eMedicine Specialties > Infectious Diseases > Sexually Transmitted Diseases

Chlamydial Genitourinary Infections: Differential Diagnoses & Workup

Author: Larry I Lutwick, MD, Professor of Medicine, State University of New York, Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus
Coauthor(s): Renuka Heddurshetti, MD, Fellow in Infectious Diseases, Department of Internal Medicine, State University of New York at Brooklyn; Jeffrey Blitstein, MD, Staff Physician, Department of Internal Medicine, Division of Infectious Disease, VA New York Harbor Health Care System at Brooklyn
Contributor Information and Disclosures

Updated: Apr 20, 2009

Differential Diagnoses

Herpes Simplex

Other Problems to Be Considered

Gonorrhea
Ureaplasma infection
Trichomonas infection
Foreign body
Periurethral abscess
Mycoplasma genitalium infection
Prostatitis

Workup

Laboratory Studies

  • Because of the possibility of multiple sexually transmitted infections, all patients with any sexually transmitted disease (STD) should be evaluated for chlamydial infection because chlamydial treatment is included in the Centers for Disease Control and Prevention (CDC) STD treatment regimens.
  • Cytologic diagnosis
    • This is used mainly for the diagnosis of infant inclusion conjunctivitis and in ocular trachoma by the demonstration of intracytoplasmic C trachomatis inclusions in HeLa cells (ie, continuously cultured carcinoma cell line used for tissue cultures).
    • Cytologic diagnosis also is used to evaluate endocervical scrapings, but interpretation is difficult and sensitivity and specificity have been low.
  • Isolation in cell culture
    • C trachomatis grows well in a variety of cell lines (eg, McCoy, HeLa cells) that can be maintained in tissue culture.
    • Incubation in tissue culture is 40-72 hours, depending on the cell type and specific biovar.
    • Intracytoplasmic inclusions can be detected either by Giemsa stains or by immunofluorescent staining with monoclonal antibodies.
    • Because of its high specificity (100%) and sensitivity, cell culture is the only test that should be used to establish the presence or absence of infections in cases with legal implications such as rape or sexual abuse.
  • Antigen detection and nucleic acid hybridization
    • By direct fluorescent antibody (DFA)
    • By enzyme-linked immunosorbent assay
    • Detection of chlamydial ribosomal RNA (rRNA) by hybridization with a DNA probe
      • Advantage: This is simpler and less expensive. Most studies report sensitivities greater than 70% and specificities of 97-99% in populations of men and women with a prevalence of infection of 5% or more. Antigen detection may well be the most appropriate diagnostic test for a primary care setting in the United States if a definitive diagnostic test is required.
      • Disadvantage: It is less sensitive when compared to tissue culture. In low-prevalence populations (ie, <5% infected), a highly significant proportion of positive test results are false-positive results. Therefore, verification of a positive test result is desirable in certain cases. Such verification can be by culture (eg, a second nonculture test that identifies a different chlamydial antigen or nucleic acid sequence than the first test), a blocking antibody, or competitive probe.
  • Detection of chlamydial genes by DNA amplification tests
    • Polymerase chain reaction (PCR)
    • Ligase chain reaction (LCR)
    • Specific chlamydial rRNA using transcription-mediated amplification
    • Both PCR and LCR detect C trachomatis in urine or self-administered vaginal swab specimens with sensitivity comparable to that with urogenital swab specimens.
  • Serology
    • Complement fixation test
      • All patients with LGV or psittacosis have complement-fixing antibody titers of greater than 1:16.
      • Fifteen percent of men with urethritis and 45% of women with endocervical infection have titers 1:16 or greater.
    • Microimmunofluorescence test
      • This is more sensitive than complement fixation test.
      • Results are positive in 99% or more of women with cervicitis and in 80-90% of men with urethritis.
  • Antibody classes
    • Antichlamydia IgM is uncommon in adults with genital tract infection.
    • The prevalence of antichlamydia IgG is high in sexually active adults, even in those who do not have an active infection, and it likely is due to past infection.
    • A statistically significant association exists between chlamydia-specific serum IgA and active disease.
    • The sensitivity, specificity, and predictive values are not high enough to make any serology clinically useful in the diagnosis of active disease. Therefore, chlamydial serologies are not recommended for diagnosis of genital tract disease.
  • The choice of the most appropriate test depends on the clinical setting, the facilities available, and the relative cost.

More on Chlamydial Genitourinary Infections

Overview: Chlamydial Genitourinary Infections
Differential Diagnoses & Workup: Chlamydial Genitourinary Infections
Treatment & Medication: Chlamydial Genitourinary Infections
Follow-up: Chlamydial Genitourinary Infections
References
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References

  1. Centers for Disease Control and Prevention. Chlamydia screening among sexually active young females enrollees of health plans - United States, 2000-2007. MMWR Weekly. April 17, 2009;58(14):362-365. [Full Text].

  2. Quinn TC, Gaydos C, Shepherd M. Epidemiologic and microbiologic correlates of Chlamydia trachomatis infection in sexual partnerships. JAMA. Dec 4 1996;276(21):1737-42. [Medline].

  3. Bell TA, Sandstrom IK, Eschenbach DA. Treatment of Chlamydia trachomatis in pregnancy with amoxicillin. In: Mardh PA, Holmes KK, Oriel JD, Piot P, Schachter J, eds. Chlamydial Infections. New York, NY: Elsevier Biomedical; 1982:221-4.

  4. Bowie WR. Nongonococcal urethritis. Urol Clin North Am. Feb 1984;11(1):55-64. [Medline].

  5. CDC. Diseases characterized by urethritis and cervicitis (see update from April 13, 2007). MMWR Morb Mortal Wkly Rep [serial online]. Aug 4 2006;55(RR-11):35-49. Available at http://www.cdc.gov/std/treatment/2006/urethritis-and-cervicitis.htm#uc4.

  6. CDC. Update to CDC's sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. Apr 13 2007;56(14):332-6. [Medline]. [Full Text].

  7. CDC, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55(RR-11):1-94. [Medline]. [Full Text].

  8. Cook RL, Hutchison SL, Østergaard L, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med. Jun 7 2005;142(11):914-25. [Medline].

  9. Donders GG. Management of genital infections in pregnant women. Curr Opin Infect Dis. Feb 2006;19(1):55-61. [Medline].

  10. Donovan B. Sexually transmissible infections other than HIV. Lancet. Feb 14 2004;363(9408):545-56. [Medline].

  11. Dorman SA, Danos LM, Wilson DJ. Detection of chlamydial cervicitis by Papanicolaou stained smears and culture. Am J Clin Pathol. Apr 1983;79(4):421-5. [Medline].

  12. Ehret JM, Judson FN. Susceptibility testing of Chlamydia trachomatis: from eggs to monoclonal antibodies. Antimicrob Agents Chemother. Sep 1988;32(9):1295-9. [Medline].

  13. Hook EW 3rd, Smith K, Mullen C. Diagnosis of genitourinary Chlamydia trachomatis infections by using the ligase chain reaction on patient-obtained vaginal swabs. J Clin Microbiol. Aug 1997;35(8):2133-5. [Medline].

  14. Katz BP, Fortenberry D, Orr DP. Factors affecting chlamydial persistence or recurrence one and three months after treatment. In: Stephens RS, Byrne GI, Christiansen G, et al, eds. Chlamydial Infections, Proceedings of the Ninth International Symposium on Human Chlamydial Infection. San Francisco, Calif: International Chlamydial Symposium; 1998:35-8.

  15. Magat AH, Alger LS, Nagey DA. Double-blind randomized study comparing amoxicillin and erythromycin for the treatment of Chlamydia trachomatis in pregnancy. Obstet Gynecol. May 1993;81(5 ( Pt 1)):745-9. [Medline].

  16. Martin DH, Mroczkowski TF, Dalu ZA. A controlled trial of a single dose of azithromycin for the treatment of chlamydial urethritis and cervicitis. The Azithromycin for Chlamydial Infections Study Group. N Engl J Med. Sep 24 1992;327(13):921-5. [Medline].

  17. Rahman MU, Hudson AP, Schumacher HR Jr. Chlamydia and Reiter's syndrome (reactive arthritis). Rheum Dis Clin North Am. Feb 1992;18(1):67-79. [Medline].

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  19. Wehbeh HA, Ruggeirio RM, Shahem S. Single-dose azithromycin for Chlamydia in pregnant women. J Reprod Med. Jun 1998;43(6):509-14. [Medline].

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Further Reading

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Keywords

nongonococcal urethritis, nonspecific urethritis, postgonococcal urethritis, Chlamydia trachomatis, Chlamydia puerorum, Chlamydia psittaci, Chlamydia pneumoniae, C trachomatis, C puerorum, C psittaci, C pneumoniae, sexually transmitted diseases, STDs

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Contributor Information and Disclosures

Author

Larry I Lutwick, MD, Professor of Medicine, State University of New York, Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus
Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Coauthor(s)

Renuka Heddurshetti, MD, Fellow in Infectious Diseases, Department of Internal Medicine, State University of New York at Brooklyn
Renuka Heddurshetti, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Jeffrey Blitstein, MD, Staff Physician, Department of Internal Medicine, Division of Infectious Disease, VA New York Harbor Health Care System at Brooklyn
Disclosure: Nothing to disclose.

Medical Editor

John M Leedom, MD, Professor of Medicine, Keck School of Medicine, University of Southern California; Chief, Division of Infectious Diseases, Department of Internal Medicine, Los Angeles County, University of Southern California Medical Center
John M Leedom, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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