Conjunctival fibrosis and the innate barriers to Chlamydia trachomatis intracellular infection: a genome wide association study.

Chlamydia trachomatis causes both trachoma and sexually transmitted infections. These diseases have similar pathology and potentially similar genetic predisposing factors. We aimed to identify polymorphisms and pathways associated with pathological sequelae of ocular Chlamydia trachomatis infections in The Gambia. We report a discovery phase genome-wide association study (GWAS) of scarring trachoma (1090 cases, 1531 controls) that identified 27 SNPs with strong, but not genome-wide significant, association with disease (5 × 10(-6) > P > 5 × 10(-8)). The most strongly associated SNP (rs111513399, P = 5.38 × 10(-7)) fell within a gene (PREX2) with homology to factors known to facilitate chlamydial entry to the host cell. Pathway analysis of GWAS data was significantly enriched for mitotic cell cycle processes (P = 0.001), the immune response (P = 0.00001) and for multiple cell surface receptor signalling pathways. New analyses of published transcriptome data sets from Gambia, Tanzania and Ethiopia also revealed that the same cell cycle and immune response pathways were enriched at the transcriptional level in various disease states. Although unconfirmed, the data suggest that genetic associations with chlamydial scarring disease may be focussed on processes relating to the immune response, the host cell cycle and cell surface receptor signalling.

Genome expansion in bacteria: the curios case of Chlamydia trachomatis.

BACKGROUND: Recent findings indicated that a correlation between genomic % AT and genome size within strains of microbial species was predominantly associated with the uptake of foreign DNA. One species however, Chlamydia trachomatis, defied any explanation. In the present study 79 fully sequenced C. trachomatis genomes, representing ocular- (nine strains), urogenital- (36 strains) and lymphogranuloma venereum strains (LGV, 22 strains), in three pathogroups, in addition to 12 laboratory isolates, were scrutinized with the intent of elucidating the positive correlation between genomic AT content and genome size. RESULTS: The average size difference between the strains of each pathogroup was largely explained by the incorporation of genetic fragments. These fragments were slightly more AT rich than their corresponding host genomes, but not enough to justify the difference in AT content between the strains of the smaller genomes lacking the fragments. In addition, a genetic region predominantly found in the ocular strains, which had the largest genomes, was on average more GC rich than the host genomes of the urogenital strains (58.64% AT vs. 58.69% AT), which had the second largest genomes, implying that the foreign genetic regions cannot alone explain the association between genome size and AT content in C. trachomatis. 23,492 SNPs were identified for all 79 genomes, and although the SNPs were on average slightly GC rich (~47% AT), a significant association was found between genome-wide SNP AT content, for each pathogroup, and genome size (p < 0.001, R (2) = 0.86) in the C. trachomatis strains. CONCLUSIONS: The correlation between genome size and AT content, with respect to the C. trachomatis pathogroups, was explained by the incorporation of genetic fragments unique to the ocular and/or urogenital strains into the LGV- and urogential strains in addition to the genome-wide SNP AT content differences between the three pathogroups.

In vivo confocal microscopy in scarring trachoma.

OBJECTIVE: To characterize the tissue and cellular changes found in trachomatous scarring (TS) and inflammation using in vivo confocal microscopy (IVCM). DESIGN: Two complimentary case-control studies. PARTICIPANTS: The first study included 363 cases with TS (without trichiasis), of whom 328 had IVCM assessment, and 363 control subjects, of whom 319 had IVCM assessment. The second study included 34 cases with trachomatous trichiasis (TT), of whom 28 had IVCM assessment, and 33 control subjects, of whom 26 had IVCM assessment. METHODS: All participants were examined with ×2.5 loupes. The IVCM examination of the upper tarsal conjunctiva was carried out with a Heidelberg Retina Tomograph 3 with the Rostock Cornea Module (Heidelberg Engineering GmbH, Dossenheim, Germany). MAIN OUTCOME MEASURES: The IVCM images were graded in a masked manner using a previously published grading system evaluating the inflammatory infiltrate density; the presence or absence of dendritiform cells (DCs), tissue edema, and papillae; and the level of subepithelial connective tissue organization. RESULTS: Subjects with clinical scarring had a characteristic appearance on IVCM of well-defined bands and sheets of scar tissue visible. Similar changes were also seen in some clinically normal subjects consistent with subclinical scarring. Scarred subjects had more DCs and an elevated inflammatory infiltrate, even after adjusting for other factors, including the level of clinical inflammation. Cellular activity was usually seen only in or just below the epithelium, rarely being seen deeper than 30 µm from the surface. The presence of tissue edema was strongly associated with the level of clinical inflammation. CONCLUSIONS: In vivo confocal microscopy can be quantitatively used to study inflammatory and scarring changes in the conjunctiva. Dendritic cells seem to be closely associated with the scarring process in trachoma and are likely to be an important target in antifibrotic therapies or the development of a chlamydial vaccine. The increased number of inflammatory cells seen in scarred subjects is consistent with the immunopathologic nature of the disease. The localization of cellular activity close to the conjunctival surface supports the view that the epithelium plays a central role in the pathogenesis of trachoma. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

[Retinal lesion in experimental chlamydia eye infection].

Until the present time, ophthalmic chlamydiasis has been generally associated with diseases of auxiliary organs of the eye and its anterior segment: conjunctivitis and iridocyclitis. The morphological substrate of eye posterior segment lesion caused by C. trachomatis and C. pneumonia was studied in this investigation. The pathomorphological pattern characteristic of chlamydia-induced rabbit retinal and vitreous body lesions is composed of vitreoretinal lymphocyte-macrophageal infiltrations of varying intensity, posterior hyaloid membrane detachment, peripheral foci or folding of the retina, impaired nuclei of photoreceptors and bipolar neurons, pigment epithelial damage occurring in different concurrences in relation to the species of a causative agent and the clinical picture.

Combination of adult inclusion conjunctivitis and mucosa-associated lymphoid tissue (MALT) lymphoma in a young adult.

PURPOSE: To report a patient who was diagnosed with combined adult inclusion conjunctivitis (AIC) and mucosa-associated lymphoid tissue (MALT) lymphoma. METHODS: This is a case report. RESULTS: An 18-year-old male patient presented with chronic conjunctivitis and giant follicles. Evaluation by chlamydial antigen assay was positive. Conjunctival biopsy for the immunohistochemical stain and polymerase chain reaction of the left eye showed MALT lymphoma. CONCLUSIONS: MALT lymphoma can masquerade as other ocular surface diseases. Chlamydial infection causes chronic inflammation of the conjunctiva. Both of these diseases should be considered as a differential diagnosis of refractory follicular conjunctivitis. It is worthy of further study to determine whether chronic inflammation resulting from chlamydial infection increases the risk of MALT lymphoma or it is coincidental.

Detection of novel chlamydiae in cats with ocular disease.

OBJECTIVE: To detect and characterize the full range of chlamydial infections in cats with ocular disease by use of polymerase chain reaction (PCR) assays, cytologic examination, immunohistochemical analysis, and evaluation of clinical information including status for feline herpesvirus-1 (FeHV-1). SAMPLE POPULATION: DNA extracted from 226 conjunctival samples obtained from cats with clinically diagnosed keratitis or conjunctivitis and 30 conjunctival samples from healthy cats. PROCEDURE: PCR assays for the 16S rRNA gene specific for the order Chlamydiales and a new Chlamydophila felis (formerly Chlamydia psittaci) species-specific 23S rRNA gene were performed. Seventy-four conjunctival samples were prepared with Romanowsky-type stain, grouped on the basis of inflammatory pattern, and screened for chlamydial inclusions by use of immunohistochemical analysis. Clinical information and FeHV-1 status were recorded. RESULTS: 26 (12%) specimens had positive results for the only known feline chlamydial pathogen, C felis. Surprisingly, an additional 88 (39%) were positive for non-C felis chlamydial DNA. Identification of non-C felis chlamydial DNA by direct sequencing revealed 16S rRNA gene sequences that were 99% homologous to the sequence for Neochlamydia hartmannellae, an amebic endosymbiont. Chlamydial prevalence was significantly higher in cats with ocular disease. CONCLUSIONS AND CLINICAL RELEVANCE: Application of a broad-range detection method resulted in identification of a new agent associated with ocular disease in cats. Finding chlamydia-like agents such as N hartmannellae in coinfections with their obligate amebic host, Hartmannella vermiformis, raises questions about the potential role of these microorganisms in causation or exacerbation of ocular disease in cats.

Ocular chlamydial infections: pathogenesis and emerging treatment strategies.

Chlamydiae cause a spectrum of diseases in multiple organ systems, and chlamydial infections of the eye lead to sequelae varying from mild conjunctivitis to blindness. This paper reviews current concepts in the pathogenesis and management of ocular chlamydial infections. Trachoma, the leading cause of preventable blindness in the world, is compared with other ocular chlamydial diseases to underscore key concepts in chlamydial pathogenesis. Emerging treatment strategies are discussed in the context of chlamydial pathogenesis and the World Health Organization initiative to eradicate trachoma by 2020.

Conjunctivitis caused by a swine Chlamydia trachomatis-like organism in gnotobiotic pigs.

The objective of this study was to determine whether a chlamydial strain recovered from growing and finishing swine with conjunctivitis or keratoconjunctivitis could cause the same infections in gnotobiotic pigs. The strain shares biological characteristics with Chlamydia trachomatis. After propagation in Vero cells and preparation of the inoculum (10(7) inclusion-forming units/ml), chlamydial strain H7 was instilled into the ventral conjunctival sac (0.15 ml/sac) of 12 anesthetized 3-day-old gnotobiotic piglets. Four age-matched gnotobiotic piglets were anesthetized and sham infected with uninfected cell culture lysates. None of the principal piglets developed clinical symptoms of conjunctivitis or keratoconjunctivitis. Principal piglets necropsied 7 days postinfection (DPI) had histologic lesions of mild or moderate conjunctivitis; immunohistochemical evaluation revealed chlamydial antigen in conjunctival epithelium. A majority of principal piglets necropsied at 14-28 DPI had histologic lesions of mild conjunctivitis, but chlamydial antigen was not detected by immunohistochemistry. The results indicated that chlamydial strain H7 can cause mild or occasionally moderate conjunctivitis in gnotobiotic pigs, but the conjunctival infection is asymptomatic.

Murine model of ocular infection by a human biovar of Chlamydia trachomatis.

PURPOSE: A human biovar of Chlamydia trachomatis was used to develop a murine model of ocular chlamydial infection. The inbred mouse model will allow detailed immunologic studies during ocular infection, and use of a human biovar for infection may aid in identification of appropriate vaccine strategies against chlamydial infections. METHODS: BALB/c, C3H/HeN, and C57B1/6J mice (n = 5 to 10 mice/group) were topically infected in the conjunctiva with C serovar of C. trachomatis. The effects were tested of single and repeated infection with 5000 inclusion-forming units (IFU) in 5 microliters and different inoculum doses. Conjunctival surfaces of both eyes were swabbed for microbiologic signs (isolation culture or direct fluorescent antibody staining) of infection over 4 to 6 weeks. Conjunctivae were removed for histopathologic study, and lymphocytes from draining cervical lymph nodes and spleens were tested for chlamydia-specific proliferative responses. Serum was obtained from all mice and tested for anti-chlamydial antibodies. RESULTS: BALB/c and C3H/HeN mice developed dose-dependent microbiologic, histopathologic, and immunologic evidence of ocular infection. Eyes of mice were culture-positive from day 7 through at least day 21, with the peak of infection at days 10 to 14 after infection. Histopathologically, the development of conjunctival subepithelial mononuclear infiltration, exudate, and loss of goblet cells occurred within 1 week. Dose-dependent lymphoproliferative responses to whole chlamydial elementary bodies were observed; anti-chlamydial antibody was detected by immunoblotting only in infected mice. CONCLUSIONS: Several strains of inbred mice are susceptible to human chlamydial biovars and may provide a useful alternative disease model in which to study the immunopathogenesis of ocular chlamydial infection and test of vaccine candidates derived from clinically relevant human biovars.

Systemic immunization with Hsp60 alters the development of chlamydial ocular disease.

PURPOSE: To determine whether immunization with recombinant Hsp60 would exacerbate ocular pathology on challenge with viable chlamydial elementary bodies. METHODS: Guinea pigs were immunized either subcutaneously with recombinant Hsp60 or both subcutaneously with recombinant Hsp60 and ocularly with attenuated Salmonella typhimurium expressing the guinea pig inclusion conjunctivitis (GPIC) Hsp60 antigen. All animals were challenged in the conjunctiva with the agent of GPIC, and the degree of gross ocular pathology was determined. Immunoglobulin G (IgG) and immunoglobulin A (IgA) antibody titers to Hsp60 were measured in ocular secretions as a measure of the degree of immunization. RESULTS: In primary and challenge GPIC infection, the degree of gross ocular pathology was lower in the immunized group. The presence of high IgA and IgG antibody titers to Hsp60 in tears suggested that the response may have been modified by the presence of blocking antibodies that either may have removed the antigen quickly or prevented interaction with sensitized T cells. In contrast to subcutaneous immunization, the combined immunization regimen, consisting of subcutaneous recombinant Hsp60 followed by ocular inoculation of the attenuated Salmonella, resulted in no difference in gross pathology after reinfection of guinea pigs with GPIC. CONCLUSIONS: These data indicated that the immunization with Hsp60 did not produce exacerbated disease on challenge with viable organisms; however, the data suggested that the route of administration, form of antigen, or both may be critical in the disease process.

Cell-mediated immunity in trachomatous scarring. Evidence from a leprosy population.

BACKGROUND: There is limited understanding of the mechanisms that mediate immunity after infection by Chlamydia trachomatis. Since it is known that the clinical course of leprosy is related to cell-mediated immunity and that such immunity contributes to the development of trachomatous conjunctival scarring, the authors examined patients to determine if there might be an association between leprosy status and trachomatous conjunctival scarring. METHODS: Leprosy patients registered at Shashemane Hospital were interviewed, examined, and patients with siblings residing in the vicinity were asked to return for further clinical examination. A subsample of sibships was selected for laboratory evaluation of cell-mediated immunity, measured by lymphocyte proliferative responses in vitro to stimulation by mycobacterial antigens. RESULTS: Conjunctival scarring was less severe in multibacillary leprosy patients (with suppressed cell-mediated immunity) than in their healthy siblings and more severe in paucibacillary leprosy patients (with enhanced cell-mediated immunity) than in their healthy siblings. The mean lymphocyte proliferative responses to mycobacterial antigens were greater in the sibling (whether leprous or healthy) with more severe conjunctival scarring, regardless of type of leprosy. CONCLUSION: The specific cellular immune responses to Mycobacterium leprae and p65 antigen in patients with increased conjunctival scarring provide evidence that early in the course of infection with C. trachomatis, factors related to an individual's cellular response are crucial to the development of conjunctival scarring. A delayed-type hypersensitivity reaction ("reversal reaction") found in paucibacillary leprosy patients could contribute to the increased trachomatous conjunctival scarring in these patients.

Lymphocyte proliferative responses to chlamydial antigens in human chlamydial eye infections.

In order to study the relationship between cell-mediated immune responses to Chlamydia trachomatis and the pathogenesis of human chlamydial eye disease, we have measured the peripheral blood lymphocyte proliferative responses to whole chlamydial elementary bodies in 40 subjects with oculogenital chlamydial infection of varying severity, 13 subjects with genital chlamydial infections and 12 healthy seronegative controls. The mean stimulation index was significantly higher in those with oculogenital infections than in controls. There was a strong correlation between the response to C. trachomatis serotypes B and L1. We studied the relationship between proliferative responses and four clinical parameters: follicular conjunctivitis, papillary hypertrophy, corneal pannus and epithelial punctate keratitis, but were unable to show a significant association with any of these. Nor was there any association between proliferative response and serum antibody titre to C. trachomatis (pooled serotypes D-K), duration of disease or quantitative isolation of chlamydia from the conjunctiva. The depletion of CD8+ cells had no consistent effect on proliferative responses to serotype L1 in 13 subjects.

Antichlamydial specificity of conjunctival lymphocytes during experimental ocular infection.

Antigen-specific responses to chlamydiae have been demonstrated with lymphocytes isolated from the conjunctiva after primary ocular infection and after topical challenge of chlamydia-immune cynomolgus monkeys with noninfectious, Triton X-100-extracted antigen. Proliferative to viable elementary bodies homologous to the original infecting serovar were demonstrated. In addition, in vitro production of antichlamydial antibody by conjunctival B cells was demonstrated by enzyme-linked immunosorbent assay of culture supernatants collected after 7 to 21 days of culture. These findings demonstrate that antigen-specific lymphocytes appear in the conjunctiva as a result of ocular chlamydial infection and that a noninfectious chlamydial antigen stimulates their reappearance or expansion at the site of original infection.

Guineapig inclusion conjunctivitis (GPIC) in a commercial colony.

Serological findings in a commercial colony of Hartley guineapigs revealed that about 70% had antibodies to Chlamydia psittaci as detected by the microimmunofluorescence method. Conjunctivitis was evident in 14% of 86 guineapigs examined. Chlamydial antigen was detected in conjunctival scrapings by a direct immunofluorescence test using Chlamydia-specific monoclonal antibody; however, C. psittaci was not demonstrated by other methods.

[Phlyctenular keratoconjunctivitis in bacterial epibulbar infections]. / Phlyktänuläre Keratokonjunktivitis bei bakteriellen epibulbären Infektionen.

Phlyctenular keratoconjunctivitis is now a rare clinical entity. Histologic staging has been updated by infection-immunological findings: phlyctenules have been identified as delayed-type cellmediated immune responses involving bacterial, mycobacterial, chlamydial, fungal or parasitic pathogens. Establishment of a correct diagnosis should include conjunctival and systemic work-ups for pathogenic agents. Case reports of three patients are presented.

Conjunctival cytology of adult chlamydial conjunctivitis.

We assessed the diagnostic value of ocular cytologic examination by reviewing Giemsa-stained smears of conjunctival scrapings. Of 387 patients with a clinical diagnosis of adult chlamydial conjunctivitis, intracytoplasmic inclusions were found in 30 (8%). Both polymorphonuclear leukocytes and lymphocytes were common; the predominant cell type was not useful to differentiate chlamydial from adenoviral conjunctivitis. More sensitive cytologic features included the presence of plasma cells, Leber cells, blastoid cells, and multinucleated cells. Giemsa-stained conjunctival cytologic examination can provide a useful method to support the clinical diagnosis and to direct further laboratory testing.

Importance of reinfection in the pathogenesis of trachoma.

The authors' epidemiologic studies of trachoma on Taiwan and experimental monkey eye infections with and without Chlamydia trachomatis immunization are reviewed for the data they provide on the pathogenesis of trachoma. These studies indicate that trachoma is an immunopathologic disease in which the more severe progressive trachoma infections with pannus and scar formation occur only after reinfection. This hypothesis is supported by a 10-year study of 32 family households that were followed with repeated clinical and laboratory observations. Although most cases of active trachoma healed spontaneously, there were 26 persons in nine families who developed clinical and laboratory evidence of 29 episodes of new trachoma eye infection. On the basis of the clinical disease, its persistence, and the laboratory findings, these 29 new infections could be divided into 10 primary, nine secondary, and 10 tertiary infections. Details of the different stages of infection leading to chronic trachoma are presented.