History
C trachomatis is a sexually transmitted microorganism that is responsible for a wide spectrum of diseases, including cervicitis, salpingitis, endometritis, urethritis, epididymitis, conjunctivitis, and neonatal pneumonia. In chlamydial infection, unlike gonorrhea, most men and women who are infected are asymptomatic; thus, diagnosis is delayed until a positive screening result is obtained or a symptomatic partner discovered. Chlamydia screening programs have been demonstrated to reduce the rates of PID in women. [27, 28]
The US Preventive Services Task Force has made the following recommendations with regard to screening women for chlamydial infection [6, 7] :
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Screen for chlamydial infection in all sexually active nonpregnant young women aged 24 years or younger and for older nonpregnant women who are at increased risk
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Screen for chlamydial infection in all pregnant women aged 24 years or younger and in older pregnant women who are at increased risk
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Do not routinely screen for chlamydial infection in women aged 25 years or older, regardless of whether they are pregnant, if they are not at increased risk
Chlamydia has been isolated in approximately 40-60% of males presenting with nongonococcal urethritis. Epidemiologic studies indicate a high prevalence of asymptomatic men who act as a reservoir for chlamydial infections. A 1996 study by Quinn et al (1996) estimated that the transmission probability was 68% in both men and women. [29]
Although genitourinary carriage of chlamydiae is often asymptomatic, certain manifestations of disease are commonly seen, including local mucosal inflammation associated with a discharge, urethritis in males, and urethritis/vaginitis/cervicitis in females.
The following may be noted in all patients with chlamydial infection:
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Possible history of sexually transmitted diseases (STDs)
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Dysuria
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Yellow mucopurulent discharge from the urethra
The following may be noted in females with chlamydial infection:
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Vaginal discharge
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Abnormal vaginal bleeding (postcoital or unrelated to menses)
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Dyspareunia
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History of sexual activity without condoms or condom failure
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Proctitis, rectal discharge, or both in cases of receptive anal intercourse
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Slow onset and progression of lower abdominal pain
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Fever (in pelvic inflammatory disease [PID])
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No symptoms (in 80%)
The following may be noted in males with chlamydial infection:
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Urethral discharge
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History of sexual activity without condoms or condom failure
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Proctitis, rectal discharge, or both in cases of receptive anal intercourse
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Unilateral pain and swelling of the scrotum
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Fever
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No symptoms (in 50%)
The following may be noted in newborns with chlamydial infection:
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Symptoms of pneumonia (if present), beginning at 1-3 months
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Symptoms of conjunctivitis (if present), developing at 1-2 weeks
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In pneumonia, cough and fever (though the classic description is afebrile)
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In conjunctivitis, eye discharge, eye swelling, or both
The following may be noted in mothers diagnosed with or suspected of having a chlamydial infection during pregnancy:
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Injected conjunctivae
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Mucopurulent discharge from the eyes
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Bilateral involvement of the eyes
Physical Examination
Signs of chlamydial infection in women may include the following:
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Cervical friability (easy bleeding on manipulation)
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Intermenstrual bleeding
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Mucopurulent cervical or vaginal discharge
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Urethral discharge (usually thin and mucoid)
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Mucopurulent rectal discharge (from anal intercourse)
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Cervical motion tenderness
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Dysuria
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Adnexal fullness or tenderness, associated with progression to PID
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Lower abdomen tender to palpation
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Upper right quadrant abdominal tenderness (Fitz-Hugh-Curtis syndrome)
Signs of chlamydial infection in men may include the following:
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Mucopurulent urethral discharge (elicited by having the examiner or patient milk the urethra)
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Mucopurulent rectal discharge (from anal intercourse)
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Urinary frequency or urgency
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Dysuria
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Scrotal pain, tenderness, or swelling (sometimes unilateral)
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Perineal fullness (related to prostatitis)
Signs of chlamydial infection in newborns may include the following:
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Fever, cough, wheezing, and crackles (in pneumonia)
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Conjunctival erythema, mucoid discharge, or periorbital swelling (in conjunctivitis), often bilateral
Signs of lymphogranuloma venereum (LGV) may include the following:
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Localized inguinal adenopathy or buboes
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Genital ulceration
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“Groove sign” – Separation of the inguinal and femoral lymph nodes by the inguinal ligament (seen in 15-20% of patients)
Complications
Chlamydial infection is one of the leading causes of infertility in women. It is also a leading cause of PID. PID is a serious disease that often requires hospitalization for inpatient care, including intravenous (IV) antibiotics, testing to rule out tubo-ovarian abscess, and intensive counseling on the complications of recurrent infections.
The risk of ectopic pregnancy in women who have had PID is 7-10 times greater than that for women without a history of PID. In 15% of women who have contracted PID, chronic abdominal pain is a long-term manifestation that most likely is related to pelvic adhesions in the ovaries and fallopian tubes.
Fitz-Hugh-Curtis syndrome (perihepatitis) is a rare complication of PID that is 5 times more likely to be caused by Chlamydia than by N gonorrhoeae. It frequently presents without the typical examination findings associated with PID (ie, the pelvic examination is normal).
Women with a chlamydial infection (especially one caused by serotype G) are at increased risk for the development of cervical cancer; the risk is as much as 6.5 times greater than it is in women without infection. Chlamydial infections also increase the risk of acquiring HIV infection by increasing genital mucosal inflammation.
Pregnant women with a chlamydial infection can pass the infection on to their infants during delivery, and this may develop into chlamydial pneumonia or chlamydial conjunctivitis. Untreated neonatal conjunctivitis can result in blindness.
Reiter syndrome, a reactive arthritis secondary to an immune-mediated response, has been associated with a primary chlamydial infection. It may present as asymmetric polyarthritis, urethritis, inflammatory eye disease, mouth ulcers, circinate balanitis, and keratoderma blennorrhagica. Its etiology may not be completely clear, but 2 strong associations are observed: Reiter syndrome usually follows an infectious episode, and 80% of affected patients are positive for human leukocyte antigen (HLA)-B27.
Other potential complications of chlamydial infection are miscarriage, [30] preterm delivery, [31] and urethral scarring in men.
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Pap smear showing chlamydia in the vacuoles. Magnification, 500x. Image courtesy of the National Institutes of Health, National Cancer Institute.
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This photomicrograph reveals McCoy cell monolayers with Chlamydia trachomatis inclusion bodies; magnified 200X. Image courtesy of the Centers for Disease Control and Prevention.
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CT scan of adolescent with chlamydial Fitz-Hugh-Curtis syndrome demonstrating perihepatic fluid collection anterior to liver.
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CT scan of adolescent with chlamydial Fitz-Hugh-Curtis syndrome demonstrating free peritoneal fluid.
