New Chlamydia Cure

Essential Guide to Cure Chlamydia

Is Chlamydia easily curable? The Answer is a big Yes! Chlamydia is one of the sexually transmitted diseases with proven treatment methods. In fact, there are two main treatment options available both of which have guaranteed results: Conventional medicine and natural medicine. These treatment options And lots of other previously unknown facts about Chlamydia have been explained at great length in this eBook. The Essential guide to Cure Chlamydia unveils the mystery of Chlamydia and methodically presents all the important bits of information that you should know about Chlamydia. The Banish Chlamydia Book tackles the sensitive subject of Chlamydia from the perspective of a professional and presents you with a goldmine of information and facts in a way that has never been done before. Read more...

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Genitourinary Chlamydial Infection

Chlamydia trachomatis infection of the genitourinary tract is the most common bacterial STD in both the United States (> 4 million new cases per year) and worldwide (> 50 million new cases per year). Many infected individuals of either sex are asymptomatic but symptomatic urethritis is common in men, whereas women may present with a mucopurulent cervicitis and acute salpin-gitis. The most serious complication of infection in men is epididymitis. Without treatment, more than 40 of infected women may develop pelvic inflammatory disease, which may lead to tubal infertility or increased risk of ectopic pregnancy. Pregnant women may transmit their infection to their babies as they pass through the infected endocervix at the time of delivery. The baby may develop a mild, neonatal conjunctivitis and or afebrile pneumonia. Infection stimulates host inflammatory and immune responses, but the immunity is of short duration and reinfection occurs frequently.

Chlamydia Trachomatis Genital Infections

Genital infection with Chlamydia trachomatis is sexually transmitted and may present in several different manners. There may be evidence of urethritis, epididymitis, cervicitis, or acute salpingitis, or the infection may be completely asymptomatic. It is therefore essential to test for Chlamydia whenever there is a suspicion of infection or when there is evidence of other sexually transmitted infection. Chlamydia also may cause conjunctivitis or pneumonia in newborns through perinatal transmission. Finally, Chlamydia causes lymphogranuloma venerum, which is discussed below. The diagnosis of Chlamydia is confirmed through either a positive culture or detection of the antigen or nucleic acid on immunofluorescence.

Chlamydia trachomatis

Chlamydia are gram-negative bacteria which have a unique developmental cycle. C. trachomatis is the only reproductive tract pathogen. The C. trachomatis serovars D-K and L,_, are involved in urogenital infections and cause in excess of 50 million cases of genital infection worldwide, including urethritis, mucopurulent cervicitis, and salpingitis (serovars D-K), as well as lymphogranulovenerium (l.GV) (serovars L,_3). The chlamydia infect primarily columnar epithelial cells where the organisms undergo a unique rep-licative cycle. Multiplication occurs in intercytoplas-mic vacuoles where they are energy parasites and use ATP producedby the host cell. The cell wall contains the major outer membrane protein (MOMP) which is responsible for the rigidity of the cell wall since chlamydia lack peptidoglycan. These molecules are responsible for the species-specificity of the organisms. The cell wall also contains a lipopolysaccharide (LPS) (Figure 2). Although nonspecific host responses to C...

Phylum Chlamydiae

Formerly grouped with the Rickettsia (see above), these non-motile obligate parasites of birds and mammals are now assigned a separate phylum comprising only five genera, of which Chlamydia is the most important. Like the Rickettsia, members of the Chlamydiae have extremely small cells, and very limited metabolic capacities, and depend on the host cell for energy generation. Unlike that group, however, they are not dependent on an arthropod vector for transmission from host to host. Chlamydia trachomatis is the causative agent of trachoma, a major cause of blindness in humans. Different strains of this same species are responsible for one of the most common forms of sexually transmitted disease. C. psittaci causes the avian disease psittacosis, and C. pneumoniae causes chlamydial pneumonia in humans as well as being linked to some cases of coronary artery disease. Representative genus Chlamydia

Description Of The Genus Taxonomy

C. pneumoniae belongs to the genus Chlamydia, which also contains the species Chlamydia trachomatis, Chlamydia psittaci, and Chlamydia pecorum. Due to the detection of new Chlamydia-like organisms and genetic analysis, in 1999 a new taxonomy was proposed which divides the common chlamydiae into the two families, Chlamydophila (including C. pneumoniae) and Chlamydia, and adds two more families containing the newly detected chlamydia-like organisms (Table 1). 1 This proposal, however, is still controversial, leading to the concomitant usage of old and new taxonomies in current publications.1-1,2-1

Pathogenetic Mechanisms

The various chlamydial infections show an analogous pattern of pathology. 25 Initially, polymorphonuclear leukocytes infiltrate the locus of infection followed by lymphocytes, macrophages, and plasma cells. A strong Th1 response seems to be of major importance for the clearance of infection. Recurrence of infection frequently occurs. This may be explained by the survival of chlamydiae inside the protected cell, possibly in the aforementioned so-called persistent state. Another possibly important factor is the ability of chlamydiae to suppress apoptosis. 26

Oligosaccharide Specific Side Chains

The O-specific side chain consists of a polymer of repeating sugars and determines the O-specificity of the parent bacterial strain (4). The O-chain can be highly variable, even within a given gram-negative bacterial species, and is responsible for the LPS molecule's ability to escape an effective mammalian antigenic response due to the number of different sugars and combinations of sugars that are presented by different strains. Serological identification of members of the family Enterobacteriaceae utilizes the variation inherent in this region of LPS and is the only means of identifying certain pathogenic strains of E. coli (12) such as E. coli O157, which has been implicated in recent outbreaks of food-borne illness (13). The O-chain generally (for the most highly studied family, Enterobactereaceae) contains from twenty to forty repeating saccharide units that may include up to eight different six-carbon sugars per repeating unit and may occur in rings and other structures. Some...

Biology Of The Organisms

Chlamydiae are obligate intracellular bacteria of limited metabolic capability, characterized by a dimorphic growth cycle. The infectious form is called the elementary body (EB) and is a condensed sporelike spheroid. The EB is metabolically inactive, consisting of a tightly compacted chromosome or nucleoid, and an outer membrane of covalently linked lipopolysaccharides. When it encounters host cells, the EB is taken in by receptor-mediated endocytosis. It has been suggested that a trimolecular mechanism is used to bridge a host receptor with a chlamydial receptor by glycosaminoglycan. 1 The man-nose receptor has also been suggested to have a role in the EB's entry into the cell. 2 The engulfed EB is enclosed in an endosome which does not fuse with a lysosome. Several hours after entering the cell, the EB converts to a metabolically active form called the reticulate body (RB) that undergoes binary fission, forming microscopically visible inclusions containing hundreds of organisms...

Genomics And Molecular Typing

The Chlamydia genome is composed of a chromosome of approximately 1.04 million base pairs and a plasmid of 7493 base pairs. 19 The trachoma and LGV biovars have high gene sequence homology and usually only single The major outer membrane protein (MOMP) gene exhibits extensive sequence variation within the serovars. The differences are mainly clustered in four regions (VD1 through 4), which form the basis of serovar differentiation, using sequencing methods and antibody typing. 20,21 The finding that the tryptophan synthase gene becomes inactivated in the ocular infection could prove to be useful in differentiating ocular chlamydial isolates from those normally causing genital tract disease. 22 The finding of polymorphism in the pmpH gene has enabled us to differentiate the trachoma from the LGV biovars. 23

Clinical Features

Chlamydia pneumoniae, which may cause wheezing associated with acute bronchitis and chronic asthma, has a 30-day incubation period and is found mainly in the elderly. Patients may be afebrile and produce minimal sputum, and laryngitis may be more common than with mycoplasmal or viral infections. Symptoms may persist even after adequate antibiotic therapy.

HandsOn versus Hands Off Management

From a medical point of view, there is contention whether veterinarians ought to treat wildlife diseases. Like all physicians, veterinarians seek good health. Colorado veterinarians treated a lungworm disease in bighorn sheep successfully. By contrast, when an epidemic of pinkeye ravaged the bighorn sheep of Yellowstone Park, authorities refused to let Wyoming veterinarians treat the disease. The welfare of the sheep, they said, required letting the disease take its course disease-resistant sheep would survive and the genetic fitness of the herd would improve. Whether the disease is introduced by humans is a factor. The Chlamydia parasite producing pinkeye was not thought to be introduced some said that the lungworm was introduced from domestic sheep, or at least that the sheep were weakened due to human disruptions, especially of their winter range. Although over half the Yellowstone herd perished by starvation and injury following partial blindness, the herd has recovered, although...

Characteristics of the organism and its antigens

The genus Chlamydia of the order Chlamydiales con Chlamydiae are obligate intracellular parasites and as such are incapable of replicating outside of a host cell, apparently depending upon the host pools for growth. They are able to infect a variety of host cells both in vivo and in vitro and survive intracellularly by preventing phagosome-lysosome fusion. Chlamydiae are unique among pathogenic bacteria in that they undergo a developmental growth cycle which consists of two stages. The elementary body (0.3 xm) is metabolically inert and is the infectious form of the organism. It attaches to the host cell via a mechanism(s) which is not yet clearly defined. Potential adhesins including the major outer membrane protein (MOMP) ( 40 kDa), a cysteine-rich 60 kDa protein (Omp2), and the 70 kDa protein have been suggested although binding via heparan sulfate and surface glycoproteins has also been proposed. After internalization within an inclusion vacuole, the elementary body differentiates...

Immune responses of the host

Because chlamydiae infect a wide array of animal species as well as different anatomical species, it is difficult to define a single pattern of host response. There are undoubtedly similarities in the effector mechanisms involved in eliminating the organism, but the critical effector mechanisms appear to vary with the site of the infection, the host species, the particular strain of a host species, and even the infecting strain or serovar of the chlamydiae. The majority of our information regarding immune responses to chlamydial infections has been derived from in vitro studies and from genital, respiratory and ocular animal models of infection which can basically be divided into protective host responses and pathologic host responses. In virtually all chlamydial infections, the initial host response is an acute inflammatory reaction consisting of polymorphonuclear leukocytes (PMNs) which can be chlamydicidal but also may be responsible for tissue pathology. The mechanism by which...

Evasive strategies by the organism

A key feature of chlamydiae is their unique replication cycle and their ability to replicate inside host cells. Obviously, growth intracellularly protects the organism to some extent from antibody although the elementary body is susceptible to neutralization. In order to survive in the host cell, the organisms have developed a mechanism for preventing phagosome-lysosome fusion. Nevertheless, the prevention of phagosome-lysosome fusion is overcome when chlamydial elementary bodies are opsonized by antibody. A potentially significant mechanism of host immune response invasion may be associated with the apparent ability of chlamydiae to remain in a persistent or latent infection state. Evidence for such a form has been provided by the detection of chlamydial DNA, RNA and antigen in the absence of organisms which could be isolated by standard technology. A variety of other data suggest that a latent form may be present. While the mechanism for latency or persistence has not been defined,...

Peptidoglycan And Lipoteichoic Acid

ABaek et al. cite that positive LAL tests have been reported with lipoteichoic acid from Streptococcus faecalis, lipoglycans from different strains of mycoplasma, cell wall fractions from Micropolyspora faeni and Chlamydia psittaci, hot phenol-water extracts of Listeria monocytogenes, and pure preparations of Plasmodium berghei.

History And Physical Examination

A pelvic examination should be performed whenever pregnancy is part of the differential diagnosis. Appearance of the cervix and the presence of discharge or blood in the vaginal vault should be noted. Wet preparation and culture for Neisseria gonorrhoeae and Chlamydia trachomatis may be indicated. Bimanual examination determines size and tenderness of the uterus and adnexa.

Physical Examination

Patients without vaginal bleeding should be examined both bimanually and with a sterile speculum. Patients presenting with vaginal bleeding should initially be evaluated with ultrasound prior to any speculum or bimanual examination to rule out placenta previa (see below). 1 If ultrasound is not available for an actively bleeding patient in labor, careful examination with sterile speculum may be performed to estimate the degree of cervical dilatation. However, no digital exam should be performed, and emergent obstetric consultation should be obtained. If spontaneous rupture of membranes (SROM) is suspected, examination with a sterile speculum should be performed and digital exam avoided, as studies have shown an increased risk of infection after a single digital examination. 2 It is particularly important to avoid digital examinations in the preterm patient where prolongation of gestation is desired. Sterile speculum examination allows confirmation of SROM, visualization of the cervix...

Pathology and Risk Factors

Most cases of PID are presumed to originate with sexually transmitted disease (STD) of the lower genital tract followed by ascending infection of the upper tract. The original STD may not be symptomatic. It is estimated that 10 to 20 percent of untreated gonococcal or chlamydial cervicitis may progress to PID. The precise mechanisms by which infection in the upper genital tract is initiated and propagated remain unclear. The female genital tract is an open system therefore a vehicle to transport potential pathogens is unnecessary. Although the cervical mucus serves as a functional barrier to ascending infection much of the time, its efficacy may be decreased by hormonal changes during ovulation and by retrograde menstruation. Bacteria may also be carried by or along with sperm into the uterus and tubes. Uterine infection is usually limited to the endometrium but may be more invasive in a gravid or post-partum uterus. Initial gonorrheal adherence is to non-ciliated cells, but it is...

Chapter References

Landers DV, Sung ML, Bottles K, et al Does addition of anti-inflammatory agents to antimicrobial therapy reduce infertility after murine chlamydial salpingitis Sex Trans Dis 20 121, 1993. 11. Sellors SW, Mahony JB, Chernesky MA, et al Tubal factor infertility An association with prior chlamydial infection and asymptomatic salpingitis. Fertil Steril 49 451, 1988. 23. Yearly DM, Greene TJ, Hobbs GD Underrecognition of cervical Neisseria gonorrheae and Chlamydia trachomatis infections in the emergency department. Acad Emerg Med 4 962, 1997. Acad Emerg Med 4 962, 1997.

Pelvic Inflammatory Disease

-Ofloxacin (Floxin, 400 mg PO twice daily) or levofloxacin (Levaquin, 500 mg once daily) with or without metronidazole (Flagyl, 500 mg twice daily) for 14 days. OR -Ceftriaxone (Rocephin, 250 mg IM), cefoxitin (Mefoxin, 2 g IM plus probenecid 1 g orally), or another parenteral third-generation cephalosporin, followed by doxycycline (100 mg orally twice daily) with or without metronidazole for 14 days. Quinolones are not recommended to treat gonorrhea acquired in California or Hawaii. If the patient may have acquired the disease in Asia, Hawaii, or California, cefixime or ceftriaxone should be used. OR -Azithromycin (Zithromax, 1 g PO for Chlamydia coverage) and amoxicillin-clavulanate (Amoxicillin, 875 mg PO) once by directly observed therapy, followed by amoxicillin-clavulanate (Amoxicillin, 875 mg PO BID) for 7 to 10 days.

Molecular Diagnostics

When a particular diagnosis is suspected, species-specific PCR assays can also be employed. Protocols have been developed for many of the agents of culture-negative IE including C. burnetti, Bartonella spp., Brucella spp., Tropheryma whipplei, Chlamydia spp. and Legionella spp. 34 .

The balance of atherosclerosis

Atherosclerosis is a dynamic balance between the destructive influence of inflammatory cells and the reactive, stabilising effects of VSMCs. The balance is biased in favour of plaque rupture by factors such as high low density lipoprotein (LDL) cholesterol, lipid peroxidation and, probably, genetic variability in the inflammatory molecules involved. For example, there is a correlation between plaque progression and a polymorphism in the stromelysin-1 gene promoter. Also, it is entirely plausible that infective agents, in particular Chlamydia pneumoniae, which can be found in plaque macrophages, may exacerbate the inflammatory process and tip the balance in favour of plaque rupture this hypothesis is currently being tested in clinical trials.

Systemic Zoonoses Infections

Zoonotic infections are caused by an extremely diverse group of microorganisms. A myriad of classification approaches focus on the pathogen, animal vector, mode of transmission, geographic range, and clinical syndrome. For emergency physicians, the best approach is one of clinical syndrome presentation, but systemic zoonoses are most difficult to diagnose. Often, they present as an undifferentiated febrile illness with pyrexia, cephalgia, myalgia, malaise, and weakness. This presentation is very common in patients in an emergency department and can indicate pathology other than that of a zoonotic infection. The concern is how to differentiate a zoonotic infection from a benign febrile illness. In this regard, risk factors for acquiring a zoonotic infection are very important, as is recognizing the seasonal variation of most zoonotic infections. In the United States, most zoonoses show an increased incidence in the spring and summer. 8 However, systemic zoonotic infections should be...

Inpatient Therapy Regimen A

Course 10-14 days (except azithromycin as noted) (levofloxacin preferred in areas with S. pneumoniae macrolide resistance) Organisms S. pneumoniae, Mycoplasma pneumoniae, Chlamydia pneumoniae (TWAR), Legionella sp., H. influenzae Organisms S. pneumoniae, H. influenzae, M. catarrhalis, Legionella sp., Chlamydia pneumoniae, coliforms Pulmonary Tuberculosis

Epidemiology and Diagnosis

Urinalysis should be performed on the urine obtained immediately after catheterization (if the patient is completely unable to void) and if anything abnormal is seen, the urine should be sent for formal microscopy and culture, and if sexually transmitted infection is suspected, particularly in younger sexually active patients, urine should also be sent for gonorrhea and chlamydia PCR testing (see also Sect. 11.2.5.2).

Approach to Infective Endocarditis at Surgery or Autopsy

Communication with the clinicians may save much frustration if the special stains are negative and the organism is known from prior cultures. This is common in patients who have received prior antimicrobial agents. In culture-negative IE, the common culprit organisms include Eikenella, Brucella, Neisseria, fungi, Chlamydia, acid-fast bacilli, or right-sided endocarditis, where the lungs filter out the organisms. HACEK (Hemophilus,

Nonstreptococcal Pharyngitis

Mycoplasma and Chlamydia have been suggested as uncommon causes of pharyngitis in adults and adolescents, however neither organism appears to be an important cause of pharyngitis in children.2 25 Many organisms viral, bacterial, fungal, and even protozoal have been associated with pharyngitis however, only a relatively few are of practical significance to the emergency evaluation of pharyngitis in the immune competent child. Recent studies have suggested that Arcanobacterium haemoliticum (formerly Corynebacterium haemoliticum) might be a cause of non-GABHS tonsillopharyngitis with or without a scarlatiniform rash. 26 Erythromycin is the treatment of choice however, no prospective therapeutic studies are available. Among bacterial pathogens, GABHS is clearly the most important, accounting for 15 to 40 percent of all pharyngeal infections in school-age children. GABHS pharyngitis is unusual in children under 3 years of age, and rheumatic fever is rare in this age group.252 N....

Infection and cardiovascular disease

Human atherosclerotic heart or cerebrovascular disease has been associated with previous exposure to the bacteria Chlamydia pneumoniae,68,69 Helicobacter pylori, or Porphyromonas gingivalis '11 and with the viruses cytomegalovirus,72 herpes simplex virus type 1 and 2,73 enteroviruses,74 or hepatitis A virus,73 but prospective studies remain limited for all but the first two infections. Overall, current data have not convincingly demonstrated an important role for infections in human CV disease. Chlamydia pneumoniae Chlamydia pneumoniae is a Gram-negative, obligate intra-cellular pathogen which has been demonstrated within human atherosclerosis.75 The interpretation of cross-sectional seroepidemiologic data has been difficult due to inter-laboratory differences in antibody measurement and cut off values, varying control groups, emphasis on multiple subgroup analyses, and incomplete ascertainment of potential confounders. A meta-analysis of 15 prospective studies which included 3169...

Disorders Involving the Foreskin

Physical examination of a child with balanoposthitis reveals redness (100 percent), swelling (91 percent), discharge (up to 73 percent in one series but usually far less common), and soreness. Systemic fever and constitutional symptoms are atypical. Any urethral discharge is swabbed for detection of streptococcal antigen, and rapid antigen assays that test negative are cultured. If the rapid streptococcal antigen test result is negative, a smear of the discharge is examined using Gram stain. The presence of polymorphonuclear leukocytes on Gram stain of a urethral smear of a prepubertal boy whose rapid test for Streptococcus pyogenes is negative should alert the physician to the possibility of a sexually transmitted infection. The emergency physician should be cognizant of the forensic diagnostic criteria for documentation of infections due to Neisseria gonorrhoeae and Chlamydia trachomatis in his or her community and should select the appropriate culture methods, DNA probes, or other...

Case presentation continued Diagnostic tests

The complete blood count and serum chemistries are all within normal limits. You calculate that the patient has a PSI score of 83 (Class III) and contemplate admitting him to the hospital versus treating him in the outpatient setting. If you admit him to the hospital, what diagnostic tests should you order Should you order a sputum Gram's stain and culture What about blood cultures Should you order tests to detect the presence of atypical pathogens (mycoplasma, chlamydia, legionella)

Blood culture negative IE

In a variable percentage of cases where there is convincing clinical and echocardiographic evidence of IE the blood cultures are negative. In such cases it is essential to send blood for antibodies to bacteria that cannot be cultured by routine blood culture methods, specifically Coxiella burnettii (Q fever), Chlamydia species, and Bartonella species. A detailed history may reveal possible clues to these infections and it is worth noting that Bartonella species cross react with Chlamydia species. Also important in blood culture negative cases is a careful history of previous antibiotic administration which may necessitate a call to the general practitioner, because if antibiotics have been given and blood culturees are negative the pathogen is likely to be an oral streptococcus. Occasionally in blood culture negative IE the pathogen can be isolated from an excised valve or embolus, or sometimes detected on microscopy of such material even if this is sterile on culture. Blood cultures...

Simultaneous Detection Of Several Mollicute Species

A variety of assays for simultaneous detection of mollicutes and other pathogens have been described, e.g., a multiplex real-time PCR assay to detect M. pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila in respiratory samples. 17 In addition, a multiplex RT-PCR for the detection of M. pneumoniae and eight additional respiratory pathogens has been constructed.1-18-1 Simultaneous detection of M. hominis together with the bacterial vaginosis-associated pathogens Lactobacillus spp. and Gardnerella vaginalis by real-time PCR has been described. 19

Clinical evaluation

A new sexual partner increases the risk of acquiring sexually transmitted diseases, such as trichomonas, chlamydia, or Neisseria gonorrheae. Trichomoniasis often occurs during or immediately after the menstrual period candida vulvovaginitis often occurs during the premenstrual period.

Diagnostic studies

A diagnosis of cervicitis, typically due to Neisseria gonorrhoeae or Chlamydia trachomatis, must always be considered in women with purulent vaginal discharge. The presence of high-risk behavior or any sexually transmitted disease requires screening for HIV, hepatitis B, and other STDs.

Atrisk women should receive additional tests

Testing for sexually transmitted diseases (eg, HIV, syphilis, hepatitis B surface antigen, chlamydia, gonorrhea) should be repeated in the third trimester in any woman at high risk for acquiring these infections all women under age 25 years should be retested for Chlamydia trachomatis late in pregnancy. E. Pap smear, urine pregnancy test, urinalysis and urine culture. Cervical culture for gonorrhea and chlamydia.

Clinical assessment at third trimester visits

Testing for sexually transmitted diseases (eg, HIV, syphilis, hepatitis B surface antigen, chlamydia, gonorrhea) should be repeated in the third trimester in any woman at high risk for acquiring these infections all women under age 25 years should be retested for Chlamydia trachomatis late in pregnancy.

Reproductive Tract Infections

The reproductive tracts of the male and female are anatomically distinct and present different sites for microbial colonization and pathogenesis. Primary infections of the reproductive tract are preceded by colonization of the tissue. A variety of microbial agents are frequently associated with the infections. These include Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Ureaplasma urea-

TABLE 903 Cost Comparison of Urinary Antimicrobial Agents 10Day Course

One should be suspicious that Chlamydia is responsible for symptoms in these settings a woman with a recent, new sexual partner a partner with urethritis examination findings of cervicitis or when there is low-grade pyuria with no bacteria seen on urinalysis. A seven-day course of doxycycline or a single dose of azthromycin is the preferred treatment.

Clinically Relevant Pilot Applications

The practical RCA potential to identify nucleic acid targets, antibodies, and antigens in clinical samples has recently been demonstrated in several feasibility studies. Specifically, the RCA-based protocol for an automated scoring of single nucleotide polymorphisms (SNPs) in a set of human genomic DNA samples with the nanogram sensitivity was developed. 15,20 Highly sensitive multiplex detection of hotspot somatic mutations present at very low abundance was also reported. 21 The RCA capability for pathogen diagnosis was convincingly proved by comparative study of RCA vs. PCR and ligase chain reaction (LCR) in detection of Chlamydia trachomatis in cervical specimens. 22 The workability of immuno-RCA for identification of allergen-specific immunoglobulins in samples from patients was shown in a microarray format. 23 In addition, RCA has been

Sexually Transmitted Disease Prophylaxis

Most of the literature demonstrates poor compliance of sexual assault patients with follow-up.7,1 l8 Therefore, prophylaxis for sexually transmitted diseases (STDs) should be given to all sexual assault victims. At a minimum, treatment for gonorrhea and chlamydia should be offered. The current guidelines from the Centers for

Prevention of STI condoms other contraceptives

Evidence exists to support the effectiveness of latex male condoms in preventing transmission of several different STI. A prospective study of the impact of condom use on acquisition of either HIV or other STI in a community in Uganda found consistent condom use to be associated with a reduced risk of acquiring HIV infection (RR 0-4 95 CI 0-2-0-9 ), syphilis (OR 0-7 95 CI 0-5-0-9 ) and gonorrhea or chlamydia (OR 0-5 95 CI 0-3-1-0 ). These effects were seen despite the fact that condom users had riskier sexual practices than non-users.138 No reduction in risk was associated with inconsistent condom use. Another prospective cohort study in a cohort of Kenyan sex trade workers found consistent condom use to be associated with a decreased risk of chlamydia (HR 0-6 95 CI 0-4-0-9 ) gonorrhea (HR 0-6 95 CI 0-4-0-8 ), genital ulcer disease (HR 0-5 95 CI 0-3-0-9 ), and PID (HR 0-6 95 CI 0-4-0-9 ), after adjustment for such covariates as place of work and number of sexual encounters per...

Classification of endometritis

Chronic endometritis in the nonobstetric population is due to infections (eg, chlamydia, tuberculosis, and other organisms related to cervicitis and PID), intrauterine foreign bodies (eg, intrauterine device, submucous leiomyoma), or radiation therapy. In the obstetric population, chronic endometritis is associated with retained products of conception after a recent pregnancy.

Sexually Transmitted Diseases

Sexually transmitted diseases are epidemiologically associated with HIV infection. Diseases that cause genital ulcers, such as herpes, chancroid, and syphilis, are believed to provide vascular portals of entry for HlV. Prevalence studies demonstrate a three- to fivefold increased odds ratio of HIV seropositivity in patients with genital ulcers.24 A similarly increased risk of HIV infection has recently been found among patients with gonorrhea and chlamydial infections. These studies, along with recent emergency-department-based prevalence surveys, have led to a recommendation for increased surveillance of sexually transmitted diseases as a means of controlling HIV transmission.2526 All patients with symptoms suggestive of sexually transmitted disease should be tested for gonorrhea, chlamydia, and syphilis. Primary (chancre) and secondary (rash, mucocutaneous lesions, and adenopathy) syphilis should be treated with a single intramuscular dose of benzathine penicillin, 2.4 million...

Macromolecular Composition

Chlamydiae have a bilayered cell membrane similar to other Gram-negative bacteria. The cell membrane contains species-specific antigens such as the major outer membrane protein (MOMP), as well as common antigens such as lipopolysaccharide (LPS). 4 Major outer membrane protein is the most prominent membrane protein making up about 60 of the surface proteins. Variable domains of this protein allow the division of C. trachomatis but not C. pneumoniae, into different serovars. In the genome of C. pneumoniae open reading frames of 21 putative polymorphic membrane proteins (Pmp) have been found. 5 For some, presence on the surface of chlamydiae and immunogenicity could be All chlamydiae share the same LPS structure 7 with a comparably low number of acylic groups, which is probably responsible for the low endotoxic activity. Lipopolysaccharide is used as a group complementation fixation antigen and recombinant ELISA-antigen for chlamydial serodiagnosis. Heat shock proteins, such as the...

Vaginal Bleeding during the Second Half of Pregnancy

Many known factors are associated with preterm labor. More common ones include PROM, abruptio placentae, drug abuse (particularly of cocaine and amphetamines), multiple gestations, polyhydramnios, cervical incompetence, and infection. Sexually transmitted diseases, including syphilis, gonorrhea, Chlamydia, and bacterial vaginosis are two to three times more likely to be associated with preterm labor. The presence of low-grade infection is felt to be one of the most important causes of PROM because bacterial colonization can reduce the tensile strength of membranes. 16 Of importance is the association of digital pelvic examinations and increased frequency of PROM. As a result of this finding, cervical examinations should not be performed from 37 weeks gestation unless the results of the examination will clearly influence clinical management. Of course, all digital examinations during pregnancy should be done using sterile gloves. In addition to the routine physical examination, the...

Gastrointestinal Complications

Anorectal disease is common in AIDS patients. Proctitis is characterized by painful defecation, rectal discharge, and tenesmus. Common causative organisms include Neisseria gonorrhoeae, Chlamydia trachomatis, syphilis, and herpes simplex. Proctocolitis includes the same symptoms in the presence of diarrhea, and multiple bacterial organisms may be responsible (most commonly Shigella, Campylobacter, and Entamoeba histolytica). Diagnostic evaluation should include anoscopy, with microscopic examination, Gram stain, and culture of pus and or stool.

Ruling out other problems

Doctors can diagnose STDs by taking a blood sample (for syphilis) or a cervical swab (for chlamydia and gonorrhea). If a teen has been sexually active, the speculum may be easier to insert into the vagina than with a teen who isn't sexually active. A Pap test is also necessary if a teen has had intercourse because the test can detect changes in the cervix that may lead to cervical cancer, which the doctor can then treat relatively early and easily.

The Female Rape Examination

EVIDENTIARY EXAMINATION41011 Informed consent is required prior to evidence collection, and a system to maintain chain of evidence should be established. Most hospitals have a prepackaged rape kit with equipment and directions. The least invasive procedures should be performed first, and unnecessary duplication of procedures should be avoided. Any particulate matter should be collected. Examination with a Wood's lamp will reveal semen stains on a patient's body these areas should be swabbed with a moistened cotton-tipped applicator. Saliva is obtained for secretor status during the oral cavity examination. Fingernail scrapings and hair samples are collected. During the pelvic examination, vaginal swabbings should be collected, along with gonorrhea and chlamydia cultures. Some physicians prefer to treat prophylactically and consider cultures irrelevant. If indicated by history, rectal or buccal swabs for sperm are collected. A rectal examination is performed if anal assault occurred....

The Male Rape Examination

Victims of oral penetration require a careful examination of the oral cavity pharyngeal edema or mucosal lacerations may be found. Swabs should be taken of buccal and gingival areas if indicated by history, and gonorrhea and chlamydia cultures of the pharynx can be taken. 6 In cases of anal assault, inspect the anus externally for signs of trauma. Up to half of victims will have minor genital injuries such as perineal contusions, anal fissures, or rectal mucosal tears. 5 Swabs from the victim's penis should be collected and may be examined for saliva if there is a history of oral copulation. If there is evidence of bleeding on rectal exam, the source should be sought via anoscopy or sigmoidoscopy. Obtain a rectal swabbing or a rectal aspirate in cases of anal assault for evidentiary purposes. 6 Sterile saline can be injected into the rectum, allowed to equilibrate, and then aspirated.

TABLE 1192 Standards for Tachypnea in Infants and Children

Typical clinical presentations have been described for some specific pathogens. Pneumonia due to S. aureus is notorious for being particularly rapid in the progression of clinical findings. Patients with B. pertussis pneumonia typically develop prodromal symptoms, including mild cough, conjunctivitis, and coryza, that lasts 1 to 2 weeks. A severe, paroxysmal cough often associated with emesis and dehydration, because coughing prevents eating and drinking, is characteristic of the catarrhal phase of pertussis infections. The inspiratory whoop is generally present only in older children. A history of maternal pelvic or conjunctival chlamydial infection is present in up to 50 percent of cases in which the infant develops C. trachomatis pneumonia. An infant with a chlamydial infection is usually afebrile, has a distinct staccato cough (i.e., short, abrupt onset), and diffuse rales on auscultation. Such infants rarely appear systemically ill. Chlamydial pneumonia in adolescents is usually...

Urinary Tract Infection

Any patient with prostatitis and or epididymoorchi-tis should be evaluated with a full sexual health history to rule out gonococcal and chlamydial urinary tract infections, as these may require slightly different treatment as well as formal contact tracing to limit the community impact of these potentially sexually transmitted infections.

Eye Discharge Redness and Conjunctivitis

Neonates with red eyes are most likely suffering from conjunctivitis. Neonatal conjunctivitis occurs in 1.6 to 12 percent of newborns during the first month of life. The chemical irritation from antimicrobial prophylaxis against bacterial infection is the most frequent cause, followed by Chlamydia trachomatis infection. Other important pathogens in this setting are H. influenzae and Streptococcus pneumoniae. Neisseria gonorrhoeae is no longer a major cause of neonatal conjunctivitis in the United States because of mandated use of neonatal ocular prophylaxis. The failure rate of antimicrobial prophylaxis is 1 percent. However, because N. gonorrhoeae can damage the eye severely, it is important to always test for this pathogen as the possible cause of neonatal conjunctivitis. Viruses rarely cause isolated neonatal conjunctivitis as an isolated problem. They usually cause conjunctivitis as part of a generalized viral syndrome affecting many organs. For example, herpes simplex virus...

TABLE 1191 Common Causes of Pneumonia

Very young infants (1 to 3 months) may present with what is often referred to as afebrile pneumonitis, or atypical pneumonia. This syndrome is typified by cough, tachypnea, and sometimes progressive respiratory distress in the absence of fever. Apneic episodes can occur with RSV, chlamydia, and pertussis. There is often radiographic evidence of bilateral diffuse pulmonic infiltrates with air trapping. The viruses listed above are the most common etiologic agents. 14 Chlamydia trachomatis is also often identified in this scenario.1 l4 Ureaplasma urealyticum, Mycoplasma hominis, Pneumocystis carinii, and B. pertussis have also been implicated in this syndrome, but the extent of their role is not as well defined.1 l5 SCHOOL AGE AND ADOLESCENCE Once children reach school age, M. pneumoniae is the most frequent bacterial cause of pneumonia.12 21 The peak incidence is between 10 and 15 years of age.22 Streptococcus pneumoniae also remains a common pathogen in this age group.1 Chlamydia...

The immune response to infections

The only mechanism for specifically preventing infection is antibody directed towards certain epitopes present on 'protective' antigens of the infectious agent. In the case of viruses, usually one or two surface proteins glycoproteins are important with bacteria, proteins or oligo polysaccharides are important. An in vitro test which measures the neutralization of infectivity is used to predict the protective effect of an antibody preparation. The epitope(s) recognized may be a linear sequence, e.g. the outer membrane protein of Chlamydia, or discontinuous but adjacent sequences, as with many viruses, such as influenza or polio, so that conformation is critical.

Mechanisms of immunopathology

See also Bacillus, infection and immunity Bacterial cell walls Bacteroides, infection and immunity Bord-etella, infection and immunity Borrelia, infection and immunity Brucella, infection and immunity Campylobacter, infection and immunity Complement, alternative pathway Chlamydia, infection and immunity Coccidioides, infection and immunity Complement, classical pathway Complement deficiencies Complement fixation test Complement, genetics Complement, membrane attack pathway Complement

Multiplex Nasba And

Greijer et al. 5 designed a multiplex real-time NASBA using molecular beacon probes labeled with three different fluorophores to quantify human cytomegalovirus (CMV) IE1 mRNA by competitive coamplification of wild-type and calibrator RNA. A simultaneous detection of late pp67mRNA in whole-blood samples of CMV-infected lung transplant patients was also obtained. Despite the somewhat lower sensitivity of the real-time NASBA compared with the conventional NASBA, the simultaneous quantification of IE1 and detection of pp67 RNA was reproducible and accurate. Loens et al. 6 also developed a multiplex real-time NASBA for the simultaneous detection of Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila RNA in respiratory specimens by using three fluorophores. They also found a slightly lower sensitivity of the multiplex real-time assay compared to the conventional ECL detection on spiked respiratory samples. Gaydos et al. 10 evaluated the performance of the APTIMA Combo 2...

Tetracyclines

Tetracycline are bacteriostatic antibiotics with a broad spectrum of activity. They have been used clinically since the 1940s and as a result acquired resistance to them is widespread. In veterinary medicine tetracyclines are used most frequently for atypical bacterial diseases due to Chlamydia (particularly in cats), Borrelia, Rickettsia, Haemobartonella and Mycoplasma. Tetracyclines are the drugs of choice for Erlichia canis and Rickettsia rickettsii infections.

Therapy

The recommendations for antibiotic treatment of C. pneumoniae infections are based on in vitro studies, animal experiments, case reports, and experiences with the treatment of other chlamydial infections. Therapeutic regimens for C. pneumoniae include doxycycline, erythromycin, or clarithromycin for 2-3 weeks or a 5-day course of azithromycin. For recurrent infection a second course with a different antibiotic is recommended. There are singular publications of development of resistance in C. trachomatis, but resistance in C. pneumoniae has never

Trachoma

Trachoma remains the most common cause of preventable blindness in the world. It is found in communities with poor hygiene or sanitation facilities and inadequate access to potable water. The infection is endemic in many tropical and subtropical areas, especially countries in northern and southern Africa, the Middle East, and on the Indian subcontinent. It is transmitted by direct contact or by flies, which act as mechanical vectors. Trachoma presents as conjunctivitis of both the palpebral and bulbar conjunctivae, followed by the formation of lymphoid follicles the sequelae, entropion, and trichiasis arise as a result of conjunctival scarring, causing corneal damage. Repeated infection and associated bacterial superinfection can result in visual impairment and blindness. The conjunctival epithelium of infected children is the most important reservoir of infection in the affected communities. High chlamydial loads occur in very young children and have been directly correlated with...

Diagnostic Tests

A definitive diagnosis of chlamydial genital infection can be established solely on the basis of laboratory testing. In the past, the standard laboratory test for C. trachomatis genital infections was isolation of the causative organisms in cell culture. By definition, this test is 100 specific but it lacks sensitivity when compared to the newer NAATs. Several commercial tests are currently available (Table 1), and new tests are being developed every year. 8-11 The Roche Amplicor and Cobas Amplicor CT NG tests use polymerase chain reaction 12 the Becton-Dickinson B-D-

Immunologic studies

In all of the above the antibody patterns were specific to patients with endocarditis and the level of IgM correlated with disease. The resolution of infection by appropriate antibiotic therapy saw a rapid reduction in IgM levels when samples were measured weekly. The description of these patterns has led to a further study in which they were used as a way of diagnosing culture-negative endocarditis. This is a syndrome in which the patient has proven endocarditis but consistently negative blood cultures. Negative serology was found in 28 patients where the diagnosis of endocarditis was rejected or, if proven, staphylococcal, yeast, gram-negative, systemic lupus erythematosus, due to Q fever or Chlamydia psittaci or nonbacterial thrombotic. Positive serology was found in 27 of the 34 patients where the response to antibiotics suggested streptococcal or enterococcal infections. In 22 of these there was objective evidence of endocarditis. Positive serology was also found in three out of...

Term Neonates

Children 1 month-5 years old -Cefuroxime (Zinacef) 100-150 mg kg day IV IM q8h OR -Ampicillin 100 mg kg day IV IM q6h AND -Gentamicin (Garamycin) or Tobramycin (Nebcin) 7.5 mg kg day IV IM q8h (normal renal function). -If chlamydia is strongly suspected, add erythromycin 40 mg kg day IV q6h.

Clinical Findings

Laboratory evaluation in the ED should always include a pregnancy test. The possibility of ectopic pregnancy or septic abortion must be considered, and concurrent pregnancy will affect the treatment for PID. Saline-treated and potassium hydroxide-treated wet preparations of vaginal secretions should be examined for leukorrhea (more than 1 pmn epithelial cell), trichomoniasis, and clue cells. The absence of leukorrhea has been suggested to be a good negative predictor for PID. 13 Endocervical swabs should be sent for culture and can be gram stained for gonococci. DNA probes for gonorrhea and chlamydia are useful, if available. Elevated white blood cell counts, sedimentation rates, and or C-reactive protein support the diagnosis of PID. The syphilis test for rapid plasma reagin should be performed. Patients should be counseled on testing for hepatitis and HIV. HIV-infected women with PID may present with more severe symptoms and more frequent coinfection with Candida and human...

Epididymitis

1-3 days following a course of reassurance, scrotal elevation, and nonsteroidal anti-inflammatories. There is usually no role for antibiotics however, if the urine is positive for bacteruria, an appropriate course of antimicrobial therapy is obviously warranted. The most common underlying bacterium in prepubertal children is Escherichia coli however, Chlamydia trachomatis must also be considered in sexually active postpu-bertal boys.

Pneumonia

The lungs are the most common site of infection in neonates. Group B streptococcus is the most common cause of lower respiratory infection in newborns. The infection is most likely acquired in utero from a contaminated amniotic environment. Affected infants frequently develop fulminant illness within hours of birth. Other common bacterial pathogens in newborns and infants include Streptococcus pneumoniae and Haemophilus influenzae serotype B. Chlamydial pneumonia usually occurs after 3 weeks of age and is accompanied by conjunctivitis in 50 percent of cases. Infants with bacterial as well as viral pneumonia may present with fussiness, stuffy nose, decreased appetite, abrupt onset of high fever (< 39 C), nasal flaring, grunting, retraction, tachypnea, and tachycardia. Patients with chlamydial pneumonia are usually afebrile and tachypenic and have a prominent cough. Respiratory syncytial virus (RSV), adenovirus, and parainfluenzavirus can also cause pneumonia in otherwise well...

Radiographs

Differentiating the various microbiologic causes of pneumonia is often more difficult. Typical patterns of clinical presentation and epidemiologic data on incidence have been described above but often overlap. Radiographically, viral pneumonias tend to appear as diffuse interstitial infiltrates, frequently with hyperinflation, peribronchial thickening, and areas of atelectasis. Bacterial pneumonias tend to have lobar or segmental consolidation. Pneumatocele formation and a combination of pneumothorax and empyema are highly suggestive of S. aureus infection. However, bacterial pneumonias with perihilar interstitial and nodular patterns on radiographs have been reported.3 34 Chlamydia trachomatis infections usually lead to hyperexpansion and diffuse alveolar or perihilar interstitial infiltrates. Radiographic patterns in M. pneumoniae infections are variable. Lower-lobe streaky or patchy infiltrates are the most common, but many other patterns are possible, including lobar infiltrates...

Laboratory Studies

The white blood count is usually elevated with a left shift in bacterial pneumonia, especially early in the illness. 35 Typically, viral, chlamydial, and pertussis pneumonias produce lymphocytosis. However, it is not unusual for viral pneumonia to initially provoke a significant polymorphonuclear cell response. In patients with mycoplasmal pneumonia, the total white blood count and differential count are usually normal, but the erythrocyte sedimentation rate may be elevated. Chlamydial infections or parasitic infections often produce eosinophilia. Cultures of the nasopharynx and throat for viral pathogens, chlamydia, pertussis, and mycoplasma often reveal the causative agent in patients with pneumonia caused by these organisms. Bacterial cultures of these regions have no diagnostic value. 6 Fluorescent antibody tests for C. trachomatis and B. pertussis are preferable to culture in some settings. Rapid viral antigen tests exist for a number of organisms, including RSV and influenza....

Serology

Serologic testing can be useful in determining the cause of IE in true culture-negative cases, which are usually caused by organisms that are difficult to culture including Coxiella burnetti, Bartonella spp., Chlamydia spp., and Legionella species. The immune response to C. burnetti involves development of antibodies against phase 1 and phase 2 antigens. In acute infection, IgM and IgG antibodies develop against phase 2, and only IgM antibodies develop against phase 1. Endocarditis is a manifestation of chronic Q fever, which is characterized by high anti-phase 1 IgG titers. Positive Q fever serology, defined as a phase 1 IgG titer of > 1 800, is listed as one of the major modified Duke criteria. A Bartonella antibody titer of 1 1,600 has been reported to have a positive predictive value of 88 for Bartonella IE 34 . However, titers may not be reproducible given lot-to-lot variability of antigen preparations used for testing. Patients with Bartonella infection also frequently develop...

Virulence Factors

Clinical diagnosis of chancroid is unreliable because of similarities of the clinical presentation of different etio-logic agents of GUD, the presence of mixed infections, and atypical ulceration due to long-standing disease. 8 Next to H. ducreyi, causative pathogens of GUD are herpes simplex virus type 2 (HSV-2) and type 1 (HSV-1) and the bacteria T. pallidum (TP), which cause syphilis, and Chlamydia trachomatis, which cause lymphogranuloma venereum. In about 20-40 of GUD cases none of these pathogens are found despite use of the most sensitive assays. 9,10 Coinfection of H. ducreyi and HSV occurs commonly in the tropics. 6

STDs without Lesions

CHLAMYDIAL INFECTIONS Chlamydia trachomatis is an obligate intracellular bacterium that has a growth cycle that alternates between two morphologic forms. Chlamydial infections present with a wide spectrum of clinical manifestations. In men, infection causes urethritis, epididymitis, and proctitis. In women, urethritis, cervicitis, and PID are common. In both sexes, the prevalence of asymptomatic infection is high, ranging from 3 to 5 percent in the general population to 15 to 20 percent among individuals attending STD clinics. Patients with gonorrhea have an even higher incidence of concomitant chlamydial infection. Untreated chlamydial infections are thought to be an important cause of infertility in women. The incubation period is 1 to 3 weeks, and symptoms, if present, can range from mild vaginal burning or irritation to peritonitis.

Psittacosis

Psittacosis is a disease found among bird handlers that presents with fever, chills, headache, photophobia, cough, and myalgia. In the laboratory, any of the following methods will confirm the diagnosis (1) isolation of Chlamydia psittaci from respiratory secretions, (2) a fourfold or greater increase in antibodies against C. psittaci by complement fixation or microimmunofluorescence (MIF) to a reciprocal titer of at least 32 between paired acute and convalescent serum samples, or (3) detection of serum IgM to C. psittaci by MIF to a reciprocal titer of at least 16.

Pcrldr And GapLCR

A major problem of the LCR reaction is joining of blunt end duplexes to each other and to themselves, all of which can serve as templates for further amplification, although no real target DNA is present in the original sample 7 and this poses significant limitations on the sensitivity of LCR. 6 To overcome this problem, several modifications have been developed, including a combined PCR LDR method and Gap-LCR (G-LCR). In PCR LDR, the amplification step for LDR is PCR utilizing outside primers and employing only one pair of adjacent probes to detect the proper sequence in the PCR produced. This procedure does not produce double-stranded oligonucleo-tides to blunt end ligate. 4 A recent study showed that PCR LDR was more accurate than FISH in the quantification of HER2 neu gene copy numbers. 19 Gap-LCR is a version of LCR where the probes are not adjacent but are separated by one to three bases on both the sense and antisense strand. A nonstrand displacing thermostable DNA polymerase,...

Investigations

Difficult to isolate in culture such as Coxiella burnetii (Q fever), Tropheryma whipplei, Brucella, Mycoplasma, Chlamydia, Histoplasma, Legionella and Bartonella, and HACEK organisms (Haemophilus aphrophilus, Actinobacillus actino-mycetemcomitan, Cardiobacterium homini, Eikenella corroden, and Kingella kingae). Blood cultures may need to be incubated longer (up to 21 days) for some of these organisms (e.g., HACEK group). Other tests, such as polymerase chain reaction on valve tissue, may need to be performed for C. burnetii and Bartonella. In other instances special media may need to be used. Antibody titers for C. burnetti can also be helpful. Local microbiology expertise should be sought when an atypical organism is suspected to be the cause of IE.

Vaccination

Basic vaccination programs for goats include vaccinations against Clostriduim perfringens types C and D and Clostridium tetani. 1'3'6 There are multivalent clostridial vaccines, including those against black leg, malignant edema, and bacillary hemoglobinuria, used in goats. These are unusual diseases in goats, and vaccination to prevent them is usually not economically justified. Vaccines against contagious ecthyma, caseous lymphadenitis, and Chlamydia are incorporated in the vaccination program if there is a need in that particular herd. 1-3,5

Serologies

Serologic tests for Mycoplasma pneumoniae include enzyme-linked immunosorbent assay (ELISA), complement fixation, and cold agglutinins for Chlamydia pneumoniae they include microimmunofluorescence and for Legionella spp. immunofluorescence assay.66 However, results from serologic tests to diagnose atypical pathogens often return after the patient has been discharged and do not impact the treatment plan.67 This is particularly challenging for SARS where real-time diagnosis is needed.

Inpatients

A secondary analysis of a prospective study (N 385) investigated patients with atypical-pathogen pneumonia to identify associated clinical factors, rates of co-infection with other respiratory pathogens, and the relationship between mortality and macrolide-based treatment. Treatment for atypical agents (i.e. at least one dose of a macrolide or tetracycline) was provided for only seven (54 ) of 13 patients with Legionella pneumophila, nine (57 ) of 15 patients with Chlamydia spp., and two (66-7 ) of three patients with M. pneumoniae. Furthermore, only four (9-3 ) of 29 patients with atypical pathogens received at least 1 week of treatment for atypical agents. However, none of the 29 patients with atypical pneumonia died, including those who did not receive antibiotics with atypical activity.67

Recommendations

Health care providers should maintain a low threshold for the diagnosis of PID, and sexually active young women with lower abdominal, adnexal, and cervical motion tenderness should receive empiric treatment. The specificity of these clinical criteria can be enhanced by the presence of fever, abnormal cervical vaginal discharge, elevated ESR and or serum C-reactive protein, and the demonstration of cervical gonorrhea or chlamydia infection.

Eosinophils

Although monocytes and macrophages play crucial roles in host defense against facultative and obligate intracellular parasites, their nonoxidative mechanisms for killing intracellular organisms or inhibiting their replication are not well understood. This may be due to the inherent complexity of the mononuclear phagocyte system, interspecies differences and the multiple effects of activation, differentiation and immunoregulatory cytokines on macrophage composition and function. It may also be that macrophages follow 'just-in-time' manufacturing principles for producing antimicrobial peptides and proteins, rather than stockpiling them in cytoplasmic granules in the manner of neutrophils and eosinophils. Strong evidence supporting the existence of nonoxidative antimicrobial mechanisms has been adduced from studies with diverse organisms, including Toxoplasma gondii, Trypanosoma cruzi, Chlamydia psittaci, Candida albicans, Aspergillus fumi-gatus, Mycobacterium bovis and Mycobacterium...

Pharyngitis

Causal agents of pharyngitis include viruses, bacteria, fungi, and parasites ( Tab-le .2.3.5.-.1). Most often, viruses are the culprits. Rhinovirus and adenovirus are the most common, but Epstein-Barr virus, herpes simplex virus, influenzavirus, parainfluenzavirus, and coronavirus are responsible for about 5 percent of the infections. 2 Fungal and, very rarely, parasitic infection occurs in an immunocompromised host, but such infections are rarely found in immunocompetent patients. The most common bacteria causing pharyngitis include Streptococcus pyogenes group A b-hemolytic streptococcus (GABHS) , Mycoplasma, Chlamydia, Neisseria, and Corynebacterium. GABHS is responsible for 15 percent of all pharyngitis and is associated with significant nonsuppurative sequelae in the form of acute rheumatic fever (ARF) or acute glomerulonephritis (AGN).2 Because of the sequelae associated with GABHS, there is a greater emphasis placed on early diagnosis and treatment of this causal agent. This...

Application

The practical uses of RAM assay to detect target nucleic acids in clinical samples have been demonstrated in several studies (Fig. 2). Zhang et al. have applied the RAM assay to detect Chlamydia trachomatis, a leading cause of sexually transmitted disease (STD) in the United States, in cervical specimens collected in PreservCyt cytological solution. 10 They demonstrated the RAM assay can detect as few as 10 C. trachomatis elementary bodies in less than 2 hr, comparable with those of Amplicor PCR and ligase chain reaction (LCR), and they further tested 30 clinical specimens and detected all positive samples confirmed by PCR and LCR. The RAM assay can be an alternative to PCR and LCR to detect sexually transmitted agents because of its simplicity and isothermal amplification nature. Furthermore, it is possible to screen simultaneously cervical intraepithelial lesions and to detect STD agents in a single collection vial. Zhang et al. have also successfully applied the RAM assay for...

Bullous Myringitis

MICROBIOLOGY Although bullous myringitis was originally associated with influenza epidemics, since then numerous pathogens have been implicated in its etiology, including Mycoplasma pneumoniae, Chlamydia psittaci, and numerous viral pathogens. Herpes simplex has not been implicated as a causative agent.21

Myocarditis

Myocarditis is the term used to indicate acute infective, toxic or autoimmune inflammation of the heart. Reversible toxic myocarditis occurs in diphtheria and sometimes in infective endocarditis when autoimmune mechanisms may also contribute. Persistent viral infection of the myocardium was first demonstrated a decade ago.1 Slow growing organisms such as chlamydia and trypanosomal infection in Chagas' disease are causes of chronic myocarditis. Non-infective causes in sarcoidosis and the collagen vascular diseases need to be sought. Myocarditis can be caused by many different viruses and the microbial pathogenesis may be complex. Most cases of myocarditis with onset in otherwise healthy people probably have an infectious origin, although the pathogenesis is not yet fully understood (such as the finding of a link between chlamydia and heart disease through antigenic mimicry). In western countries enteroviruses, especially coxsackie B 1-6 serotypes, are the most frequent, and the recent...

Crohns Disease

Crohns' disease is a chronic inflammation that can involve any part of the gastrointestinal system from the mouth to the anus. In the small intestine, Crohns' disease typically affects the ileum however, other parts of the small intestine can be affected. It produces a segmental, full-thickness inflammation, with formation of fissures and abscesses, fistulas, and fibrotic stenoses, and it may follow a chronic relapsing course. The cause of Crohns' disease is unknown, although several hypotheses such as infections (mycobacteria, chlamydia, and viruses) have been put forward. The discovery of susceptibility gene variants in NOD2 CARD-15 suggests predisposition to the disease by abnormalities of the intra-cellular sensors of bacterial lipopolysaccharide and their effect on the caspase and nuclear factor- B signalling pathways and macrophage function.

Presentation

There are numerous serotypes of chlamydia generally speaking. Serotypes A-K cause more localized GU manifestations and the L serotypes a systemic disease (lymphogranuloma venereum). Serotypes A-K of Chlamydia trachomatis can have the following presentation Serotypes L1-L3 of Chlamydia trachomatis cause lymphogranuloma venereum. This is a systemic disease that can present in several forms Chlamydia is twice as common as gonorrhea. Fitz-Hugh-Curtis perihepatitis presents as right upper quadrant pain, fever, nausea, and vomiting. It can be caused by gonorrhea or chlamydia.

Polyanionic polymers

Within the viral gp120 that bind to HIV-1 co-receptors on target cells. In addition to their projected potential for blocking sexual transmission of HIV-1, many of the polyanionic polymers have excellent laboratory profiles as potent inhibitors of other STIs such as herpes simplex virus, human papilloma virus, gonorrhea, and Chlamydia. The anticipated performance of these candidate products to block sexual transmission of both HIV-1 and other STIs associated with increased transmission of HIV-1 was a major factor in their advancement to clinical trials. styrene sulfonate (N-PSS), a long chain sulfonated polymer (751 kDa) SPL7013 (VivaGel ), a synthetic sulfonated lysine dendrimer (16.58 kDa), and mandelic acid condensation polymer (SAMMA), a sulfuric acid-treated mandelic acid (256 Da) that has previously been tested clinically as a urinary antiseptic during bladder irrigant procedures 46, 47 . Each of these compounds has reported activity against one or more non-HIV-1 STIs such as...

Conjunctivitis

NEONATAL CONJUNCTIVITIS (OPHTHALMIA NEONATORUM) Newborns with conjunctivitis require a careful history to elicit exposure to herpesvirus, Chlamydia, or Neisseria gonorrhoeae in the maternal birth canal. Conjunctivitis occurring in the first 28 days needs to be cultured with immediate Gram staining followed by the institution of both topical and systemic antibiotics. A careful examination to rule out systemic infection is essential. Infection with N. gonorrhoeae and herpes simplex virus (HSV) II can occur in the first 3 days of life the former can cause rapid corneal ulceration and perforation if not treated. HSV II can occur in the first 3 to 15 days, and concomitant systemic involvement can be devastating. Chlamydia, Haemophilus, Staphylococcus aureus, and Streptococcus pneumoniae usually present 5 to 10 days after delivery. Treatment for N. gonorrhoeae consists of topical erythromycin ointment qid and systemic ceftriaxone (1 g IM or 30 to 50 mg kg per day IV). HSV II requires...

Vaginal Bleeding

The differential diagnosis of vaginal bleeding during the first trimester should include abortion (most common cause), ectopic pregnancy, and GTD. Other causes include implantation bleeding (physiologic) seen around or just after the time of expected menses due to the burrowing of the embryo into the highly vascular decidual tissue, cervical ectropion, and cervicitis due to infection from gonorrhea, Chlamydia, or bacterial vaginosis.

Urethral Syndrome

The term urethral syndrome describes a complex of symptoms involving the lower urinary tract including urinary frequency, urgency, dysuria, suprapubic discomfort, postvoid fullness, incontinence, and or dyspareunia with no objective findings of urologic pathology. Grandmultiparity, delivery without episiotomy, two or more abortuses, and pelvic relaxations appear to predispose.3 The true incidence of urethral syndrome in the United States among adult women is unknown, as is the cause. The most widely accepted etiology of this enigmatic syndrome is an inflammatory process. Other etiologies include psychogenic factors, Chlamydia or Mycoplasma infection, atrophic urethritis in the perimenopausal postmenopausal patient, fastidious organism bacterial infection, urethral stenosis and or spasm, allergy, neurogenic, and trauma during intercourse. The diagnosis is one of exclusion founded on a thorough history and physical examination, followed by urine microscopic examination and culture....

Diagnosis of STI

Sexually transmitted pathogens cause several common syndromes. Infection with Neisseria gonorrhoea or Chlamydia trachomatis frequently results in urethritis, cervicitis, or the constellation of symptoms and signs that suggest the presence of pelvic inflammatory disease. HSV, Treponema pallidum, and Haemophilus ducreyi are common agents of ulcerative genital disease, while vaginal discharge is commonly caused by infection with Trichomonas vaginalis or Candida spp. or by bacterial vaginosis. However, STIs other than HIV infection may also result in chronic medical illness or long-term complications. Genital chlamydia infection is associated with tubal infertility,13 ectopic pregnancies,14,15 and chronic pelvic pain.16,17 HPVs are strongly associated with cervical and anal cancers.18,19 Infection of pregnant individuals with sexually transmitted pathogens may increase the risk of premature delivery, and may cause severe illness in the newborn.20-25 Table 10.2 Use of urine leukocyte...

Longterm infections

Chlamydia trachomatis is an obligate intracellular bacterium which infects mucosal epithelia. Serovars A, B, Ba and C cause trachoma, an important cause of preventable blindness in developing countries. Infection is transmitted directly from eye to eye. In See also Adenovirus, infection and immunity Chlamydia, infection and immunity Eye, autoimmune disease Herpes simplex virus, infection and immunity Mycobacteria, infection and immunity Onchocerciasis Paramyxoviruses, infection and immunity Picornavirus, infection and immunity Staphylococcus, infection and immunity.

Barrier Methods

Barrier methods include mechanical barriers such as male and female condoms, the female diaphragm and cervical cap, and chemical barriers such as spermicidal products. Nonprescription barrier contraceptives are an important contraceptive option because of their wide availability, relative ease of use, and acceptably high efficacy when used correctly and consistently. While the contraceptive efficacies of the various barrier methods when used alone are comparable to each other (typically about twenty pregnancies per one hundred women per year), their use in combination adds significantly to their effectiveness. In addition, male latex condoms and female vaginal sheaths, when used consistently and correctly, provide a high degree of protection against both the acquisition and the transmission of a number of sexually transmitted pathogens, including gonorrhea, chlamydia, syphilis, and some viral pathogens, including hepatitis B virus and HIV (human immunodeficiency virus), the virus that...

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