Thissiteisintendedforhealthcareprofessionals

ChlamydialGenitourinaryInfections
Updated:Oct07,2016
Author:ShahabQureshi,MDChiefEditor:MichaelStuartBronze,MDmore...

OVERVIEW

Background
Chlamydialinfectioncancausediseaseinmanyorgansystems,includingthegenitourinarytract.
Chlamydiaearesmallgramnegativeobligateintracellularmicroorganismsthatpreferentiallyinfect
squamocolumnarepithelialcells.TheyincludethegeneraChlamydia(ofwhichthetypespeciesis
Chlamydiatrachomatis)andChlamydophila(eg,ChlamydophilapneumoniaeandChlamydophila
psittaci).
Ctrachomatiscanbedifferentiatedinto18serovars(serologicallyvariantstrains)onthebasisof
monoclonalantibodybasedtypingassays.Theseserovarsareassociatedwithdifferentmedical
conditions,asfollows:
SerovarsA,B,Ba,andCTrachoma,aseriouseyediseaseendemicinAfricaandAsiathatis
characterizedbychronicconjunctivitisandcanleadtoblindness
SerovarsDKGenitaltractinfections
SerovarsL1L3Lymphogranulomavenereum(LGV),whichisassociatedwithgenitalulcer
diseaseintropicalcountries
Ctrachomatisinfectionaffectsthecervix,urethra,salpinges,uterus,nasopharynx,andepididymis[1,
2,3] itisthemostcommonlyreportedbacterialsexuallytransmitteddisease(STD)intheUnited
Statesandaleadingcauseofinfertilityinwomen.Ctrachomatisinfectioncausesotherdiseasesas
well,includingconjunctivitis,pneumoniaorpneumonitis,afebrilepneumoniasyndrome(ininfantsborn
vaginallytoinfectedmothers),FitzHughCurtissyndrome,andtrachoma(theworldsleadingcauseof
acquiredblindness).[4]
Cpneumoniaeinfectionisspreadviarespiratorydropletsandcausespharyngitis,bronchitis,and
pneumonia.Cpsittaciinfectionisspreadbybirddroppingsandaerosolsandcausespsittacosis.
Theseinfectionsarenotdiscussedinthisarticle.
Atpresent,fewerthan50%ofsexuallyactiveyoungfemalesintheUnitedStatesarescreenedforthe
presenceofchlamydiae.Nationally,theannualscreeningrateincreasedfrom25.3%in2000to43.6%
in2006,thendecreasedslightlyto41.6%in2007.[5]
TheUSPreventiveServicesTaskForceScreeninghasreleasedarecommendationstatementfor
chlamydialinfections,inwhichroutineChlamydiascreeningofsexuallyactiveyoungwomenis
recommendedtopreventconsequencesofuntreatedchlamydialinfection(eg,pelvicinflammatory
disease(PID),infertility,ectopicpregnancy,andchronicpelvicpain).[6,7]Aguidelinesynthesisisalso
availablefromtheNationalGuidelineClearinghouse.[8]

Pathophysiology
Thepathophysiologicmechanismsofchlamydialinfectionarepoorlyunderstoodatbest.Chlamydia
infectscolumnarepithelialcells,whichplacestheadolescentfemaleatparticularriskbecauseofthe
presenceofthesquamocolumnarjunctionontheectocervixuntilearlyadulthood.Theinitialresponse
ofepithelialcellstoinfectionisaneutrophilicinfiltration,followedbylymphocytes,macrophages,
plasmacells,andeosinophilicinvasion.Thereleaseofcytokinesandinterferonsbytheinfected
epithelialcellinitializesthisinflammatorycascade.
Infectionwithchlamydialorganismsinvokesahumoralcellresponse,resultinginsecretory
immunoglobulinA(IgA)andcirculatoryimmunoglobulinM(IgM)andimmunoglobulinG(IgG)
antibodiesandacellularimmuneresponse.A40kdmajoroutermembraneprotein(MOMP)and10
and60kdchlamydialheatshockproteins(cHSPs)havebeenimplicatedintheimmunopathologic
response,butfurtherstudiesareneededtoprovideabetterunderstandingofthesecellmediated
immuneresponses.[9]
Chlamydiaehaveauniquebiphasiclifecyclethatisadaptabletobothintracellularandextracellular
environments.Intheextracellularmilieu,thesocalledelementarybody(EB)isfound.EBsare
metabolicallyinactiveinfectiousparticlesfunctionally,theyaresporetypestructures.Onceinsidea
susceptiblehostcell,theEBpreventsphagosomelysozymefusionandthenundergoes
reorganizationtoformareticulatebody(RB).
TheRBsynthesizesitsownDNA,RNA,andproteinsbutrequiresenergyintheformofadenosine
triphosphate(ATP)fromthehostcell.AfterasufficientamountofRBshaveformed,sometransform
backintoEBs,exitingthecelltoinfectothers.
Thebacteriumisusuallyspreadthroughsexualactivity.Aninfectedmalehasa25%chanceper
sexualencounteroftransmittingtheinfectiontoanuninfectedfemale.Chlamydiaecanbevertically
spreadaswell.Thetransmissionratefrominfectedmothertonewbornis5060%,causing
conjunctivitis(inmostcases)orpneumonia(in1020%ofcasesseeAfebrilePneumoniaSyndrome).
Infectionofthegenitaltractisthemostcommonclinicalpresentation.Theincubationperiodis13
weeks.Approximately50%ofinfectedmalesand80%ofinfectedfemalesareasymptomatic,but
infectionmaycauseamucopurulentcervicitisinfemalesandurethritisinmales.Ascendinginfection
canresultinPIDinwomenandisthemostcommoncauseofepididymitisinmenyoungerthan35
years.OfwomenwithPID,510%developperihepatitis(ie,FitzHughCurtissyndrome).
AlthoughpatientswithanySTDareatincreasedriskofcoinfectionwithanotherSTD,coinfectionof
chlamydiaandgonorrheaismostcommon.Fortypercentofwomenand20%ofmenwithchlamydial
infectionarecoinfectedwithgonorrhea.Patientswithchlamydiaalsohaveahigherfrequencyof
Reitersyndrome(ie,urethritis,conjunctivitis,reactivearthritis)thanthegeneralpopulation.
LGVisrareintheUnitedStatesbutisresponsiblefor10%ofcasesofgenitalulcerdiseaseintropical
countries.Localizedinguinaladenopathyandulcerationdevelop212weeksafterexposure.Proctitis,
rectalstrictures,andlymphaticobstructionwithsecondaryelephantiasiscanoccurinuntreated
disease.

Etiology
Chlamydialtransmissionusuallyiscausedbysexualcontactthroughoral,anal,orvaginal
intercourse.Neonatalinfection(eg,conjunctivitisorpneumonia)mayoccursecondarytopassage
throughthebirthcanalofaninfectedmother.Specificriskfactorsforchlamydialinfectionincludethe
following:

Nonwhiterace
Multiplesexualpartnersoranewsexualpartner
Age1524years(especially<19years)
Poorsocioeconomicconditions(eg,homelessness)
Exchangeofsexfordrugsormoney
Singlemaritalstatus
Intercoursewithoutabarriercontraceptive
HistoryofapreviousSTDorcurrentcoinfectionwithanotherSTD
CertaincytokinepolymorphismsThesehavebeenassociatedwithseverediseaseandriskof
tubalfactorinfertility[10]
CertainvariantsinTolllikereceptor1and4genesThesepredisposetoinfection[11]
Havingbeenafosterchild(malesonly)[12]

Epidemiology
UnitedStatesstatistics
ChlamydialinfectionisthemostfrequentlyreportedinfectiousdiseaseintheUnitedStates,andits
prevalenceishighestinpersonsaged24yearsoryounger.[13]TheannualincidenceofCtrachomatis
genitalinfectionswasestimatedtobe2.86millioncasesintheUnitedStatesin2008.[14]
Sexuallyactivefemalepopulationsaveragechlamydialcarriageratesofabout20%.Manypatients
areasymptomatic.Theincidenceis23timesthatofNeisseriagonorrhoeae.
Theprevalenceofchlamydiahasbeenreportedtobeashighas14%amongAfricanAmerican
femalesaged1826yearsand17%amongfemaleswithahistoryofgonorrheaorchlamydiainthe
previous12months.Inaddition,approximately100,000neonatesareexposedtochlamydiae
annually.The20072012NationalHealthandNutritionExaminationSurvey(NHANES)indicatesthat
anestimated1.8millionpersonsaged1439yearsintheUnitedStateshaveagenitalchlamydial
infection.[15]

Internationalstatistics
Morethanonemillionsexuallytransmittedinfections(STIs)areacquiredeverydayworldwide.[16]C
trachomatisgenitaltractinfectionsarecommon,withanestimated105.7millionnewworldwidecases
in2008.[17]SerosurveyshavedocumentedsimilarincidencefiguresinAustralia,[18]NewZealand,
[19] France,[20] Germany,[21] andtheNetherlands.[22] AreportfromtheWorldHealthOrganization
(WHO)InitiativeforVaccineResearch(IVR)estimatedthatthereweremorethan140millioncasesof
Ctrachomatisinfectionworldwide.[23]

Age,sex,andracerelateddemographics
Agefactorsinchlamydialgenitourinaryinfectionrelatetotheageoffirstsexualexposureandthe
frequencyofexposure.Chlamydiaismostprevalentinpersonsaged1524years.Acquisitionrates
arecomparableforthe2sexes.Womenaremorelikelytobeasymptomaticthanmen(80%vs50%)
however,theyarealsomorelikelytodeveloplongtermcomplications(eg,PIDandinfertility).
Datafrom2011demonstratethatthediseaseismostcommoninadolescentsandyoungadultsaged
1524years,withhigherratesinwomenandAfricanAmericansthaninHispanicsandnonHispanic
whites.[24]

Prognosis
Antibiotictreatmentis95%effectiveforfirsttimetherapy.Theprognosisisexcellentiftreatmentis
initiatedearlyandtheentirecourseofantibioticsiscompleted.Althoughtreatmentfailureswith
primarytherapiesarequiterare,relapsemayoccurwithalternativetherapies.Reinfectionisvery
commonandisrelatedtonontreatmentofinfectedsexualpartnersoracquisitionfromanewpartner
thusallsexualpartnersshouldbetreated.
Deathsarerareandarecausedbyprogressiontosalpingitisandtuboovarianabscesswithrupture
andperitonitis.Themostsignificantmorbidityoccurswhenrepeatedepisodesofchlamydialeadto
obstructionandscarringofthefallopiantubes,resultinginpartialortotalsterility.Chlamydiaisan
indirectcauseofmortalityfromectopicpregnancies.[25]Mortalityduetoectopicpregnancyis
probablymorecommonthanisdeathduetotuboovarianabscess.

PatientEducation
Appropriatecounselingofinfectedindividualsmustbeperformed.Informpatientsofthepossiblelong
termrisksandcomplicationsoftheirinfection,includingthepossibilityofinfertility.Educatethem
regardingtheriskofotherSTDs.Counselpatientstotakestepstopreventreinfection.Theyshould
avoidsexualcontactuntiltheirtreatmentiscompletedandallpartnersalsohavebeenevaluatedand
treated.Theyshouldalsoconsiderusinglatexcondomstominimizethechancesofreinfection.
ClinicalPresentation
WhattoReadNextonMedscape
RelatedConditionsandDiseases

PituitaryTumorsPathology
AcquiredNystagmus
BeckwithWiedemannSyndrome
IntestinalEnterokinaseDeficiency
PelizaeusMerzbacherDisease
Alpha1AntitrypsinDeficiency
News&Perspective

BreakthroughPain:JustPain?

PopularHeartburnMedicationLinkedtoIncreasedStroke

AlternateDayFastingPosesNoThreattoBoneHealth
Tools

DrugInteractionChecker
PillIdentifier
Calculators
Formulary
MostPopularArticles

AccordingtoInfectiousDiseasePhysicians
1.MumpsCasesSpike,IndicatingPossibleNeedforVaccineBoosters
2.FalsePositivesCommonWithLabCorpZikaTesting,FDAWarns
3.EbolaVaccine100%EffectiveinClinicalTrial
4.HowHospitals,NursingHomesKeep'Superbug'OutbreaksSecret
5.LatentTuberculosis:NewTestingRecommendations
ViewMore