CHAPTER

23 The Spirochetes
A. Christian Whelen

CHAPTER OUTLINE
■ LEPTOSPIRES Borrelia recurrentis and Similar Borreliae
General Characteristics Borrelia burgdorferi
Virulence Factors and Pathogenicity ■ TREPONEMES
Infections Caused by Leptospires General Characteristics
Epidemiology Clinically Significant Species
Laboratory Diagnosis Treponema pallidum subsp. pallidum
Antimicrobial Susceptibility Other Treponemal Diseases
■ BORRELIAE
General Characteristics
Clinically Significant Species

OBJECTIVES
After reading and studying this chapter, you should be able to:
1. Describe the general characteristics of the genera of spirochetes. 6. Compare and contrast the four human pathogens of the genus
2. List the risk factors associated with Borrelia spp. endemic relapsing Treponema.
fever infection. 7. Describe the primary, secondary, and tertiary clinical manifestations
3. Describe the pathogenesis and clinical manifestations of Borrelia of syphilis.
spp. infection, including high-risk factors. 8. Discuss the epidemiology of leptospirosis in the United States.
4. Compare the causative agents and arthropod vectors of relapsing 9. Evaluate the diagnostic tests used to identify Treponema pallidum in
fever and Lyme disease. the clinical laboratory.
5. Describe the laboratory diagnosis of relapsing fever and how it 10. Describe the two-tiered approach to laboratory diagnosis of Lyme
differs from the diagnosis of other spirochete diseases in the United disease.
States.

Agents that cause influenza-like illness and methods to

Case in Point
■

identify or rule out those agents

A 29-year-old man arrived at a local medical clinic in Los Angeles ■ Effective prophylaxis, if available, for influenza-like
complaining of diarrhea, fever, chills, muscle aches, and head- illness
aches. He had returned 2 days earlier after competing in the ■ Empiric therapy options
Eco-Challenge in Malaysian Borneo. During the competition, he
had completed various events, including mountain biking,
caving, climbing, jungle trekking, swimming, and kayaking in
fresh and salt water. He was still recovering from multiple abra-
Key Terms
sions from the jungle trekking and mountain biking. While kaya- Chancre Endemic Relapsing fever
king the Segama River, his kayak capsized and he had Endemic relapsing fever Rapid plasma reagin (RPR)
inadvertently swallowed several mouthfuls of river water. His two Endemic syphilis test
teammates were on doxycycline as malaria prophylaxis before Epidemic relapsing fever Spirochetes
and during the race. Neither of them became ill. Erythema migrans (EM) Syphilis
Gummas Venereal Disease Research
Jarisch-Herxheimer reaction Laboratory (VDRL) test
Issues to Consider Leptospirosis Weil disease
After reading the patient’s case history, consider: Lyme borreliosis Yaws
■ Risk factors for acquiring infectious disease for the Pinta Zoonoses
patient

529
530 PART II Laboratory Identification of Significant Isolates

μ
μ

Virulence Factors and Pathogenicity

Leptospires
General Characteristics

μ μ

Infections Caused by Leptospires

FIGURE 23-1 Dark field image of Leptospira interrogans sero-

type Sejroe Wolffi 3705. The tight coils and bent ends are
characteristic of this organism (×1000). (Courtesy State Labo-
ratories Division, Hawaii Department of Health.)
 CHAPTER 23 The Spirochetes 531

Isolation and Identification

Epidemiology

Serologic Tests

Case Check 23-1 Antimicrobial Susceptibility

✓
Leptospires are present in water and mud contaminated by the urine of
reservoir animals. The Case in Point describes significant and repeated
exposure risk that should be reported to the primary health provider on
presentation. Otherwise, the initial clinical impression might resemble
influenza, especially if presentation occurs during periods of high influ-
enza activity.

Laboratory Diagnosis
Specimen Collection and Handling

✓ Case Check 23-2

At least two deaths occurred in 2009, when confusion with pandemic
influenza delayed appropriate antimicrobial therapy in patients with
severe leptospirosis. The Case in Point describes two teammates who
were on doxycyline for malaria prophylaxis, which is also effective against
many bacterial agents, including Leptospira. Adherence to this preventive
medicine likely contributed to disease avoidance in these individuals.
Microscopic Examination

Borreliae
General Characteristics
532 PART II Laboratory Identification of Significant Isolates

Epidemiology

FIGURE 23-2 Appearance of Borrelia recurrentis (arrows) in

blood (Giemsa stain, ×850).

μ μ

Laboratory Diagnosis
Microscopic Examination.

Clinically Significant Species

Isolation and Identification.

Borrelia recurrentis and

Similar Borreliae
Virulence Factors

Antimicrobial Susceptibility

Clinical Manifestations
Borrelia burgdorferi
Virulence Factors
 CHAPTER 23 The Spirochetes 533

Antimicrobial Susceptibility

Clinical Manifestations

Treponemes
General Characteristics

μ μ

Clinically Significant Species

Epidemiology

Treponema pallidum Subsp. pallidum

Virulence Factors

Laboratory Diagnosis
Specimen Collection and Handling.

Serologic Tests.

FIGURE 23-3 Scanning electron micrograph of Treponema

pallidum. Two treponemes are shown adjacent to an erythro-
cyte (Nichols strain, ×2500).
534 PART II Laboratory Identification of Significant Isolates

Clinical Manifestations

Congenital Syphilis.

Epidemiology
Primary Stage of Syphilis.

Secondary Stage of Syphilis.

Tertiary Stage of Syphilis.

Laboratory Diagnosis
Specimen Collection and Handling.
 CHAPTER 23 The Spirochetes 535

Microscopic Examination.

Serologic Tests.
Antimicrobial Susceptibility

Other Treponemal Diseases

Yaws

Endemic Syphilis
536 PART II Laboratory Identification of Significant Isolates

Pinta 9. Compare the difference(s) between treponemal and nontrepone-

mal tests for syphilis.
10. What is the recommended methodology for laboratory diagnosis
of Lyme borreliosis?

BIBLIOGRAPHY

Points to Remember
■ Spirochetes are slender, flexuous, helically shaped bacteria.
■ Leptospires are most likely to enter the human host through small
breaks in the skin or intact mucosa.
■ The incubation period of leptospirosis is usually 10 to 12 days but
ranges from 3 to 30 days after inoculation. The onset of clinical
illness is generally abrupt, with nonspecific, influenza-like consti-
tutional symptoms such as fever, chills, headache, severe myalgia,
and malaise.
■ The pathogenic borreliae commonly are arthropod-borne (by a tick
or louse) and cause relapsing fever and Lyme disease.
■ B. recurrentis and similar species cause relapsing fever. The relapses
are caused by immune evasion, including antigenic variation.
During the course of a single infection, borreliae systematically
change their surface antigens.
■ During the febrile period, diagnosis of relapsing fever is readily
made by Giemsa or Wright staining of blood smears. Relapsing
fever is the only spirochetal disease in which the organisms are
visible in blood with bright field microscopy.
■ Laboratory diagnosis of Lyme borreliosis caused by B. burgdorferi
sensu lato is accomplished by a two-tiered serology. Initial positive
or equivocal EIA results are confirmed with Western blot.
■ Treponemes can cross the placenta and be transmitted from an
infected mother to her fetus. Congenital syphilis affects many body
systems and is therefore severe and mutilating. All pregnant
women should have serologic testing for syphilis early in
pregnancy.

Learning Assessment Questions

1. What are the general characteristics of spirochetes?
2. What risk factors are associated with Borrelia spp. endemic
relapsing fever infection?
3. Which tickborne species of Borrelia is associated with a skin rash
or lesion?
4. What is the significance on infectious disease transmission of
finding partially engorged ticks attached to the skin?
5. What is the test of choice for the laboratory diagnosis of relaps-
ing fever borreliosis?
6. Name the four strains of the genus Treponema that are patho-
genic for humans.
7. What are the stages of a Treponema pallidum subsp. pallidum
infection? Is the final stage usually seen in developed countries?
8. Where are most cases of leptospiroses contracted within the
United States, and why is this important when considering the
typical incubation period of the infection?