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Chlamydia Infection

Chlamydia infection is a general term that may refer to a variety of diseases triggered by bacterial pathogens belonging to the family of Chlamydiaceae. Genital infections with Chlamydia trachomatis serovars D and respiratory disease induced by Chlamydophila pneumoniae are the most common types of Chlamydia infection in industrialized nations. Other conditions triggered by Chlamydiaceae include, but are not limited to, trachoma, lymphogranuloma venereum, and ornithosis.

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Presentation

Chlamydia infection may comprise distinct organ systems, and clinical symptoms largely depend on the causative agent.

C. trachomatis serovars D-K account for a major disease burden and most commonly affect the urogenital tract [1] [2]. Patients may develop symptoms several weeks after contracting the respective sexually transmitted infection: Dysuria due to chlamydial urethritis may be described and may be accompanied by mucopurulent or purulent vaginal/penile discharge. Bleeding after sexual intercourse has also been reported. Upon anal exposure, patients may develop rectal inflammation manifesting in pain, tenesmus, discharge, and hemorrhages. Oral sex may predispose to pharyngeal infections [3].

Another very common pathogen is Cp. pneumoniae, biovar TWAR. It is spread through aerosolized respiratory secretions and induces acute respiratory infections manifesting in sinusitis, laryngitis, pharyngitis, bronchitis, and atypical pneumonia. Patients with preexisting respiratory disorders may experience an exacerbation of symptoms. In sum, the severity of symptoms developed after an incubation time of about three weeks varies largely and ranges from asymptomatic or mild disease to severe community-acquired pneumonia. Most infections follow a mild course. Symptoms like fever, chills, myalgia, hoarseness, and cough are non-specific and don't allow for the clinical confirmation of Cp. pneumoniae infection [4]. Other triggers of respiratory infections have to be considered during the workup, including Cp. psittaci [5].

Both C. trachomatis and Cp. pneumoniae have been related to reactive arthritis, as have other intracellular pathogens and Gram-negative bacteria. Affected individuals usually have a history of genital or respiratory Chlamydia infections, and they may present with arthralgia, joint swelling, joint effusion, stiffness, and reduced motion range. Contrary to what had initially been assumed, Chlamydia-induced reactive arthritis is associated with persistent, intraarticular infections, and Chlamydia may be detected in synovial fluid samples [6] [7]. Furthermore, Cp. pneumoniae has been related to atherosclerosis, but its role in the pathogenesis of this cardiovascular disease remains poorly defined [8].

Other Chlamydiaceae may provoke conjunctivitis (C. trachomatis serovars A-C and Cp. felis), inguinal lymphadenitis, proctitis, and proctocolitis (C. trachomatis serovars L1, L2, and L3), and abortion (Cp. abortus).

Fever
  • Symptoms that may occur include: a painful or burning sensation when urinating, an unusual discharge from the penis, testicular pain or swelling, or fever.[en.wikipedia.org]
  • Though it’s possible to contract it without knowing it, symptoms of a chlamydia infection in your throat include cough, fever, and sore throat.[healthline.com]
  • In men: Epididymitis - infection of the tubes that carry sperm to the testicles, which can result in fever, scrotal pain and swelling.[avert.org]
  • Symptoms in women include Abnormal vaginal discharge, which may have a strong smell A burning sensation when urinating Pain during intercourse If the infection spreads, you might get lower abdominal pain, pain during sex, nausea, or fever.[nlm.nih.gov]
  • Chlamydial pneumonia can occur at one to three months of age, manifesting as a protracted onset of staccato cough, usually without wheezing or fever.[web.archive.org]
Hoarseness
  • Symptoms like fever, chills, myalgia, hoarseness, and cough are non-specific and don't allow for the clinical confirmation of Cp. pneumoniae infection.[symptoma.com]
Rectal Pain
  • Infection of the anus (rectum) presents with rectal pain, discharge, or bleeding. Self-Care Guidelines Seek medical care if you suspect chlamydia. Avoid any sexual activity until a week after treatment is finished.[skinsight.com]
  • If symptoms of a rectal infection do occur, however, they may include rectal pain, discharge, or bleeding. Additionally, women can develop a throat infection if they perform oral sex on someone with the infection.[healthline.com]
  • pain, discharge, and/or bleeding.[nlm.nih.gov]
  • When contracted anally, the disease may manifest in rectal pain, tenesmus, discharge, and hemorrhages.[symptoma.com]
  • Persons who have receptive anal intercourse may acquire chlamydial infection in the rectum, which can cause rectal pain, discharge, or bleeding. Chlamydia can also be found in the throats of women and men having oral sex with an infected partner.[emedexpert.com]
Rectal Discharge
  • Features of chlamydial infection in the bottom can include soreness and rectal discharge – but there could be no symptoms. Oral sex. Chlamydia can also be transmitted by oral sex.[netdoctor.co.uk]
  • Anal exposure may result in proctocolitis, rectal discharge, pain, constipation, or tenesmus. 1 If left untreated, it may lead to chronic symptoms, including fistulas and strictures.[aafp.org]
Hypertrophic Pyloric Stenosis
  • pyloric stenosis (IHPS) has been reported in infants aged Although data on the use of azithromycin for the treatment of neonatal chlamydia infection are limited, available data suggest a short course of therapy might be effective ( 530 ).[cdc.gov]
Joint Effusion
  • Affected individuals usually have a history of genital or respiratory Chlamydia infections, and they may present with arthralgia, joint swelling, joint effusion, stiffness, and reduced motion range.[symptoma.com]
Myalgia
  • Symptoms like fever, chills, myalgia, hoarseness, and cough are non-specific and don't allow for the clinical confirmation of Cp. pneumoniae infection.[symptoma.com]
Pelvic Pain
  • To avoid severe sequelae such as female infertility, ectopic pregnancy, neonatal infection, such as ophthalmitis, and chronic pelvic pain prompt and appropriate antibiotic treatment seems the best policy in treating this group of patients.[ncbi.nlm.nih.gov]
  • Symptoms may include intermenstrual or postcoital bleeding; an odourless, mucoid vaginal discharge; pelvic pain; or dysuria. In men, chlamydia infection can occur in the urethra, causing a penile discharge.[bestpractice.bmj.com]
  • Untreated infections in women can result in pelvic inflammatory disease, infertility, ectopic pregnancy, and chronic pelvic pain. In men, the infection can be associated with urethritis, epididymitis, and, in men who have sex with men, proctitis.[nejm.org]
  • Untreated chlamydia can lead to other health problems: In women: Pelvic inflammatory disease (PID) – infection of the uterus, ovaries and fallopian tubes that causes pelvic pain and fever.[avert.org]
  • Women are usually asymptomatic, although vaginal discharge, dysuria, increased urinary frequency and urgency, pelvic pain, dyspareunia, and symptoms of urethritis may occur.[merckmanuals.com]
Vaginal Discharge
  • Specimens for microscopy were taken from the endocervix and urethra as well as the vaginal discharge, and bacterial vaginosis was examined for.[ncbi.nlm.nih.gov]
  • Symptoms may include intermenstrual or postcoital bleeding; an odourless, mucoid vaginal discharge; pelvic pain; or dysuria. In men, chlamydia infection can occur in the urethra, causing a penile discharge.[bestpractice.bmj.com]
  • Women with infection of the genital tract (cervix, the mouth of the womb; or urethra, the urinary opening), may have a yellow-white vaginal discharge, spotting between periods, fluid discharge from the urethra, or burning with urination.[skinsight.com]
  • If females have symptoms, they may include vaginal discharge and painful urination. When and for how long is a person able to spread chlamydia? From the time a person is infected with chlamydia, he or she can spread the disease.[health.ny.gov]
  • Symptoms in women include Abnormal vaginal discharge, which may have a strong smell A burning sensation when urinating Pain during intercourse If the infection spreads, you might get lower abdominal pain, pain during sex, nausea, or fever.[nlm.nih.gov]
Dysuria
  • Women are usually asymptomatic, although vaginal discharge, dysuria, increased urinary frequency and urgency, pelvic pain, dyspareunia, and symptoms of urethritis may occur.[merckmanuals.com]
  • Symptoms may include intermenstrual or postcoital bleeding; an odourless, mucoid vaginal discharge; pelvic pain; or dysuria. In men, chlamydia infection can occur in the urethra, causing a penile discharge.[bestpractice.bmj.com]
  • In men, the infection usually is symptomatic, with dysuria and a discharge from the penis. Untreated chlamydial infection in men can spread to the epididymis.[web.archive.org]
  • Patients may develop symptoms several weeks after contracting the respective sexually transmitted infection: Dysuria due to chlamydial urethritis may be described and may be accompanied by mucopurulent or purulent vaginal/penile discharge.[symptoma.com]
Urethral Discharge
  • A urethral discharge can be elicited by compressing the urethra during the pelvic examination. Urinalysis usually will show more than five white blood cells per high-powered field, but urethral cultures generally are negative.[web.archive.org]
  • Common symptoms of STIs include vaginal discharge, urethral discharge or burning in men, genital ulcers, and abdominal pain. Scope of the problem STIs have a profound impact on sexual and reproductive health worldwide.[who.int]
  • Urethritis was defined by the presence of dysuria or urethral discharge. References 1. Centers for Disease Control and Prevention (CDC), Sexually Transmitted Disease Surveillance, 2000, Atlanta: CDC, 2001. 2.[guttmacher.org]
Premature Ejaculation
  • Ejaculation in Chronic Prostatitis Patients: Results from a Cross‐Sectional Study, The Journal of Sexual Medicine, 11, 12, (3085-3092), (2014).[doi.org]

Workup

Chlamydia infection is ideally diagnosed by providing evidence for the presence of Chlamydiaceae in the affected organ system. Mucosal swabs are generally analyzed to this end, but other types of samples may be used depending on the clinical presentation. In the workup of genital infections, first-void urine samples may replace endocervical, urethral, and vaginal swabs, while placenta and fetal tissues should be examined in the case of an abortion possibly caused by Cp. abortus [9]. Molecular biological techniques are commonly applied to detect nucleic acids of Chlamydiaceae [3]. Such assays yield reliable results within a short period of time and have been shown to be more sensitive than bacteriological cultures [10]. Nevertheless, Chlamydiaceae may be grown in host cells, which are ideally collected alongside the specimens for microbiological analysis [4]. These samples may subsequently be subjected to microscopic and immunohistochemical analyses.

There is a variety of serological assays available to confirm prior exposure to Chlamydiaceae. These tests may be specific at the family, species, or serovar level. It should be noted, though, that previous exposure to ubiquitous pathogens like C. trachomatis serovars and Cp. pneumoniae is not sufficient to prove a causal relation.

Treatment

Antibiotic therapy is the mainstay of treatment. Uncomplicated urogenital infections should be treated with azithromycin or doxycycline. The former is administered as a single dose of 1 g, while doxycycline is applied at a dose of 100 mg, twice daily for seven days. Both regimens are equally effective and should be followed in both sexual partners, if feasible, to prevent reinfections [3]. Still, reinfections are likely and retesting for C. trachomatis is strongly recommended about 3 months after the completion of treatment [7].

Besides the aforementioned compounds, other macrolide and tetracycline antibiotics may be employed in the management of Chlamydia infection. For instance, erythromycin and tetracycline have been recommended to treat respiratory infections triggered by Cp. pneumoniae [4]. If contraindicated or ineffective, fluoroquinolones may be used [3].

Prolonged treatment is required to combat Chlamydia-induced reactive arthritis. Affected individuals are typically treated for six months and may receive azithromycin, doxycycline, or rifampicin plus azithromycin or doxycycline [3] [7]. Infectious elementary bodies are not affected by antibiotics, so an interruption of antibiotic therapy may be considered after three months of treatment - to induce persistent bacteria to return to active reproduction [6].

Prognosis

Antibiotic resistances have rarely been reported, and if patients comply with treatment recommendations, they use to respond well to therapy. Thus, the prognosis of treated patients is very good. Long-term sequelae are feasible, though, if the infection persists. The majority of asymptomatic patients remains undiagnosed, and irreversible tissue damage may occur until complications arise. In this context, the generation of a protracted inflammatory response in the female reproductive organs may cause tubal scarring and occlusion, leading to infertility in women [11]. Male infertility has similarly been related to Chlamydia infection [12].

Etiology

Chlamydia infection may refer to distinct entities caused by different bacterial pathogens. In this context, the family of Chlamydiaceae comprises two relevant genera, namely Chlamydia (C.) and Chlamydophila (Cp.). The following representatives of these genera have been shown to be pathogenic in humans [13]:

  • C. trachomatis, serovars A-C, which constitute biovar trachoma, etiologic agent of ocular infections referred to as trachoma
  • C. trachomatis, serovars D-K, provoke chlamydial urethritis, one of the most frequent bacterial sexually transmitted diseases
  • C. trachomatis, serovars L1, L2, and L3, which correspond to biovar LGV, causative agent of lymphogranuloma venereum
  • Cp. pneumoniae, biovar TWAR, accounts for respiratory infections
  • Cp. abortus, a zoonotic agent that may cause abortion in humans, primarily known as a trigger of endemic abortion in ruminants [9]
  • Cp. felis, a zoonotic pathogen that may cause conjunctivitis in humans and cats [14]
  • Cp. psittaci, causative agent of ornithosis in mammals including humans, as well as psittacosis in birds, mainly in parrots [5]

Epidemiology

By far the most common species causing chlamydia infection are C. trachomatis and Cp. pneumoniae. Other Chlamydiaceae are mainly of veterinary importance but may trigger zoonoses like ornithosis.

C. trachomatis is the causative agent of one of the most common sexually transmitted diseases. According to estimates published by the World Health Organization, about 4.2% of women worldwide are infected with this pathogen. Regional values range from 1.8% to 7.6%, with the highest prevalence rates reported in the Americas and Western Pacific Region. Similar regional trends have been observed in the male population, but the overall prevalence among men is significantly lower. It amounts to 2.7% on a global scale. The annual incidence of C. trachomatis infection ranges from 33-38 per 1,000 persons [15].

Similarly, Cp. pneumoniae is widely spread throughout industrialized and developing countries. Serological evidence of prior exposure to the pathogen is found in about 50% of young adults and >75% of the elderly [4]. Due to the large share of asymptomatic and mildly symptomatic cases, the overall incidence of Cp. pneumoniae infections is difficult to establish.

Incidence and prevalence of zoonotic Chlamydia infections vary largely. In most countries with surveillance programs, <1 case of ornithosis per 1,000,000 inhabitants is reported annually [16]. The occurrence of hot spots has been confirmed occasionally but may be more common than generally assumed [17]. Mild cases may not be reported, thereby distorting the epidemiological picture. The same may apply to other forms of Chlamydia infection, which are supposed to be even rarer. Furthermore, the complete host range of Chlamydiaceae is not yet known and new species are likely to be described in the near future [18]. It can only be speculated whether these species account for or contribute to known entities.

Sex distribution
Age distribution

Pathophysiology

Chlamydiaceae are obligate intracellular bacteria characterized by a unique biphasic developmental cycle. This cycle comprises the conversion of infectious elementary bodies to replicative reticulate bodies and vice versa. Elementary bodies infect epithelial cells by binding to pathogen recognition receptors and inducing endocytosis. Once inside the host cell, elementary bodies differentiate into reticulate bodies. This is a prerequisite for the replication of Chlamydiaceae. Reticulate bodies are metabolically active, grow, divide by binary fission, form microcolonies, and eventually condense to form elementary bodies [4]. The latter are released upon cell lysis and may subsequently infect other cells of the same host or be transmitted to another one.

Prevention

The risk of contracting Chlamydia infection via the sexual route may significantly be diminished by the correct and consistent use of condoms, the reduction of the number of sexual partners, and abstinence [3]. Of note, the infectivity of genital secretions is maintained during a short symptomatic and a much longer asymptomatic period, so the absence of symptoms does not protect from spreading the disease. The overall infectious period for C. trachomatis has been estimated to about one year [19].

Summary

Chlamydia infection is caused by Chlamydiaceae spp. All members of this family are obligate intracellular bacteria that share common biological features, e.g., a reproductive cycle comprising infectious, extracellular elementary bodies and replicative, intracellular reticulate bodies [20]. The family of Chlamydiaceae comprises two genera, namely Chlamydia and Chlamydophila, and there are at least five human pathogen species [13] [21]:

These species are implied in a variety of disorders that are most reliably diagnosed by the genetic confirmation of the causative agent. Distinct species may trigger similar diseases (e.g., atypical pneumonia may be caused by Cp. pneumoniae and Cp. psittaci), and different conditions may be attributed to the same species (e.g., C. trachomatis may cause genital infections and conjunctivitis).

This article aims at summarizing the diversity of Chlamydia infections but will focus on genital infections with C. trachomatis and respiratory infections induced by Cp. pneumoniae. With regards to other entities related to Chlamydiaceae, the interested reader is referred to the respective articles available on this platform.

Patient Information

Chlamydia infection is a general term referring to a variety of diseases caused by bacteria belonging to the family of Chlamydiaceae. In this context, Chlamydia trachomatis, Chlamydophila pneumoniae, and - in rare cases - Chlamydophila felis, Chlamydophila abortus, and Chlamydophila psittaci should be considered as potential triggers. Accordingly, Chlamydia infection may comprise distinct organ systems, and clinical symptoms largely depend on the causative agent:

While it is increasingly difficult to prevent infections with Chlamydophila pneumoniae, safer sex may considerably reduce the risk of contracting those types of Chlamydia trachomatis that are related to genital infections. While the majority of Chlamydia infections is readily treatable, asymptomatic disease is common and rarely diagnosed. Persistent infections, however, may have long-term consequences, such as irreversible scarring of the Fallopian tubes and infertility in women and men. Similarly, ocular infections should be treated as soon as possible to prevent permanent vision loss.

References

Article

  1. Jenkins WD, Zahnd W, Kovach R, Kissinger P. Chlamydia and gonorrhea screening in United States emergency departments. J Emerg Med. 2013; 44(2):558-567.
  2. van Lier A, McDonald SA, Bouwknegt M, et al. Disease Burden of 32 Infectious Diseases in the Netherlands, 2007-2011. PLoS One. 2016; 11(4):e0153106.
  3. Mishori R, McClaskey EL, WinklerPrins VJ. Chlamydia trachomatis infections: screening, diagnosis, and management. Am Fam Physician. 2012;86(12):1127-1132.
  4. Burillo A, Bouza E. Chlamydophila pneumoniae. Infect Dis Clin North Am. 2010; 24(1):61-71.
  5. Knittler MR, Berndt A, Bocker S, et al. Chlamydia psittaci: new insights into genomic diversity, clinical pathology, host-pathogen interaction and anti-bacterial immunity. Int J Med Microbiol. 2014;304(7):877-893.
  6. Rizzo A, Domenico MD, Carratelli CR, Paolillo R. The role of Chlamydia and Chlamydophila infections in reactive arthritis. Intern Med. 2012;51(1):113-7.
  7. Zeidler H, Hudson AP. New insights into Chlamydia and arthritis. Promise of a cure? Ann Rheum Dis. 2014; 73(4):637-644.
  8. Honarmand H. Atherosclerosis Induced by Chlamydophila pneumoniae: A Controversial Theory. Interdiscip Perspect Infect Dis. 2013; 2013:941392.
  9. Longbottom D, Coulter LJ. Animal chlamydioses and zoonotic implications. J Comp Pathol. 2003; 128(4):217-244.
  10. Bachmann LH, Johnson RE, Cheng H, et al. Nucleic acid amplification tests for diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis rectal infections. J Clin Microbiol. 2010;48(5):1827-1832.
  11. Schuchardt L, Rupp J. Chlamydia trachomatis as the Cause of Infectious Infertility: Acute, Repetitive or Persistent Long-Term Infection? Curr Top Microbiol Immunol. 2018; 412:159-182.
  12. Gimenes F, Souza RP, Bento JC, et al. Male infertility: a public health issue caused by sexually transmitted pathogens. Nat Rev Urol. 2014; 11(12):672-687.
  13. Rohde G, Straube E, Essig A, Reinhold P, Sachse K. Chlamydial zoonoses. Dtsch Arztebl Int. 2010; 107(10):174-180.
  14. Hartley JC, Stevenson S, Robinson AJ, et al. Conjunctivitis due to Chlamydophila felis (Chlamydia psittaci feline pneumonitis agent) acquired from a cat: case report with molecular characterization of isolates from the patient and cat. J Infect. 2001;43(1):7-11.
  15. Newman L, Rowley J, Vander Hoorn S, et al. Global Estimates of the Prevalence and Incidence of Four Curable Sexually Transmitted Infections in 2012 Based on Systematic Review and Global Reporting. PLoS One. 2015; 10(12):e0143304.
  16. Harkinezhad T, Verminnen K, De Buyzere M, Rietzschel E, Bekaert S, Vanrompay D. Prevalence of Chlamydophila psittaci infections in a human population in contact with domestic and companion birds. J Med Microbiol. 2009; 58(Pt 9):1207-1212.
  17. Branley JM, Weston KM, England J, Dwyer DE, Sorrell TC. Clinical features of endemic community-acquired psittacosis. New Microbes New Infect. 2014;2(1):7-12.
  18. Joseph SJ, Marti H, Didelot X, Castillo-Ramirez S, Read TD, Dean D. Chlamydiaceae Genomics Reveals Interspecies Admixture and the Recent Evolution of Chlamydia abortus Infecting Lower Mammalian Species and Humans. Genome Biol Evol. 2015;7(11):3070-3084.
  19. Althaus CL, Turner KM, Schmid BV, Heijne JC, Kretzschmar M, Low N. Transmission of Chlamydia trachomatis through sexual partnerships: a comparison between three individual-based models and empirical data. J R Soc Interface. 2012; 9(66):136-146.
  20. Hooppaw AJ, Fisher DJ. A Coming of Age Story: Chlamydia in the Post-Genetic Era. Infect Immun. 2015; 84(3):612-621.
  21. Bachmann NL, Polkinghorne A, Timms P. Chlamydia genomics: providing novel insights into chlamydial biology. Trends Microbiol. 2014; 22(8):464-472.

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Last updated: 2019-07-11 21:14