Question

Vanessa is an 18-year-old female who presents to the clinic with a complaint of low backache, lower abdominal cramping, and increased vaginal discharge. She is afebrile. A pelvic examination reveals greenish mucopurulent discharge from her cervix and positive cervical motion tenderness. She is diagnosed with mucopurulent cervicitis. Her urine tested positive for Chlamydia.

Answer 1

Ans) C. trachomatis is an obligate intracellular organism that does not gram stain. Infected cells contain cytoplasmic Giemsa stain-positive inclusions. C. trachomatis has at least 15 different immunotypes. Types D through K are responsible for the majority of genital infections, including mucopurulent cervicitis, urethritis, proctitis, epididymitis, salpingitis, endometritis, and perihepatitis. Types L1 through L3 are associated with lymphogranuloma venereum. Ocular trachoma (a chronic follicular keratoconjunctivitis which is a common cause of acquired blindness in other countries), is caused by types A-C.

- ChlamydiaChlamydia is one of the most prevalent bacterial STIs in the United States, accounting for an estimated 3-4 million new cases each year, more frequently diagnosed in adolescents than gonorrhea. Up to 85% of women and 40% of men who are infected with chlamydia are asymptomatic. Yet if recognition and treatment are inadequate, pelvic inflammatory disease (PID) will develop in 20-40% of women with chlamydia. As with some other inflammatory STIs, transmission of HIV can be facilitated by chlamydial infection.

- C. trachomatis infects the endocervix most often, in addition to the urethra, anus, Bartholin's glands, and fallopian tubes. The most common signs of C. trachomatis cervicitis include yellow/green mucopurulent endocervical discharge and an edematous, friable cervix (hypertrophic ectropion) which may present with abnormal vaginal bleeding. A wet-mount or gram stain of the discharge usually reveals greater than 30 polymorphonucleocytes (PMN) per high power field and absence of gonococci (although the presence of gonorrhea does not rule out concurrent chlamydia infection). Chlamydia urethritis should be suspected in sexually active females with prolonged dysuria (greater than 7-10 days) unresponsive to traditional treatment for bacterial cystitis (J). In males, chlamydial infection can also cause non-gonococcal urethritis, acute epididymitis, or proctitis. Chlamydial pharyngitis or conjunctivitis can occur in both males and females.

- Chlamydia is diagnosed by cervical culture, antigen detection techniques (e.g., enzyme immunoassay, direct fluorescent antibody test), or DNA based testing (e.g., nucleic acid hybridization probe, DNA amplification). Although cervical culture for chlamydia is costly and technically difficult (it requires cell media culture because it is an obligate intracellular organism similar to a virus), it remains the gold standard and the procedure against which new diagnostic methods are measured (4). Tests for detecting chlamydial antigen have a sensitivity of approximately 60-80% (7). DNA amplification tests are the most recent development, including polymerase chain reaction (PCR) and ligase chain reaction (LCR). Both PCR and LCR are highly sensitive and specific with endocervical, urethral, and urine specimens from men and women (5,7,8). The U.S. Preventive Services Task Force strongly recommends that "all sexually active women 25 years and younger and other asymptomatic women at increased risk of infection" be routinely screened for chlamydial infection. This was based on evidence that screening women at risk reduces the incidence of PID (9). Urine-based home testing for chlamydia is expected to increase availability of low-cost screening. Shafer et al. reported that urine-based LCR screening, rather than routine pelvic examinations, was the most cost-effective strategy in asymptomatic sexually active adolescent girls because of greater acceptance of urine testing.

- A single dose of azithromycin (1 gram) has been shown to be equally effective in treating chlamydia but at a modestly greater cost than a 7-day course of doxycycline (100 mg BID).

- Azithromycin is an alternative regimen for pregnant women or patients for whom compliance is an issue. Either regimen is recommended for children older than 8 years of age. Patients should be encouraged to refer their sexual partners for diagnosis and treatment to prevent reinfection. A test of cure should be performed approximately 6 weeks after completion of treatment.