The genital mycoplasmas (first of two parts)

Mycoplasma infections of the human urogenital tract with particular reference to non-gonococcal urethritis

The criteria which need to be fulfilled before regarding a microorganism as a cause of non-gonococcal urethritis (NGU) are considered in relation to Mycoplasma hominis, Ureaplasma urealyticum and M. genitalium. There is no evidence to support an aetiological role for M. hominis, but few appropriate investigations have been undertaken. The criteria have been met, for the most part, in the case of U. urealyticum, but further quantitative studies are required. The role of M. genitalium is unknown, but its biological and morphological features and ability to cause genital disease in animals suggest that it may be pathogenic for man. It is emphasized that the criteria for regarding a microorganism as a cause of NGU should also be used where feasible when investigating the infectious aetiology of other genito-urinary conditions.

Comparison of tetracycline and minocycline in the treatment of non-gonococcal urethritis

The activity of tetracycline hydrochloride and minocycline hydrochloride was compared against 12 strains of Chlamydia trachomatis and Ureaplasma urealyticum; minocycline was more active in vitro against both organisms. A group of 145 men with non-gonococcal urethritis was treated for one week with either tetracycline hydrochloride 500 mg six hourly or minocycline 50 mg twice daily. The clinical results obtained were similar: 61 of 77 (79%) men treated with tetracycline and 53 of 68 (78%) men treated with minocycline were free from urethritis one to two weeks after completing treatment. Both antibiotics were clinically effective against C trachomatis, but activity against U urealyticum was less consistent. Side effects were noted in 14 (18%) men treated with tetracycline and eight (12%) men treated with minocycline; they were predominantly gastrointestinal.

Urine as a specimen for diagnosis of sexually transmitted diseases

The case of specimen collection has led to the suggestion that urine might be a useful specimen for the isolation of sexually transmitted disease agents. It would only be an appropriate specimen for agents that infect the urethra, such as Neisseria gonorrhoeae or Chlamydia trachomatis. Comparative tests have shown that culture of urine for chlamydiae (from men with urethritis) or for gonococci from women is an insensitive procedure. Gonococci can be isolated from urine from men at rates essentially equivalent to culture of urethral swabs. If specimens can be processed promptly (to avoid bactericidal effects of urine), culture of urine can likely be useful for screening asymptomatic men for gonococcal infection.

Mycoplasma hominis septicaemia

Mycoplasma hominis septicaemia occurred in a patient with a malignant lymphoma of lymphoblastic type in leukaemic phase. M hominis was isolated several times from blood cultures with antibody titres against the micro-organism rising to a high level despite severe immunosuppression. M hominis was detected in the blood after subculture of the blood culture bottles despite their macroscopically normal appearance. The patient's pyrexia resolved without treatment with antibiotics effective against M hominis.

Septicaemia in a renal transplant patient due to Mycoplasma hominis

Opportunistic infections are an important cause of mortality in transplant patients. Here we report a case of Mycoplasma hominis septicaemia in a renal transplant patient that was successfully treated with doxycycline.

Broadly reactive immunofluorescence test for measurement of immunoglobulin M and G antibodies to Ureaplasma urealyticum in infant and adult sera

The indirect immunofluorescence test was used to measure immunoglobulin M (IgM) and IgG antibodies to acetone-fixed Ureaplasma urealyticum organisms in sera from 128 adults with genital infections and from 713 symptomatic newborns and babies 1 day to 18 months old. Thirty-four percent of the adults had demonstrable IgG antibody to ureaplasma. IgM antibody was detected in 2 of the adult sera and in 17 of the infant sera. These babies were divided into two distinct groups. Ten of the infants presented at birth with various physical findings, whereas the onset of symptoms for the other 7 occurred 3 to 13 weeks after birth, and the major clinical finding in 6 of the 7 was respiratory distress. The results of this study suggested that U. urealyticum infection may be associated with fetal damage and infant pneumonia, and if this is substantiated, the indirect immunofluorescence test employing acetone-fixed antigen to measure IgM antibody to U. urealyticum may be an important diagnostic tool.

Measurement of antibody to Ureaplasma urealyticum by an enzyme-linked immunosorbent assay and detection of antibody responses in patients with nongonococcal urethritis

The optimum conditions for the detection of human immunoglobulin G (IgG), IgM, and IgA antibodies to Ureaplasma urealyticum by an enzyme-linked immunosorbent assay (ELISA) were established by using a cell lysate antigen and commercially available alkaline phosphatase conjugates. No significant cross-reactions were observed among rabbit antisera to a variety of mycoplasmas of human origin and ureaplasma antigen, thus demonstrating the specificity of the ELISA. All human sera were assayed at a 1:200 dilution. Antigen was used at 20 mug of protein/ml and conjugates were diluted 1:500. Presence of IgG antibody to U. urealyticum was significantly associated with isolation of U. urealyticum (P < 0.001) in 110 women. Seventeen acute-phase and 19 convalescent-phase sera from male nongonococcal urethritis (NGU) patients were tested for the presence of antibody by both the metabolism inhibition assay and by ELISA, with overall agreements of 82 and 95% for acute- and convalescent-phase sera, respectively. Serum antibody responses were demonstrated to selected serotypes in the metabolism inhibition test, but the response as measured by the ELISA was independent of the serotype of the antigen used. Serum antibody levels in NGU patients were significantly higher (P < 0.002) than the normal serum standard in the IgG, IgM, and IgA classes. Additionally, the magnitude of change between acute- and convalescent-phase sera was greater for NGU patients than for normal asymptomatic ureaplasma-positive male controls. A significant change in antibody levels of one or more antibody classes was detected for 12 of 18 (67%) NGU patients by ELISA. Ten of the 12 (83%) individuals had a change in the IgM class, which is suggestive of an active infectious process. The ELISA is advantageous in that it requires only a single serotype antigen, uses one serum dilution, is class specific, and allows quantitative detection of differences between acute- and convalescent-phase sera.

Isolation and serological typing of ureaplasma in human saliva

Ureaplasmas were detected in the saliva of 3.5 per cent (12/342) of subjects. A total of 60 isolated strains did not revert to bacterial forms on repeated subculture in antibacterial agent-free media, failed to grow in serum-free media, were inhibited by digitonin and hydrolysed urea but not glucose or arginine. Twenty-five strains were divided into serotypes: I (5), II (3), III (5), IV (4) and VI (8 strains). Ureaplasmas of serotype I, II, III, IV and VI were harboured by 2, 1, 1, 1 and 3 subjects respectively and the remaining 4 subjects harboured 2 different serotypes. Ureaplasma-positive subjects were young and middle-aged and, except for 1 subject with mandibular arthrosis, suffered from periodontitis, pericoronitis, gingivitis and maxillary sinusitis. These accounted for only 6.1 per cent (11/180) of the series of subjects examined.

Reactive arthritis--infectious agents and genetic susceptibility in the pathogenesis of sero-negative arthritis

In this review we discuss the role of genetic and infectious factors in the aetiology of ‘reactive’ arthritis. Two broad categories of reactive arthritis are considered—the sero-negative HLA B27 related spondarthritides, and a miscellaneous group of reactive arthritides occuring after bacterial infection but which are not HLA B27 related.

The pathogenicity of a newly discovered human mycoplasma (strain G37) for the genital tract of marmosets

In an attempt to demonstrate the pathogenicity of a newly discovered mycoplasma (strain G37) isolated from the human genital tract, six female marmosets (Callithix jacchus) were inoculated intravaginally. Four of the animals were infected as indicated by repeated recovery of the organisms on vaginal swabbing, and infection persisted for 72-149 days or more. In addition, the infected marmosets exhibited a serum antibody response detected most easily by an immunofluorescence technique, and a persistent vaginal polymorphonuclear leucocyte response not seen in two uninfected and in two uninoculated animals.

Mycoplasma hominis septicemia

We report a case of Mycoplasma hominis septicemia in a patient with chronic lymphocytic leukemia and prostatic obstruction. Signs of sepsis followed urinary catheterization, and M. hominis was recovered repeatedly from blood, urine, and pleural fluid. Detection in blood was accomplished by routine subculture from grossly negative blood culture bottles.

Chronic cystitis and urethritis associated with ureaplasmal and mycoplasmal infection in primary hypogammaglobulinaemia

Six of 58 patients with primary hypogammaglobulinaemia developed chronic urethritis and/or cystitis. We have some evidence that this complication may be caused by infection with strains Rof Ureaplasma urealyticum. This is important because ureaplasmas are usually resistant to most antibiotics routinely used to treat lower urinary tract infections. It appears that hypogammaglobulinaemic patients develop less localised and more severe ureaplasmal infections than immunocompetent subjects, which indicates that antibodies are important in controlling the growth of these organisms in the bladder and urethra.

Evidence for an association between Chlamydia trachomatis and cervical intraepithelial neoplasia

Attempts were made to isolate Chlamydia trachomatis, Mycoplasma hominis and Ureaplasma urealyticum from women with cervical intraepithelial neoplasia (CIN), from those with microinvasive or invasive cervical cancer, and from a control group of similar women with other gynaecological problems. C. trachomatis was found in a significantly greater proportion of women with CIN (8%) or cervical cancer (18%) than in the control group (1%), whereas M. hominis and U. urealyticum were approximately as common in each group. Histological examination of the cervix in cone biopsies or hysterectomy specimens from 26 women with CIN and from 39 women of similar age with no evidence of CIN showed lymphoid follicles, previously reported to be associated with chlamydial infection, in nine of the specimens with CIN, but in none of the specimens without CIN.

Expanded serotyping scheme for Ureaplasma urealyticum strains isolated from humans

For the last decade the serological heterogeneity of strains of Ureaplasma urealyticum isolated from humans has been represented by eight serotypes. We have identified two additional serotypes, strains Vancouver and Western. Using a modified metabolic inhibition test and a colony indirect epifluorescence method, we tested antisera to the above 10 types against the 11 members of the independent Lin-Kass classification. Four of the latter, K2, U24, U26, and U38, showed unique specificities; these were confirmed by reciprocal testing with antisera prepared against the respective strains. With the addition of these strains, the serotyping scheme now has 14 members. Since this expanded classification allows greater discrimination between strains, it will allow also for their future characterization. It provides, in addition, a potentially more effective epidemiological tool.

Isolation of mycoplasmas and bacteria from the blood of postpartum women

Mycoplasmas and/or bacteria were recovered from the blood cultures of 26 (20.8%) of 125 febrile postpartum women. Genital mycoplasmas were recovered from 16 (12.8%) of the 125 febrile women and from none of 60 afebrile postpartum women (p less than 0.005). The presence of mycoplasmaemia was associated with a young age, primigravidity, and nulliparity. The isolation of organisms from the blood was also associated with fever during labor, internal monitor use, and a cesarean delivery.

Vaginitis in sexually active women: relationship to nine sexually transmitted organisms

Women seen for symptoms suggestive of vulvovaginitis were studied for the detection of Mycoplasma hominis. Ureaplasma urealyticum, yeast, Neisseria gonorrhoeae, Chlamydia trachomatis, Gardnerella vaginalis, herpes simplex virus, group B beta-hemolytic streptococci, aerobes, anaerobes, and Trichomonas vaginalis. Asymptomatic women who reported to be sexually active and agreed to undergo comprehensive genital cultures were used as controls. There was a significant association of vulvovaginitis with the recovery of sexually transmitted organisms. However, all organisms were also recovered from asymptomatic patients. A total of 468 sexually transmitted organisms were recovered from 253 symptomatic patients (1.85 organisms per patient), while 125 were recovered from 130 asymptomatic patients (0.96 organisms per patient). The difference in prevalence between symptomatic and asymptomatic women for Chlamydia trachomatis, group B streptococcus, and the mycoplasmas was not statistically significant. Factors that predispose patients to the manifestations of symptoms are not clearly understood.

Rosaramicin and tetracycline in the treatment of non-gonococcal urethritis. A comparison of clinical and microbiological results

The clinical and microbiological outcome of the treatment of 94 men for uncomplicated non-gonococcal urethritis (NGU) was studied. Rosaramicin 250 mg six hourly for seven days was given to 46 men and tetracycline 250 mg six hourly for seven days to 48 men; the follow-up period was up to six weeks. Complete resolution of the clinical signs of infection was seen in 40 (87%) of the men treated with rosaramicin and in 37(77%) of those treated with tetracycline. Chlamydia trachomatis was eliminated from 17 of the 18 men treated with rosaramicin and from all of the 16 men treated with tetracycline. Ureaplasma urealyticum was eliminated from 12 of the 14 men treated with rosaramicin and from 15 of the 19 receiving tetracycline. Clinical recovery correlated well with the elimination of C trachomatis but less well with that of U urealyticum. The two antimicrobial agents were equally effective in the therapy of NGU, but gastrointestinal side effects were significantly more common in men treated with rosaramicin.

Acute salpingitis in the adolescent female

Acute salpingitis is an important complication of sexually transmitted disease in young women and should be considered in the differential diagnosis of abdominal pain in all young women. Many organisms, in addition to N. gonorrhoeae, have been associated with this tubal infection giving support to polymicrobial etiology. However, the exact pathophysiologic role of these organisms needs to be clearly defined. The microbiology of acute salpingitis, through direct culture from the site of infection, the fallopian tubes, needs to be clearly elucidated. Early recognition and treatment of acute salpingitis is essential in preventing the major long-term problem, involuntary infertility. Curran has estimated the reproductive outcome for a cohort of adolescent women reaching reproductive age in 1970. By the year 2000, there will have been one episode of salpingitis for every two women; 15% will be hospitalized for salpingitis with over half of these women requiring major gynecologic surgery; 10% will be rendered nonsurgically sterile; and 3% will have experienced an ectopic pregnancy. Adolescent females may be more susceptible to upper genital tract infection than older women due to possible unique biologic characteristics and sexual behaviors. Prospective microbiologically controlled studies of women with salpingitis using laparoscopy need to be developed to evaluate treatment regimens. Until such studies are undertaken, diagnosis, treatment, and fertility in women with acute salpingitis will remain unsatisfactory.

Effect of gaseous conditions on isolation and growth of Ureaplasma urealyticum on agar

Five laboratory-adapted strains of Ureaplasma urealyticum showed comparable colony counts when incubated in eight gaseous environments including air, in different concentrations of carbon dioxide, and under anaerobiosis. For primary isolation on genital mycoplasma agar 95% N2-5% CO2 gave 100% correlation with growth in bromothymol blue broth, whereas certain strains failed to grow on agar incubated in air, the TABCO2 system (Lab-Tek Division, Miles Laboratories, Ltd., Rexdale, Canada), 100% CO2, or under anaerobiosis.

Mycoplasma hominis, Ureaplasma urealyticum, and Corynebacterium genitalium recovered from the lower genital tracts of adolescent women

The lower genital tracts of 137 adolescent women were examined for the presence of Mycoplasma hominis, Ureaplasma urealyticum, and Corynebacterium genitalium in relation to sexual activity, previous pregnancy, presence of vaginal discharge and oral contraceptive use. None of the sexually inactive and 10% of the sexually active adolescent females were colonized with U. urealyticum. None of the sexually inactive and 4% of the sexually active adolescent females were colonized with C. genitalium. Nineteen percent of the sexually inactive and 36% of the sexually active adolescent females were colonized with M. hominis. The presence of M. hominis in the lower genital tract was not associated with any clinically identifiable vaginal discharge or inflammatory changes in exfoliated cervical and vaginal epithelial cells. The presence of M. hominis in the lower genital tract did not appear to be related to the use of oral contraceptives or antecedent pregnancy. There was no significant difference in the recovery rates of these microorganisms when we compared women who had non-specific vaginitis with those who did not. There is no evidence from this study that any of these microorganisms is responsible for non-specific vaginitis.

A microbiological study of non-gonococcal proctitis in passive male homosexuals

In a study of 180 male homosexual patients attending a venereal disease clinic, a correlation was sought between symptoms and signs of proctitis and the isolation of Neisseria gonorrhoeae, group B streptococci, Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis and herpes simplex virus. Faecal specimens were examined for enteric pathogens and serological tests for hepatitis B virus, syphilitic and chlamydial infections were performed.

There was no association between proctitis, as diagnosed by examination of a Gram-stained rectal smear, and the isolation of any micro-organism or detection of a positive serological test. There was, in addition, no association between any symptom or abnormal physical sign and any positive microbiological findings. Since 23% of patients from whom N. gonorrhoeae was isolated had no abnormal physical signs, it is difficult to assign a pathogenic role to other micro-organisms isolated from patients with and without clinical signs of proctitis. Approaches to further investigation of the problem are discussed.

Clinical and microbiological study of non-gonococcal urethritis with particular reference to non-chlamydial disease

A double-blind placebo-controlled study of minocycline in 221 men with non-gonococcal urethritis (NGU) was undertaken. Techniques were used which enabled diagnoses of chlamydial and mycoplasmal infections to be made within 24 hours of a patient attending a clinic. All patients from whom Chlamydia trachomatis was isolated were treated with minocycline, while patients from whom Ureaplasma urealyticum or Mycoplasma hominis was isolated, or from whom no micro-organisms were isolated, were treated on a double-blind basis with either minocycline or placebo. Chlamydia were isolated from 77 (35%) patients and were eradicated by minocycline from 76 (99%). Ureaplasmas were isolated initially from 96 (43%) patients. Treatment with minocycline eradicated them from 43 of 52 (83%) patients, and they disappeared from six of 31 (19%) patients who were treated with placebo. After one week significantly more patients had responded clinically to minocycline than to placebo. The response to minocycline was not influenced by the microbiological status of the patients, which suggests that ureaplasmas are playing a similar role to chlamydia in the pathogenesis of the disease and that an antibiotic-sensitive micro-organism may be producing disease in the isolate-negative group. An immunological approach is required to resolve the problem of the persistent urethral inflammation which occurred despite eradication of the micro-organisms.

Antimicrobial therapy of postpartum endomyometritis. II. Prospective, randomized trial of mezlocillin versus ampicillin

Seventy patients with postpartum endomyometritis were treated with either intravenous mezlocillin (16 gm/day) or ampicillin (8 gm/day) in a prospective, randomized, double-blind comparison. Endocervical dilatation was routinely performed. Clindamycin (2 gm/day) was added if patients failed to improve within 48 hours of beginning therapy. Pretreatment clinical and microbiologic profiles were comparable in the two groups. Bacteremia was documented in 21 patients (30%). Anaerobic cocci and Bacteroides spp. (non-B. fragilis) comprised 19 of 29 (65%) blood isolates. Thirty of 33 mezlocillin-treated patients (91%) and 30 of 37 ampicillin-treated patients (81%) responded to initial therapy (P greater than 0.4). Resolution was noted after the addition of clindamycin in all ten nonresponders; two of these patients also required surgical wound debridement. Objective parameters of clinical response were not significantly different in the two treatment groups. Side effects of mezlocillin therapy were minimal. We conclude that mezlocillin and ampicillin are equally effective and safe for therapy of postpartum endomyometritis. That mezlocillin was not superior to ampicillin, despite expanded activity against B. fragilis and members of Enterobacteriaceae, suggests that these pathogens are less important than was previously considered in postpartum endomyometritis.

The effect of genital mycoplasmas on human fetal growth

The relation between maternal genital colonization by mycoplasmas and fetal growth was examined in a study of 195 women. Swabs were taken from the endocervix on three occasions during pregnancy and once post partum. Ureaplasma urealyticum organisms (ureaplasmas) were recovered from 42.7 per cent of Caucasian women and from 34.6 per cent of Asian women at their first antenatal visit. These isolation rates remained similar throughout pregnancy, although there was a decrease in isolation after delivery. Mycoplasma hominis was recovered from 6.5 per cent of Caucasians and from 11.5 per cent of Asians at their first antenatal visit and these rates remained fairly constant during pregnancy and after delivery. Caucasian women colonized by ureaplasmas had a longer mean length of gestation (p less than 0.025) than non-colonized women. Furthermore, the colonized women gave birth to infants who had a statistically significant greater mean birth weight and a greater mean birth weight-for-dates than those of the non-colonized Caucasians. There was no correlation between gestational length, birth weight, or birth weight-for-dates and genital colonization of Asian mothers by ureaplasmas or M. hominis. It is clear the ureaplasmas are not associated with low birth weight in our population.

Three years' experience of sexually transmitted diseases in Seville, Spain

At present there are no reliable statistics on the relative prevalences of sexually transmitted diseases (STDs) in Spain. In a report of the first three years' experience in an STD diagnostic centre between 1977 and 1979 a total of 879 patients (534 men adn 345 women) were seen. They mainly consisted of university students and the mean age was 22 years in 1977 and 23 years in the following two years. All the patients were examined for syphilis and all women for gonorrhoea and trichomoniasis. Investigations for Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma urealyticum, Candida albicans, and Herpesvirus hominis infections were carried out according to the presenting symptoms. Non-specific genital infections occurred most commonly (25.7%); chlamydia were isolated from 30% of the patients with non-gonococcal urethritis (NGU). The second commonest infection was candidosis (13.5%). Gonorrhoea, which was found in 10.6% of the patients, was diagnosed more frequently in men (13.5%) than in women (6%). No strains of beta-lactamase-producing Neisseria gonorrhoeae were detected and all were sensitive to penicillin. Syphilis was diagnosed in 4.4% of patients (2% women and 5% men). Condylomata acuminata were diagnosed in 2.8% of patients and more frequently in men (4%). Herpes genitalis and venereophobia were uncommon (1.9% and 1.2% respectively) and were diagnosed only in men.

Preliminary study of the flora in the lower genital tracts of sexually active adolescent females in relation to symptoms and inflammatory response

The lower genital tracts of 20 sexually active adolescent females were examined for the presence of Mycoplasma hominis, Ureaplasma urealyticum, Corynebacterium genitalium, and Corynebacterium pseudogenitalium. Fifty percent of the asymptomatic adolescent females and 50% of the symptomatic adolescent females were colonized with M. hominis, which is higher than the percentage reported in adult females. None of the asymptomatic adolescent females and only 10% of the symptomatic adolescent females were colonized with U. urealyticum, which is much lower than the percentage reported in adults. None of the study patients was colonized with C. genitalium, but 25% were colonized with C. pseudogenitalium. No relationship was found between the presence of M. hominis in the lower genital tract and a clinically identifiable vaginal discharge or inflammatory changes in exfoliated cervical and vaginal epithelial cells. The presence of M.hominis in the lower genital tract does not appear to be influenced by use of oral contraceptives or antecedent pregnancy.

Antimicrobial susceptibility of Ureaplasma urealyticum

An antimicrobial susceptibility test, a tow-tube broth dilution and disk elution method for Ureaplasma urealyticum, was modified to incorporate some of the standard procedures followed in traditional antimicrobial testing. The susceptibility pattern of the species was reevaluated by determining the effect of various antimicrobial agents on 21 vaginal isolates. All isolates were inhibited by tetracycline congeners (1 to 6 micrograms/ml) and killed by methenamine mandelate (0.6 mg/ml). All but one isolates were inhibited by erythromycin (0.4 to 3 micrograms/ml). Only eight isolates were inhibited by nalidixic acid (1 to 6 micrograms/ml), and seven were inhibited by nitrofurantoin (20 to 60 micrograms/ml), whereas all isolates were resistant to rifampin (1 microgram/ml) and trimethoprim-sulfamethoxazole (5 micrograms/ml). The in vitro technique described can readily be performed on individual patient isolates before the initiation of antimicrobial therapy.