The association of Chlamydia trachomatis/gonococcal infection and tubal factor infertility

A retrospective cohort study examining STI testing and perinatal records demonstrates reproductive health burden of chlamydia and gonorrhea

Adverse reproductive health outcomes, such as pelvic inflammatory disease, ectopic pregnancy and tubal factor infertility, have been associated with Chlamydia trachomatis and Neisseria gonorrhoea infections. These reproductive health outcomes could be complemented by measuring subsequent pregnancies to assess impact on fertility. The study design was a cohort study of women in Queensland (QLD), Australia, using data linkage methods to link chlamydia and/or gonorrhea testing records (including an unexposed group undergoing full blood count tests; 2000 and 2005) with the QLD Perinatal Registry (2000-2013). The cohort included 132 962 women, with 69 533 records of pregnancies. Women in the exposed group, with no prior pregnancy, had a reduced odds of a pregnancy during the follow up of the study (20-year-old (at 2005) aOR 0.91 95% CI 0.87-0.95, and 25-year-old aOR 0.71 95% CI 0.68-0.75). Women in the exposed group with a prior pregnancy had increased odds of pregnancy during the follow up of the study (20-year-old (at 2005) aOR 1.72 95% CI 1.59-1.86, and 25-year-old aOR 1.35 95% CI 1.26-1.45). Our data provides further evidence at a population level of the significant impact on reproductive outcomes associated with chlamydia and gonorrhea.

The low-molecular-mass, penicillin-binding proteins DacB and DacC combine to modify peptidoglycan cross-linking and allow stable Type IV pilus expression in Neisseria gonorrhoeae

Neisseria gonorrhoeae is the causative agent of the sexually transmitted infection gonorrhea and is adapted to survive in humans, its only host. The N. gonorrhoeae cell wall is critical for maintaining envelope integrity, resisting immune cell killing and production of cytotoxic peptidoglycan (PG) fragments. Deletion of the N. gonorrhoeae strain FA1090 genes encoding two predicted low-molecular-mass, penicillin-binding proteins (LMM PBPs), DacB and DacC, substantially altered the PG cross-linking. Loss of the DacB peptidase resulted in global alterations to the PG composition, while loss of the DacC protein affected a much narrower subset of PG peptide components. A double ΔdacB/ΔdacC mutant resembled the ΔdacB single mutant, but had an even greater level of cross-linked PG. While single ΔdacB or ΔdacC mutants did not show any major phenotypes, the ΔdacB/ΔdacC mutant displayed an altered cellular morphology, decreased resistance to antibiotics and increased sensitivity to detergent-mediated death. Loss of the two proteins also drastically reduced the number of Type IV pili (Tfp), a critical virulence factor. The decreased piliation reduced transformation efficiency and correlated with increased growth rate. While these two LMM PBPs differentially alter the PG composition, their overlapping effects are essential to proper envelope function and expression of factors critical for pathogenesis.

Sexually transmitted diseases and infertility

Female infertility, including tubal factor infertility, is a major public health concern worldwide. Most cases of tubal factor infertility are attributable to untreated sexually transmitted diseases that ascend along the reproductive tract and are capable of causing tubal inflammation, damage, and scarring. Evidence has consistently demonstrated the effects of Chlamydia trachomatis and Neisseria gonorrhoeae as pathogenic bacteria involved in reproductive tract morbidities including tubal factor infertility and pelvic inflammatory disease. There is limited evidence in the medical literature that other sexually transmitted organisms, including Mycoplasma genitalium, Trichomonas vaginalis, and other microorganisms within the vaginal microbiome, may be important factors involved in the pathology of infertility. Further investigation into the vaginal microbiome and other potential pathogens is necessary to identify preventable causes of tubal factor infertility. Improved clinical screening and prevention of ascending infection may provide a solution to the persistent burden of infertility.

ksgA mutations confer resistance to kasugamycin in Neisseria gonorrhoeae

The aminoglycoside antibiotic kasugamycin (KSG) inhibits translation initiation and thus the growth of many bacteria. In this study, we tested the susceptibilities to KSG of 22 low-passage clinical isolates and 2 laboratory strains of Neisseria gonorrhoeae. Although the range of KSG minimum inhibitory concentrations (MICs) was narrow (seven-fold), clinical isolates and laboratory strains fell into three distinct classes of KSG sensitivity, susceptible, somewhat sensitive and resistant, with MICs of 30, 60-100 and 200 microg/mL, respectively. Two genes have previously been shown to be involved in bacterial KSG resistance: rpsI, which encodes the 30S ribosomal subunit S9 protein; and ksgA, which encodes a predicted dimethyltransferase. Although sequencing of rpsI and ksgA from clinical isolates revealed polymorphisms, none correlated with the MICs of KSG. Ten spontaneous KSG-resistant (KSG(R)) mutants were isolated from laboratory strain FA1090 at a frequency of <4.4x10(-6) resistant colony-forming units (CFU)/total CFU. All isolated KSG(R) variants had mutations in ksgA, whilst no mutations were observed in rpsI. ksgA mutations conferring KSG resistance included four point mutations, two in-frame and one out-of-frame deletions, one in-frame duplication and two frame-shift insertions. These data show a narrow range of susceptibilities for the clinical isolates and laboratory strains examined; moreover, the differences in MICs do not correlate with nucleotide polymorphisms in rpsI or ksgA. Additionally, spontaneous KSG(R) mutants arise by a variety of ksgA mutations.

Pathological study of Fitz-Hugh-Curtis syndrome evaluated from fallopian tube damage

AIM

To analyze the causative pathogen, surgical indication and fallopian tube damages in Fitz-Hugh-Curtis syndrome (FHCS) cases diagnosed by laparoscopy.

METHODS

Laparoscopic findings in 3568 cases at our hospital were reviewed retrospectively. Of these, 108 cases were diagnosed to have FHCS and examined for causative pathogens. Chlamydial infection was determined by both Chlamydia trachomatis (CT) antigens in the cervix and serum anti-CT antibodies. One hundred and four cases with chronic FHCS were divided into hydrosalpinx (H) and normal (N) groups based on the fallopian tube conditions, and were compared for patient profiles, tubal functions and perihepatic adhesion.

RESULTS

Among surgical indications, tubal infertility and ectopic pregnancy were more often associated with FHCS than any other diseases. The primary causative pathogen of FHCS was CT. In 104 cases with chronic FHCS, there was no difference in CT antigen positivity between the H and N groups. The serum anti-CT IgG titer also did not differ between the two groups, although anti-CT IgA was slightly higher in the H group. The peritubal adhesion score was significantly higher in the H group, but it was not correlated with the degree of perihepatic adhesion.

CONCLUSION

While some FHCS patients had severe fallopian tube dysfunctions, such as hydrosalpinx and tubal occlusion, 30% of FHCS cases did not show any abnormalities in the fallopian tube. Our study indicated that the severity of tubal dysfunctions associated with FHCS is determined by the host's reactivity to CT.

Prevalence of Chlamydia trachomatis in human immunodeficiency virus-infected women in Cuba

To determine the prevalence rates and serovar distribution of Chlamydia trachomatis cervical infections in Cuban women, two different groups were selected. Group I consisted of 60 human immunodeficiency virus (HIV-1) seropositive women from different regions of Cuba and group II of 60 randomly selected women HIV seronegative and apparently healthy. C. trachomatis was detected in cervical scrapes by mean of nested polymerase chain reaction (PCR) specific for major out membrane protein. The overall prevalence rate of C. trachomatis in cervical scrapes determined by nested PCR was 10% in group I and the estimated prevalence was 6.6% for group II; 83.3% of HIV seropositive women with C. trachomatis infection reported history of pelvic inflammatory disease followed by cervicitis (50%). The control group C. trachomatis-infected women referred a history of cervicitis in 75% of cases. Other reports in the latter group included infertility and pelvic inflamatory disease in 50%. The present study is the first report of C. trachomatis prevalence in Cuba. It showed that there was not significantly difference in the prevalence rate of C. trachomatis between both groups.

A variable genetic island specific for Neisseria gonorrhoeae is involved in providing DNA for natural transformation and is found more often in disseminated infection isolates

Neisseria gonorrhoeae (the gonococcus) is the causative agent of the sexually transmitted disease gonorrhoea. Most gonococcal infections remain localized to the genital tract but, in a small proportion of untreated cases, the bacterium becomes systemic to produce the serious complication of disseminated gonococcal infection (DGI). We have identified a large region of chromosomal DNA in N. gonorrhoeae that is not found in a subset of gonococcal isolates (a genetic island), in the closely related pathogen, Neisseria meningitidis or in commensal Neisseria that do not usually cause disease. Certain versions of the island carry a serum resistance locus and a gene for the production of a cytotoxin; these versions of the island are found preferentially in DGI isolates. All versions of the genetic island encode homologues of F factor conjugation proteins, suggesting that, like some other pathogenicity islands, this region encodes a conjugation-like secretion system. Consistent with this hypothesis, a wild-type strain released large amounts of DNA into the medium during exponential growth without cell lysis, whereas an isogenic strain mutated in a peptidoglycan hydrolase gene (atlA) was drastically reduced in its ability to donate DNA for transformation during growth. This genetic island constitutes the first major discriminating factor between the gonococcus and the other Neisseria and carries genes for providing DNA for genetic transformation.

Identification of discrete domains within gonococcal transferrin-binding protein A that are necessary for ligand binding and iron uptake functions

The availability of free iron in vivo is strictly limited, in part by the iron-binding protein transferrin. The pathogenic Neisseria spp. can sequester iron from this protein, dependent upon two iron-repressible, transferrin-binding proteins (TbpA and TbpB). TbpA is a TonB-dependent, integral, outer membrane protein that may form a beta-barrel exposing multiple surface loops, some of which are likely to contain ligand-binding motifs. In this study we propose a topological model of gonococcal TbpA and then test some of the hypotheses set forth by the model by individually deleting three putative loops (designated loops 4, 5, and 8). Each mutant TbpA could be expressed without toxicity and was surface exposed as assessed by immunoblotting, transferrin binding, and protease accessibility. Deletion of loop 4 or loop 5 abolished transferrin binding to whole cells in solid- and liquid-phase assays, while deletion of loop 8 decreased the affinity of the receptor for transferrin without affecting the copy number. Strains expressing any of the three mutated TbpAs were incapable of growth on transferrin as a sole iron source. These data implicate putative loops 4 and 5 as critical determinants for receptor function and transferrin-iron uptake by gonococcal TbpA. The phenotype of the DeltaL8TbpA mutant suggests that high-affinity ligand interaction is required for transferrin-iron internalization.

The transferrin receptor expressed by gonococcal strain FA1090 is required for the experimental infection of human male volunteers

Iron, an essential nutrient for most microorganisms, is sequestered by the host to decrease the concentration of iron available to bacterial pathogens. Neisseria gonorrhoeae, the causative agent of gonorrhoea, can acquire iron by direct interaction with human iron-binding proteins, including the serum glycoprotein, transferrin. Iron internalization from host transferrin requires the expression of a bacterial receptor, which specifically recognizes the human form of transferrin. Two gonococcal transferrin-binding proteins have been implicated in transferrin receptor function, TbpA and TbpB. We constructed a gonococcal transferrin receptor mutant without the introduction of additional antibiotic resistance markers and tested its ability to cause experimental urethritis in human male volunteers. The transferrin receptor mutant was incapable of initiating urethritis, although the same inoculum size of the wild-type parent strain, FA1090, causes urethritis in >90% of inoculated volunteers. To our knowledge, this is the first experimental demonstration that a bacterial iron acquisition system is an essential virulence factor for human infection.