Mycoplasma genitalium in chronic non-gonococcal urethritis.

Seventy-eight men with a history of chronic urethritis were referred for investigation. Of 52 men diagnosed as having persistent or recurrent non-gonococcal urethritis (NGU) at the time of referral, 11 (21%) were infected with Mycoplasma genitalium and three with Chlamydia trachomatis. Men who were M. genitalium-positive had not previously received less antibiotic, in terms of treatment duration, than those who were M. genitalium-negative, suggesting a possible resistance to the antibiotics given. In the current investigation, of 11 M. genitalium-positive men with persistent or recurrent NGU who were treated for four to six weeks with erythromycin, 500 mg four times daily, nine (82%) responded clinically and microbiologically, but later six relapsed without M. genitalium being detected. The results of observing and investigating a patient for about one year, the only one to have concurrent chlamydial and mycoplasmal infections, is presented, a feature being the intermittent persistence of the mycoplasma.

Detection of several Mycoplasma species at various anatomical sites of homosexual men.

In order to determine the colonisation patterns of several Mycoplasma species in homosexual men, urethral, oral and rectal specimens from 10 homosexual men with acute non-gonococcal urethritis (NGU) and 18 without NGU were examined using sensitive methods. Mycoplasma hominis and Ureaplasma urealyticum existed in both groups, which is in keeping with previous studies of heterosexual men. Mycoplasma genitalium was detected in the rectum of both NGU-positive and NGU-negative men and in the urethra of one man with chlamydia-negative NGU, but not in those without urethritis. Mycoplasma fermentans was found in the throat and rectum only and Mycoplasma penetrans in all three anatomical sites. In contrast, Mycoplasma pirum was found in the rectum only, that is, in 5 of the 28 men studied. Infrequent examination of this site is a possible explanation for previous failures to detect Mycoplasma pirum at a mucosal surface.

Do all men attending departments of genitourinary medicine need to be screened for non-gonococcal urethritis?

We investigated the influence of symptoms and signs on the detection of Chlamydia trachomatis, Mycoplasma genitalium and Ureaplasma urealyticum organisms (ureaplasmas) in men with non-gonococcal urethritis (NGU). Two hundred and forty-two men attending the Jefferiss Wing at St Mary's Hospital for a sexual health assessment were evaluated, of whom 169 had NGU. Urethral inflammation was diagnosed if there were either > or =5 polymorphonuclear leucocytes (PMNLs) per high-power field (HPF) in five or more microscope fields of a Gram-stained urethral smear, or > or =10 PMNLs per HPF in five or more fields of a Gram-stained thread from 15-20 mL of a first-passed urine (FPU) specimen. C. trachomatis was diagnosed by direct immunofluoresence, M. genitalium by a polymerase chain reaction assay and ureaplasmas by culture. On multivariate analysis, to control for potential confounding by age, ethnicity, sexual lifestyle and co-infection, an urethral discharge remained significantly associated with the detection of C. trachomatis and M. genitalium in men with acute urethritis [OR 12.3, 95% CI (2.39-63.5) and OR 35.2, 95% CI (3.9-319.6), respectively], but dysuria or penile irritation did not. The detection of ureaplasmas was not associated with any clinical feature. In addition, on multivariate analysis men with NGU who were either symptomatic or had an observable discharge were more likely to have C. trachomatis or M. genitalium detected [(OR 6.92, 95% CI 1.41-33.9) and (OR 5.18, 95% CI 0.99-27.1), respectively], but not ureaplasmas (OR 1.19, 95% CI 0.33-4.35). The findings suggest that in men with acute NGU, symptoms or signs, and in particular a urethral discharge, are associated with the detection of C. trachomatis and M. genitalium, but not ureaplasmas. Currently, there is no precise answer to the question of whether all men attending a GUM clinic need to be screened for NGU, but if clinically asymptomatic NGU is found not to be associated with a sexually transmitted pathogen, the UK clinical guidelines requiring the preparation of a urethral smear from such men would need to be revised.

The prevalence of Mycoplasma fermentans in patients with inflammatory arthritides.

OBJECTIVES: To search for evidence that Mycoplasma fermentans is involved in the pathogenesis of some forms of human arthritis by testing for the presence of mycoplasmal DNA in joint material. METHODS: M. fermentans DNA was detected by the identification of a 104-base pair amplification product of the polymerase chain reaction (PCR). RESULTS: M. fermentans DNA was detected in synovial fluid samples from six (17%) of 35 patients with rheumatoid arthritis (RA) and 18 (21%) of 85 patients with seronegative arthritis. These detection rates were significantly greater than in samples from patients with osteoarthritis or crystal synovitis, none of 26 of these being positive. CONCLUSIONS: M. fermentans could be involved in the pathogenesis of some forms of inflammatory arthritis and this possibility is worthy of further study.

An association of disseminated Mycoplasma fermentans in HIV-1 positive patients with non-Hodgkin's lymphoma.

We examined the relationship between the haematogenous dissemination of Mycoplasma fermentans and non-Hodgkin's lymphoma (NHL) in 265 HIV-1 positive patients. A polymerase chain reaction (PCR) assay was used to detect M. fermentans in peripheral blood mononuclear cells (PBMCs) from 50 patients enrolled consecutively from an HIV outpatient clinic in 1991 (cohort 1), 56 patients with lower respiratory tract infection who underwent bronchoscopy in 1992 (cohort 2), and 159 patients who were enrolled into a natural history cohort study in 1994 (cohort 3). The incidence of NHL among the patients was determined in 1998. The PBMCs of 29 patients (10.9%) were positive for M. fermentans (8 in cohort 1, 13 in cohort 2 and 8 in cohort 3) and 11 patients (4.2%) developed NHL which was confirmed histologically (3 in cohort 1, 4 in cohort 2 and 4 in cohort 3). We found a statistically significant association between the presence of M. fermentans and the development of NHL in the combined cohort (risk ratio [RR]=6.78 [95% confidence interval (CI) 2.21--20.84], P=0.003 Fisher's exact test [FET]). This association remained significant even after adjustment in a multivariate analysis for CD4 cell count and HIV disease status at the time of M. fermentans testing (RR=7.97 [95% CI=2.16--29.47], P=0.002).

Role of Mycoplasma genitalium and Ureaplasma urealyticum in acute and chronic nongonococcal urethritis.

One hundred fourteen heterosexual men with acute nongonococcal urethritis (NGU) and 64 patients without NGU were studied. We determined that Chlamydia trachomatis and Mycoplasma genitalium were strongly associated with acute NGU after controlling, by means of multivariate analysis, for age, race, sexual lifestyle, and coinfection (odds ratio [OR], 13.0, 95% confidence interval [CI], 2.6-64.5; and OR, 17.9, 95% CI, 2.0-160, respectively). Eighty-six men with acute NGU reattended at least once 10-92 days after treatment; 59 (69%) of these 86 men had urethritis. Seven men had M. genitalium detected during 10-92 days of follow-up, and all had urethritis. Ureaplasmas were not associated with acute NGU in multivariate analysis, but their detection was associated with the presence of urethritis during follow-up (P=.014). Ureaplasmas or M. genitalium were associated with both chronic NGU, which was defined as urethritis that occurred 30-92 days after the commencement of treatment (P=.028), and chronic NGU with symptoms or signs (P=.005).

The association of Chlamydia trachomatis and Mycoplasma genitalium with non-gonococcal urethritis: observations on heterosexual men and their female partners.

Our objectives were to study the distribution of Chlamydia trachomatis and Mycoplasma genitalium in men with or without non-gonococcal urethritis (NGU) and their respective female partners. A case-control study was carried out to which men with or without NGU and their female partners were recruited. All study participants were tested for the presence of C. trachomatis and M. genitalium. An analysis firstly of the distribution of each of these microorganisms among men with or without urethritis and their respective female partners was carried out. Furthermore, we examined the association of each of these microorganisms and NGU when the other had been excluded. Chlamydia trachomatis was present in 14 (36%) of 39 men with NGU compared to none of 12 men without NGU (P=0.022). The prevalence rates for female partners of men with NGU were 10 (26%) of 39 compared to none of 12 partners of men without NGU (P=0.092). M. genitalium was detected in 12 (33%) of 36 men with NGU compared to 1 (9%) of men without NGU (not significant; P=0.147). The prevalence rates for female partners of men with NGU were 10 (32%) of 31 women compared to none of 7 partners of men without NGU (not significant; P=0.156). There was a greater concordance than discordance of carriage of each of the 2 microorganisms among the study couples and each tended to be carried independently of the other by men. Analysis of the association between the presence of C. trachomatis in men and NGU was significantly improved by the exclusion of men with M. genitalium (P=0.0058). Likewise, the association between the presence of M. genitalium in men and NGU was significantly improved by the exclusion of couples in whom either the man or woman was C. trachomatis-positive (P=0.049). The independent carriage of C. trachomatis and M. genitalium by men with NGU, coupled with the improved association between each pathogen and NGU by exclusion of the other provides support for the separate role of each in the aetiology of NGU.

Detection of Mycoplasma fermentans in healthy students and patients with congenital immunodeficiency.

OBJECTIVES: To determine the prevalence of M. fermentans at different anatomical sites in healthy subjects and in patients with congenital immunodeficiency, and to determine whether haematogenous invasion occurs among the latter. METHODS: A polymerase chain reaction (PCR) assay was used to detect M.fermentans in throat swabs and urine specimens from healthy students, and from patients with congenital immunodeficiency. Peripheral blood mononuclear cells (PBMCs) from the latter group were also tested. RESULTS: Sixty-two students provided throat swabs, of which 11 (18%) were M. Jermentans-positive; 46 provided urine specimens, of which eight (17%) were positive. Of the 45 students who provided both throat and urine specimens, 12 (27%) had M. fermentans-positive samples; four in the throat and urine, four in the throat only and four in the urine only. Nineteen of the 20 patients with congenital immunodeficiency provided throat swabs, of which one (5%) was M. fermentans-positive; 19 also provided urine specimens, of which three (16%) were positive. All of the immunodeficient patients provided a PBMC sample, but none was positive. CONCLUSION: M. fermentans occurred frequently at mucosal sites in a healthy population and in subjects with congenital immunodeficiency. However, such a deficiency did not lead to overt haematogenous invasion.

The association of Mycoplasma hominis, Ureaplasma urealyticum and Mycoplasma genitalium with bacterial vaginosis: observations on heterosexual women and their male partners.

The prevalence of 3 mycoplasmas (Mycoplasma hominis, Ureaplasma urealyticum and Mycoplasma genitalium) was determined in a cohort of women with or without bacterial vaginosis (BV) and in their respective male partners. Heterosexual women with or without BV and their male partners were recruited and genital sampling for these microorganisms was performed. Seventeen women with BV and 21 women with normal flora, and their respective male partners, were recruited. M. hominis was present in 9 (53%) of 17 women with BV compared with none of 21 women without BV (P=0.0001). Of the 17 male partners of women with BV, 8 (47%) had M. hominis compared to 5 (24%) of 21 male partners of women without BV (not significant [n/s]). U. urealyticum was detected in 11 (65%) of 17 women with BV in comparison with 10 (48%) of 21 women without BV (n/s). U. urealyticum was present in 4 (24%) of 17 male partners of women with BV compared to 6 (29%) of 21 male partners of women without BV (n/s). M. genitalium was not detected in any of 15 women with BV and in only 2 (12%) of 17 women without BV (n/s). M. genitalium was present in 4 (25%) male partners of 16 women with BV in comparison with 3 (16%) male partners of 19 women without BV (n/s). Thus, M. hominis was the only mycoplasma detected significantly more often in women with, rather than in those without, BV. None of the mycoplasmas was found significantly more often in male partners of women with, rather than those without, BV. Overall, M. genitalium behaved somewhat similar to Chlamydia trachomatis. It was the least commonly occurring mycoplasma, a reflection perhaps of the relatively low incidence of partner change in this study population.

Mycoplasma species in rapid and slow HIV progressors.

We determined the relationship between the presence of Mycoplasma fermentans and Mycoplasma penetrans and the rate of progression of HIV-associated disease in a nested case-control study based on a cohort of 159 HIV-infected patients with different rates of disease progression. Study participants were divided into 3 progression groups: non-progressors who had been HIV-1 seropositive for at least 9 years and had remained asymptomatic with a CD4 cell count of > 500/mm3; slow progressors who had been HIV-1 seropositive for at least 9 years and whose CD4 cell count had fallen below 500 cells, and who had developed symptomatic disease or AIDS; and rapid progressors who had developed AIDS within 5 years of HIV infection. Peripheral blood mononuclear cells (PBMCs) were collected at enrollment and examined by mycoplasma polymerase chain reaction (PCR) assays. Three (7%) of 46 non-progressors, 3 (3%) of 86 slow progressors, and 2 (7%) of 27 rapid progressors were M. fermentans positive. The PBMCs from 91 subjects were tested for M. penetrans DNA and none was positive. The small proportion of M. fermentans-positive patients indicates that the mycoplasma cannot be important in the development of AIDS in the large majority of patients. Furthermore, no association was found between its presence and more rapid HIV disease progression.

Detection of genital mycoplasmas by PCR.

Mycoplasmas are the smallest prokaryotes capable of self-replication. They belong to the class Mollicutes (meaning soft-skin) and have evolved regressively, by genome reduction, from Gram-positive bacterial ancestors, namely certain clostridia (1). The taxonomy of the class Mollicutes containing four orders, five families, and eight genera, is shown in Table 1 (2). The term 'mollicute' is sometimes used trivially to describe any organism in the class. The term 'mycoplasma' might be used best to describe any member of the genus Mycoplasma, but is also used, as in this chapter, in a trivial way to refer to any organism in the class.

Mycoplasma and ureaplasma infections.

Organisms of the class Mollicutes (meaning soft-skin) have regressively evolved, by genome reduction, from Gram-positive bacterial ancestors, namely certain clostria (1). The taxonomy of the class Mollicutes, containing four orders, five familes, and eight genera, is shown in Table 1 (2) The term "mollicute" is sometimes trivially used to describe any organism in the class. The term "mycoplasma" might be used best to describe any member of the genus Mycoplasma, but is also used, as in this chapter, in a trivial way to refer to any organism in the class. Table 1 Taxonomy and Properties of Mycoplasmas (class Mollicutes; Adapted from ref. 2 ) Classification Current no. of Recognized species Genome size(kbp) Mel%G+C content Distinctive properties Habitat Order I: Mycoplasmatales Family I:Mycoplasmataceae Genus I:Mycoplasma 100 580-l300 23-41 Optimum growth at 37°C Humans,animals,plants,insects Genus II Ureaplasma 6 730-1160 27-30 Urease positive Humans,animals Order II Entomoplasmatales Family I Entomoplasmataceae Genus I Entomoplasma 5 790-l140 27-29 Optimum growth Plants,insects at 30°C Genus II Mesoplasma 12 870-1100 27-30 Plants,insects Family II Spiroplasmataceae Genus I:Spiroplasma 17 940-2240 25-31 Helical filaments Arthropods(includ- ing insects), plants Order III Acholeplasmatales Family I Acholeplasmataceae Genus I Acholeplasma 13 About 1600 27-36 Animals,plants, insects Order IV Anaeroplasmatales Family I Anaeroplasmataceae Genus I.Anaeroplasma 4 About 1600 29-33 Oxygen-sensitive Bovine-ovine rumen obligate anaerobes Genus II Asteroleplasma 1 About 1600 40 Oxygen-sensitrve Bovine-ovine rumen obligate anaerobes Uncultivated,unclassified MLOs 506-1185 23-29 Uncultivated as yet Plants,insects.

Mycoplasma fermentans, but not M penetrans, detected by PCR assays in synovium from patients with rheumatoid arthritis and other rheumatic disorders.

AIM/BACKGROUND: Mycoplasmas, especially Mycoplasma fermentans, were suggested more than 20 years ago as a possible cause of rheumatoid arthritis but this hypothesis was never substantiated. In view of the superior sensitivity of the polymerase chain reaction (PCR) assay over culture, the aim was to use this method to seek M fermentans and M penetrans in synovial samples from patients with various arthritides. METHODS: Synovial fluid samples (n = 154) and synovial biopsy specimens (n = 20) from 133 patients with various rheumatic disorders were stored at -80 degrees C for between one and 40 months. Aliquots (500 microliters) of the synovial fluid samples were centrifuged and the deposit, and also the synovial biopsy specimens (approximately 1 g) were placed in lysis buffer with proteinase K for DNA extraction. The DNA was tested by using a semi-nested PCR assay for M fermentans and a single-round PCR for M penetrans. RESULTS: M fermentans was detected in the joints of eight (21%) of 38 patients with rheumatoid arthritis, two (20%) of 10 patients with spondyloarthropathy with peripheral arthritis, one (20%) of five patients with psoriatic arthritis, and four (13%) of 31 patients with unclassified arthritis. M fermentans was not found in the joints of the seven patients with reactive arthritis, the 29 with osteoarthritis or post-traumatic hydrarthrosis, the nine with gouty arthritis, nor the four with chronic juvenile arthritis. M penetrans was not detected in any sample. CONCLUSIONS: These findings show that the presence of M fermentans in the joint is associated with inflammatory rheumatic disorders of unknown cause, including rheumatoid arthritis. However, whether this organism triggers or perpetuates disease of behaves as a passenger remains conjectural.

Failure to detect Mycoplasma fermentans, Mycoplasma penetrans, or Mycoplasma pirum in the urethra of patients with acute nongonococcal urethritis.

Urethral swab specimens collected from 108 male Japanese patients with acute nongonococcal urethritis (NGU) and from 50 Japanese men without NGU were examined for the presence of Mycoplasma fermentans, Mycoplasma penetrans, and Mycoplasma pirum by means of polymerase chain reaction-based assays. These mycoplasmas were not detected in any of the specimens, which suggests that they are unlikely to have a pathogenic role in acute NGU.

Infrequent detection of Chlamydia trachomatis in a longitudinal study of women with treated cervical infection.

OBJECTIVE: To determine how often Chlamydia trachomatis cervical infections are detected in women following completion of a currently recommended treatment regimen and the reason for recurrence. METHODS: A longitudinal follow-up study of 43 initially C trachomatis-positive women for periods of up to two years. RESULTS: C trachomatis was detected in three women, 19, 16 and about four months, respectively after completion of treatment. All specimens from the other 40 women which were taken during visits two to seven, that is periods of three to 700 days after treatment, were chlamydia-negative. CONCLUSION: Although C trachomatis is usually eradicated from the genital tract by conventional treatment, occasionally it may be found again. It is difficult to determine whether detection after treatment is due to persistence or reinfection and further studies are required.

Mycoplasma genitalium in the joints of two patients with arthritis.

Mycoplasma genitalium was sought in synovial fluids from 13 patients, of whom five had Reiter's syndrome, four had rheumatoid arthritis, and one each had systemic lupus erythematosus, psoriatic arthritis, rheumatic fever and undefined arthritis. The mycoplasma was detected by a PCR assay in the knee joint of a 25-year-old man with Reiter's syndrome, from whom urethral ureaplasmas were isolated and whose synovial fluid mononuclear cells responded to ureaplasmal antigens in a proliferation assay. Mycoplasma genitalium was also detected in the knee joint during an exacerbation of arthritis in a 58-year-old man who had had seronegative juvenile polyarthritis that had evolved to seronegative rheumatoid arthritis.

Association of Mycoplasma genitalium with acute non-gonococcal urethritis.

Chlamydia trachomatis is known to be a cause of acute non-gonococcal urethritis (NGU), though the aetiology of this disorder is not fully understood. Mycoplasma genitalium has been isolated from a few men with NGU, but culture has remained difficult and reliable detection became possible only with a specific polymerase chain reaction (PCR). We have used the PCR to examine the role of M genitalium in NGU. M genitalium was detected in urethral samples from 24 (23%) of 103 men with symptoms, signs, or both, of acute NGU, but from only 3 (6%) of 53 men without NGU (p < 0.006). This association was independent of the presence of C trachomatis and could not be explained by differences in age, ethnic, origin, lifetime number of sexual partners or a change in sexual partner during the previous 3 months. The clinical response of the mycoplasma-positive men to doxycycline treatment was at least as satisfactory as that of the chlamydia-positive men. These findings suggest that the association of M genitalium with NGU is likely to be causal, a notion consistent with the known virulence characteristics of this microorganism and its ability to cause urethritis in male sub-human primates.

Occurrence of Mycoplasma genitalium in different populations and its clinical significance.

Mycoplasma genitalium is predominantly flask-shaped with cytadsorptive and glass-adhering properties. These biological features of pathogenicity are reflected in its ability to cause urethritis and salpingitis in subhuman primates when given experimentally, although its role in human disease is less clear. M. genitalium was initially recovered by culture of specimens from two of 13 men with acute nongonococcal urethritis (NGU), but culture remains a laborious and insensitive means of detection. This organism has, however, been detected in the urethra of > or = 20% of men with acute NGU by using a polymerase chain reaction (PCR) and in a similar proportion of men with chronic NGU. The possibility of sexual transmission of M. genitalium is supported by the fact that by using the PCR it has been detected in the lower genital tract of about 20% of women who were attending a clinic for sexually transmitted diseases. It has also been detected, together with Mycoplasma pneumoniae, in a joint of a hypogammaglobulinemic patient who was suffering from polyarthritis after pneumonia and has been isolated, again with Mycoplasma pneumoniae, from the throat in culture. Such detection raises the question of the preferred mucosal site of M. genitalium, which has yet to be determined.