella: newly named & previously Bacteroides B. melaninogenicus (Recently PrevotellaB. melaninogenicus (Recently Prevotella melaninogenicus )- black, brown colonies Majormelaninogenicus )- black, brown colonies Major group in oral flora.group in oral flora. Peptostreptococcus-Peptostreptococcus- -Normal flora of skin ,mucus membrane-Normal flora of skin ,mucus membrane Species- P. micros, P. anaerobius P. magnusSpecies- P. micros, P. anaerobius P. magnus (abscess)(abscess)
  • 22. PeptococcusPeptococcus FusobacteriumFusobacterium Clostridium - spore formingClostridium - spore forming Gas gangrene, food poisoning, tetanus, colitisGas gangrene, food poisoning, tetanus, colitis Cl. Perfringens- Toxin- hemolytic- dermonecrotic,Cl. Perfringens- Toxin- hemolytic- dermonecrotic, Phospholipase c, LecithinasePhospholipase c, Lecithinase Wound contamination- cellulitis- myositisWound contamination- cellulitis- myositisļƒ ļƒ  gasgas gangrene.gangrene.
  • 23. Infection due to anaerobes- mostly polymicrobialInfection due to anaerobes- mostly polymicrobial Abscess cavity or necrotic tissueAbscess cavity or necrotic tissue Failure of abscess to yield organism on routineFailure of abscess to yield organism on routine culturecultureļƒ ļƒ  clue for anaerobic organismclue for anaerobic organism Abscess in deeper body tissueAbscess in deeper body tissue Putrid smelling infection site or dischargePutrid smelling infection site or discharge
  • 24. Acute Necrotizing UlcerativeAcute Necrotizing Ulcerative Gingivitis(ANUG)/ Trench Mouth/Vincentā€™sGingivitis(ANUG)/ Trench Mouth/Vincentā€™s StomatitisStomatitis -Etiology. :Fusobacterium-Etiology. :Fusobacterium Nucleatum, BorreliaNucleatum, Borrelia VincentiVincenti - Tender bleeding gums,- Tender bleeding gums, foul breathe &bad tastefoul breathe &bad taste -Gingival mucosa esp.-Gingival mucosa esp. papilla-ulcerated&papilla-ulcerated& covered with greycovered with grey exudateexudate -Fever, Cervical-Fever, Cervical lymphadenopathy &lymphadenopathy & leucocytosisleucocytosis
  • 25. Acute Necrotizing UlcerativeAcute Necrotizing Ulcerative Mucositis / Noma/Cancrum OrisMucositis / Noma/Cancrum Oris Usually a/w ulcerativeUsually a/w ulcerative gingivitisgingivitis Anaerobes esp.Anaerobes esp. B.porphyromonasB.porphyromonas Rapid tissueRapid tissue destructiondestructionļƒ ļƒ teeth fallteeth fall outoutļƒ ļƒ bone/wholebone/whole mandible sloughmandible slough Heal leaving disfiguringHeal leaving disfiguring defectdefect
  • 26. Acute Necrotizing infection of PharynxAcute Necrotizing infection of Pharynx Usu.a/w ulcerativeUsu.a/w ulcerative gingivitisgingivitis C/F:fever,sore throat,foulC/F:fever,sore throat,foul breath,badbreath,bad taste,sensation of chokingtaste,sensation of choking O/E: Greyish membraneO/E: Greyish membrane over Tonsillar pillars thatover Tonsillar pillars that peel easilypeel easily Lymphadenopathy &Lymphadenopathy & LeucocytosisLeucocytosis May spread to larynxMay spread to larynx
  • 27. PeriPharyngeal spacePeriPharyngeal space infectioninfection Peritonsillar abscessPeritonsillar abscess - Complication of Tonsillitis orComplication of Tonsillitis or De novoDe novo - Mixed flora containing bothMixed flora containing both Anaerobes & GABHSAnaerobes & GABHS - Association betweenAssociation between Periodontal disease (sourcePeriodontal disease (source of anaerobic organism) andof anaerobic organism) and PTA.PTA. - Ludwigā€™s AnginaLudwigā€™s Angina
  • 28. ActinomycosisActinomycosis Member of normal oral flora-Member of normal oral flora- gingival crevicesgingival crevices G+ve, anaerobic,branchingG+ve, anaerobic,branching rodsrods A.israelii-most common.A.israelii-most common. A.naeslundii,A.naeslundii, A.odontolyticus,A.viscous etcA.odontolyticus,A.viscous etc
  • 29. Disruption of mucosalDisruption of mucosal barrierbarrierļƒ ļƒ local infectionlocal infectionļƒ ļƒ slowlyslowly progressiveprogressiveļƒ ļƒ chronic phasechronic phase with single or multiple induratedwith single or multiple indurated lesionslesions Trauma, F.B. poor oral hygieneTrauma, F.B. poor oral hygiene Chronic granulomatousChronic granulomatous infectioninfection
  • 30. Firm indurated mass- central necrosis withFirm indurated mass- central necrosis with fibrotic ā€˜wooden wallā€™(neutrophils & sulfurfibrotic ā€˜wooden wallā€™(neutrophils & sulfur granules)granules) Multiple sinus tract which discharge pusMultiple sinus tract which discharge pus Usu. angle of jaw involvedUsu. angle of jaw involved
  • 32. Sulphur granules-characteristicSulphur granules-characteristic D/D- Malignancy or GranulomatousD/D- Malignancy or Granulomatous diseasedisease Any mass lesion or relapsing infection inAny mass lesion or relapsing infection in head & neck regionhead & neck regionļƒ ļƒ rule outrule out actinomycosisactinomycosis
  • 33. Sinusitis &OtitisSinusitis &Otitis Anaerobes implicated in (0-88)% of CRSAnaerobes implicated in (0-88)% of CRS (Doyle, Ramadan, Brook)(Doyle, Ramadan, Brook) anaerobes in CRS (0 to 52%)(Harrison 17anaerobes in CRS (0 to 52%)(Harrison 17thth edn.)edn.) Peptostreptococcus, Fusobacterium & P.Peptostreptococcus, Fusobacterium & P. acnesacnes COMCOM - Anaerobes in Upto 50% casesAnaerobes in Upto 50% cases - B.fragilis in upto 28% cases of COMB.fragilis in upto 28% cases of COM
  • 34. Complications of AnaerobicComplications of Anaerobic Head & Neck InfectionHead & Neck Infection Continuous spreadContinuous spread - Craniad: Osteomyelitis of skull /mandible orCraniad: Osteomyelitis of skull /mandible or intracranial complications(brainintracranial complications(brain abscess,subdural empyema)abscess,subdural empyema) - Caudal :Mediastinitis or PleuropulmonaryCaudal :Mediastinitis or Pleuropulmonary infectioninfection - Hematogenous disseminationHematogenous dissemination - Lemierreā€™s Syndrome-Lemierreā€™s Syndrome- Fusobacterium necrophorumFusobacterium necrophorum
  • 35. Approach to the patientsApproach to the patients Harmless commensals, disease proximityHarmless commensals, disease proximity to mucosal site colonisedto mucosal site colonised Site of lower oxidation-reduction potentialSite of lower oxidation-reduction potential Polymicrobial naturePolymicrobial nature Negative cultureNegative culture ļƒ ļƒ ā€˜clueā€™ā€˜clueā€™ Foul or putrid infection site or dischargeFoul or putrid infection site or discharge diagnosticdiagnostic
  • 36. DiagnosisDiagnosis 3 critical steps3 critical steps 1.1. Proper specimenProper specimen collectioncollection 2.2. Rapid transportRapid transport preferably in anaerobicpreferably in anaerobic mediamedia 3.3. Proper handling ofProper handling of specimen by the labspecimen by the lab
  • 37. Specimen collectionSpecimen collection Sterile body fluid ā€“ blood,Sterile body fluid ā€“ blood, pleural, peritoneal fluid,CSFpleural, peritoneal fluid,CSF and aspirates or biopsies fromand aspirates or biopsies from normally sterile sitesnormally sterile sites Specimen unacceptable:Specimen unacceptable: expectorated sputum ,nasalexpectorated sputum ,nasal tracheal suction, bronchoscopytracheal suction, bronchoscopy specimen,voided urine &specimen,voided urine & faecesfaeces
  • 38. Ways of eliminating oxygen gasWays of eliminating oxygen gas Gas pac jarGas pac jar : -: - Contains aContains a packet of sodiumpacket of sodium borohydride, sodiumborohydride, sodium bicarbonate & citric acid.bicarbonate & citric acid. - Addition of water causes- Addition of water causes production of H2, CO2 gas &production of H2, CO2 gas & displaces air (and thusdisplaces air (and thus oxygen).oxygen).
  • 39. Gas exchange jar : Air in theGas exchange jar : Air in the jar is replaced with O2-freejar is replaced with O2-free gas (from a tank).gas (from a tank). Glove box:Glove box: Box is filled withBox is filled with anaerobic (O2-free) gasanaerobic (O2-free) gas ,usually a mixture of H2 and,usually a mixture of H2 and CO2.CO2. -Positive pressure-Positive pressure keeps O2 outkeeps O2 out
  • 41. TreatmentTreatment Surgical drainage (mostSurgical drainage (most circumstances) + antimicrobialscircumstances) + antimicrobials DOC: Penicillin GDOC: Penicillin G For Beta ā€“lactamase producingFor Beta ā€“lactamase producing Bacteroides and PrevotellaBacteroides and Prevotella -Clindamycin (DOC infections above-Clindamycin (DOC infections above diaphragm) & Metronidazolediaphragm) & Metronidazole
  • 42. Mycobacterium TuberculosisMycobacterium Tuberculosis Rod shaped, obligateRod shaped, obligate aerobes ,slow growingaerobes ,slow growing Acid-fast ā€“ high contentAcid-fast ā€“ high content of mycolic acidof mycolic acid Low cell wallLow cell wall permeability topermeability to antibioticsantibiotics
  • 43. No exotoxin norNo exotoxin nor endotoxinendotoxin Damage done byDamage done by immune system (CMI)immune system (CMI) Tuberculin(surfaceTuberculin(surface protein) along withprotein) along with mycolic acidmycolic acidļƒ ļƒ delayeddelayed type hypersensitivity &type hypersensitivity & CMICMI
  • 44. Nasal TuberculosisNasal Tuberculosis ROUTES OFROUTES OF SPREADSPREAD - Direct inoculation:- Direct inoculation: Nose Pricking orNose Pricking or Finger nail TraumaFinger nail Trauma - Droplet Spread:- Droplet Spread: Coughing, SneezingCoughing, Sneezing - Haematogenous- Haematogenous disseminationdissemination
  • 45. 3 FORMS3 FORMS 1. Nodular1. Nodular 2.Ulcerative2.Ulcerative 3.Sinus Granuloma3.Sinus Granuloma
  • 46. 1.Nodular1.Nodular Begins in VestibuleBegins in Vestibule APPLE JELLY NODULEAPPLE JELLY NODULE Untreated-scar and deformityUntreated-scar and deformity 2.Ulcerative form2.Ulcerative form Usually cartilaginous septum or inferior TurbinateUsually cartilaginous septum or inferior Turbinate Septal PerforationSeptal Perforation 3.Sinus granuloma3.Sinus granuloma Isolated sinus involvement without any sign and symptomsIsolated sinus involvement without any sign and symptoms in the nose.in the nose. Unilateral , Maxillary Sinus- usuallyUnilateral , Maxillary Sinus- usually
  • 47. Tuberculous Otitis MediaTuberculous Otitis Media Incidence < 1% COMIncidence < 1% COM Spread: Insuffalation via E.tube,Spread: Insuffalation via E.tube, Hematogenous, contiguousHematogenous, contiguous Presentation:Presentation: -Chronic Otorrhoea-Chronic Otorrhoea -Hearing loss (moderate to severe-Hearing loss (moderate to severe CHL, mixed)CHL, mixed) -Dizziness-Dizziness
  • 48. O/EO/E Multiple perforations (hall mark)-Multiple perforations (hall mark)- later coalesce into a single largelater coalesce into a single large perforationperforation AbundantAbundant pale granulationpale granulation tissue - characteristictissue - characteristic Handle of Malleus- denudedHandle of Malleus- denuded Middle ear mucosa- paleMiddle ear mucosa- pale Complications:Complications: -Profound SNHL-Profound SNHL -Facial n. palsy-Facial n. palsy
  • 49. Diagnosis-HPEDiagnosis-HPE - ME Mucosal biopsy & Aural polpectomy- ME Mucosal biopsy & Aural polpectomy specimen positive in 30% & 35%specimen positive in 30% & 35% respectivelyrespectively - Management:Management: - ATT- ATT - Mastoidectomy- Mastoidectomy
  • 50. Tuberculous Cervical AdenitisTuberculous Cervical Adenitis Most common Cause of LNMost common Cause of LN swelling in neckswelling in neck Children & young adultsChildren & young adults Primary foci ā€“ usually tonsilsPrimary foci ā€“ usually tonsils 90% single LN group usually90% single LN group usually Deep Jugular chainDeep Jugular chain Stages:Stages: Stage of LymphadenitisStage of Lymphadenitis Stage of Periadenitis includingStage of Periadenitis including ā€œcollar studā€ā€œcollar studā€ abscessabscess Stage of sinus formationStage of sinus formation
  • 51. Differential diagnosisDifferential diagnosis 1.Persistent Generalised Lymphadenopathy(PGL)1.Persistent Generalised Lymphadenopathy(PGL) 2.Lymphoma2.Lymphoma 3.Kaposiā€™s Sarcoma3.Kaposiā€™s Sarcoma 4.Carcinomatious Metastasis4.Carcinomatious Metastasis 5.Sarcoidosis5.Sarcoidosis 6.Drug Reaction(eg.Phenytoin)6.Drug Reaction(eg.Phenytoin)
  • 52. Diagnosis:Diagnosis: - Tuberculin skin test,Tuberculin skin test, - FNAC-70%sensitivityFNAC-70%sensitivity - LN excisional biopsy-LN excisional biopsy- 80% sensitivity80% sensitivity - Treatment: ATT+Treatment: ATT+ excision of LNexcision of LN
  • 53. Oropharyngeal TuberculosisOropharyngeal Tuberculosis Secondary to coughingSecondary to coughing heavily of infected sputumheavily of infected sputum Oral lesion ā€“ not commonOral lesion ā€“ not common -Ulceration :dorsum of tongue-Ulceration :dorsum of tongue -Painless , irregular-Painless , irregular ,granulating floor,granulating floor Pharynx-not commonPharynx-not common - Site of primary infectionSite of primary infection (Tonsils, Adenoids)(Tonsils, Adenoids)
  • 54. Mycobacterial infection of theMycobacterial infection of the Salivary glandsSalivary glands Etiology.: atypical or NTMEtiology.: atypical or NTM Parotid, submandibular glandsParotid, submandibular glands Presentation :Presentation : -Children age group 3 ā€“ 4 years-Children age group 3 ā€“ 4 years -Painless mass in neck or face-Painless mass in neck or face -Skin breakdown &sinus-Skin breakdown &sinus formationformation
  • 55. TB Esophagitis:TB Esophagitis: -swallowed sputum or direct-swallowed sputum or direct spread from adjacent LNspread from adjacent LN -stricture,fistula, mucosal-stricture,fistula, mucosal irregularitiesirregularities GranulomatousGranulomatous cheilitis-cheilitis- rarerare
  • 56. TB LarynxTB Larynx Nearly always aNearly always a complication of advancecomplication of advance cavitatory PTBcavitatory PTB C/F:C/F: -Dysphonia-Dysphonia -Pain on swallowing &-Pain on swallowing & speakingspeaking -Otalgia-Otalgia
  • 57. O/EO/E -Predominantly posterior-Predominantly posterior 1/31/3rdrd of glottisof glottis -Diffuse redness &-Diffuse redness & edemaedema -Ulcerations-Ulcerations Diagnosis:Diagnosis: -Biopsy of laryngeal-Biopsy of laryngeal tissuetissue
  • 58. TreatmentTreatment -Securing airway-Securing airway -ATT-ATT ComplicationsComplications - Stenosis- Stenosis - Vocal cord fixation- Vocal cord fixation
  • 59. DIAGNOSISDIAGNOSIS SpecimenSpecimen 1.1.Sputum- 3 early morning specimenSputum- 3 early morning specimen 2.2.Swab- larynx / gastric aspirateSwab- larynx / gastric aspirate 3.3.Tissue biopsy :Tissue biopsy : AFB Microscopy: -Low sensitivity (40 -60)%AFB Microscopy: -Low sensitivity (40 -60)% Culture- definite diagnosisCulture- definite diagnosis - Lowenstein- Jensen medium: 4 to 8- Lowenstein- Jensen medium: 4 to 8 weeksweeks BACTEC media ā€“growth 2 weeksBACTEC media ā€“growth 2 weeks DNA amplification/ PCR : allows diagnosis inDNA amplification/ PCR : allows diagnosis in several hoursseveral hours
  • 60. RadiologyRadiology Tuberculin skin test-Tuberculin skin test- Mantoux test, zone of induration after 48- 72 hrMantoux test, zone of induration after 48- 72 hr
  • 61. TB Skin TestTB Skin Test
  • 63. Mycobacterium tuberculosisMycobacterium tuberculosis bacteria usingbacteria using acid-fastacid-fast Ziehl-Neelsen stainZiehl-Neelsen stain..
  • 64. Colonies ofColonies of M. tuberculosisM. tuberculosis growing on mediagrowing on media
  • 66. TB on AFB smearTB on AFB smear
  • 67. TREATMENT & PREVENTIONTREATMENT & PREVENTION BCG vaccinationBCG vaccination ChemotherapyChemotherapy
  • 68. 11STST Line TreatmentLine Treatment Rifampicin ā€“ Dose- 10mg/kg body wt.Rifampicin ā€“ Dose- 10mg/kg body wt. Isoniazid ā€“ Dose-5mg/kg,Administer vitamin B6Isoniazid ā€“ Dose-5mg/kg,Administer vitamin B6 Pyrazinamide ā€“25mg/kgPyrazinamide ā€“25mg/kg Ethambutol ā€“ 15mg/kgEthambutol ā€“ 15mg/kg Streptomycin -15mg/kgStreptomycin -15mg/kg
  • 69. 22NDND LINE TREATMENT OR NEWER DRUGSLINE TREATMENT OR NEWER DRUGS AMINOGLYCOSIDES: Capreomycin,amikacin,kanamicinAMINOGLYCOSIDES: Capreomycin,amikacin,kanamicin THIOAMIDES: Ethionamide,prothionamideTHIOAMIDES: Ethionamide,prothionamide PAS(Para-Aminosalicyclic acid)PAS(Para-Aminosalicyclic acid) CYCLOSERINE (or trizidone)CYCLOSERINE (or trizidone) FLUOROQUINOLONES-FLUOROQUINOLONES- ofloxacin,ciprofloxacin,sparfloxacinofloxacin,ciprofloxacin,sparfloxacin &Gatifloxacin,Sparfloxacin-latest(improved activity)&Gatifloxacin,Sparfloxacin-latest(improved activity) Rifabutin, RifamycinRifabutin, Rifamycin ThiocetazoneThiocetazone Rifapentine- latest one 600mg/weeklyRifapentine- latest one 600mg/weekly Macrolide- clarithromycin.Macrolide- clarithromycin. Linezolide :Oxazolidinone antibioticLinezolide :Oxazolidinone antibiotic
  • 70. MDR-MDR- TBTB MDR suspected :MDR suspected : -History of irregular multi-drug therapy and sputum-History of irregular multi-drug therapy and sputum remaining positiveremaining positive -No good response in a smear positive case put-No good response in a smear positive case put on standard re-treatment regimen.on standard re-treatment regimen. - Sputum- Sputum C/S testC/S test Causes:Causes: - inappropriate regimen ,non compliance,interruption of drug- inappropriate regimen ,non compliance,interruption of drug supply,lack of diagnosis and free treatmentsupply,lack of diagnosis and free treatment
  • 71. XDR-TBXDR-TB Extensively drug resistant TB:TB that has developedExtensively drug resistant TB:TB that has developed resistance to at least rifampicin & isoniazid as well as toresistance to at least rifampicin & isoniazid as well as to any member of the quinolone family & at least one of theany member of the quinolone family & at least one of the following 2following 2ndnd line anti-TB injectable drugs:line anti-TB injectable drugs: kanamycin,capreomycin or amikacinkanamycin,capreomycin or amikacin (Global Task Force on XDR-(Global Task Force on XDR- TB,WHO,2006)TB,WHO,2006) 11STST line drug misused, mismanagedline drug misused, mismanagedļƒ ļƒ  MDR- TBMDR- TB 22NDND line drug misused, mismanagedline drug misused, mismanagedļƒ ļƒ  XDR-TBXDR-TB
  • 72. POTENTIAL NEWER THERAPIES FORPOTENTIAL NEWER THERAPIES FOR TUBERCULOSISTUBERCULOSIS Protein kinase inhibitors: pyridomycin, RifadineProtein kinase inhibitors: pyridomycin, Rifadine Pyridine analogues like NAD (NicotinamidePyridine analogues like NAD (Nicotinamide adenine dinucleotide) and Streptolydigin whichadenine dinucleotide) and Streptolydigin which inhibits initiation of RNA synthesis.inhibits initiation of RNA synthesis. Cytokine Immunotherapy: IL-2- subcutaneous lowCytokine Immunotherapy: IL-2- subcutaneous low dose for patients with active tuberculosis todose for patients with active tuberculosis to augment the immune cell response.augment the immune cell response. IFN Gammatherapy by aerosol toIFN Gammatherapy by aerosol to accelerateaccelerate M.tuberculosisM.tuberculosis killing.killing. Interleukin-12: for restoring impaired cellularInterleukin-12: for restoring impaired cellular immune function in AIDS and tuberculosis.immune function in AIDS and tuberculosis.
  • 73. Recent Advances in theRecent Advances in the Diagnosis & Management ofDiagnosis & Management of Tuberculosis:Tuberculosis: 1.BACTEC TM 460-liquid culture method1.BACTEC TM 460-liquid culture methodļƒ ļƒ detectsdetects radiolabeled CO2 releasedradiolabeled CO2 released 2.MGIT(mycobacterial growth indicator tube)2.MGIT(mycobacterial growth indicator tube) 3.PCR3.PCR 4.PA-824 :a nitroimidazopyran compound related to4.PA-824 :a nitroimidazopyran compound related to metronidazole activity against both slow &rapidlymetronidazole activity against both slow &rapidly dividing mycobact.dividing mycobact.ļƒ ļƒ may enter human testingmay enter human testing soonsoon
  • 74. 5.Rifacinna5.Rifacinna 6.Benzofuro(2,3-b) quinolone derivative6.Benzofuro(2,3-b) quinolone derivative 7.Interferon gamma release assay(IGRAs)-mtb-7.Interferon gamma release assay(IGRAs)-mtb- specific antigens,ESAT-6 & CFP-10specific antigens,ESAT-6 & CFP-10 8.Dipiperidines8.Dipiperidines 9.Multiplex SNaphot technique-identification of9.Multiplex SNaphot technique-identification of diff.species of mycobacteriadiff.species of mycobacteria 10.R207910(TMC207)-a lead compound10.R207910(TMC207)-a lead compound
  • 75. Atypical MycobacteriaAtypical Mycobacteria Mycobacteria other than M.tuberculosis & M.bovisMycobacteria other than M.tuberculosis & M.bovis Mycobacteria Other Than Tuberculosis(MOTTS)=NonMycobacteria Other Than Tuberculosis(MOTTS)=Non Tuberculous MycobacteriaTuberculous Mycobacteria Oppurtunistic infection in human beingsOppurtunistic infection in human beings Non contagiousNon contagious 4 groups-based on pigment production & rate of growth4 groups-based on pigment production & rate of growth 1.1. Photochromogens ā€“ yellow orange colonies in lightPhotochromogens ā€“ yellow orange colonies in light eg.M.kansasii , M. marinumeg.M.kansasii , M. marinum 2. Scotochromogens ā€“pigment in dark eg. M scrofulaceum2. Scotochromogens ā€“pigment in dark eg. M scrofulaceum 3. Nonchromogens ā€“no pigments,eg.MAC3. Nonchromogens ā€“no pigments,eg.MAC 4. Rapid growers ā€“eg M.Fortuitum ,M. chelonei4. Rapid growers ā€“eg M.Fortuitum ,M. chelonei
  • 76. Mycobacterium LepraeMycobacterium Leprae Hansen (1868)-first bacterial pathogen ofHansen (1868)-first bacterial pathogen of humans to be describedhumans to be described Acid fast rodAcid fast rod Obligate intracellular-canā€™t be cultured inObligate intracellular-canā€™t be cultured in vitro, but in mouse footpadvitro, but in mouse footpad Optimum temp.growth-less than bodyOptimum temp.growth-less than body temptempļƒ ļƒ  preference for skin, mucosa &preference for skin, mucosa & superficial nervesuperficial nerve
  • 77. Transmission- nasal dischargeTransmission- nasal discharge Both Humoral & cellularBoth Humoral & cellular immune responseimmune response Clinically- ChronicClinically- Chronic granulomatous diseasegranulomatous diseaseļƒ ļƒ skin,skin, peripheral nerve & nasalperipheral nerve & nasal mucosamucosa
  • 79. ENT PRESENTATIONENT PRESENTATION Early involvement of nasal mucosaEarly involvement of nasal mucosa Nasal obstruction ,crust formation & blood stainedNasal obstruction ,crust formation & blood stained discharge.discharge. Atrophic rhinitis, Cartilaginous perforation & DorsalAtrophic rhinitis, Cartilaginous perforation & Dorsal saddling ā€“latesaddling ā€“late Nasopharynx to oropharynx- Granulomatous lesion,Nasopharynx to oropharynx- Granulomatous lesion, ulcers, healing with fibrosisulcers, healing with fibrosis Larynx- lesion like TB & SyphilisLarynx- lesion like TB & Syphilis - Supraglottic- mainly epiglottis, aryepiglottic folds- Supraglottic- mainly epiglottis, aryepiglottic folds -Epiglottis : hollow rod, mucosa studded with tiny-Epiglottis : hollow rod, mucosa studded with tiny nodules- laryngeal stenosis & airway obstructionnodules- laryngeal stenosis & airway obstruction..
  • 80. TuberculoidTuberculoid LepromatousLepromatous Cell mediatedCell mediated immuneimmune systemsystem Strong CMIStrong CMI Weak CMIWeak CMI LepromineLepromine skin testskin test ++ __ No. ofNo. of organismorganism LowLow HighHigh No. of lesion &No. of lesion & symptomssymptoms Fewer lesions,Fewer lesions, Macular, nerveMacular, nerve enlargement,enlargement, paresthesiaparesthesia Numerous lesions- nodular,Numerous lesions- nodular, loss of eyebrows,loss of eyebrows, destruction of nasal septum,destruction of nasal septum, parasthesia, Leonine faciesparasthesia, Leonine facies
  • 81. Diagnosis:Diagnosis: Punch biopsy,Punch biopsy, nasal scrapings,nasal scrapings, skin lesionsskin lesions & ear lobules& ear lobules
  • 82. FormForm ofof LeprosLepros yy WHO Recommended RegimenWHO Recommended Regimen (1982)(1982) TubercTuberc uloiduloid (paucib(paucib acillary)acillary) Dapsone-100 mg/d,Dapsone-100 mg/d, unsupervised)unsupervised) ++ Rifampin-600 mg/month,Rifampin-600 mg/month, supervised for 6 monthssupervised for 6 months LepromLeprom atousatous (multiba(multiba cillary)cillary) Dapsone-100 mg/d+Dapsone-100 mg/d+ clofazimine -50mg/d, unsupervised;clofazimine -50mg/d, unsupervised; rifampin-rifampin-600 mg +600 mg + clofazimine-clofazimine-300300 mg monthly (supervised)mg monthly (supervised) for 1ā€“2 yearsfor 1ā€“2 years
  • 83. TREPONEMATREPONEMA trepos=turn, nema= threadtrepos=turn, nema= thread Spiral, round or pointed endsSpiral, round or pointed ends Member of genera SpirochetesMember of genera Spirochetes subspecies:subspecies: 1.Pallidum- venereal Syphilis1.Pallidum- venereal Syphilis 2.Endemicum - endemic Syphilis2.Endemicum - endemic Syphilis (bejel)(bejel) 3.Pertenue- Yaws3.Pertenue- Yaws 4.Carateum-4.Carateum- PintaPinta
  • 84. Treponema PallidumTreponema Pallidum Thin walled spiral organismThin walled spiral organism Motile : endoflagella(axialMotile : endoflagella(axial filaments)filaments) Thin not reliably seen in gramThin not reliably seen in gram stain,stain, darkfield microscopy ordarkfield microscopy or immunofluorescenceimmunofluorescence Not grown on bacteriologic mediaNot grown on bacteriologic media or cell cultureor cell culture
  • 86. Nasal SyphilisNasal Syphilis Primary SyphilisPrimary Syphilis - External nose or Vestibule- External nose or Vestibule -chancre-rare-chancre-rare -Self limiting disappears in-Self limiting disappears in 6-10 weeks6-10 weeks -contagious-contagious
  • 87. Secondary SyphilisSecondary Syphilis Most infectiousMost infectious MUCOUS PATCHES ON THE TONGUE OF A PATIENT WITH SECONDARY SYPHILIS
  • 88. Tertiary SyphilisTertiary Syphilis Most common stage ofMost common stage of nasal syphilisnasal syphilis Bony portion of NasalBony portion of Nasal SeptumSeptum Gumma ā€“pathognomicGumma ā€“pathognomic punched out ulcerpunched out ulcer
  • 90. Congenital SyphilisCongenital Syphilis EARLY:EARLY: first 3mos of life,manifestfirst 3mos of life,manifest as snufflesas snufflesļƒ ļƒ nasalnasal discharge purulentdischarge purulent LATE:manifest at pubertyLATE:manifest at puberty gummatous lesiongummatous lesion destroys nasal structure,destroys nasal structure, Keratitis,deafness,hutchisoKeratitis,deafness,hutchiso nā€™s teethnā€™s teeth
  • 91. Syphilitic PharyngitisSyphilitic Pharyngitis May be congenital or acquired by sexualMay be congenital or acquired by sexual intercourseintercourse Secondary stage most likelySecondary stage most likely incidence risingā€“ Mainly in HIV positiveincidence risingā€“ Mainly in HIV positive
  • 92. Primary SyphilisPrimary Syphilis Extragenital sites : lips,Extragenital sites : lips, tongue, buccal mucosatongue, buccal mucosa and tonsilsand tonsils Begins as a Papule,Begins as a Papule, breaks down to form abreaks down to form a painless ulcer withpainless ulcer with indurated marginindurated margin (chancre)(chancre) Non tender cervicalNon tender cervical lymphadenopathylymphadenopathy Spontaneous healingSpontaneous healing
  • 93. Secondary SyphilisSecondary Syphilis -is infectious-is infectious Hyperemia and inflammation ofHyperemia and inflammation of pharynx and soft palatepharynx and soft palate Snail Track ulcer :-OralSnail Track ulcer :-Oral cavity and oropharnyxcavity and oropharnyx -Ulcerated leison covered with-Ulcerated leison covered with greyish white membranegreyish white membrane which when scraped haswhich when scraped has pink basepink base with no bleeding.with no bleeding.
  • 94. Tertiary SyphilisTertiary Syphilis Typically painless .Typically painless . No lymphadenopathy unless secondaryNo lymphadenopathy unless secondary infection.infection. GUMMA are characterstic.GUMMA are characterstic. - Seen in Hard palate, Nasal septum- Seen in Hard palate, Nasal septum ,Tonsil ,PPW or larynx.,Tonsil ,PPW or larynx. VDRL may be negativeVDRL may be negative
  • 95. EAREAR- TM perforation, granular- TM perforation, granular middle ear, COM- if super infection.middle ear, COM- if super infection. -Infection mimic TB.-Infection mimic TB. -Inner ear: Hennebertā€™s sign ,-Inner ear: Hennebertā€™s sign , Tullioā€™signTullioā€™sign -SNHL, Vertigo, Endolymphatic-SNHL, Vertigo, Endolymphatic hydrops- Fibrous adhesion bet.hydrops- Fibrous adhesion bet. Stapes foot-plate & Labyrinth.Stapes foot-plate & Labyrinth.
  • 96. Syphilis LarynxSyphilis Larynx Rarely involvedRarely involved Secondary & Tertiary more commonSecondary & Tertiary more common Hoarseness & Dysphagia ā€“ commonHoarseness & Dysphagia ā€“ common O/EO/E - Epiglottis & Aryepiglottic folds- Epiglottis & Aryepiglottic folds principally involvedprincipally involved
  • 97. DiagnosisDiagnosis 1.Immunoflurorescence or dark field microscopy1.Immunoflurorescence or dark field microscopy 2. Biopsy:2. Biopsy: 3.Serology:3.Serology: Non-treponemal antibody tests:VDRL,RPR,ARTNon-treponemal antibody tests:VDRL,RPR,ART For screening and treatment follow upFor screening and treatment follow up Treponema specific antibody tests:forTreponema specific antibody tests:for confirmation,usu.remains positive for life,confirmation,usu.remains positive for life, FTA-ABS test,TPHAFTA-ABS test,TPHA
  • 98. Stage of SyphilisStage of Syphilis TreatmentTreatment Primary, secondary, or earlyPrimary, secondary, or early latentlatent Penicillin G benzathine (singlePenicillin G benzathine (single dose of 2.4 mU IM)dose of 2.4 mU IM) Late latent (or latent ofLate latent (or latent of uncertainuncertain duration), cardiovascular, orduration), cardiovascular, or benign tertiarybenign tertiary benzathine Penicillin Gbenzathine Penicillin G (2.4 mU IM weekly for 3 weeks)(2.4 mU IM weekly for 3 weeks) Procain penicillin- 1.2mu for 20Procain penicillin- 1.2mu for 20 days.days. Alternative drugsAlternative drugs Doxycycline- 100mg bd/ 15 daysDoxycycline- 100mg bd/ 15 days Erythromycin- 500mg qid for 15Erythromycin- 500mg qid for 15 days.days. Ceftriaxone1gm/ im/ 7-15 daysCeftriaxone1gm/ im/ 7-15 days