Chlamydial Infection - a comprehensive view
The majority of women with Chlamydia infection are without symptoms. Many men are asymptomatic as well. Regular screening for Chlamydia, as recommended by the USPSTF, can significantly reduce the incidence of pelvic inflammatory disease (PID), one of the most serious sequelae of untreated infection. In women with untreated Chlamydia infection, in addition to PID, tubo-ovarian abscess, tubal scarring and ectopic pregnancy, and infertility can all result. As previously mentioned, regular screening is currently recommended for all sexually active women under age 24, all pregnant women under 24, and at-risk pregnant and nonpregnant women over 24. Chlamydia testing can be performed on several liquid-based Papanicolaou (Pap) tests. Endocervical swabs for nucleic acid amplification are acceptable when a conventional Pap smear is being used. Given the recent liberalization of recommendations about Pap testing for women under 21 years of age, urine nucleic acid amplification is a readily...
After an incubation period of 1 to 3 weeks, males with chlamydial urethritis may present with a thin, often clear urethral discharge and or dysuria. Up to 10 of these men may be asymptomatic. Women may also develop urethritis, which may only cause dysuria with pyuria but not bacteruria and can be misdiagnosed as a urinary tract infection. Chlamydial cervicitis in women is almost always asymptomatic. Women may develop pelvic inflammatory disease with upper genital tract infection. Men may develop epididymitis.
Chlamydial infections are a leading cause of ophthalmia neonatorum. There is a high incidence of this type of infection because of the frequent exposure to the newborn during delivery and the lack of effective prophylaxis. The onset of infection can occur at any time. The typical picture is a mild unilateral or bilateral mucopurulent conjunctivitis with moderate
Chlamydia infections during pregnancy, including those that are asymptomatic, can be treated with azithromycin, amoxicillin, or erythromycin to reduce the risk of preterm labor and neonatal infection (Table 47-8). 8-30 Doxycycline should be avoided in pregnant women owing to known teratogenic effects when used after 16 weeks of
Screening and treatment for Chlamydia infection in high-risk, asymptomatic women has been demonstrated to reduce significantly their incidence of PID after 12 months of follow-up. There have been no published studies of the effectiveness of screening women not at increased risk. Although treatment of men eradicates infection, there is no evidence that screening men reduces transmission, acute infection, or sequelae in women. Potential harms of screening and treatment include the effects of false-positive test results, patient anxiety, unnecessary antibiotic use, and adverse drug reactions (Meyers et al., 2007).
In 2006, infection with Neisseria gonorrhoeae was the second most common reportable disease in the United States, with a reported rate just under 119 cases per 100,000 population. Unlike Chlamydia infection, which has seen increasing rates over the past decade, rates of N. gonorrhoeae infection have been stable since the mid-1990s. Infection rates are highest among girls and women between ages 15 and 24 years and men between 20 and 24 years. Although rates are increasing among white and Hispanic populations, the rate among blacks in 2006 (663 cases per 100,000) was almost 20 times higher than for whites. Other risk factors for infection include a history of previous gonorrhea or other STI, new or multiple sexual partners, inconsistent condom use, sex work, and drug use. The prevalence of gonorrhea varies widely among regions of the United States, with the South and Midwest having notably higher rates than the Northeast and West, and among communities (CDC, 2007).
Less common ulcerating STIs include lymphogranuloma venereum (LGV) and granuloma inguinale (Figure 16-5). LGV causes regional adenopathy and often an ulcer at the point of entry. Rectal LGV may cause a proctocolitis with anal pain, discharge, bleeding, and diarrhea. LGV is caused by Chlamydia trachomatis serotypes and can be detected by testing swabbed material from open lesions or aspirates from lymph nodes with culture, DFA, or nucleic acid detection. Treatment is noted above (Table 16-10). Granuloma inguinale, caused by Klebsiella granulomatis, is rare in the United States and causes progressive ulcerative disease of the genitals.
Routine fetal heart auscultation, urinalysis, and assessment of maternal weight, blood pressure, and fundal height generally are recommended, although the supportive evidence varies (Kirkham et al., 2005). Women should be offered ABO and Rh blood typing and screening for anemia during the first prenatal visit. Genetic counseling and testing should be offered to couples with a family history of genetic disorders, a previously affected fetus or child, or a history of recurrent miscarriage. All women should be offered prenatal serum marker screening for neural tube defects and aneu-ploidy. Women at increased risk for aneuploidy should be offered amniocentesis or chorionic villus sampling (CVS). Counseling about the limitations and risks of these tests, as well as their psychologic implications, is necessary. Folic acid supplementation beginning in the preconception period and early pregnancy reduces the incidence of neural tube defects. Laboratory testing during the first prenatal visit...
Urethritis may present as a urethral discharge or simply dys-uria. Family physicians should suspect urethritis in patients with symptoms of UTI, pyuria, presence of leukocyte esterase, and negative urine culture. N. gonorrhoeae and C. trachomatis are the most important causative organisms. Gonococcal urethritis is typically symptomatic. Chlamydia causes most cases of nongonococcal urethritis (CDC, 2006). Various treatment options exist (see Table 40-10). Fluoroquinolones are no longer recommended as a treatment option due to resistance rates (del Rio et al., 2007). Patients with gonorrhea who are not ruled out for chlamydia should be treated for it because co-infection is common (CDC, 2006).
Gay men sometimes report difficulty in obtaining adequate health care caused by providers' bias and fear of discrimination. Any male patient who presents for treatment of urethri-tis should be asked about participation in oral-genital sex or receptive anal intercourse, because some treatment regimens for urethral gonorrhea and chlamydia are not effective against pharyngeal and anal infections. A careful exposure history should be taken, even if the patient self-identifies as heterosexual, because some heterosexual-identified men may have same-gender sexual experiences.
In contrast to gonococcal conjunctivitis, which has declined in the developed world, chronic follicular conjunctivitis and acute conjunctivitis in newborns have been on the increase along with other sexually transmitted diseases. Chlamydia trachomatis serotypes D through K is now the most common sexually transmitted infection in the developed world (Insler 1987). It causes not only conjunctivitis in newborns and adults but also genital tract infections. In adults symptoms of chronic follicular conjunctivitis include foreign body sensation, tearing, redness, photophobia, and lid swelling. In newborns inclusion conjunctivitis or blennorrhea of the newborn usually appears 5 to 14 days after birth, since the baby acquires the chlamydial infection during its passage through the birth canal. Descriptions of infants with purulent ophthalmia - abnormal discharges of mucus some days after birth - may suggest this disease. Because purulent ophthalmia usually does not lead to severe visual loss,...
Infective causes for sperm oxidative stress include local infections such as Male Accessory Gland Infection (MAGI) or systemic infections such as Hepatitis, HIV, TB and Malaria. Leukocytes are professional producers of free radicals, releasing ROS at relatively high concentrations to destroy infective pathogens. Therefore, it is not surprising that activation of the immune system within the male reproductive tract is likely to result in sperm oxidative damage. Up to 50 of men will experience prostatitis at some point in their lives, with prostatitis becoming chronic in 10 of men 50 . Bacteria responsible for prostate infection may originate from the urinary tract or can be sexually transmitted 51 . Typical non-STD pathogens include streptococci (Streptococcus viridans and S. pyogens), coagulase-negative staphylococci (Staphylococcus epidermidis, S. haemolyticus), gram-negative bacteria (Escherichia coli, Proteus mirabilis) and atypical mycoplasma strains (Ureaplasma urealyticum,...
Lyss S, Kamb M, Peterman T, et al. Chlamydia trachomatis among patients infected with and treated for Neisseria gonorrhea in sexually transmitted disease clinics in the United States. Ann Intern Med. 2003 139 178-185. 12. Young F. Sexually transmitted infections. Genital chlamydia Practical management in primary care. J Fam Health Care 2005 15 19-21.
Moxifloxacin, gemifloxacin) (see Table 82-3).32 The causative organisms for CAP are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and atypical organisms (Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila). S. pneumoniae accounts for 60 of the deaths associated with CAP, and is resistant to penicillin and macrolides (multidrug resistant S. pneumoniae MDRSP) 30 to 40 of the time.32,33 Controversy exists relating to the clinical significance of this resistance for nonmeningitis infections. Respiratory fluoroquinolones (levofloxacin, moxifloxacin, and gemifloxacin) may be utilized for MDRSP however, clinical data have not shown them to be superior to cephalosporins plus a macrolide or doxycycline. The Centers for Disease Control and Prevention recommends reserving
This 2830-g female infant was born at 38 2 7 weeks to a 47-year-old G1 P0-0-0-0 mother by NSVD (normal spontaneous vaginal delivery) at 1 35 am on 1 16 2008. The pregnancy was complicated by chronic hypertension, for which the mother was treated with Aldomet (methyldopa). The mother is O+ and hepatitis B surface antigen, syphilis, HIV, and Chlamydia negative. Amniocentesis at 14 weeks revealed a 47,XX trisomy 21 karyotype. The mother continued the pregnancy, despite the amniocentesis results, explaining that she ''wanted to know what I would be facing beforehand.'' At 36 weeks, a vaginal culture for group B streptococcus was negative. Mother went into labor at 38+ weeks she developed malignant hypertension unresponsive to magnesium sulfate, so a C-section (cesarean section) was performed under general anesthesia after 17 hours of labor. Rupture of membranes was at delivery. The baby's Apgar scores were 5 and 8, with points off for tone, reflex, respiratory effort, and color at 1...
Chlamydia, herpes, syphilis, human papillomavirus) are more common in SUD patients than in the general population, and patients should be screened routinely. Other infections common in IV drug users include skin abscesses, cellulitis, infectious endocarditis, and pneumonia.
Atherosclerosis is a common disease and a major risk factor for stroke. Its etiology can largely be explained by the classic risk factors (age, gender, genetic predisposition, hypertension, diabetes, hypercholesterolemia, diet, smoking, low physical activity, etc.). Additionally, pathogens such as Helicobacter pylori, cytomegalovirus, herpes simplex virus and Chlamydia pneumoniae have been proposed to be associated with atherosclerosis. Most studies on the infectious etiology of atherosclerosis have been focused on Chlamydia pneu-moniae (for review see Watson and Alp 5 ). C. pneumoniae is an obligate intracellular bacterium and usually causes mild upper respiratory tract infections, and occasionally pneumonia. Exposure to this agent is common and by the age of 20 years 50 of individuals are seropositive.
PGDs are of importance where a high volume of patients will present for a specific treatment, but it is unknown who will attend. Examples of this are the supply of the antibiotic azithromycin for people with chlamydia infection at a sexually transmitted diseases (STD) clinic, or the supply of vaccines at a travel clinic.
Parental therapy is continued until the patient is pain-free, afebrile for 24-48 h, the leukocyte count returns to normal, and oral liquids and solids are tolerated. There is no need to continue with oral antibiotics after stopping parental treatment. Patients with positive cultures for chlamydia should receive a 7-day course of azithromycin or doxycycline, even if there is good response to the initial empirical antibiotic regimen. Azithromycin and doxy-cycline, although good antichlamydial agents, are bacteriostatic drugs and should not be used as first-line antimicrobial agents to treat endometritis.
Initial laboratory studies should include CD4+ CD8+ counts (absolute cell counts and percentages) and, if possible, HIV-1 RNA levels. CBC with differential count, electrolyte and liver function panel, hepatitis screen, reactive protein reagin (RPR) or VDRL, anti-toxoplasma IgG antibodies purified protein derivative (PPD) with anergy panel, and chest x-ray should also be obtained. Ophthalmological, dental, and gynecological examinations (including a PAP smear, chlamydia and gonorrhea studies) should be pursued. The stage of HIV-1 infection will then determine follow-up, prophylaxis, and therapeutic strategies.
Ceftriaxone 125 mg intramuscularly or ciprofloxacin 500 mg orally or cefixime 400 mg orally or levofloxacin 250 mg orally plus treatment for chlamydial infection if it has not been ruled out. MSM or Heterosexuals With a History of Recent Travel* Ceftriaxone 125 mg intramuscularly or cefixime 400 mg orally plus treatment for chlamydial infection if it has not been ruled out. Uncomplicated Gonococcal Infection of the Pharynx* Ceftriaxone 125 mg intramuscularly or ciprofloxacin 500 mg orally plus treatment for chlamydial infection if it has not been ruled out. MSM or Heterosexuals With a History of Recent Travel* Ceftriaxone 125 mg intramuscularly plus treatment for chlamydial infection if it has not been ruled out. Coverage for Coinfection With Chlamydia trachomatis Azithromycin 1 g orally as a single dose or doxycycline 100 mg orally twice daily for 7 days.
Trachoma (also called granular conjunctivitis and Egyptian ophthalmia) has been defined as a contagious keratonconjunctivitis caused by Chlamydia trachomatis (serotypes A, B, Ba, and C). It is characterized by the formation of inflammatory granulations on the inner eyelid, severe scarring of the eye Ophthalmia neonatorum is a term used for eye disease in newborns since the Greeks, but vague historical references make it difficult to identify the actual disease. Blindness in newborns may be due to various infections acquired in the birth canal. Before the twentieth century, ocular gonorrhea may have been the major cause of blindness in newborns, but in the twentieth century (at least in the industrialized nations) chlamydial infection is the most common type of ophthalmia neonatorum (Thygeson 1971 Rodger 1981 Insler 1987).
A variety of other rare infections with the gonococcus have been documented. Adults occasionally develop gonococcal conjunctivitis, with a potential for more serious ocular involvement, through direct (i.e., hand-to-eye) contact with infected secretions. Gonococcal endocarditis, myocarditis, hepatitis, and meningitis may occur as part of the disseminated syndrome. Perihepatitis (termed the Fitz-Hugh-Curtis syndrome) has traditionally been attributed to gonococcal infection in the upper right quadrant, usually in association with classic PID. Recent evidence, however, indicates that the syndrome is more often associated with chlamydial, rather than gonococcal, infection.
Treatment topical and systemic antibiotics - to be given over a period of weeks. All in-contact cats need to be treated to control further outbreaks. Chlamydia is sensitive to disinfectants, so kennels must be thoroughly cleaned. Prevention Vaccination of animals in contact with Chlamydia carriers.
Patients with pneumonia can present with cough, fever, dyspnea, or malaise. Cough can be productive or nonproductive, and blood tinged or with frank blood. The clinical presentation of pneumonia in otherwise healthy patients often follows one of two patterns that can indicate the cause. A rapid onset of cough and shortness of breath with a high fever can indicate classic bacterial lobar pneumonia such as that produced by a pneumococcus. Physical findings once consolidation occurs include decreased breath sounds, dullness to percussion, and egophony on the affected side. The white blood cell (WBC) count is often elevated ( 15,000), with a predominance of neutrophils. A smoldering onset with low-grade fever and fewer constitutional symptoms can indicate an atypical pneumonia, which can be caused by organisms such as respiratory viruses or by Mycoplasma, Chlamydia, or Legionella species. In infants, potential causes of pneumonia are tied to specific periods in the first few months of...
Nucleic acid amplification tests (NAATs), such as polymerase chain reaction (PCR) and transcription-mediated amplification (TMA), can identify chlamydial infection in asymptomatic women (nonpregnant and pregnant) and asymptomatic men. NAATs have high sensitivity ( 80 ) and specificity ( 99 ) and can be used with urine, vaginal, and cervical swabs (Meyers et al., 2007). It is important to remember that even with a test with high sensitivity, in a low-prevalence population, a positive screening result is more likely to be a false positive than an actual case. When screening a 20-year-old woman with no other risk factors other than her young age, given a prevalence rate of 1 , the positive predictive value for a positive chlamydial screen with an NAAT is only 47 . Point-of-care tests are becoming available that can be conducted in the office setting in about 30 minutes. Their sensitivity remains substantially lower than for laboratory-conducted NAATs, although their specificity is high...
Short, simple depression screening instruments accurately identify patients who can benefit from early identification and treatment. Using local health departments as a resource, a family physician's knowledge of his or her patient population is the best guide to developing a risk-based screening strategy for sexually transmitted infections (e.g., HIV, chlamydia, gonorrhea). Diabetes screening should be offered to adults with hypertension. All women age 65 years or older and women age 60 or older with risk factors should be routinely screened for osteoporosis. Intensive behavioral counseling about consuming a healthy diet should be offered to all adults with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic diseases. Prevention plays a critical role in caring for all age groups. Special concerns about children, pregnant women, and elderly persons include ethical issues, competing causes of mortality, and the role of shared decision making.
Antibiotic therapy for men with MAGI may reduce the inflammatory stimulus causing neutrophils and macrophages to release ROS in close proximity of sperm. Two studies have now confirmed the ability of antibiotic treatment to reduce sperm oxidative stress and subsequently improve sperm quality 168, 169 . One relatively large and well-conducted study randomised men with Chlamydia or Ureaplasma infection to either 3 months of antibiotics or no treatment 169 . Compared to the controls, the antibiotic treated group exhibited a significant fall in seminal leukocytes and ROS production at 3 months, an improvement in sperm motility and a significant improvement in natural conception. A smaller study using only 10 days of antibiotic treatment did not produce any significant decline in seminal leukocyte count or improvement in motility 62 . While this study did not measure ROS production in semen, it is likely that prolonged courses of antibiotics (3 months) are required to completely irradiate...
Abstract Male accessory gland infections (MAGI) are included among the conventional diagnostic categories recognized to cause male infertility. They constitute a clinical model of oxidative stress for a number of considerations (a) some uropathogens or etiological agents of sexually transmitted diseases (Chlamydia trachomatis, Ureaplasma urealyticum) by themselves, microbial products, and or toxic metabolites may contribute to an overproduction of reactive oxygen species (ROS) (b) the canalicular spread of pathogens to one or more male accessory glands causes a further increase of ROS production, since they become the site of inflammation as shown by the presence of morphostructural abnormalities. The infecting pathogen triggers an inflammatory process which includes a series of multiple persistent components, such as kinetic of leukocyte subpopulations, pattern of cytokine production, and morphostructural abnormalities of the infected glands. This results in a final impairment of...
The response of the genito-urinary tract to the invasion of microorganisms and inflammation is an important component of the immune defense system 10 . The reaction is considered to be extremely similar to the reaction in other body sites 11 . Therefore, a semen analysis can serve as a valuable diagnostic tool in assessing possible disorders of the male genital tract and the secretory pattern of the male accessory sex glands 9 . The most common infective bacteria in mixed accessory gland infection (MAGI) are Chlamydia trachomatis (41.4 ), a common sexually transmissible pathogens in sexually active young men, followed by Ureaplasma urealyticum (15.5 ) and Mycoplasma hominis (10.3 ) 12,13 as well as Neisseria gonorrhoeae, an additional marker of seminal tract infection 8, 14 . In men experiencing infertility issues, the presence or colonization of U. urealyticum and M. hominis in semen is a common finding 14 and semen cultures of bacterial pathogens remain the most common diagnostic...
Genitourinary tract infections may be caused by a number of bacteria, including Escherichia coli, Klebsiella pneumonia, Enterococcus faecalis, Chlamydia trachomatis, and Ureaplasma urealyticum 36 , Genitourinary tract infection may originate in the kidney, bladder, epididymis, prostate, or urethra, and includes diagnoses such as prostatitis, epididymitis, orchitis, pyelonephritis, bacterial cystitis, and urethritis. These types of infections are associated with inflammation and increased leukocytes in the seminal fluid, which may lead to increased levels of ROS and OS 8 ,
Patients infected with gonorrhea often are coinfected with Chlamydia trachomatis and should receive therapy to eradicate both organisms concurrently. While fluoroquinolones and broad-spectrum cephalosporins have been effective in the treatment of gonorrhea, resistant strains of N. gonorrhoeae have still emerged. In the far-eastern countries, as many as 50 of gonococcal strains exhibit decreased susceptibility to fluoroquinolones. Though ciprofloxacin is still an option for treatment, go-nococcal resistance to ciprofloxacin is usually indicative of its resistance to other fluoroquinolones. As a result, monitoring for fluoroquinolone resistance is now essential to ensure proper treatment and to ascertain the maximum time that this class may be employed as a treatment option.
Unprotected sex is a major risk factor for contracting STIs. Although the purulent discharge is consistent with gonorrhea infection, a positive urethral swab coupled with an incubation period consistent with gonorrhea confirms the diagnosis. A serologic test for syphilis should be performed on all pregnant women at the first prenatal visit and a RPR should be performed at the time pregnancy is confirmed and treatment provided. Although the patient has confirmed gonorrhea, infection with Chlamydia trachomatis occurs commonly in this setting. Additionally, pregnant patients should be tested for this infection during the first prenatal visit and treated appropriately. Further, the presence of a rash could possibly suggest that the patient may have contracted syphilis previously, potentially indicative of secondary syphilis.
Pharyngitis is usually a component of upper respiratory infections caused by rhinovir-us, coronavirus, adenovirus, influenza virus, parainfluenza virus, or Epstein-Barr virus. Group A Streptococcus, or S. pyogenes, is the most common bacterial cause of acute pharyngitis, responsible for 15 to 30 of cases in children and 5 to 10 of adult infections.33, 6 Infection is most common in late winter and early spring and is spread easily through direct contact with contaminated secretions. Clusters of infection are common within families, classrooms, and other crowded areas. Less common causes of bacterial pharyngitis are Corynebacterium diphtheriae, groups C and G streptococci, Chlamydia pneumoniae, Mycoplasma pneumoniae, and Neisseria go-norrhoeae. This section will focus on group A streptococcal disease in which antimicrobial therapy is indicated.
To cause infection in the respiratory tract. Therefore, it is not surprising that S. pneumoniae is the predominant bacterial pathogen associated with CAP. The second most common pathogen is one of the atypical organisms, Mycoplasma pneumoniae. Nontypeable Haemophilus influenzae intermittently colonizes about 80 of the population and the incidence of permanent colonization increases in chronic obstructive pulmonary disease (COPD) patients and those with cystic fibrosis. Therefore the likelihood of nontypeable H. influenzae causing pneumonia increases in COPD patients. Moraxella catarrhalis is a more common cause of pneumonia in the young children and the elderly. Chlamydia pneumoniae and Legionella pneumophila are less frequent causes than the other bacterial and atypical organisms. Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is associated with necrotizing and severe pneumonia in healthy children and young adults. Less than 2 of all CA-MRSA infections are...
Trachoma is the leading cause of infectious blindness in the world. It is endemic in areas of Africa, Asia, Latin America, the Middle East, and aboriginal communities in Australia. Trachoma is a chronic follicular conjunctivitis caused by Chlamydia trachomatis and is prevalent in populations with limited access to adequate sanitation and clean water. It is spread from person to person through ocular and respiratory secretions with flies constituting a major means of transmission.
Lymphogranuloma venereum (LGV) is caused by a serotype of Chlamydia trachomatis and is primarily a disease of lymphatic tissue. Initially, LGV causes a painless genital ulceration that is not noticed by the patient more than 90 of the time. Patients usually present with painful, nonfluctuant inguinal adenopathy, which is often but not always unilateral. Lymphadenopathy may lie above and below the inguinal ligament, causing the groove sign suggestive of this diagnosis. The enlarged lymph nodes may spontaneously open into draining sinus tracts to the skin.
The most frequent acute infection in reproductive age, nonpregnant women is pelvic inflammatory disease. It is an enormous public health problem. In 1998, direct costs were estimated to be around 1.9 billion (11). Chlamydia is the most common infectious disease reported to health departments among young, sexually active females. Chlamydia and Neisseria gonorrhea are among the major causes of cervicitis and pelvic inflammatory disease. The U.S. Centers for Disease Control and Prevention, however, recommends coverage for a mix of pathogens not just limited to these two organisms. Chlamydia and Neisseria gonorrhea are included as well as a mix of anaerobes, gramnegative facultative bacteria, and streptococci.
Gram stain and culture of conjunctival scrapings should be done if gonococcal or chlamydial conjunctivitis is suspected, as these types require systemic as well as topical therapy. Most other bacterial conjunctivitis responds well to fluoroquinolone drops or polymyxin trimethoprim drops topically, and patients with these
Neonatal conjunctivitis comprises a number of entities, including chemical irritation caused by antimicrobial prophylaxis (most common cause), infections acquired through direct contact between the neonate and the mother's cervix and vagina during delivery, and infections transmitted by cross-inoculation in the neonatal period. Common causative organisms include Chlamydia trachomatis (most common), Neisseria gonorrhoeae (most threatening), Haemophilus species, Streptococcus species, Staphylococcus aureus, and viruses such as Herpes simplex (HSV). Clinical findings in include drainage, conjunctival hyperemia, Chemosis, and lid edema. Timing of presentation following birth and maternal findings often are useful in determining the most likely etiology.
An anal fissure is a longitudinal tear of the skin of the anal canal and extends from the dentate line to the anal verge. Fissures are thought to be caused by the passage of hard or large stools with constipation, but may also be seen with diarrhea. The fissures are typically a few millimeters wide and occur in the posterior midline, but may occur elsewhere. An anal fissure that is off the midline may have a secondary cause, such as inflammatory bowel disease or sexually transmitted infection. Although often seen in infants, this condition is found mostly in young and middle-aged adults. Patients present with intense sharp, burning pain during and after bowel movements. They may see bright red blood at the time or shortly after the passage of stool. Gentle examination with separation of the buttocks usually provides good visualization. The diagnosis of inflammatory bowel disease, ulcerative colitis, or Crohn disease should be considered in the differential, particularly if the fissure...
Dacryoadenitis is an uncommon inflammatory disorder of the lacrimal gland, located under the lateral portion of the upper lid. The most common causes are mumps and herpes virus. Bacterial causes include Staphylococcus, Streptococcus, gonorrhea, Chlamydia, and syphilis. Dacryoadenitis is associated with systemic inflammatory conditions such as sarcoidosis, and Sjgren syndrome. Clinical findings include painful swelling of the lateral third of the upper lid, conjunctival hyperemia, chemosis, and an S-shaped curve to the lid margin from ptosis of the upper lid. Diplopia may be present from involvement of the lateral rectus muscle.
Prenatal care includes screening tests, counseling, preventive medications, and immunizations. Screening laboratory tests include a complete blood cell count, blood type, Rh sensitivity, urinalysis for bacteriuria, screening for several STIs (e.g., syphilis, HIV, hepatitis B, gonorrhea high risk , Chlamydia high risk ), screening for neural tube defects, gestational diabetes mellitus, and group B streptococci (Kirkham et al., 2005).
Ophthalmia neonatorum is an infection or inflammation of the conjunctiva that occurs during the first 4 weeks of life. Possible causes include chemical conjunctivitis, Neisseria gonorrhoeae, and chlamydial infection. The increased incidence of venereal disease and shortcomings in silver nitrate prophylaxis are significant factors in the constantly evolving clinical picture. Ophthalmia neonatorum frequently is a manifestation of a systemic infection, requiring determination of the exact cause in all but the most transient cases. Table 41-3 outlines the management of the various types of ophthalmia neonatorum. At present, erythromycin is the medication of choice. Povidone-iodine ophthalmic solution (0.5 ) is less toxic, inexpensive, and effective, but is not generally used because of confusion over povidone solution versus povidone soap.
In male patients with symptomatic urethritis, a causative agent may not be identified, a situation often referred to as nongonococcal urethritis (NGU). Technically, Chlamydia is included in this category. Organisms such as Ureaplasma urealyticum and Mycoplasma genitalium may be the cause and may be difficult to detect. Treatment for these infections is the same as for symptomatic Chlamydia, with azithromycin or doxycycline (Table 16-11). It is recommended that partners of patients with NGU should be evaluated and treated. In some cases, testing of partners may detect a specific organism as the cause of infection (e.g., Chlamydia).
As noted earlier, all U.S. communities do not present the same infection risk. For example, both syphilis and gonorrhea have significantly higher prevalence rates in the South and many urban centers. Because of underlying social factors that increase STI risk, including poverty, discrimination, and social networks, black and Hispanic Americans have higher prevalence rates of most STIs. When considering screening for STIs, physicians should consult with local public health officials and use national, regional, and local epidemiologic data to tailor screening programs based on communities and populations they serve. In addition to behavioral risk factors, physicians should remember that for chlamydial infection and gonorrhea, all sexually active women age 24 years and younger are considered at increased risk (Meyers et al., 2008).
Intravascular Catheter-related endocarditis, meningococcemia, gono-coccemia, Listeria, Brucella, rat-bite fever, relapsing fever. Viral, rickettsial, and chlamydial Infectious mononucleosis, cytomegalovirus, human immunodeficiency virus, hepatitis, Q fever, psittacosis. Parasitic Extraintestinal amebiasis, malaria, toxoplasmosis.
The rate of ectopic pregnancy in women with known history of pelvic inflammatory disease (PID) is 6 to 10 times higher than in women with no prior history. PID usually results from invasion by either gonorrhea or chlamydia from the cervix into the uterus and tubes. The infection in these tissues causes an intense inflammatory reaction. Bacteria, white blood cells, and other fluids fill the tubes as the body combats the infection. During the healing process, however, the delicate tubal mucosa is permanently scarred. The fim-briated end of the fallopian tube as well as the lumen may become partially or completely blocked with scar tissue. If PID is treated very early and aggressively with intravenous (IV) antibiotics, the tubal damage might be minimized and fertility preserved. Other conditions associated with ectopic pregnancies include progestin-bearing intrauterine devices (IUDs), previous tubal surgery, and tubal ligation.
Chlamydia trachomatis and Neisseria gonorrhoeae cause most cases in men younger than 35 and usually coexist with asymptomatic urethritis (CDC, 2006). Other causative organisms include gram-negative enteric bacteria. Fungi and tuberculosis are other possible infectious causes. Treatment includes antibiotics, analgesia, and scrotal elevation. In patients in whom gonorrhea or chlamydia is the likely cause, ceftriaxone (single dose, 250 mg IM) and doxycycline (100 mg twice daily for 10 days) is the treatment of choice. In patients who are allergic to these, or likely to have an enteric organism as the cause, 10 days of treatment with ofloxacin or levofloxacin is appropriate (CDC, 2006 del Rio, 2007).
Because the most frequent cause is viral, bronchitis has often been overtreated with antibiotics, which would be a preventable source of antibiotic resistance. However, in patients with a productive cough persisting beyond 10 to 14 days, treatment with antibiotics may be indicated to treat bacterial co-infection, especially in smokers or in patients with underlying pulmonary disease. In a study of community-acquired acute bronchitis in France, polymerase chain reaction (PCR) testing revealed that 4.1 of patients were infected with Chlamydia pneumoniae and 2.3 with Mycoplasma pneumoniae (Gaillat et al., 2005).
Bartholin glands and ducts are located over the lower third of the introitus near the labia minora. A cyst or abscess can result from an obstructed duct, which usually occurs secondary to scarring from trauma, delivery, or episiotomy. Infection of the cyst is usually with mixed vaginal or fecal flora (Escherichia coli) but may also contain Neisseria gonorrhoeae and Chlamydia trachomatis. Progressive enlargement and infection lead to increasing pain, swelling, and dyspareunia. A tender, fluctuant cystic mass with surrounding labial edema is easily appreciated on examination. Epidermal inclusion cysts and sebaceous cysts of the labia majora, hidradenitis suppurativa, vulvar hematomas, leiomyomas, lipomas, and fibromas may be confused with a noninfected Bartholin cyst.
Trachoma (also called granular conjunctivitis and Egyptian ophthalmia ) is caused by Chlamydia trachomatis. It is characterized by inflammatory granulations on the inner eyelid that severely scar the eye, eventually causing blindness (but not in all cases). It was a leading cause of blindness in the past and still blinds millions in Asia, the Middle East, and Africa. Two estimates place the number of victims worldwide at between 400 and 500 million, with perhaps 2 million totally blinded.
Chlamydia trachomatis, 230-31 chlorosis, 23, 71-74. See also iron deficiency anemia cholangitis, 134 cholecystitis, 134 cholelithiasis, 134-36 cholera, 74-78, 93, 128, 180 cholera morbus, 74, 76 cholera nostras, 74 cholesteatoma, 209 cholesterol, 33, 134, 160 chorea, 168-69, 304 chorioretinitis, 84 Christianity Black Death and, 50-52 epilepsy and, 119 ergotism and, 120-21 leprosy and, 194 Saint Anthony's fire and, 287-88 scrofula and, 293-94 sudden infant death syndrome and, 309 Christmas disease, 54-55, 57 chromatolysis, 323
Erythema nodosum is an acute inflammatory process involving the fatty tissue layer underlying the skin (pan-niculitis). The condition is more frequently seen in women, and although often idiopathic, many cases are associated with streptococcal infections of the upper respiratory tract, drugs such as estrogens oral contraceptives, sarcoidosis, and inflammatory bowel disease. Other, less frequent bacterial causes include tuberculosis, brucellosis, mycoplasma, and chlamydia. Fungal infections such as blastomycosis and his-toplasmosis may also cause erythema nodosum. Rare causes are Behcet's disease, acute myelogenous leukemia, and Hodgkin's disease.
Syphilis is a spirochetal infection that has resurged since 2001, the nadir year since 1996. Syphilis infection rates are highest in men who have sex with men. Syphilis is much less common than the other STIs, with an infection rate of 5.6 per 100,000 population in the United States (vs. 496 per 100,000 for Chlamydia).
Of premature labor as well any contraindications to tocolytic therapy. Urinalysis, as well as culture, is obtained and antibiotic therapy instituted if the urinalysis is suspicious. If there is a possibility of rupture of membranes, a sterile speculum examination of the cervix should be performed and vaginal fluid for nitrazine and ferning obtained. Cultures for GBS, Chlamydia, and possibly herpesvirus and Neisseria gonorrhoeae are often performed in this setting. If there is no historical or physical evidence of rupture of membranes, digital examination of the cervix with careful assessment of consistency as well as dilation and effacement is performed. Chorioamnionitis should be ruled out by assessing degree of uterine tenderness, leukocytosis, maternal fever, and fetal well-being.