Recognition and management of genital chlamydial infection

Reiter's syndrome and reactive arthritis: a current view

This paper reviews advances in the understanding of the pathogenesis of reactive arthritis that have occurred over the last decade. Inflammatory aseptic joint disease has been linked with prior infection initiated by many different species of microorganisms. The presence of intra-articular bacterial antigens has now been firmly established with the demonstration of bacteria, bacterial fragments, DNA, RNA, and bacterial lipopolysaccharide in joints of patients with reactive arthritis. Chlamydia trachomatis, Salmonella enteritidis, and Shigella flexneri have all been detected in the joint by immunological techniques, although there is still some doubt as to the form in which they reach the joint and whether or not they persist. A number of phlogistic bacterial components could be acting as arthritogens. Negative joint culture results from patients with reactive arthritis make it unlikely that bacteria in the joint are viable, although chlamydial DNA has been shown in the joints of patients with sexually acquired reactive arthritis using the polymerase chain reaction. The use of antimicrobial therapy in the treatment of reactive arthritis is under review; data suggests that long-term antibiotic treatment warrants further study. The role of HLA-B27 in disease pathogenesis is discussed as are possible mechanisms of interplay between germ and gene. HLA-B27 might confer disease susceptibility by affecting immune mechanisms other than classical antigen presentation. The immunopathogenesis of joint inflammation in reactive arthritis is explored with reference to studies of humoral and cellular immune responses. Serological evidence to support the concept of molecular mimicry is far from conclusive; the results of relevant studies are summarized. Lymphocyte proliferation experiments suggest that antigen presenting cells play an important role. Finally, our views on reactive arthritis in the 1990s, and areas of new and potentially fruitful future research are presented.

Women's health: potential for better coordination of services

OBJECTIVE

To determine the proportion of women attending a genitourinary medicine clinic (GUMC) who are in need of contraception and the proportion of women attending a family planning clinic (FPC) who may require screening or treatment for sexually transmitted disease (STD).

DESIGN

Cross-sectional survey.

SETTING

A large FPC (17,600 attendances by women a year) and a large GUMC (20,060 attendances by women a year) in an inner London health district.

SUBJECTS

All clients attending the two clinics in consecutive weeks (356 GUMC and 335 FPC). In addition a non-random cluster of other women attending the same clinics later in the year were interviewed in depth (21 GUMC and 20 FPC).

RESULTS

Of women at the GUMC 10.4% (95% CI 7.2-13.6) were at risk of unwanted pregnancy and not using contraception. Women aged under 20 years and women not registered with a general practitioner (GP) were more likely to be in this group. A further 13.8% may have been using contraception unreliably as they were not obtaining contraception from a GP or FPC. Of women at the FPC 1.8% (95% CI 0.3-3.2) complained of symptoms of genitourinary infection. In-depth interviews showed that some women assumed the staff at both clinics would counsel them in all aspects of sexual health.

CONCLUSIONS

The opportunities presented at GUMCs to reduce the incidence of unwanted pregnancy and the opportunities presented at FPCs to reduce the incidence and prevalence of STD should not be missed.

The incidence of urogenital Chlamydia trachomatis infections among patients in Kumasi, Ghana

The incidence of urogenital chlamydia infections among selected patients in Kumasi, Ghana was evaluated using an immunofluorescent monoclonal antibody technique. Chlamydia trachomatis was identified in 4 of 110 patients presenting for prenatal care, 2 of 55 female patients with infertility and 6 of 15 males with acute urethritis. The findings demonstrate that C. trachomatis is a frequently identified pathogen among male patients presenting with symptoms of acute urethritis; however, the incidence of chlamydia infections among asymptomatic patients is relatively low.

Diagnosis of Chlamydia trachomatis infection--culture versus serology

The diagnostic value of different laboratory methods in detecting Chlamydia trachomatis infections in high risk groups was analysed. The efficiency of a direct specimen test was compared with serology (IgG and IgM ELISA) and culture in L929 cells, stained either with fluorescein conjugated monoclonal antibodies or with iodine. Patients (no. = 1041) with localized genital infections attending a STD clinic, sexual contacts and patients with ascending infections from urological and gynecological clinics were examined. Chlamydia trachomatis was detected in 225 patients: 210 (93.3%) were reactive in the direct test (smears stained with monoclonal antibodies), whereas culture missed only 5 (sensitivity 97.8%) when stained by the same method. Cultures stained with iodine produced the lowest recovery rate (73.8%), but this rate increased to 80.9% when a second passage was performed. In addition the prevalence of Neisseria gonorrhoeae, Mycoplasma hominis, Ureaplasma urealyticum, Candida albicans and Trichomonas vaginalis was investigated. In patients with non-gonococcal urethritis (no. = 331) and cervicitis (no. = 353), Chlamydia trachomatis was isolated in 32.3% and 12.8% respectively. However, this pathogen could be isolated in only 3 (15.8%) out of 19 patients with epididymitis and 15 (14%) out of 107 patients with adnexitis, although 66.7% and 93.3% respectively had specific IgG antibodies. Specific IgM could by detected with a sandwich ELISA in patients with adnexitis (46.7%), epididymitis (33.3%), cervicitis (22.2%), non-gonococcal urethritis (14%) and in the sexual partners of patients with genital infections (35.7%). The direct specimen test with monoclonal antibodies is the method of choice for the diagnosis of a C. trachomatis infection in patients with urethritis and cervicitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Preventing complications of sexually transmitted disease. New treatment guidelines for an expanded spectrum of problems

Newly recognised sexually transmitted diseases have combined with the traditional venereal diseases to present clinicians with a demanding management challenge. Besides the increases in incidence of some of these diseases, many of the associated organisms are becoming more resistant to commonly used antimicrobial drugs. Predictably, accompanying this trend are increasing numbers of serious complications affecting men, women and infants. Timely and appropriate management of patients presenting with sexually transmitted diseases are imperative to stem the swelling tide of these conditions and prevent their insidious consequences. Clinicians must therefore remain knowledgeable about the effective therapies (and regimens) that are available. An update of the treatment guidelines for sexually transmitted diseases is provided in this article. As well as selecting appropriate antimicrobial regimens, it is equally important that clinicians educate their patients about their disease and its probable course, explain the administration of medications clearly to patients, and follow them up appropriately to detect resistant cases and non-compliers, and ultimately ensure effective treatment. In addition, no patient should be considered appropriately managed until his or her sexual partners have been properly dispositioned. For most patients, this will entail examining their sexual partners and treating them immediately. Execution of these treatment guidelines and management principles will help protect the reproductive capability of many women by preventing pelvic inflammatory disease, ectopic pregnancy, and infertility.

Chlamydial cervicitis: a research study from general practice

Chlamydia trachomatis was isolated from the cervix in five out of 294 women at routine cervical cytology screening. Significant sera antibody titres were obtained from six out of 115 isolate-negative women similarly screened. The antibody response increased in proportion to the past frequency and severity of cervical pathology and sexually transmitted disease.It is suggested that the true incidence of chlamydial genital infection in general practice will be five times as high as the current cervical isolation rate.

Chlamydial screening of pregnant women in a sexually transmitted diseases clinic

Fifty-three consecutive pregnant women seen over six months were screened for chlamydial infection, syphilis, gonorrhoea, trichomoniasis, and candidosis. Chlamydia trachomatis was isolated in 20 (37.7%) patients, of whom six were sexual partners of known cases of non-gonococcal urethritis (NGU) (two had associated gonorrhoea or candidosis) and six had gonorrhoea (three had associated trichomoniasis and candidosis). If treatment is given to contacts of NGU 14 patients with other presenting conditions would not have been treated unless chlamydial cultures had been performed. This may lead to potentially serious complications of chlamydial infection in both mothers and neonates.

Provision of a chlamydial culture service to a sexually transmitted diseases clinic

Urethral specimens from 215 men were inoculated on to McCoy cell cultures, both at the local laboratory and at a central reference laboratory, Chlamydia trachomatis was isolated from 58 (28%) patients; 12 of these isolates were, however, obtained only at the local laboratory. The results show the feasibility and convenience of a central laboratory supplying a peripheral laboratory with uninoculated prepared cell cultures. Such a service is not only more cost effective but obviates the problems of transporting specimens to a central laboratory.

Chlamydia trachomatis and clinical genital infections: a general review

Genital infections caused by Chlamydia trachomatis (immunotypes D to K) are briefly reviewed. Urethritis is not only the most important chlamydial infection in men, but is also the most common sexually transmitted disease. The complication of this form of nongonococcal or postgonococcal urethritis include prostatitis, epididymitis and arthritis. Urethritis and cervicitis are the primary infections in women, and may lead to salpingitis, peritonitis or perihepatitis. Chlamydial infection is transmitted to the infant at birth, causing conjunctivitis or pneumonia. The diagnosis and treatment of genital chlamydial infections are briefly reviewed. Finally, some general recommendations on genital chlamydial infections are presented.

Chlamydia trachomatis and herpes simplex virus IgA antibodies in cervical secretions of patients with cervical atypia

The association of Chlamydia trachomatis (CT) and herpes simplex virus (HSV) with malignant or premalignant changes in the cervix uteri was studied by determining immunoglobulin A (IgA) antibodies in the cervical secretions of 28 women with inflammatory, 28 with dysplastic, 7 with malignant changes of the uterine cervix, and 26 healthy controls. In cervical secretions IgA antibodies to CT were found in 24 of 35 (69%) patients with malignant or premalignant changes, in 11 of 28 (39%) with cervicitis and in 3 of 26 (12%) controls. IgA antibodies to HSV were found in 10 of 35 (28%) patients with malignant atypic or dysplasia but in none of the women with cervicitis or the controls. The highest frequency of antibodies was found in the patients with cervical carcinoma. Serum IgA antibodies to CT and HSV were found equally on the patients and the controls. Our results suggest that in patients with cervical atypic, local IgA CT antibody production occurs. Whether this association is aetiological or coincidental can not be concluded from this study.

The presentation and incidence of paratrachoma in adults

Thirteen definite and 3 probable cases of chlamydial eye infection were diagnosed in young adults attending the Bristol Eye Hospital between June 1978 and May 1980, and incidence of about 1 case per 44000 per year in the 15 to 44-year-old community served by this hospital, and 1 per 100000 in the total population of this community. These patients presented with a sub-acute follicular conjunctivitis or kerato-conjunctivitis, which had usually been present for several weeks and had often failed to respond to topical chloramphenicol treatment before presentation. Sera obtained from 14 patients, all had chlamydial antibody titres of 64 or more. Over the same period of time, an estimated 2500 patients per year from the same community attended the Venereology Department at the Bristol Royal Infirmary with genital chlamydial infections. These figures suggest that chlamydial infection of the eye complicates no more than 1 in 300 chlamydial infections of the genital tract in adults.

Evidence of Chlamydia trachomatis infection in sexually acquired reactive arthritis

Thirty male patients with sexually acquired reactive arthritis (SARA) have been studied at the time of their initial presentation and thereafter. Chlamydia trachomatis was isolated from the urethral exudate of 9 (36.0%) of the 25 patients from whom urethral specimens were taken, and elevated titres of IgM antibody of C. trachomatis were detected in 11 (36.6%) of the 30 initial sera. Thirteen (43.3%) of the patients has a positive urethral culture and/or elevated titre of IgM antibody, and it is therefore suggested that 43.3% of these patients suffered an acute chlamydial infection at or near the time of the onset of their joint disease. The demonstration of 4-fold or greater rises and/or falls in IgM antibody titre (8 patients) and IgG antibody titre (6 patients) in a group of 15 men studied throughout the course of their disease strongly supports this conclusion. A positive urethral culture and/or raised titre of IgM serum antibody was also detected in 25 (50%) of 50 men with uncomplicated nongonococcal urethritis (NGU), suggesting that the prevalence of chlamydial infections in the 2 conditions is similar. Titres of IgG serum antibody to C. trachomatis were, however, significantly higher in patients with SARA than in those with NGU or other rheumatic diseases, and in healthy controls. The geometric mean titres (GMT) of IgG serum antibody in patients with SARA, NGU, rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, and in healthy controls were 1:47.5, 1:8.6, 1:2.2, 1;2.2, 1:3.5, and 1:1.4, respectively. These findings suggest that an exaggerated antibody response to acute infection by C. trachomatis may be an important factor in the development of SARA in some but not all patients.

Value and feasibility of screening women attending STD clinics for cervical chlamydial infections

A chlamydial screening service was provided in Bristol over a three-month period for women attending the sexually transmitted disease (STD) clinic either for the first time or with a new complaint. Isolation of Chlamydia trachomatis was attempted in cytochalasin-treated McCoy cells. Of 919 specimens, valid results were obtained in 796. Chlamydial infections were identified and treated in 154 (19%) of these 796 women. Chlamydia were isolated from 52 (37%) of 152 female partners of men with nongonococcal urethritis (NGU); these patients already routinely receive treatment with tetracylcines in this clinic. The remaining 102 infections (34 (48%) of 71 women with gonorrhoea and 68 (12%) of the other 573 women) would have been unrecognised and usually untreated without chlamydial isolation studies. These figures confirm the need to provide chlamydial diagnostic services for selected STD clinic attenders.

Vaginal oxytetracycline concentrations

Although tetracycline preparations are widely used in departments of genitourinary medicine, or sexually transmitted diseases clinics, little is known of the concentrations of these preparations in genital secretions. For this reason a microbiological method was used for estimating oxytetracycline concentrations in vaginal secretions. These concentrations varied from 0.6 to 6.5 microgram/ml in 19 women who had had sexual contact with a man with non-specific urethritis and who were taking oxytetracycline dihydrate 250 mg four times daily. They were well in excess of the minimum inhibitory concentration of oxytetracycline (0.2 microgram/ml) for the strains of Chlamydia trachomatis isolated from the patients with positive culture results. Thus, oxytetracycline 250 mg four times daily appears to be a satisfactory regimen for the treatment of chlamydial genital infection in women.

The need for a chlamydial culture service

In a prospective study of unselected, female patients attending a sexually transmitted disease clinic one in eight patients would have been errouneously declared free of infection in the absence of a chlamydial culture service. Chlamydia trachomatis is now accepted as a causative organism of non-specific urethritis and post-gonococcal urethritis in men and non-specific genital infection in women. Thus, facilities for isolation of C. trachomatis should be an essential aid in the management of women attending STD clinics. Male patients would also benefit if such facilities were readily available.