Haemophilus influenzae Case File

Haemophilus influenzae Case File

Eugene C.Toy, MD, Cynthia Debord, PHD, Audrey Wanger, PHD, Gilbert Castro, PHD, James D. Kettering, PHD, Donald Briscoe, MD

CASE 11

A 19-month-old child is brought to the emergency room following a seizure. His mother says that he had a cold for 2 or 3 days with a cough, congestion, and low-grade fever, but today he became much worse. He has been fussy and inconsolable, he would not eat and has slept most of the morning. He then had two grand-mal seizures. He has no history of seizures in the past. His mother reports that he has not received all of his immunizations. She is not sure which ones he’s had, but he’s only had two or three shots in his life. On examination his temperature is 38.1°C (100.5°F), his pulse is 110 beats per minute, and he appears very ill. He does not respond to your voice but does withdraw his extremities from painful stimuli. He grimaces when you try to bend his neck. His skin is without rash and his HEENT (head, eyes, ear, nose, throat), cardiovascular, lung, and abdominal examinations are normal. His white blood cell count is elevated, and a CT scan of his head is normal. You perform a lumbar puncture, which reveals numerous small gram-negative coccobacilli.

◆ What organism is the most likely etiology of this illness?

◆ What component of this organism is the target of vaccine-induced immunity?

ANSWERS TO CASE 11: Haemophilus influenzae

Summary: A 19-month-old boy who has not received many immunizations presents with meningitis. The lumbar puncture shows multiple gram-negative coccobacilli.

◆ Organism most likely causing this infection: Haemophilus influenzae type B.

◆ Component of this organism that is the target of vaccine-induced immunity: Purified polyribitol phosphate, a component of the H. influenzae type B polysaccharide capsule.

CLINICAL CORRELATION

Haemophilus species, particularly H. parainfluenzae and H. influenzae non-type B are normal flora in the human upper respiratory tract. These strains can, however, be associated with respiratory infections such as otitis media and bronchitis. Haemophilus influenzae type B was the most common cause of pediatric meningitis (ages 2 months to 2 years of age) until the introduction of routine childhood immunization against this bacterium.

Transmission of H. influenzae occurs by close contact with respiratory tract secretions from a patient colonized or infected with the organism. Prior viral infection promotes colonization of the respiratory tract with H. influenzae. Invasive infections such as meningitis occur when the colonizing organisms invade the bloodstream and subsequently the meninges. Usually as a result of H. influenzae type B, the capsule aids in adherence of the organism and evasion of phagocytosis. Neurological sequelae can occur in up to 20 percent of cases of meningitis. Haemophilus influenzae type B can also be a cause of epiglottitis in young children, which can result in respiratory obstruction requiring intubation.

Haemophilus aphrophilus and H. paraphrophilus are causes of culture negative endocarditis named thus because of the fastidious nature and difficulty in recovering these organisms from the blood of infected patients. Haemophilus ducreyi is a cause of an uncommon sexually transmitted disease chancroid. Chancroid is characterized by genital skin lesions and lymphadenopathy, leading to abscess formation if remains untreated.

APPROACH TO SUSPECTED Haemophilus influenza MENINGITIS

Objectives

1. Know the structure and physiology of Haemophilus.
2. Know the significance of the capsule of Haemophilus in the virulence, infection, and development of protective immunity.

Definitions

Epiglottitis: Inflammation of the epiglottis usually caused by H. influenzae, which presents as sore throat, fever, and difficulty breathing.

Meningitis: Inflammation of the meninges leads to headache, stiff neck, and fever with increase in cells in the cerebrospinal fluid.

Grand-mal seizure: Seizure that results in loss of consciousness and generalized muscle contractions.

DISCUSSION

Characteristics of Haemophilus Species

Haemophilus are small, pleomorphic, gram-negative bacilli or coccobacilli. Humans are the only known reservoir. They are facultative anaerobes and grow on media that contain growth-stimulating factors known as X factor (hematin) and V factor (NAD). Heated sheep blood agar, chocolate agar, contains both of these factors and is used to grow Haemophilus. Many strains of Haemophilus have a polysaccharide capsule, and specific capsular antigens are used to identify strains of H. influenzae. Six types, A through F, have been identified. The polysaccharide capsule of H. influenzae type B represents its major virulence antiphagocytic factor. The capsule contains ribose, ribitol, and phosphate, known collectively as polyribitol phosphate (PRP). Phagocytosis and complement-mediated activity are stimulated in the presence of antibodies directed at the H. influenzae type B capsule. This represents the basis for the H. influenzae type B vaccine, which contains purified PRP antigens conjugated to specific protein carriers.

Diagnosis

Acute meningitis typically involves the rapid onset (over several days) of headache, fever, and stiff neck, although in young children only fever and irritability may be evident. Rash may also be present in some forms of meningitis. Without treatment, progression of the disease includes loss of consciousness and/or seizures and coma. Specific diagnosis is based on culture of the etiologic organism from the cerebrospinal fluid (CSF). Prior to culture a rapid presumptive diagnosis of bacterial meningitis is based on increased number of polymorphonuclear leukocytes (PMNs) in the CSF as well as an elevated protein and a decreased glucose. Gram stain of the CSF may reveal the presence of bacteria if the number of organisms is high enough. In the case of H. influenzae meningitis, the presence of tiny gram-negative coccobacilli is seen in a Gram-stained smear of the CSF.

Haemophilus influenzae require both X and V factors for growth; therefore no growth would be seen on blood agar unless growth of Staphylococcus aureus on the agar allowed for lysis of the blood and release of the required factors into the media. Good growth would be evident on chocolate agar as grayish colonies after 24 hours incubation at 35°C (95°F) and 5 percent carbon dioxide. Identification of Haemophilus to the species level can be made by requirement for X or V for growth. More specifically, a commercially available identification system could be used that is based on the presence of preformed enzymes and can be made within 4 hours. Haemophilus species other than H. influenzae grow much more slowly, particularly H. ducreyi, which may require 5–7 days of incubation after culture of an infected lymph node or genital abscess.

Treatment and Prevention

Up to 50 percent of strains of H. influenzae produce a β-lactamase, rendering them resistant to ampicillin. Treatment for H. influenzae meningitis involves the use of a third-generation cephalosporin (cefotaxime, ceftriaxone). Respiratory infections caused by H. influenzae may be treated with antibiotics such as amoxicillin-clavulanate or a macrolide (such as azithromycin). Routine pediatric immunization with the vaccine against H. influenzae type B has reduced the incidence of invasive disease by approximately 90 percent and has also reduced respiratory colonization. Haemophilus ducreyi is usually treated with erythromycin or a newer macrolide antibiotic. An alternative for therapy of chancroid includes a fluoroquinolone.

COMPREHENSION QUESTIONS

[11.1] A 2-year-old child has high fever, is irritable, and has a stiff neck. Gram-stain smear of spinal fluid reveals gram-negative, small pleomorphic coccobacillary organisms. Which of the following is the most appropriate procedure to follow to reach an etiologic diagnosis?

A. Culture the spinal fluid in chocolate blood agar and identify the organism by growth factors.

B. Culture the spinal fluid in mannitol salt agar.

C. Perform a catalase test of the isolated organism.

D. Perform a coagulase test with the isolate.

E. Perform a latex agglutination test to detect the specific antibody in the spinal fluid.

[11.2] Haemophilus influenzae synthesizes immunoglobulin A (IgA) protease, which enables the bacterium to penetrate and invade the host’s respiratory epithelium. This is an example of a bacterium’s ability to evade which of the host’s immune system responses?

A. Cellular or cell-mediated immunity (CMI) against H. influenzae

B. Nonspecific humoral immunity

C. Nonspecific innate immunity

D. Phagocytic function and intracellular killing of bacteria

E. Specific humoral immunity against H. influenzae

[11.3] An 18-month-old baby girl is suspected to have H. influenzae meningitis. She has not been immunized with the HIB vaccine. A rapid latex agglutination test is performed with the spinal fluid to make a definitive diagnosis. What chemical component in the spinal fluid are we detecting with this assay?

A. IgG antibody

B. IgM antibody

C. Lipopolysaccharide (LPS)

D. Polypeptide

E. Polysaccharide capsule

[11.4] The H. influenzae vaccine contains which of the following?

A. Lipopolysaccharide (LPS)

B. Live attenuated H. influenzae

C. Polypeptide antigens containing D-glutamate

D. Polyribitol phosphate antigens

E. Teichoic acid

F. Toxoids

[11.5] Cerebrospinal fluid from a spinal tap of a patient complaining of a severe headache, fever, and nuchal rigidity revealed the presence of gram-negative coccobacilli. Further testing revealed growth of the organism on growth factor X and V supplemented chocolate agar, and no hemolysis when grown on blood agar. Which of the following organisms represents the above description?

A. Bordetella pertussis

B. Haemophilus ducreyi

C. Haemophilus haemolyticus

D. Haemophilus influenzae

E. Haemophilus parainfluenzae

Answers

[11.1] A. The organism in the above description is H. influenzae. This organism is differentiated from other related gram-negative bacilli by its requirements of a chocolate media supplemented with growth factors, such as X and V factors, and by its lack of hemolysis on blood agar.

[11.2] E. Immunoglobulin A (IgA) is associated with immunological protection of the host at the epithelial boundary. An IgA protease has the ability to breakdown IgA and thereby act as a virulence mechanism enabling the bacterium to invade the host through an unprotected epithelial boundary. Because IgA is an antibody associated with the humoral (specific) arm of the immune system, IgA protease allows the bacterium the ability to evade the specific humoral immunity of the host.

[11.3] E. The latex agglutination test involves the use of latex beads coated with specific antibody that become agglutinated in the presence of homologous bacteria or antigen. This test is used to determine the presence of the capsular polysaccharide antigen of H. influenzae in serum or spinal fluid.

[11.4] D. Encapsulated H. influenzae contains capsular polysaccharides of one of six types (A–F). Haemophilus influenzae type B is an important human pathogen with its polyribose phosphate capsule being its major virulence factor. As a result, active immunity is built using polyribitol phosphate antigens (capsular polysaccharide) of H. influenzae.

[11.5] D. Haemophilus haemolyticus and H. influenzae are the only organisms listed above that require both growth factors X and V for growth; however, they can be distinguished from each other in that H. influenzae is hemolysis negative on blood agar, whereas H. haemolyticus is hemolysis positive.

MICROBIOLOGY PEARLS ❖ Haemophilus species other than H. influenzae type B are still a significant cause of systemic infections. ❖ The widespread use of H. influenzae vaccines in developed countries has decreased the incidence of H. influenzae meningitis. ❖ Haemophilus influenzae meningitis is treated with cefotaxime or ceftriaxone. ❖ Haemophilus species are a significant cause of otitis (middle ear infections), sinusitis, and epiglottitis in young children.

REFERENCES

Murray PR, Rosenthal KS, Pfaller MA. Pasteurellaceae. In: Murray PR, Rosenthal KS, Pfaller MA. Medical Microbiology, 5th ed. St. Louis, MO: Mosby, 2005:367–76. 

Slack MPE. Gram-Negative Coccobacilli in Infectious Diseases. Philadelphia, PA: Mosby, 1999;8(20):1–18.

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