Medical Microbiology

Chapter 13
Vibrio, Mobiluncus, Gardnerella and Spirillum

Key Points
● Vibrio cholerae belong to serogroup O1
○ Causative agent of epidemic cholera
● V. cholerae O139 is emerging cause of epidemic cholera
● Cholera toxin is key pathogenic mechanism
○ Leads to: extensive loss of water and electrolytes
■ In form of rice-water stools
○ Death from cholera prevented with rehydration therapy
● V. parahaemolyticus is major cause of diarrhea in Japan and South-East Asia
○ Infection is associated with consumption of seafood
● .Infection with V. vulnificus can cause:
1. Rapid-onset
2. Fatal septicaemia
○ Especially in people with conditions of iron overload
○ Associated with consumption of seafood
● Mobiluncus spp. and Gardnerella vaginalis are major cause of bacterial vaginosis
○ Changes in normal vaginal flora allow these organisms to cause disease
● Spirillum minus causes rat bite fever
Vibrio
● Distinguishable features:
1. Gram-negative
2. Curved rod with polar flagella
3. Oxidase-positive
4. Vibrionaceae
5. Grow on alkaline media
TCBS (thiosulfate citrate bile salt sucrose medium)
Do not grow on acidic media
● Medically important species:
1. Vibrio cholerae
2. Vibrio parahaemolyticus
3. Vibrio vulnificus
 Species Infection source Clinical disease

V. cholerae Water, food Gastroenteritis

V. parahaemolyticus Shellfish, seawater Gastroenteritis, wound

infection, bacteremia

V. vulnificus Shellfish, seawater Bacteremia, wound infection,

cellulitis

V. alginolyticus Seawater Wound infection, external

otitis

V. hollisae Shellfish Gastroenteritis, wound

infection, bacteremia

V. fluvialis Seawater Gastroenteritis, wound

infection, bacteremia

V. damsela Shellfish Wound infection

V. metschnikovii Unknown Bacteremia

V. mimicus Fresh water Gastroenteritis, wound

infection, bacteremia

V. furnissii Seawater Gastroenteritis

V. cincinnatiensis Unknown Bacteremia, meningitis

V. carbariae Seawater Wound from shark bite

Vibrio Cholerae
● Distinguishable features:
1. Causes rice-water diarrhea
2. Grows on TCBS
● Found in human colon
○ No vertebral animal reservoir
○ Copepods or shellfish can get contaminated by water contamination
● Human carriage can persist after untreated infection for months after infection
○ Permanent carrier state is rare
● > 200 serogroups found
○ Based on O-antigen presence:
1. O1 serogroup:
a. 2 biotypes:
 1. El Tor
Hemolysin on sheep RBC
Resistant to polymyxin B
Exhibits agglutination of:
a. Chicken RBC
b. Positive Voges-Proskauer (VP)
2. Classical / cholerae
b. 3 serotypes:
1. Ogawa
2. Inaba
3. Hikojima
Some strains do not produce cholera enterotoxin
—> atypical / non-toxigenic O1 V. cholerae
2. Non-O1 serogroup
Strains identical to O1 strains
—> do not agglutinate in O1 antiserum
Non-cholera vibrios (NCV) / non-agglutinating vibrios (NAG)
Include O139 serogroups
○ O1 and O139 serogroups cause classic epidemic cholera
● Transmitted fecal-oral
○ Sensitive to stomach acid
○ Needs high dose > 107 organisms to cause infection if stomach acid is normal
● Pathogenesis:
1. Motility
2. Mucinase / hemagglutination protease
Induces:
a. Intestinal inflammation
b. Degradation of tight junction
3. Siderophores
Scavenge iron for growth
4. Neuraminidase
Increases toxin receptors
5. Toxin coregulated pili (TCP)
Helps in attachment to intestinal mucosa
6. Cholera enterotoxin / Choleragen
Causes persistent activation of adenylate cyclase
Acts locally
 —> similar to E. coli LT
Does not invade intestinal wall
Few neutrophils in stool
Fluid loss originates in duodenum / upper jejunum
Ileum less affected
Colon insensitive to toxin
● Causes cholera disease
○ Symptoms:
1. Rice-water stools
1 L/hour
2. Huge fluid loss
3. Hypovolemic shock if not treated
4. Vomiting
5. Cramps
6. No fever
7. Death in 18 hours-several days if not treated
■ Happen 2-3 days after consumption of contaminated food / water
○ Usually mild or asymptomatic
■ 75% asymptomatic
■ 20% mild
■ 2-5% severe
○ Infection with El Tor biotype stays asymptomatic or have mild illness
Cholera Gravis
● Has more severe symptoms
● Causes fat loss of body fluids
○ 6 L/hour
■ 107 vibrios found per mL
● > 10% of body weight lost rapidly
● Symptoms:
1. Dehydration
2. Shock
3. Death within 12 hours or less
Can even happen within 2-3 hours
● Consequences of severe dehydration:
1. Intravascular volume depletion
2. Severe metabolic acidosis
3. Hypokalemia
 4. Cardiac and renal failure
5. Sunken eyes
Due to: decreased skin turgor
6. Almost no urine production
● Mortality rate of 120 000 deaths/year worldwide
○ With rehydration < 1%
○ Without treatment = 50-60%
● Cholera suspected when patients have:
1. Watery diarrhea
2. Severe dehydration
● Clinical presentation:
1. Decreased skin turgor
2. Sunken eyes and cheeks
3. Almost no urine production
4. Dry mucous membranes
5. Watery diarrhea
Consists of:
a. Fluid without RBC or proteins
b. Electrolytes
c. Huge numbers of vibrio cholerae
107 vibrios/mL
● Specimens taken:
1. From patients with watery stools and mucous flakes
2. Contact and carriers
○ Using rectal swabs
● Diagnosis:
1. Direct microscopy
Unreliable method
Wet preparation in saline / dark field
Used to observe darting movement of bacteria
Movements stop when antisera is added
2. Transport media:
a. Cary-Blair medium
Semisolid medium
Recommended
b. Venkataraman-Ramakrishnan (VR)
3. Enrichment medium
 Alkaline peptone broth
Vibrios survive and replicate at high pH
Other organisms killed or cannot replicate
4. Selective / differential culture medium
TCBS agar
V. cholerae grows as yellow colonies
5. Biochemical and serological tests
● Treatment:
1. Oral rehydration
Reduces mortality rate from > 50% to < 1%
Recovery within 3-6 days
At least 1.5x amount of liquid lost in stools is administered
Used when < 10% of body weight is lost in dehydration
Electrolyte solution with glucose used for energy recovery
Uses oral rehydration salts (ORS)
—> packets distributed by WHO and UNICEF
—> dissolve in 1 L water

ORS contents Amounts (g)

NaCl 2.6

KCl 1.5

NaHCO3 2.9

Glucose 13.5

2. Intravenous rehydration
Used when > 10% of body weight is lost in dehydration
Patient cannot drink water
—> due to: vomiting
Only treatment for severe dehydration
3. Antimicrobial therapy
Doxycycline or ciprofloxacin
—> used to:
a. Shorten disease
b. Reduce carriage
Resistance to tetracycline reported
Not recommended
 —> due to:
a. Short illness duration
b. Antibiotic resistance
4. Vaccines
Localize mucosal immune response
—> oral vaccine used
Not recommended
—> due to:
a. Low risk for travelers of contamination
1-2 cases per million international trips
b. Not cost-effective to administer in endemic regions
c. Brief and incomplete immunity
2 types approved for humans:
a. Killed whole-cell vaccine
b. Live-attenuated vaccine
○ Rehydration therapy started immediately
■ Even before identifying disease cause
■ Due to: death can happen within few hours
● Prevention:
1. Disrupt fecal-oral transmission
2. Water Sanitation
3. Water treatment
Outbreak Update: Cholera in Yemen
● Yemen's Ministry of Public Health and Population reported:
1. 15,201 suspected cholera cases
2. 37 deaths
● Cumulative total of suspected cholera cases from is 1,207,596,
○ Had 2,510 associated deaths
■ Case fatality rate of 0.21%
● Children < 5 years of age represent 30.5% of suspected cases
● Outbreak affected 22 out of 23 governorates and 306 out of 333 districts in Yemen
● Governorates with highest number of suspected cases are Amran, Al Hudaydah, Dhamar,
Sana'a, and Amanat Al Asimah
● Suspected cases have been increasing for 15 consecutive weeks
○ Had notable increases in Aden, Amran, Al Hudaydah, and Taizz governorates
● WHO in coordination with partners supports:
1. Disease surveillance
 2. Case management
3. Sanitation improvement efforts
● Out of 7,321 samples collected, 1,875 cases were confirmed as cholera positive by culture
● WHO:
1. Established Oral Rehydration Corners (ORCs)
2. Supports medication distribution
3. Supports health education
● Health Cluster partners operate ORCs and Diarrhea Treatment Centers (DTCs) in 98 districts
across 14 governorates
● WHO, UNICEF, and MOPHP are preparing for 2nd round of oral cholera vaccination campaign in
the northern governorates
Vibrio Parahaemolyticus
● Distinguishable features:
1. Marine environments
2. Halophilic
Needs NaCl to grow
3. Does not grow on CLED (cystine-lactose-electrolyte-deficient) agar
4. Non-sucrose fermenter
Forms green colonies on agar plates
Especially on TCBS agar
● Identified as enteritis cause in Japan, 1953
○ Due to: consumption of raw or undercooked seafood
● Pathogenesis:
1. Kanagawa phenomenon
Thermostable direct hemolysin
Ability of some V. parahaemolyticus strains to cause hemolysis on Wagatsuma agar
2. Selective growth medium
Wagatsuma agar has alkaline pH and high salt concentration
—> makes it selective for V. parahaemolyticus
Also has crystal violet
—> inhibit most gram-positive bacteria growth
Enteropathogenic V. parahaemolyticus strains are kanagawa-positive
—> produce haemolysin
—> forms transparent clearing zone of blood cells around colony
3. Diarrhea mechanism
Not fully understood
4. Genome sequencing
 Shows clusters of genes most likely associated to virulence
● Diseases:
1. Cholera-like disease
Symptoms:
a. Watery Diarrhea
b. Abdominal cramps
c. Nausea
d. Vomiting
e. Fever and chills in 25% cases
Has incubation period of 4 hours-4 days
Symptoms present for 3 days
2. Dysentery
Less common
Symptoms:
a. Severe abdominal cramps
b. Nausea
c. vomiting
d. Bloody / mucoid stools
● Treatment:
1. Self limiting
2. No antibiotics / hospitalization
● Severe infection
○ Due to: underlying disease
■ Include:
1. DM type2,
2. Pre-existing liver diseases
3. Iron overloaded states
4. Immunosuppression
Foodborne Outbreak of Gastroenteritis Caused by Vibrio Parahaemolyticus Associated with
Cross Contamination from Squid in Korea
● Rare case of Vibrio gastritis occurred after residents consumed food at bazaar in Seoul
● Out of approximately 299 visitors, 237 (79.3%) showed symptoms,
○ 116 (48.9%) seeked hospital consultation and 53 (45.6%) hospitalized.
○ Retrospective study was conducted by:
1. Investigating exposed individuals
2. Interviewing medical staff
 3. Conducting microbiological testing
4. Examining ingredient handling and cooking processes
● Total of 237 individuals were affected
○ Including 6 food handlers
○ Prevalence of 79.2%)
● V. parahaemolyticus found in 34 patients and 4 food handlers during microbiological testing
○ Consumption analysis revealed high relative risk associated with kimbap
○ Investigation found cross-contamination between squid and egg sheets during food
preparation
■ Leads to: outbreak.
● Outbreak of Vibrio gastritis resulted from cross-contamination during squid preparation
rather than seafood consumption
○ Enhanced hygiene management during food processing and handling is crucial to
prevent Vibrio parahaemolyticus infections
Vibrio Vulnificus
● Distinguishable features:
1. Most common cause of severe vibrio infections in USA
2. Proliferates in warm summer methods
3. Needs saline environment for growth
4. Affects men > 40 years of age
5. Causes 2 syndromes:
a. Primary sepsis
b. Primary wound infection
● Pathogenesis by capsule
○ Gives resistance to phagocytosis
○ Resists bacterial activity of human serum
○ Produces cytolysin
● Virulence increased hemochromatosis
● Causes primary sepsis
○ Rarely happens without underlying disease
■ Including:
1. Cirrhosis
2. Hemochromatosis
3. Hematopoietic disorders
4. Chronic renal insufficiency
5. Immunosuppressive medications
6. Alcoholism
 ○ Has median incubation period of 16 hours
○ Symptoms:
1. Malaise
2. Fever and chills •
3. Hypotension
4. Cutaneous manifestations
After 36 hours of onset
5. Extremities left > right
Left more affected
6. Sepsis + bullous skin
Suggest diagnosis
7. Necrosis
8. Sloughing
● Lab studies showed:
1. Leukopenia / decreased WBCs count
Rather than leukocytosis / increased WBCs count
2. Thrombocytopenia / decreased platelet count
● Diagnosed by blood / cutaneous lesions cultures
● Has mortality rate of 50%
● Treatment:
1. Empirical antibiotics
2. Aggressive debridement
3. General supportive care
○ Early initiation of treatment is important
● Can cause primary wound infection
○ Due to: fresh or old wound making contact with sea water
○ Patient does not need to have underlying disease
○ Has short incubation period of 4 hours-4 days
■ Has mean of 12 hours
○ Symptoms:
1. Swelling
2. Erythema
3. Intense pain around wound
4. Fever
5. Leukocytosis
○ Can progress to cellulitis
■ Spreads fast
 ■ Characterized by vesicular bullous necrotic lesions
○ Early initiation of treatment needed
Case Study
● 73 year old male fisherman has history of diabetes mellitus and oral cancer
○ Experienced right hand pain and swelling for 2 days after fish handling
○ Preoperative images showed:
1. Severe patchy
2. Purpura
3. Hemorrhagic bullae
4. Edema
■ On right forearm
● Emergency fasciotomy revealed extensive necrosis of underlying skin and turbid fascial layer
○ 3 days later, wound cultures confirmed Vibrio vulnificus infection
● Treatment included:
1. Repeated debridement
2. Vacuum-assisted closure (VAC) therapy
○ Skin grafting performed on 42nd day post-fasciotomy
○ Patient was discharged on the 50th day
● Follow-up in clinic showed good skin growth on right forearm
● Case underscores severity of Vibrio vulnificus infection
○ Especially in individuals with underlying health conditions
○ Highlights importance of timely intervention and wound management for successful
recovery
Vibrio Alginolyticus
● Causes infections in:
1. Eye
2. Ear wound
● Most salt-tolerant vibrios
○ Can grow in salt concentrations > 10%
● Can cause superinfected wounds
○ Due to: contamination at beach
● Severity varies
● Treatment:
1. Antibiotics
2. Drainage
3. Tetracycline
Mobiluncus
● Distinguishable features:
1. Obligate anaerobe
2. Gram-variable
Gram-positive rods:
a. Have gram-positive cell wall
b. Lack endotoxin
c. Susceptible to:
1. Vancomycin
2. Clindamycin
3. Erythromycin
4. Ampicillin
d. Resistant to colistin
3. Curved rods with tapered ends
● Pathological features:
1. Undergrowth of lactobacilli
Characterized by ph > 4.5
2. Characteristic vaginal discharge
Thin homogeneous
Rotten fish smell
3. Association with Garderella vaginalis
4. Isolation from:
a. Male urethra
b. Breast abscesses
5. Poorly understood disease mechanism
6. Thermo-stable toxin production
Toxic for vero cells

Gardnerella Vaginalis
● Distinguishable features:
1. Gram-variable rod
Gram-positive cell has envelope
2. Facultative anaerobe
3. Catalase-negative
4. Oxidase-negative
● Found in human vagina
 ● Transmitted endogenously
○ Normal flora gets disturbed
■ Due to: increases pH
● Pathogenesis:
1. Polymicrobial infections
2. Synergistic interactions
Works with other normal flora organisms
—> include:
a. Lactobacillus
b. Mobiluncus
c. Bacteroides
d. Peptostreptococcus
3. Vaginal pH increase
Reduces vaginal lactobacillus
4. Follows menses or antibiotic therapy
● Causes bacterial vaginosis
○ Characterized by:
1. Vaginal odor
2. Increased discharge
3. Thin gray adherent fluid discharge
● Diagnosis:
1. Vaginal pH measurement
Has pH > 4.5
2. Vaginal saline smear
Epithelial cells covered with bacteria
3. Whiff test
Add KOH to sample
Assess for fishy amine odor
● Treated with metronidazole or clindamycin
Rare Cause of Scrotal Abscess Due to Symbiotic Infection of Gardnerella vaginalis and
Prevotella Bivia in Adult Male
● Gardnerella vaginalis is commonly associated with bacterial vaginosis (BV) in women
● Prevotella bivia has symbiotic relationship with G. vaginalis
● Infections in males are less common
○ Some men can have G. vaginalis colonization in their urogenital or anorectal tracts
● Genitourinary infections in males due to G. vaginalis are rare
 ○ Cases include:
1. Balanitis
2. Urethritis
● Case presented describes rare occurrence of scrotal abscess
○ Due to: G. vaginalis in co-infection with P. bivia
●
Spirillum Minus
● Streptobacillus moniliformis strain causes rat bite fever
● Normal commensal of rodent oropharynx
○ Also found in ferrets and weasels
● Symptoms:
1. Fever
2. Chills
3. Headache
4. Nausea
5. Vomiting
6. Migratory arthralgias
7. Leukocytosis of about 30k
8. Rash
Can be:
a. Nonpruritic / non-itchy
b. Maculopapular / flat red patches
c. Petechial / small red or purple spots
d. Pustular
e. Purpuric / confluent
Appears after 2-4 days
● Diagnosis:
1. Gram / Giemsa stain
Stain:
a. Blood
b. Joint fluid
c. Pus
2. Culture
3. Serology
Sero-negative within 5 months-2 years
4. PCR
● Treated with penicillin, erythromycin, or tetracycline
Streptobacillus Moniliformis Endocarditis: Unusual Case of Pulmonary Valve Erosion
Resulting in Free Pulmonary Regurgitation and Aneurysm
● Streptobacillus moniliformis infection caused endocarditis in 7 month old baby
● The baby had history of rat bite at 3 months of age
● Endocarditis caused erosion of pulmonary valve
○ Leads to:
1. Free pulmonary regurgitation
2. Aneurysm
● Masses seen on echocardiography in patients with congenital heart disease should prompt
consideration of endocarditis in differential diagnosis
Case Study
● 26 year old woman comes to traveler’s clinic complaining about profound weakness and
severe diarrhea
○ For ½ day
● She returned from Arab Gulf where she worked for 2 months in refugee camp on border of
Saudi Arabia and Yemen
○ She developed on plane:
1. Abdominal bloating
2. Intestinal gurgling
3. Nausea
4. 2 loose bowel movements
5. Profuse watery diarrhea
Happening every hour
Clear stool without odor
● She looked very weak in clinic
○ Had no fever
○ Blood pressure = 94/60 lying down
■ Drops to 72/40 when standing
● She got admitted to hospital
○ Lab studies done

Test Result Normal value

Sodium 138 mEq/L 135-145 mEq/L

Potassium 2.1 mEq/L 3.5-5 mEq/L

Chloride 95 mEq/L 98-106 mEq/L

 CO2 15 mEq/L 22-26 mEq/L

Fecal leukocytes None seen None seen

Fecal occult blood Negative Negative

1. What is most probable causative agent and why
● Vibrio cholerae
○ Especially toxigenic strains
○ Suggested by:
a. Profound weakness
b. Severe watery diarrhea
c. Abdominal symptoms
d. Clear odorless stools characteristic of cholera
2. What is mechanism of transmission of pathogenicity
● Cholera transmitted through ingestion of contaminated food or water
○ Typically through fecal-oral route
● Infection due to consumption of food or water contaminated with Vibrio cholerae
○ Often from human waste
3. What host factors increase likelihood of infection
● Factors:
a. Poor sanitation
b. Inadequate access to clean water
c. Crowded living conditions
d. Compromised immune systems
Increase susceptibility
4. Describe main mechanism of action of infection
● Vibrio cholerae produces cholera toxin
○ Binds to receptors on the surface of intestinal cells
○ Leads to: activation of adenylate cyclase
■ Causes increased intracellular levels of cyclic AMP (cAMP)
● Elevated cAMP levels lead to:
1. Secretion of chloride ions into intestinal lumen
2. Passive movement of sodium ions and water
○ Leads to: profuse watery diarrhea characteristic of cholera
5. What other virulence determinant is essential for development of infection
● Pili and adhesins aid in attachment of Vibrio cholerae to intestinal mucosa
○ Facilitate colonization and subsequent toxin production
6. How would you manage dehydration
Why can oral rehydration fluid be used in many cases
● Dehydration should be managed with rehydration therapy
○ Preferably using oral rehydration solution (ORS) containing electrolytes and glucose
● ORS used because it helps replace lost fluids and electrolytes
○ Prevent dehydration without need for intravenous fluids in many cases
7. What advice would you provide to other travelers to Yemen concerning avoidance of infection
● Travelers should be advised to:
1. Drink only bottled or boiled water
2. Avoid consuming raw or undercooked seafood
3. Practice good hand hygiene
Include frequent handwashing with soap and water
Especially before eating and after using restroom
8. List 3 public health solutions to the global problem of this epidemic
● Solutions:
1. Improving access to clean water and sanitation facilities
2. Implementing vaccination programs in endemic regions
3. Enhancing surveillance and early detection systems
Done to quickly identify and respond to outbreaks