The use of serological titres of IgA and IgG in (early) discrimination between rectal infection with non-lymphogranuloma venereum and lymphogranuloma venereum serovars of Chlamydia trachomatis

Chlamydia trachomatis Seroassays Used in Epidemiologic Research: A Narrative Review and Practical Considerations

Chlamydia trachomatis (CT) is a sexually transmitted infection that can lead to adverse reproductive health outcomes. CT prevalence estimates are primarily derived from screening using nucleic acid amplification tests (NAATs). However, screening guidelines in the United States only include particular subpopulations, and NAATs only detect current infections. In contrast, seroassays identify past CT infections, which is important for understanding the public health impacts of CT, including pelvic inflammatory disease and tubal factor infertility. Older seroassays have been plagued by low sensitivity and specificity and have not been validated using a consistent reference measure, making it challenging to compare studies, define the epidemiology of CT, and determine the effectiveness of control programs. Newer seroassays have better performance characteristics. This narrative review summarizes the "state of the science" for CT seroassays that have been applied in epidemiologic studies and provides practical considerations for interpreting the literature and employing seroassays in future research.

2019 European guideline on the management of lymphogranuloma venereum

New or important issues in this updated version of the 2013 European guideline on the management of lymphogranuloma venereum (LGV): EPIDEMIOLOGY: Lymphogranuloma venereum continues to be endemic among European men who have sex with men (MSM) since 2003. Lymphogranuloma venereum infections in heterosexuals are extremely rare in Europe, and there is no evidence of transmission of LGV in the European heterosexual population.

AETIOLOGY AND TRANSMISSION

Chlamydia trachomatis serovars/genovars L2b and L2 are the causative strains in the majority of cases in Europe.

CLINICAL FEATURES

Among MSM, about 25% of the anorectal LGV infections are asymptomatic. Genital infections among MSM are rare; the ratio of genital vs. anorectal LGV infections is 1 in 15.

DIAGNOSIS

To diagnose LGV, a sample tested C. trachomatis positive with a commercial nucleic acid amplification test (NAAT) platform should be confirmed with an LGV discriminatory NAAT.

TREATMENT

Doxycycline 100 mg twice a day orally for 21 days is the recommended treatment for LGV. This same treatment is recommended also in asymptomatic patients and contacts of LGV patients. If another regimen is used, a test of cure (TOC) must be performed.

Background review for the '2015 European guideline on the management of Chlamydia trachomatis infections'

SummaryChlamydia trachomatis infections are major public health concerns globally. Of particular grave concern is that the majority of persons with anogenital Chlamydia trachomatis infections are asymptomatic and accordingly not aware of their infection, and this silent infection can subsequently result in severe reproductive tract complications and sequelae. The current review paper provides all background, evidence base and discussions for the 2015 European guideline on the management of Chlamydia trachomatis infections (Lanjouw E, et al. Int J STD AIDS 2015). Comprehensive information and recommendations are included regarding the diagnosis, treatment and prevention of anogenital, pharyngeal and conjunctival Chlamydia trachomatis infections in European countries. However, Chlamydia trachomatis also causes the eye infection trachoma, which is not a sexually transmitted infection. The 2015 European Chlamydia trachomatis guideline provides up-to-date guidance regarding broader indications for testing and treatment of Chlamydia trachomatis infections; clearer recommendation of using validated nucleic acid amplification tests only for diagnosis; advice on (repeated) Chlamydia trachomatis testing; recommendation of increased testing to reduce the incidence of pelvic inflammatory disease and prevent exposure to infection and recommendations to identify, verify and report Chlamydia trachomatis variants. Improvement of access to testing, test performance, diagnostics, antimicrobial treatment and follow-up of Chlamydia trachomatis patients are crucial to control its spread.

2015 European guideline on the management of Chlamydia trachomatis infections

Chlamydia trachomatis infections, which most frequently are asymptomatic, are major public health concerns globally. The 2015 European C. trachomatis guideline provides: up-to-date guidance regarding broader indications for testing and treatment of C. trachomatis infections; a clearer recommendation of using exclusively-validated nucleic acid amplification tests for diagnosis; advice on (repeated) C. trachomatis testing; the recommendation of increased testing to reduce the incidence of pelvic inflammatory disease and prevent exposure to infection; and recommendations to identify, verify and report C. trachomatis variants. Improvement of access to testing, test performance, diagnostics, antimicrobial treatment and follow-up of C. trachomatis patients are crucial to control its spread. For detailed background, evidence base and discussions, see the background review for the present 2015 European guideline on the management of Chlamydia trachomatis infections (Lanjouw E, et al. Int J STD AIDS. 2015).

Sexually transmitted infectious colitis vs inflammatory bowel disease: distinguishing features from a case-controlled study

OBJECTIVES

Sexually transmitted infectious (STI) colitis often raises concern for inflammatory bowel disease (IBD). In this study, we compare histologic features of IBD with STI colitis caused by syphilis and lymphogranuloma venereum.

METHODS

The STI colitis group included 10 unique colorectal biopsy specimens in patients with clinically confirmed syphilis and/or lymphogranuloma venereum. The STI biopsy specimens were compared with patients matched for age, sex, and site with Crohn disease (n = 10) or ulcerative colitis (n = 10). All IBD controls had an established history of IBD (up to 276 months of follow-up, mean follow-up = 102 months).

RESULTS

Discriminating features (P < .05) of STI colitis included its exclusive identification in human immunodeficiency virus-positive men who have sex with men, anal pain, and anal discharge. STI colitis contained the triad of (1) minimal active chronic crypt centric damage, (2) a lack of mucosal eosinophilia, and (3) submucosal plasma cells, endothelial swelling, and perivascular plasma cells. Nondiscriminating features (P > .05) included rectal bleeding, endoscopic appearance, skip lesions, ulcerations, aphthoid lesions, granulomata, foreign body giant cells, neural hyperplasia, fibrosis, and lymphoid aggregates.

CONCLUSIONS

While STI colitis shares many overlapping features with IBD, histologic and clinical discriminating features may be helpful when confronted with that differential diagnosis.

Lymphogranuloma venereum among men who have sex with men. An epidemiological and clinical review

Lymphogranuloma venereum (LGV) is a sexually transmitted infection, previously only seen in tropical regions. This changed in 2003 when the first endemically acquired LGV cases were reported in Rotterdam, the Netherlands, among predominantly HIV positive men who have sex with men (MSM). Early diagnosis is important to prevent irreversible complications and to stop further transmission in the community. In contrast to earlier reports, approximately 25% of LGV infections are asymptomatic and form an easily missed undetected reservoir. The majority of reported infections in MSM are found in the anorectal canal and not urogenital, which leaves the mode of transmission within the MSM network unclear. Given the increasing trend, the LGV endemic is clearly not under control. Therefore directed screening must be intensified.

Chlamydia trachomatis Antibody Testing in Vaginal Mucosal Material versus Blood Samples of Women Attending a Fertility Clinic and an STI Clinic

Background. Chlamydia infections often follow an asymptomatic course but may damage the reproductive tract. Chlamydia antibodies in serum are used as markers for past infections and can relate to tubal pathology and infertility. This “proof of principle” study aimed to assess whether Chlamydia antibodies are detectable in easier to obtain, noninvasive, vaginal mucosa samples and relate to current or past infection. Methods. We compared outcomes of Chlamydia IgG and IgA antibody tests in serum and vaginal mucosal swabs in (a) 77 women attending a fertility clinic, of whom 25 tested positive for serum-IgG and (b) 107 women visiting an STI centre, including 30 Chlamydia PCR-positive subjects. Results. In the STI clinic, active Chlamydia infections were linked to serum-IgG and serum-IgA (P < 0.001) and mucosa-IgA (P < 0.001), but not mucosa-IgG. In the fertility clinic, mucosa-IgG had stronger correlations with serum-IgG (P = 0.02) than mucosa-IgA (P = 0.06). Women with tubal pathology or Chlamydia history more commonly had serum-IgG and mucosa-IgA (both P < 0.001), whereas this link was weaker for mucosa-IgG (P = 0.03). Conclusion. Chlamydia IgG and IgA are detectable in vaginal mucosal material. Serum-IgG had stronger associations with current or past infections. Mucosa-IgA also showed associations with (past) infection and complications. IgA presence in vaginal mucosa warrants further epidemiological studies.

2010 European guideline for the management of Chlamydia trachomatis infections

This guideline aims to provide comprehensive information regarding the management of infections caused by Chlamydia trachomatis in European countries. The recommendations contain important information for physicians and laboratory staff working with sexually transmitted infections (STIs) and/or STI-related issues. Individual European countries may be required to make minor national adjustments to this guideline as some of the tests or specific local data may not be accessible, or because of specific laws.

The association between lymphogranuloma venereum and HIV among men who have sex with men: systematic review and meta-analysis

BACKGROUND

Lymphogranuloma venereum (LGV) is an important re-emerging sexually transmitted infection which is reported to affect particularly HIV-positive men who have sex with men (MSM). The aim of this study is to quantify the association between LGV and HIV in the context of the current emergence of LGV.

METHODS

A systematic review was performed on the emergence of LGV among MSM since 2000. We report the prevalence of HIV infection from descriptive studies of MSM with LGV, and conduct a meta-analysis to produce a summary estimate of the association between LGV and HIV from case-control studies where cases were MSM with LGV and controls were MSM with rectal chlamydia caused by non-LGV serovars.

RESULTS

The prevalence of HIV among LGV cases ranges from 67% to 100% in 13 descriptive studies. There is a significant association between HIV and LGV (odds ratio 8.19, 95% CI 4.68-14.33).

CONCLUSIONS

HIV-positive MSM are disproportionately affected by LGV highlighting the importance of prevention efforts to be targeted to this group. Further research is needed to determine whether the association is due to biological or behavioural factors.

Surveillance of sexually transmitted infections among persons living with HIV

OBJECTIVES

Surveillance of sexually transmitted infections (STI) among HIV patients in AIDS Reference Centers aims at identifying risk groups and detecting specific STI emerging in this population.

METHODS

Seven of the nine AIDS Reference Centers in Belgium participate in this surveillance. The reported STI include Chlamydia, gonorrhea, syphilis, Lymphogranuloma venereum, hepatitis B virus and newly acquired hepatitis C in men who have sex with men (MSM).

RESULTS

In 2008, 252 HIV patients (250 men, 2 women) were reported with a new STI episode. Sexual orientation was known for 245 men: 241 were MSM, 4 were heterosexual men. In total, 279 new STI episodes were reported. More than half of the diagnoses were syphilis. In 78% of the syphilis cases, the motive of the consultation was not related to an STI complaint.

CONCLUSIONS

The results underline the importance of regular STI screening among HIV-positive persons, and show a particular sexual health problem among MSM. We estimate that the proportion of HIV-positive MSM acquiring an STI in 2008 was 8.8%.

Epidemiology of Chlamydia trachomatis infection in women and the cost-effectiveness of screening

BACKGROUND

The majority of Chlamydia trachomatis infections in women are asymptomatic, but may give rise to pelvic inflammatory disease (PID) and tubal infertility. Screening programmes aim at reducing morbidity in individuals by early detection and treatment, and at decreasing the overall prevalence of infection in the population. A number of modelling studies have tried to calculate the threshold prevalence of chlamydia lower genital tract infection above which screening becomes cost-effective. There is considerable debate over the exact complication rates after chlamydia infections, and more precise estimates of PID and tubal infertility are needed, for instance to be inserted in economic models.

METHODS

With reference to key studies and systematic reviews, an overview is provided focusing on the epidemiology of chlamydia infection and the risk-estimates of its late complications.

RESULTS

In the literature, the generally assumed risk of developing PID after lower genital tract chlamydia infection varies considerably, and is up to 30%. For developing tubal infertility after PID the risks are 10-20%. This implies that the risk of test-positive women of developing tubal infertility would range between 0.1 and 6%. We included chlamydia IgG antibody testing in a model and estimated a risk of tubal infertility up to 4.6%.

CONCLUSION

The risk of developing late complications after chlamydia lower genital tract infection appears low. High quality RCTs dealing with the transition from cervicitis to infertility are needed to broaden the evidence. In screening programmes, chlamydia antibody testing, as an intermediate marker for potential adverse sequelae, might enable more precise estimates.

Advances in sexually transmitted infections of the gastrointestinal tract

The gastrointestinal mucosa is a target of many sexually transmitted infections, and major advances have increased our understanding of the consequences of such infections within the gastrointestinal system. HIV-1 is associated with a marked loss of mucosal CD4(+) T cells that express CC-chemokine receptor 5. This process seems to be more rapid and more severe in mucosa-associated lymphoid tissue than in the peripheral blood. Mechanistic insights into the underlying cause of acute and chronic gastrointestinal damage with HIV infection-microbial translocation, defects in intestinal epithelial barrier function and activation of a systemic immune response-have also been achieved. Increased understanding of the pathogenesis of mucosal HIV-1 infection may identify therapeutic targets to restore immunological function and the integrity of the intestinal mucosal epithelial barrier. The increasing prevalence of lymphogranuloma venereum in Europe, mostly in HIV-positive men who have sex with men, suggests a change in the epidemiology of what was previously considered to be a 'tropical' disease. The increasing incidence of acute HCV infection transmitted via sexual contact has also been fueled by high-risk sexual behaviors among men who have sex with men, many of whom are also HIV-positive. The first part of this Review discusses the pathogenesis and gastrointestinal complications of HIV infection, and the second part summarizes advances in our understanding of other sexually transmitted infections of the gastrointestinal system.

Manifestations and management of lymphogranuloma venereum

PURPOSE OF REVIEW

This review was prompted by a sustained outbreak of lymphogranuloma venereum that has been observed among men who have sex with men (MSM) worldwide since 2004. Recent developments in the epidemiology, diagnosis and management of the infection are summarized.

RECENT FINDINGS

Between the early 1980s and 2003, lymphogranuloma venereum was rarely seen in the developed world. In 2003, a cluster of cases was seen in the Netherlands occurring mostly in HIV-positive MSM with high levels of sexual risk. With the assistance of novel molecular diagnostic techniques, more than a thousand cases of Chlamydia trachomatis L2 serovar disease have now been reported in MSM worldwide. Almost all have presented with rectal infection, usually manifesting as severe proctitis, with ulcer adenopathy syndrome seldom seen. Oral doxycycline remains the recommended treatment and has proven effective in the recent outbreak. Conflicting data exist regarding the prevalence of asymptomatic infection, and our understanding of the exact modes of transmission remains incomplete.

SUMMARY

Lymphogranuloma venereum appears to have reestablished endemicity among MSM populations in many industrialized nations. In the relative absence of recent publications from its traditional endemic regions it can be assumed that these populations remain afflicted by the infection as well.

Lymphogranuloma venereum outbreak in Europe

Lymphogranuloma venereum (LGV) is a venereal disease caused by Chlamydia trachomatis biovars L1 to L3. Unlike other anogenital C. trachomatis infections, LGV preferably affects lymphatic tissue after invasion through an epithelial surface. LGV has been considered an exotic tropical disease in Europe. This changed in 2003 as there was an outbreak of LGV in Rotterdam followed by additional reports from other European countries and North America. Most patients were HIV-positive men who presented with proctitis. Most of these patients were infected by C. trachomatis L2b biovar, a variant that was first identified in patients from Amsterdam. This review will address the recent developments of the LGV outbreak in Europe and discuss epidemiology, clinical manifestations, new subtypes of LGV genotypes and appropriate diagnostic measures.

Is there a reservoir of sub-clinical lymphogranuloma venereum and non-LGV Chlamydia trachomatis infection in men who have sex with men?

SUMMARY

The aim of this study was to determine if a reservoir of sub-clinical LGV infection exists in men who have sex with men (MSM), as this finding might account for the recent rise in lymphogranuloma venereum (LGV) Chlamydia trachomatis infections among MSM in Canada. MSM without proctitis were enrolled between January and August 2006 in a cross-sectional study. Rectal, urine, serology and pharyngeal specimens were tested for specific C. trachomatis serovars. The median age of the 253 participants was 43 years; 53% were HIV+. We found no active cases of LGV infection; but 20 (8%) participants had positive serology. Thirteen participants (5%) had non-LGV C. trachomatis infections. Unprotected anopenetrative intercourse, rectal enema and drug use were associated with non-LGV C. trachomatis infection. Sub-clinical rectal non-LGV C. trachomatis infection was relatively common but LGV was not identified in our sample. Further studies of screening for non-LGV chlamydia infection in MSM are needed.