Chuyên môn

GENITAL – URINARY CHLAMYDIA TRACHOMATIS INFECTION IN ADULTS

  1. SUMMARY

1.1. History

Chlamydia trachomatis is one of three species of the Chlamydia group – a very important cause of blindness and sexually transmitted diseases (STDs).

Since the early 1970s, C. trachomatis has been known to cause genital tract infections with symptoms similar to gonorrhea. Bacterial isolation is difficult, so diagnosis and treatment often do not have support for bacterial testing. Antigen has recently been detected with a number of new tests, but not available in developing countries. Moreover, many people do not have symptoms or disease-specific signs, even without symptoms, especially in women. As a result, many new complications occur to know that you are ill and asymptomatic people are a source of infection to the community. Risk factors for increased disease include those who are symptomatic and asymptomatic and their sexual partners are not diagnosed and treated early, inexperienced and inexperienced physicians.

Nhiễm Chlamydia (Ảnh sưu tầm)

Chlamydia infection (Photo collection)

1.2. Epidemiology:

In the United States, the prevalence of asymptomatic males to health facilities is 3-5%, while it is 15-20% among those visiting STD clinics. Heterosexual people have more urethritis than people who have sex with men. Homosexuals who do not use condoms can get C. trachomatis rectal inflammation. In women, the prevalence of the disease is 3-5% in asymptomatic people and over 20% in those visiting STD clinics. Some studies show that subjects with a high incidence of disease are young women, 21 years old, single and taking birth control pills.

In Vietnam, a study in Hanoi in 2003 found that recruits were 9%, pregnant women 1.5%, STI  examinations 1.5%, injecting drug users 0%, female sex workers 5 , 0%. Another study in 5 border provinces on female sex workers showed that 11.9% of chlamydia infection, of which Kien Giang had the highest rate of 17.3%, Lai Chau 16.2%, the lowest of An Giang 7. , 3%.

The incidence of C. trachomatis is unknown because patients have no specific symptoms and often have no symptoms. The potential for transmission is also unknown due to the long incubation period and the difficulty of isolating C. trachomatis, but appears to be lower than gonorrhea. According to WHO estimates, there are 89 million new cases of C. trachomatis globally.

Nhiễm Chlamydia trachomatis (Ảnh sưu tầm)
Chlamydia Infection ( Photo Collection)
 Nhiễm Chlamydia trachomatis (Ảnh sưu tầm)
Chlamydia Infection ( Photo Collection)
  1. CAUSES OF DISEASES

Chlamydia is an intracellular bacterium due to its inability to synthesize high energy compounds (ATP and GTP). It differs from all other bacteria in that it basically has an abnormal replication cycle. The next cycle follows two very special patterns in response to intracellular and extracellular life. The infection body-EB (elementary body-EB) withstands extracellular life but has no metabolism. The corpuscles approach the cell, enter it and change it into a metabolic and reticulate body. It then takes the host cell material to synthesize its RNA, DNA and protein. It is this strong metabolism that makes bacteria susceptible to antibiotics. The cycle of multiplication of chlamydia is about 48-72 hours, the cell is destroyed and releases the underlying infection.

This species has three different biological variants in clinical and biological manifestations. Variant trachoma (trachoma-serovars A, B and C) causes trachoma, type of genital tract diseases in humans (urethritis, cervicitis, ovarian inflammation, uterine pathology … serovars D-> K) which mainly causes symptomatic and asymptomatic urethritis. Variants of mango seed (serovars L1, L2, L3) have the same serum group as trachoma but have a widespread invasive clinical scene that causes more damage in the genital-urinary region.

The progression of the disease and the clinical manifestations of chlamydia infection are due to the synergistic effect of cell destruction due to multiplication of chlamydia, the organization’s inflammatory response to this bacterium and the destruction of cellular necrosis. cancel. Each body releases hundreds of infectious forms, so many adjacent cells become infected, but the control mechanism of the body limits this infection. However, this mechanism is not known.

The urethra chlamydia infection may be co-infected with gonorrhea, U. urealyticum, M. genitalium, flagella, and HSV infection.

Chlamydia trachomatis infection (Photo collection)

Chlamydia trachomatis infection (Photo collection)

  1. CLINICAL SYMPTOMS

The clinical manifestations of the disease closely resemble gonorrhea. Both types of bacteria usually infect the urethra and then spread to the epididymis of the testes, cervix, lining of the uterus, fallopian tubes, peritoneum and rectum. Both bacteria can cause subcutaneous inflammation, epithelial ulcers and scarring. However, C. trachomatis causes less systemic infection. Incubation period is about 7-21 days. Women often have no symptoms or atypical symptoms so it is difficult to determine the incubation period.

3.1 C. trachomatis infection in men: C. trachomatis infection in men is mainly urethritis.

+ Urethritis: In patients with non-gonococcal urethritis (Nongonococcal urethritis – NGU), about 35-50% due to C. trachomatis. Symptoms of dyspepsia are difficult urination (painful urination, painful urination, painful urination) and urethral discharge, white or translucent mucus, small to moderate amounts. Examination of the mouth of the red flute, stomatitis, no other pathologies such as swollen inguinal lymph nodes, painful foci in the urethra, lesions of the herpes on the mouth of the flute and penis. The incubation period is quite long 7-21 days, contrary to gonorrhea 3-5 days. Many patients have no symptoms, up to 50% do not show symptoms, when testing for urethral fluid with Gram staining, do not see Gram (-) and have ³5 polymorphonuclear leukocytes / microscopy with the zoom great 1000X.

It is important to note that post-gonorrhea urethritis is not caused by C. trachomatis. These patients have the potential to have both at the same time, but chlamydia has a longer incubation period and treatment of gonorrhea does not kill chlamydia. The incidence of these two diseases at the same time is 15-35%.

+ Testicular inflammation and prostatitis: C. trachomatis is a major cause of epididymitis that was previously thought to be of unknown origin. Clinical manifestations are unilateral scrotal pain, edema, tenderness and fever – often with urethritis. However, sometimes there are no symptoms of accompanying urethritis. Treatment with tetraxyclin progresses well, which supports the notion that C. trachomatis is the cause of the disease.

The pathogenic role of C. trachomatis in non-bacterial prostatitis is unknown.

+ Rectal inflammation: In people having anal intercourse, both LGV trachomatis and non-LGV trachomatis can cause rectal inflammation. C. trachomatis other than LGV has a milder clinical illness ranging from asymptomatic to gonorrhea-like symptoms and manifested rectal pain and bleeding, mucus secretion, and diarrhea. Gram stain of rectal fluid has many polymorphonuclear leukocytes. Rectal examination reveals damaged mucosa that is easy to shatter, bleed when touched.

+ Pharyngitis caused by C. Trachomatis due to oral sex usually has no symptoms or symptoms are unclear.

+ Reiter’s syndrome: Reiter’s syndrome includes symptoms of urethritis, conjunctivitis, arthritis and specific skin and mucous lesions related to C. trachomatis infection. Immunofluorescence assays show that over 80% of patients with Hc Reiter have C. trachomatis. The disease is common in people with HLA-B27.

3.2 C. trachomatis infection in women:

+ Cervical inflammation: Most patients do not show signs and symptoms of disease, about 1/3 have local signs. Common signs are purulent discharge and enlarged glandular manifestations of edema, hyperemia and bleeding. Physical examination of the cervix shows that the cervix is ​​prone to bleeding, uterine pus fluid and edema in the cervical hypertrophy area. Gram stain of cervical secretions shows more than 30 leukocytes / microscopy, 1000X magnification.

+ Urethritis: Symptoms include urethral discharge, red urethra mouth or edema. In people with cervical secretions accompanied by difficulty urinating, urination is suggested that patients also have urethritis caused by C. trachomatis. C. trachomatis urethritis may be thought of in young sexually active young women who have difficulty urinating, urinating and pyuria, especially when their sexual partner has symptoms of urethritis. or have a new partner. Gram stain of urinary fluid shows more than 10 neutrophil / polymorphonuclear leukocytes of 1000X magnitude, gonorrhea, flagella and bacilli are not found. However, the vast majority of patients with C. trachomatis urethritis have no clinical symptoms.

+ Bartholin gland inflammation: Like gonorrhea, C. trachomatis causes Bartholin glandular discharge. Purulent Bartholin gland inflammation may be caused by C. trachomatis alone or in combination with gonorrhea.

 

+ Endometritis: Nearly half of patients with cervicitis and most ovarian inflammation have endometritis. The bacteria spread through the uterine lining to the fallopian tubes. Postpartum fever and postpartum endometritis often result from untreated C. trachomatis during pregnancy.

+ Ovarianitis: Ovarian inflammation is also a complication of C. trachomatis. However, the symptoms are very poor or have no symptoms. As a result, the evidence of scar tissue causes ectopic pregnancy and infertility.

+ Hepatitis (HC Fitz-Hugh-Cutis): Hepatitis may occur after or at the same time as ovarian inflammation. The disease can be thought of when seen in women in the age of strong sexual activity, manifested in the lower right flank pain, fever, nausea or vomiting.

  1. TESTING:

The following tests may be done to diagnose Chlamydia, but depending on the capacity of the facility, whichever is appropriate.

– Isolation culture: high specificity and sensitivity. For many years the culture was thought to be the gold standard for diagnosing Chlamydia. However, the collection, storage and transport of very difficult specimens. Moreover, labo can make Chlamydia cultured very little, expensive, so it is currently rarely used in the diagnosis of Chlamydia. Currently non-cultured testing techniques are widely used due to the advantages of technical implementation, collection and transportation of specimens.

– Direct immunofluorescence by monoclonal antibody is not highly sensitive, reaching about 60-85% compared to culture. Specificity can be reached to 99%.

– Yeast immunity: ELISA by monoclonal or polyclonal antibodies, sensitivity reaches 60-80%, specificity 97-99%.

– PCR or LCR, TMA (Transcription-mediated amplification): the most sensitive and specific technique. Specimens are taken from the cervix, urethra and urine. Specificity reaches 99%, sensitivity ranges from 70-100%.

  1. DIAGNOSTIC

a) For men: Patients with clinical symptoms. Testing is also needed for patients with gonorrhea, non-gonorrhea urethritis and other STD patients because many cases have no symptoms. Gram staining test shows> 5 leukocytes / micro-field with magnification of 1000X, without Gram (-). Culture for gonorrhea, PCR, LCR, TMA or ELISA.

b) For women: Having a history of exposure to C. trachomatis (having sex or a partner with signs or symptoms of disease) and showing some symptoms (cervicitis with pus or mucus discharge) , endometritis, pyelonephritis, urethritis, rectal inflammation) should be tested. Cervical fluid test> 30 polymorphonuclear leukocytes / micro-field magnification 1000X, without Gram (-). Culture for gonorrhea, PCR, LCR, TMA or ELISA

Women at high risk of infection should be screened for: patients coming to STD clinics, gynecology, women who have had abortions, who have multiple sexual partners.

  1. TREATMENT

Antibiotics that effectively kill C. trachomatis include cyclin, rifampixin, marcrolid, sulfonamides, fluoroquinolones and clindamycin. The therapeutic effect is achieved from 85-95% of male urethritis. C. trachomatis is not as resistant to antibiotics as gonorrhea. The antibiotics of β-lactamin group, cephalosporin and spectinomycin are not effective in killing C. trachomatis.

The treatment of choice is Tetraxyclin or Doxycycline for 1-3 weeks.

6.1 Treatment of uncomplicated C. trachomatis infection in the urethra, cervix and rectum

– Doxycycline 100mg orally, 2 capsules daily for 7 days, or

– Tetracyclin 1g / day for 7 days, or

– Azithromycin 1g orally as a single dose, or

– Erythromycin 500mg orally 4 tablets daily for 7 days, or

– Ofloxacin 200mg, taken 2 times / day for 7 days.

Azitromycin has a half-life of 5-7 days, very well penetrates into cells and organizations, so the therapeutic effect is very high, can be achieved 100% with a single dose of 1g. With this therapeutic dose, the greatest advantage is that the patient adheres to the treatment and can be applied to the partner’s sexual partner as well as difficult-to-reach objects such as young teenagers, female sex workers.

Follow-up monitoring shows that some cases (5-10%) may be due to relapses or reinfection. Some patients after treatment, although C. trachomatis is no longer symptomatic or recurrent symptoms (10-15%) may be caused by another pathogen.

6.2 Treatment for pregnant women

– Erythromycin 500mg orally 4 tablets daily for 7 days, or

– Azithromycin 1g orally single dose.

Sex partners of patients: Should be tested within 30 days after exposure or treated with tetraxyclin, doxycyclin.

Note: Do not use cyclin and quinolones for pregnant, lactating and children under 7 years old. Particularly quinolon not used for people <18 years old.

  1. DISEASE PREVENTION

The main obstacle in the effective prevention of genital infections caused by C. trachomatis is the lack of specific tests at STD clinics. More than 40% of patients infected with C. trachomatis are asymptomatic and many sexually active people are infected with C. trachomatis without seeking medical attention because there are no symptoms or symptoms are very poor. One possible measure is to screen for C. trachomatis in clinics where many patients are present, as well as to screen high-risk subjects for asymptomatic cases. Treatment of sexual partners is an important and effective method.

REFERENCES:

  1. Pham Van Hien, Trinh Quan Huan, Nguyen Duy Hung et al. Management of sexually transmitted diseases, Medical Publishing House 2003.
  2. The Ministry of Health. Sexually transmitted infections & Reproductive tract infections – Basic practice guide. Department of Reproductive Health 2006.
  3. Tony Burns, Stephen Breathnach, Neil Cox, Christopher Griffiths. Rook’s Textbook of Dermatology, Blackwell 2004.
  4. Thomas B. Fitzpatrick, Arthur Z. Eisen, Klaus Wolff, Irwin M. Freedberg, K. Frank Austen. Dermatology in General Medicine, International Edition 2005.
  5. King K. Holmes, P. Frederick Sparling et al. Sexually Transmitted Diseases / Mc Graw Hill Medical. Fouth Edition 2012.

 

Author: Assoc.Prof. Nguyễn Duy Hưng
Publisher: Social Work Department