MYCOBACTERIUM

Mycobacterium is composed of approximately

100 recognized and proposed species. The most
familiar of the species are MTB and
Mycobacterium leprae, the causative agents of
tuberculosis (TB) and Hansen disease (leprosy),
respectively. Both diseases have long been
associated with chronic illness and social
stigma. These two serves as one of the major
causes of high mortality and morbidity in the
world.
GENERAL CHARCATERISTICS:

Slender
Slightly curved or straight, rod-shaped
Size: 0.2 to 0.6 m 1 to 10 m
Nonmotile
Do not form spores
Aerobic
Acid fast bacteria (acid-fastness)

CULTURE:
Appearance: smooth, soft/rough, friable
pH: 6.5-6.8
Generation time: >12 hours

For slow growing: 2-6 weeks

For rapidly growing: 2-3 days

Mycobacterium marinum
Mycobacterium haemophilum
Mycobacterium xenopi
Mycobacterium genavense
Mycobacterium abscessus subsp.
abscessus
Mycobacterium chelonae
Mycobacterium fortuitum

Potential Pathogen

Mycobacterium abscessus subsp.

bolletti
Mycobacterium malmoense
Mycobacterium scrofulaceum
Mycobacterium simiae
Mycobacterium szulgai

Usual Saprophyte, Rare Pathogen

Mycobacterium gordonae
Mycobacterium flavescens
Mycobacterium gastri
Mycobacterium nonchromogenicum
Mycobacterium terrae
Mycobacterium phlei
Mycobacterium smegmatis
Mycobacterium vaccae
T Mycobacterium thermoresistibile

Two groups: Mycobacterium tuberculosis

complex (MTC) and Nontuberculosis
mycobacteria (NTM)

CULTURE MEDIA:

Usual Clinical Significance of

Is used to cultivate Mycobacterium spp. The

potato flour, egg, and glycerol included in LJ
medium help detoxify this medium and also
supply nutrients required for growth of these
organisms. Asparagine is included for maximum
production of niacin by certain Mycobacterium
spp. The malachite green inhibits the growth of
other bacteria that may be present in specimens.

Mycobacterium Species Isolates

Pathogen

Mycobacterium tuberculosis
Mycobacterium bovis
Mycobacterium ulcerans

Often Pathogen, Potential Pathogen

Mycobacterium avium complex

Mycobacterium kansasii

Lwenstein-Jensen

Middlebrook 7H10 and 7H11

Partially selective, bacteria other than

mycobacteria may grow if specimens are not
appropriately pretreated for decontamination.

Isoniazid-resistant strains grow better on these

media, especially Middlebrook 7H11.
Middlebrook 7H10 and 7H11are similar, except
7H11 contains casein hydrolysate, which
stimulates the growth of drug-resistant
Mycobacterium tuberculosis.
Results: Plates may be read within 5 to 7 days
after inoculation and once a week thereafter for
up to 8 weeks. White, cream or buff =
Nonchromogenic (NC) Lemon, yellow, orange,
red = Chromogenic (Ch)

OADC (Oleic Albumin Dextrose

Catalase) Growth Supplement

Enrichment supplement recommended for the

cultivation of Mycobacteria sp.
OADC Enrichment medium is used with
Middlebrook 7H10 Mycobacteria Agar

Ogawa medium

The Ogawa medium is a semi-synthetic,

selective medium applied for culture BCG
bacteria. Used for determination of active BCG
cells amount in anti-tuberculosis BSG vaccine
and in BCG suspended matter for
immunotherapy. Medium provided as a greencoloured slant. Obtained from egg yolk mass
combined with aqueous salt solution and
glycerol, as well as aqueous malachite green
solution acting as bacteriostatic agent for other
microorganisms
Cultivation 10 days, aerobic atmosphere, 28C.
MYCOBACTERIUM TUBERCULOSIS
COMPLEX
Made up of M. tuberculosis, M. bovis, M.
africanum, M. canettii, and M. microti. M.
africanum has been associated with human
cases of TB in tropical Africa, and M.microti has
been linked to TB in immunocompetent and
immunocompromised individuals.
Mycobacterium tuberculosis
MTB was first described by Robert Koch in
1882; however, TB is one of the oldest
documented communicable diseases.

GENERAL CHARACTERISTICS:

Slender
Beaded rods with X, V, Y & L formation

CULTURE:

Slow growing
Raised and dry
(Buff colored) cauliflower colonies
Rough colonies exhibit cording
Optimal growth occurs at 35 C to 37 C

BIOCHEMICAL TESTS:

(+) Catalase and niacin

reduces nitrate to nitrite

INHIBITED BY:
nitroimidazopyran (NAP)
REPLICATION PERIOD: 20-22 HRS
VIRULENCE FACTOR: Cord factor, It has
often been noted that there are no classical
bacterial virulence factors. That is, no toxin has
been identified, and there is no pathogenicity
island in the genome.
Mycobacterium bovis
Mycobacterium bovis produces TB primarily in
cattle but also in other ruminants, as well as in
dogs, cats, swine, parrots, and humans. The
disease in humans closely resembles that caused
by M. tuberculosis and is treated similarly
ACQUIRED BY :

Ingestion of contaminated milk from

infected cows
Exposure to infected animals or
carcasses

CULTURE:

Slow growing
Granular
Small
Rounded
White colonies and nonpigmented

after 21 days
of incubation at 37 C

Weight loss

BIOCHEMICAL TESTS:
(-) niacin
INHIBITED BY:

presence of T2H
the attenuated strain of Bacille-CalmitteGuerin is being used as vaccine for
newborns.

Mycobacterium africanum

Associated with human cases of TB in

Tropical Africa
Detected through spoligotyping

Mycobacterium canettii

Smooth strain of M. tuberculosis

Grows more rapidly than M.
tuberculosis 6 days on solid media
Found in AIDS patient with mesenteric
tuberculosis

BIOCHEMICAL TEST:
(+) niacin and nitrate
TUBERCULOSIS
MTB was first described by Robert Koch in
1882. TB is one of the oldest documented
communicable diseases. Not everyone infected
with TB bacteria becomes sick. As a result, two
TB-related conditions exist: latent TB infection
and TB disease.
MODE OF ACQUISITION:
Air borne droplet of nuclei (1-5 m) enters the
respiratory tract and are deposited in the alveoli
SIGNS AND SYMPTOMS:

Low grade fever

Night sweats
Fatigue
Anorexia

a. LATENT TUBERCULOSIS
In most people the body is able to
fight the bacteria to stop them from
growing.
People with latent TB infection are
not infectious and cannot spread TB
bacteria to others.
Asymptomatic
Diagnosed by PPD skin test
The pathologic feature of TB are the
result of a hypersensitivity reaction
to mycobacterial antigen. If there is
little antigen and a strong
hypersensitivity reaction, a hard
tubercle or granuloma may be
formed. When granuloma is formed
healing occurs along with fibrosis,
encapsulation & scar formation.
Necrosis, a caseous material may be
present at the site of the primary
lesion as a result of solid or
semisolid amorphous material laid
down at the site of necrosis.
Caseous lesions- cheese like
consistency of tubercle; Ghon
complex Calcified form of caseous
lesions.
b. ACTIVE TUBERCULOSIS
When the immune system can't stop the bacteria
from growing. Risk of reactivation TB is about
3.3% during the first year after a positive PPD
skin test and a total of 5% to 15% thereafter in
the persons lifetime. They may also be able to
spread the bacteria to people they spend time
with every day.
WHY DOES IT BECOME REACTIVE?

Alteration or diminution of cellular

immune system
Malnutrition
Alcoholism
Incarceration
Immunosupression

AIDS

SIGNS AND SYMPTOMS:

Coughing that lasts three or more

weeks
Coughing up blood
Chest pain, or pain with breathing or
coughing
Unintentional weight loss
Fatigue
Fever
Night sweats
Chills
Loss of appetite

TREATMENT:

TB-DOTS

The Stop TB Strategy a program of the World

Health organization that aims to dramatically
reduce the global burden of TB by 2015 in line
with the Millennium Development Goals and the
Stop TB Partnership targets.
WHO recommends Directly Observed
Treatment Short course (DOTS) strategy that
emphasizes the use of the most effective
standardized, short-course regimen, and of
fixed-dose drug combinations (FDCs) under
observation to facilitate adherence to treatment
and to reduce the risk of the development of
drug resistance. The treatment lasts for 6-9
months and direct sputum smear is done every 2
months to monitor the progress of treatment.

DOTS-Plus refers to DOTS programs that add

components for MDR-TB diagnosis,
management and treatment.
The specific characteristic of this program
require a recording system, culture and DST
results, and monitoring treatment delivery and
treatment response for 24 to 27 months with
second-line anti-TB drugs is complex.
Direct Sputum Smear Microscopy
In low income and high tuberculosis prevalence
countries, sputum smear microscopy is, and is
likely to remain for the foreseeable future, the
only cost-effective tool for diagnosing patients
with infectious tuberculosis and to monitor their
progress in treatment. Sputum smear microscopy
is a simple, inexpensive, appropriate technology
method which is relatively easy to perform and
to read. It yields timely results with a very high
sensitivity of detection of tubercle bacilli
transmitters, and provides most of the essential
laboratory-epidemiological indicators needed for
the evaluation of the National Tuberculosis
Programme (NTP).

DOT includes:

delivering the prescribed

medication
checking for side effects
watching the patient swallow
the medication
documenting the visit
answering questions

DOT should be initiated when TB

treatment starts. Do not allow the patient
to try self-administering medications
and missing doses before providing

DOT. If the patient views DOT as a

punitive measure, there is less chance of
successfully completing therapy.
Patients taking daily therapy can usually
self-administer their weekend doses.

Spot, morning and spot sputum

specimens for diagnosis.
o 2 on the spot specimen and one
morning specimen
o a case of sputum smear positive
tuberculosis is usually defined
as a person presenting with
respiratory symptoms with at
least two positive sputum smear
microscopy examinations.
Morning specimens for follow-up
There are two phases in the
treatment of tuberculosis: the
intensive phase, usually 2 to 3
months, and the continuation
phase, which is 4 to 10 months,
depending on the type of
treatment.

Method of choice: Ziehl-Neelsen (ZN) staining

technique
staining procedure requires: Staining for 5
minutes Decolourising for 3 minutes
Counterstaining for 1 minute
Size of smear: 20mm by 10mm
Fixing: pass the dried smear side up over the
flame for 4-5 seconds.
Grading of sputum smear microscopy results
AFB counts
No AFB in at least 100
fields
1 to 9 AFB in 100
fields*
10 to 99 AFB in 100
fields
1 to 10 AFB per fields in
at least 50 fields
> 10 AFB per field in at
least 20 fields

Recording/reporting
0/negative
Actual AFB counts
+
++
+++

The microscopist should take at least 5 minutes

to read 100 fields, and should never be expected
to process and read more than 25 ZN-stained
sputum specimens per day when working full
time. No more than 10 to 12 specimens should
be processed at one time.
SPUTUM SMEAR FLUORESCENCE
MICROSCOPY
Utilizes basically the same approach as Z-N
staining, but carbol fuchsin is replaced by a
fluorescent dye (auramine-O, rhodamine,
auramine-rhodamine, acridine orange etc), the
acid for decolorisation is milder and the counter
stain, though not essential, is useful to quench
background fluorescence
Potassium permanganate is used as counterstain. With auramine staining, the bacilli appear
as 5 slender bright yellow luminous rods,
standing out clearly against a dark background.
Comparative grading

RNTCP ZN
staining
grading (using
100x oil
immersion
objective and
10x eye piece)
>10 AFB/field
after
examination
of 20 fields
1-10
AFB/field
after
examination
of 50 fields
10-99
AFB/100 field
1-9 AFB/100
field
No AFB per
100 fields

Auramine O
fluorescent
staining
grading (using
20 or 25x
objective and
10x eye piece)
>100
AFB/field
after
examination
of 20 fields
1-10 AFB/
field after
examination
of 100 fields

Reporting
/Grading

Positive, 3+

Positive, 2+

Positive, 1+
1-3 AFB/100
fields
No AFB per
100 fields

doubtful
positive
/repeat
Negative

b.1. EXTRAPULMONIARY
TUBERCULOSIS
occurred much less commonly than pulmonary
TB (<15%) before the AIDS epidemic
POTTS DISEASE (TB of the spine)
SIGNS AND SYMPTOMS:

Back pain
Spine deformity

TREATMENT :

surgery to remove and replace the

affected disc with an artificial one,
antibiotics to treat the Mtb infection

MILIARY TUBERCULOSIS
When a tuberculous lesion erodes into a
blood vessel, disseminating millions of

tubercle bacilli into the bloodstream and

throughout the body. Common to
children < 4 yr, immune compromised
people, elderly. Common sites Spleen,
liver, lungs, bone marrow, kidney,
adrenal gland & eyes.

TREATMENT:

9-month course of therapy with

isoniazid and rifampin, usually
once per day.
Many regimens also include a 2to 8-week initial course of
streptomycin or ethambutol

inappropriate use of antimicrobial agents to treat

M. tuberculosis and the lack of patient
compliance.
PRIMARY MDR-TB
Resistance to at least isoniazid and rifampin,
drugs recognized as the primary treatments for
drug
EXTENSIVELY DRUG-RESISTANT TB
(XDR-TB)
MDR-TB profile + fluoroquinolones and at least
one injectable drug
(eg, streptomycin, amikacin, kanamycin, capreo
mycin). Surgery to remove localized areas of
necrotic lung tissue is important in the treatment
of advanced cases of MDR-TB or XDR-TB

TB MENINGITIS
Usually the result of a rupture of a
tubercle into the subarachnoid space.
Occurs between birth and 5 yr. Occurs
in the absence of infection at other
extrapulmonary sites. Believed to be
prevented in childhood by vaccination
with BCG.
SIGNS AND SYMPTOMS:

cranial nerve deficits

Photophobia
Altered mental status

TREATMENT
Antimicrobial therapy: isoniazid,
rifampin, pyrazinamide; addition of a
fourth drug is left to local choice

MULTIDRUG-RESISTANT
MYCOBACTERIUM TUBERCULOSIS
Risk factors for drug resistance may include
previous treatment for TB, residence in an area
endemic for drug resistance,or close contact with
an individual who is infected with MDR-TB.
Drug resistance is usually acquired by
spontaneous mutations as a result of the

NONTUBERCULOSIS MYCOBACTERIA

Photochromogens

Grows in the dark

Grows in the light
color produced:
Not pigmented unless exposed to light
-cream or buff
-yellow/orange
growth rate: 10-21 days
species: M. kansassii, M. marinum

Scrotochromogens
color produced:

Pigmented both in light and dark

-yellow to orange
growth rate: 10-21 days
species: M. scrofulaceum

Nonphotochromogens

color produced: Non pigmented both in

light and dark
growth rate: 10-21 days
species: MAC

Rapid growers
color produced: Pigmented variation
growth rate: 3-7 days
species: M. fortuitum, M. cheilonae

Rapid weight loss

Diarrhea

Mycobacterium marinum

Cause disease of the fish

Causative agent of swimming pool
granuloma

CHARACTERISTICS: moderate to long rods

with cross barring
BIOCHEMICAL TEST: (+) tween 80
hydrolysis, urease and pyrasinamidase
CULTURE: smooth to rough , wrinkled

SLOW GROWERS
Mycobacterium kansassii
MYCOBACTERIUM AVIUM COMPLEX
(MAC)

Causes pulmonary infection similar to

MTB in humans and diseases of swine
and poultry
Recovered from soil, water, house dust,
and other environmental sources.

Second next to MAC to cause NTM lung disease

in humans.
CHARACTERISTICS: Long rods with cross
bands sheperds crook, Cording
BIOCHEMICAL TEST: (+) tween 80
hydrolysis in 3days; Strong nitrate reduction

Species: M. avium, M. intracellulare, M. subsp.

Paratuberculosis & silvaticum

CULTURE: Smooth dark colonies with dark

centers and waxy edges; photochromogenic

CHARACTERISTICS:

MANIFESTATION:

Pleomorphic
short
coccobacillary without beading stains

Chronic pulmonary disease involving

the upper lobes, usually with evidence
of cavitation and scarring.

BIOCHEMICAL TEST:

Extrapulmonary infections,

(+) heat stable catalase test; (+) growth on media

with T2H

Including lymphadenitis, skin and soft

tissue infections and joint infection

JOHNES DISEASE
Typically enters a herd or flock of animals when
an infected, but healthy-looking, animal is
purchased.
Takes 3-4 months to grow
SYMPTOMS ;

Cutaneous infections in humans occur when

traumatized skin comes into contact with salt
water or inadequately chlorinated fresh water
containing the organism.
PESENTATION: tender red/blue-red
subcutaneous nodule
SITE: usually occurs on the elbow, knee, toe, or
finger.

TREATMENT: simple observation of minor

lesions, surgical excision, anti-TB drug therapy,
and the use of single antimicrobial agents

BIOCHEMICAL TEST: (+) heat stable

catalase

SUSCEPTIBLE TO: rifampin and ethambutol,

CULTURE: smooth and rough nonpigmented

colonies (6-12 weeks incubation)

RESISTANT TO: isoniazid and pyrazinamide,

and partially resistant or intermediate to
streptomycin.

BURULI ULCER
PESENTATION: starts as a painless swelling
(nodule).

Mycobacterium szulgai
CHARACTERISTIC:

medium to long rods

with some cross barring

BIOCHEMICAL TEST:

(+)hydrolysis of Tween 80
(+)nitrate reduction,

It can also initially present as a large painless

area of induration (plaque)
or a diffuse painless swelling of the legs, arms
or face (oedema)
TREATMENT: a combination of and
streptomycin or a combination of rifampicin
and clarithromycin

INHIBITED BY: presence of 5% sodium

chloride.

Mycobacterium scrofulaceum

CULTURE:

CHARACTERISTIC: medium to long rod

smooth and rough colonies

BIOCHEMICAL TEST:

37 C: yellow to orange pigment develops in the

absence of light and intensifies with exposure to
light.
22 C: are nonpigmented or buff in the absence
of light and develop yellow to orange pigment
with light exposure.
MANIFESTATION:

Pulmonary disease similar to TB

Extrapulmonary infections:
lymphadenitis and bursitis

Mycobacterium ulcerans

3rd most common after M. tuberculosis

and M. leprae .
Causative agent of Buruli ulcer

CHARACTERISTICS: Moderately long rods

without beading

(-)hydrolyze Tween 80
(-)reduce nitrate
(+) urease and catalase

CULTURE:

Organism grows slowly (4 to 6 weeks)

Temperatures: 25 C to 37 C.
Colonies are smooth with dense centers
Pigmentation from light yellow to deep
orange

CERVICAL LYMPHADENITIS
MANIFESTION:
One or more enlarged nodes, often adjacent to
the mandible and high in the neck, with little or
no pain
TREATMENT:

urgical incision and drainage

anti-TB drugs are generally not

necessary

RESISTANT TO: isoniazid, streptomycin,

ethambutol and p-aminosalicylic acid when
tested in vitro.
RAPID GROWERS
CHARACTERISTIC: Weakly gram positive
rods
CULTURE: appears within 7 days or less in a
solid media
GAINS ENTRY TO HOST THROUGH:

Inoculation into the skin

Injection
Surgery
Animal contact

FOUND IN:

Rivers
Municipal water supplies
Marine
Terrestrial life forms

TREATMENT: Amikacin (all isolates are

susptible) Prolonged medication is needed.

Mycobacterium Segmatis group

Infections of skin, lungs, bones, cutaneous
infections in immunocompromised patients
SPECIES: M. segmatis, M. goodie, M.
wolinskyi
CHARACTERISTIC:

Cells are long and tapered

Or short rods with irregular acid
fastness.
Occasionally rods are curved with
branching or Y-shaped forms
swollen, with deeper staining, beaded,
or ovoid forms

BIOCHEMICAL TEST:
(+) 3 day arysulfatase and grows in Mac
Conckey agar;
(+) nitrate reduction and iron uptake
CULTURE:

Mycobacterium fortitum

Rough, wrinkled, coarsely folded

CHARACTERISTIC:

Long
tapered to short, thick rods

Mycobacterium leprae
Invades nerve and skin cells and becomes
obligate intracellular parasite.

BIOCHEMICAL TEST:
(+) 3 day arylsulfatase test and nitrate reduction
CULTURE: 3 to 5 days of incubation at 37 C,
colonies of M. fortuitum appear rough or
smooth and nonpigmented, creamy white or buff
INFECTION:

skin and soft tissues,

including localized infections
abscesses at the site of puncture wounds

CHARACTERISTIC:

Rod shaped
cigar pocket/pocket fence
arrangement

VIRULENCE FACTOR: The virulence factors

of M. leprae are intracellular growth and wax
which coats this bacterium making it difficult to
work with
BIOCHEMICAL TEST:

(-) Heat stable catalase test

CULTURE:

Cannot be cultivated in vitro

(+) growth in living tissue mice and
foot pads of armadillo

Among these rifampicin is the most important

antileprosy drug and therefore is included in the
treatment of both types of leprosy.

TUBERCULOID LEPROSY

HANSENS DISEASE LEPROSY

Chronic disease of the skin, mucous

membranes
Invades Schwann cells (SCs) in the
peripheral nerves leading to nerve
damage and the development of
disabilities
It was once estimated that 11 million
people had Hansen disease
Long incubation period > 20 years

Human disease only

Source nasal secretions
Entry respiratory tract / skin
Not highly communicable

Strong cell-mediated immunity

Organism is extremely rare and may not
be seen in biopsy or skin scrapings
Benign form
Non progressive
No immune defect

SYMPTOMS :

Skin lesions
Loss of sensation (nerve damage)

DRUG OF CHOICE:

Rifampicin
clofazimine
dapsone

TEST: (+) lepromin test

LEPROMATOUS LEPROSY

SYMPTOMS ;

Muscle weakness

Numbness in the hands, arms, feet, and legs

Skin lesions that:

have decreased sensation to
touch, temperature, or pain
do not heal after several weeks
or month
are lighter than your normal
skin tone

DRUG OF CHOICE: (combination)

rifampicin
clofazimine
dapsone

Ineffective cell-mediated immune

response
Organisms are abundant in skin biopsy
Malignant form
Slowly progressive
Life threatening

SYMPTOMS :

Loss of facial features

Amputation: fingers & toes

DRUG OF CHOICE:

Rifampicin
dapsone

TEST: (-) lepromin test

CASE STUDY

The physical exam revealed numerous lesions

throughout her body, including those on her
nasal bridge area, cheeks, abdomen and back.
These lesions were macular in nature and did not
exhibit significant plaque, dryness or significant
discoloration other than
an erythematous appearance. The soles of her
feet appeared to be usually dry and callous, and
her legs appeared hypopigmented when
compared to the rest of the body. The eyebrows
appeared to have started thinning. Her reflexes
were hyperreflexive and her forearm
demonstrated some anesthesia, corresponding to
the ulnar nerve.

A 34 year old woman from Mexico, was

diagnosed with lepromatous leprosy
(multibacillary leprosy) after complaining of a
persistent pruritic rash throughout her body. The
diagnosis was made after a skin biopsy of skin
lesions on the abdomen revealed acid-fast
bacilli. The patient was not aware of her
diagnosis until she presented to the Infectious
Disease physician. The patient had two children,
including an infant; she had stopped smoking
several years ago and appeared to be well
nourished.
Her medical history indicated that her
symptoms started five years ago, with cramping
and spasms of her arms. She noted that her
wrists felt like they were falling asleep at times,
along with needle-like pain that would
occasionally erupt. Additionally, she reported a
significant amount of fatigue and stress. The
patients medical record indicated a diagnosis
with depression; her initial visits for the skin
condition included initial diagnoses
of atopic dermatitis and urticaria before the
biopsy was taken. The patient was prescribed
ibuprofen, fluoxetine andhydroxyzine.

The patient was counseled about leprosy, and a

course of multidrug theraphy combining dapsone (100mg/
day), clofazimine (50mg/ day)
and rifampin (600mg/monthly) was prescribed
for a period of 2 years. The monthly dose
of rifampin would be taken under supervision to
ensure compliance and to track any adverse
effects. Liver function tests were ordered to
ensurehepatotoxicity did not result from her
concurrent use of other medications.
As required by county law, the patients case
was reported to the Public Health Department
using established protocols

During the course of the interview, the patient

revealed that she had worked with flowers
extensively several years ago while in the
United States, which presents a possible
exposure to the M. leprae bacterium;
furthermore, she reported that armadillos were
endemic in her home in South America and that
her family kept a variety of household pets such
as dogs and birds. The interview was unable to
determine if any other family members, locally
or out-of-state, had similar dermatological
complaints; however, her infant reportedly had a
fungal infection suggesting potential infection of
the child.

REFERENCES:

Texbook of diagnostic microbiology, fifth ed.,

2015

Mahon, C. et al., 3251 Riverport

Lane Maryland Heights, Missouri 63043,

Haley, C. MD MPH, Extrapulmonary

Tuberculosis, University of Florida Southeast
National TB Center, September 2013

MSD manual

World Health Organization

Center for disease control and

prevention,
http://www.cdc.gov/tb/topic/basics/default.htm

http://www.hainlifescience.de/en/products/microbiology/mycoba
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http://radiopaedia.org/articles/pulmonar
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http://www.infectionlandscapes.org/2013/04/tub
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http://tbcindia.nic.in/pdfs/Flourescence_Microsc
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http://radiopaedia.org/articles/pulmonar
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http://web.stanford.edu/group/parasites/
ParaSites2006/Leprosy/patientcase2.htm

Johnes information center,

http://www.johnes.org/general/faqs.html, march
2010, September 2015

http://www.who.int/tb/dots/treatment/en/

http://health.bih.nic.in/Docs/Guidelines/Guidelin
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http://www.uphs.upenn.edu/bugdrug/antibiotic_
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http://www.infectionlandscapes.org/201
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https://www.nlm.nih.gov/medlineplus/en
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Johnes information center,

http://www.johnes.org/general/faqs.html, march
2010, September 2015

http://www.usbio.net/technicalSheet.php?
item=M3895-01

http://biomed.lublin.pl/en/index.php?
option=com_content&view=article&id=137:oga
wa-medium&catid=43:medical-devices-andreagents&Itemid=117

http://web.stanford.edu/group/parasites/
ParaSites2006/Leprosy/patientcase2.htm

Buruli Ulcer,
http://emedicine.medscape.com/article/1104891overview

MYCOBACTERIUM

SUBMITTED TO: MAAM RONALYN SANCHEZ

SUBMITTED BY: ADRIANA C. GARCIA
BSMT 3-1