Who tests whom? A comprehensive overview of Chlamydia trachomatis test practices in a Dutch region among different STI care providers for urogenital, anorectal and oropharyngeal sites in young people: a cross-sectional study.

OBJECTIVES: To evaluate and compare Chlamydia trachomatis (CT) diagnostic test practices of different sexually transmitted infection (STI) care providers in 16-29 year olds from one defined geographic Dutch region (280,000 inhabitants). Both number and proportion of positive CT tests (ie, test positivity) were assessed, and factors associated with these outcomes. METHODS: Data on laboratory testing and diagnosis of urogenital, anorectal and oropharyngeal CT between 2006 and 2010 were retrieved from general practitioners (GPs), gynaecologists, an STI clinic and a population-based chlamydia screening programme. Multivariable regression analyses explored associations between age, sex, test year, socio-economic status (SES) and STI care provider and the outcomes being the number of tests and test positivity. RESULTS: Overall, 22,831 tests were performed (1868 positive; 8.2%). Extragenital (ie, anorectal and oropharyngeal) tests accounted for 4% of all tests (7.5% positive) and were almost exclusively (99%) performed by the STI clinic. STI clinics tested most men (37.2% of all tested men), whereas GPs tested most women (29.9% of all tested women). GPs and STI clinics accounted for 73.3% (1326/1808) of urogenital CT diagnoses. In women, the number of tests increased with age, whereas test positivity decreased for all STI care providers. Lower SES was associated with higher test positivity in GP and gynaecology patients. CONCLUSIONS: STI clinics performed most CT tests in men, whereas GPs performed most CT tests in women. GPs and STI clinics accounted for the majority of positives. Extragenital CT testing is rarely performed outside the STI clinic and needs to be promoted, especially in men who have sex with men.

[Fatal case of sepsis with Capnocytophaga canimorsus after a minor dog bite]. / Fatale afloop van een sepsis met Capnocytophaga canimorsus na een triviale hondenbeet.

A healthy 54-year-old man presented at the emergency department with signs of sepsis. Four days prior he was bitten and scratched by his dog. Microscopy of the blood smear showed intracellular Gram-negative rods. Despite maximal treatment the patient died a day and a half after admission due to septic shock with multi-organ failure and disseminated intravascular coagulopathy. After extended incubation of the spleen culture a Gram-negative rod was isolated and identified as Capnocytophaga canimorsus based on 16s RNA analysis. This is a commensal microorganism found in the oropharynx of dogs and cats. Infection occurs 2-3 days after contamination. The clinical presentation is heterogeneous, and contamination can sometimes proceed to fulminant infection. The lethality of infection is 30%. A risk factor is often present, such assplenectomy, alcohol abuse or immunosuppression. Immediate antibiotic treatment may influence the course of infection. Antibiotic prophylaxis has also been proposed for high-risk patients with dog bites.

[Severe diarrhoea with invasive intestinal spirochaetosis]. / Ernstige diarree met invasieve intestinale spirochetose.

A 38-year-old heterosexual male presented with a 6 to 7 week history of severe diarrhoea but no other complaints. In routine faecal cultures and routine parasitological investigations no pathogenic micro-organisms were observed. Colonoscopy revealed a normal mucosa. Multiple biopsies were obtained. The histological diagnosis was invasive intestinal spirochaetosis. The immunostain for Borrelia burgdorferi cross-reacted with the spirochetes of the intestinal spirochaetosis. After two weeks of incubation under strict anaerobic conditions a spirochaete was cultured from a biopsy of the sigmoid mucosa. The 16SrDNA sequence was consistent with Brachyspira aalborgi. The HIV and syphilis results were negative. The patient was treated first with metronidazole and then by clindamycin. The diarrhoea subsided after the second course of treatment and the cause was presumed to have been the invasive intestinal spirochaetosis. Intestinal spirochaetosis is usually found coincidentally at histological examination of colon biopsies. There is no general consensus that intestinal spirochaetosis is the cause of the diarrhoea. There is however an association between the presence of symptoms and the invasivity of spirochaetes, morphological colon epithelial changes and evidence of immune response. The literature reports patients who improve symptomatically without specific treatment. Treatment may be given to patients with severe symptoms.

An epidemic of pertussis among elderly people in a religious institution in The Netherlands.

An epidemic of pertussis is described among elderly people in a religious institution in the Netherlands in 1992. Subjects were evaluated for their vaccination status and for history and presence of respiratory symptoms. Specimens were collected for culture, polymerase chain reaction, and serological evaluation. None of the 75 residents and 19 of 24 nonresident personnel had been vaccinated against pertussis. The overall attack rate of clinical pertussis, defined as persistent cough lasting at least 2 weeks, was 49%. In five subjects with clinical pertussis, either culture or polymerase chain reaction or both were positive for Bordetella pertussis. A significant (at least 4-fold) change in specific antibody titre was observed in 85% (41/48) and 20% (10/49) of subjects with and without clinical pertussis, respectively (P < 0.0001, chi-square 41.1). The attack rate of laboratory-confirmed pertussis was 42% (41/98). This rate was 5% (1/19), 20% (1/5), and 53% (39/74) in vaccinated personnel, nonvaccinated personnel, and nonvaccinated residents, respectively (not significant). Among residents aged between 55-74 years and 75-94 years, the attack rates were 47% (17/36) and 58% (22/38), respectively (relative risk=0.8; 95% confidence interval 0.5-1.3). Four of 75 residents (5%) died from intracranial bleeding, while they were symptomatic for pertussis. It is concluded that the attack rate of pertussis was high among nonvaccinated elderly and that pertussis tended to increase with age. There may be a considerable risk of mortality from pertussis in this population. Physicians should be alert to the diagnosis of pertussis in the elderly with nocturnal and prolonged periods of coughing.

Multiple organ involvement during experimental cytomegalovirus infection is associated with disseminated vascular pathology.

Since much of the pathogenesis of cytomegalovirus (CMV) disease is still unknown and vascular involvement may be of importance a rat model was used to study the nature and course of CMV-induced vascular pathology. In this model, local CMV infection was established by subcutaneous inoculation of rat-specific CMV (RCMV) in the sole of the foot. Sings of endothelial activation, including leucocyte adhesion, preceded detectable RCMV infection of these cells. ultimately, vasculitis and thrombotic occlusion were accompanied by diffuse tissue inflammation and necrosis. Generalized RCMV infection was induced in rats by intraperitoneal administration of the virus, which resulted in multiple organ pathology, including haemorrhages, inflammation, and gastrointestinal ulceration. RCMV-encoded antigens were found especially in mononuclear inflammatory cells in the organs and peripheral blood. In addition, multiple haemorrhages and disturbed haematological parameters indicated diffuse intravascular coagulopathy. In conclusion, this study provides evidence for extensive vascular involvement and haematological consequences during disseminated CMV infection. The nature and chronology of RCM-induced pathological vascular events were demonstrated, indicating the importance of endothelial damage. These data and further study may lead to a better understanding of the pathogenesis of CMV multiple-organ disease.

Effective treatment of experimental cytomegalovirus-induced encephalo-meningitis in immunocompromised rats with HPMPC.

Cytomegalovirus (CMV)-induced encephalomeningitis is a dramatic complication in patients with the acquired immunodeficiency syndrome (AIDS) and treatment of this infection remains a major clinical problem. In order to study the pathogenesis and treatment of CMV-induced encephalomeningitis, we experimentally induced intracranial rat CMV (RCMV) infection in rats that were immunosuppressed by total body X-irradiation. CMV infection was monitored by viral plaque assay for estimation of the viral load. CMV-induced pathology, the presence of CMV-infected cells, as well as the presence of T-lymphocytes and monocytes/macrophages were studied by histopathologic and immunohistochemical staining techniques. The meninges showed CMV infection in mononuclear infiltrative cells and in endothelium of small blood vessels 8 days after intracerebral inoculation. This was accompagnied by multiple haemorraghes and inflammatory cell infiltration. The infection and inflammatory response persisted for at least 21 days p.i. Animals were treated with (S)-1-(3-hydroxy-2-phosphonylmethoxypropyl)cytosine (HPMPC), 9-(1,3-dihydroxy-2-propoxymethyl)guanine (DHPG), hyperimmune serum (HIS) and both DHPG and HIS combined. Treatment with one dosage of HPMPC at 20 mg/kg effectively reduced virus titers. However, all other treatment modalities were not effective. In conclusion, the pathology of RCMV-induced encephalomeningitis in immunocompromised rats closely resembles that of AIDS patients. The infection is effectively treated by HPMPC.

IgM antibody detection of ppUL80A and ppUL32 by immunoblotting: an early parameter for recurrent cytomegalovirus infection in renal transplant recipients.

The value of IgM detection for the early diagnosis of an active cytomegalovirus (CMV) infection in renal transplant recipients was evaluated prospectively. Sequential serum samples obtained from 22 allograft recipients with active CMV infection were tested for the presence of CMV-specific immunoglobulin M antibodies (IgM) by an enzyme-linked immunosorbent assay (ELISA) and a microparticle enzyme immunoassay (MEIA) and were compared with the Western-immunoblotting technique (IB). The time course of CMV IgM antibody detection was evaluated in relation to the shell vial assay (SVA), CMV disease, and immunosuppressive regimen. By IB, IgM antibodies against the capsid protein ppUL80a and the basic matrix phosphoprotein ppUL32 were detected in all 22 recipients with active CMV infection. Using the MEIA and the ELISA, the presence of CMV IgM antibodies was detected in 17 (77%) and ten (46%) of these 22 recipients, respectively. The SVA was the earliest parameter for detection of primary CMV infection in seven of nine (78%) recipients, in contrast to two of 13 (15%) patients with recurrent CMV infection (P < .05). The detection of IgM antibodies by IB was the earliest parameter for detection of recurrent CMV infection in seven out of 13 (54%) recipients in contrast to one out of nine (11%) patients with primary CMV infection (P < .05). During a primary CMV infection, the development of an abundant IgM antibody response was associated with recovery from CMV disease and the end of the viremic phase.

Cytomegalovirus induces interstitial lung disease in allogeneic bone marrow transplant recipient rats independent of acute graft-versus-host response.

Interstitial lung disease (ILD) after allogeneic bone marrow transplantation (BMTx) is an important clinical problem in terms of diagnosis, therapy, and pathogenesis. Graft-versus-host disease (GvHD) and cytomegalovirus (CMV) infection seem to be major risk factors for ILD, but their role in the pathogenesis is not well established. We previously reported CMV-induced ILD in allogeneic bone marrow recipient rats, which was prevented by antiviral drug treatment. In this paper, we describe the pathology of ILD in allogeneic bone marrow transplant recipient rats and the relation of ILD with CMV infection and GvHD. Brown Norway rats received an allogeneic (Lewis) BMTx and rat CMV infection, after an allogeneic (Lewis) lung transplantation and immunosuppression. CMV infection was recorded by the amount of infectious virus and viral antigens in the lung. ILD was monitored by the presence of diffuse histopathologic changes in the alveolar septal wall. GvHD was scored by the relative splenic weights and the presence of perivascular infiltrates in the lung. Cells expressing CMV antigens were more numerous in the alveolar septa of the allogeneic recipient lungs than in the syngeneic donor lungs (p < 0.05). The high viral load in the recipient lung of allogeneic BMTx recipient rats was accompanied by diffuse ILD, marked by extensive microvascular damage and congestion of the alveolar septa. ILD was observed neither in the syngeneic donor lung nor in both lungs of mock-infected animals. GvHD was not observed in rat-CMV-infected or in mock-infected animals. Our results indicate that CMV induces microvascular damage, resulting in ILD. This process is independent of GvHD.

Combinations of ganciclovir and antibody for experimental CMV infections.

The effect of combined treatment with ganciclovir and hyper immune serum (HIS) was evaluated in three animal models. It concerned a generalized CMV infection model, a meningo-encephalitis model and an interstitial lung disease (ILD) model in immunocompromised rats. In the generalized model, the ganciclovir and HIS had a moderate synergistic effect on survival and greatly decreased virus titers in internal organs. In contrast, in the meningoencephalitis model, combined treatment had no effect on the local virus titers and the histopathology. Combined treatment with ganciclovir and HIS, however, effectively abolished CMV-induced ILD.

Pathogenicity: animal models.

Animal models offer the opportunity to study the interaction of the virus and the host and to unravel the mechanism in processes such as persistence of the virus and virus-induced pathology. Primary infection results in a generalized infection as shown by the presence of virus in many organs. During viraemia the virus is present in mononuclear cells by which it is transported through the body. In neonates and in immuno-suppressed animals the infection results in multiorgan failure, leading to death. Recent data have shown that infection of endothelial cells in the microvasculature and mononuclear cells seems to be important in the pathogenesis of cytomegalovirus (CMV)-induced disease. After primary infection the virus persists in the body. Although the exact localization of the latent virus is unknown it is clear that during latency viral DNA is present in many organs. By immune suppression the virus can reactivate from its latent state. In addition to the direct complications attributable to the virus itself, CMV has modulating effects on the immune response. Although in some instances the infection leads to immune suppression, the virus infection can also accelerate inflammatory and immune responses. Studies in mice have shown that CMV infection can exacerbate graft-versus-host reactions, and experiments in rats using allogeneic transplants indicate that CMV infection results in enhanced chronic rejection in which acceleration of the immune response is involved. Although the exact mechanism is not clear, recent data indicate that cytokines, such as tumor necrosis factor alpha are involved in these processes.

Induction of endothelial adhesion molecules by rat cytomegalovirus in allogeneic lung transplantation in the rat.

Cytomegalovirus (CMV) infection is known to be a major risk factor for the development of chronic transplant rejection in heart and lung transplantation. A possible mechanism for the induction of lung transplant rejection by CMV infection is the inflammatory upregulation of adhesion ligand molecules by the viral infection leading to an increased endothelial-leucocyte interaction. To study this question, an experimental model was established in the rat using a rat cytomegalovirus (RCMV) infection and acute lung transplant rejection in left single lung transplantation. The distribution of RCMV, intercellular adhesion molecule-1 (ICAM-1) and its leucocyte receptor CD11a (LFA-1) were investigated by immunohistochemistry. The viral infection was observed in transplant lungs of infected hosts as early as day 11. The expression of ICAM-1 on endothelial cells was induced and enhanced by RCMV infection, and infiltration of CD11a-positive leucocytes found to be increased in infected recipients. An acceleration of the rejection of the allografts by the hosts was found.

Generalized cytomegalovirus (CMV) infection and CMV-induced pneumonitis in the rat: combined effect of 9-(1,3-dihydroxy-2-propoxymethyl)guanine and specific antibody treatment.

The combined effect of 9-(1,3-dihydroxy-2-propoxymethyl)guanine (DHPG, ganciclovir) and hyper immune serum (HIS) was studied in two different rat models. In the first model, a lethal generalized rat cytomegalovirus (RCMV) infection was established in immunosuppressed Brown Norway (BN) rats. Treatment with DHPG or hyper immune serum (HIS) effectively reduced both mortality rate and virus titers in the liver and lungs. By combined treatment the effective dose of both DHPG and HIS was reduced to 25%. The fractionary effective dose was 0.5, indicating a moderate synergistic effect on survival. Combined treatment also established a significant reduction of virus titers in lungs and liver (P < 0.01), but not in spleen. In the second model, interstitial pneumonia (IP) was established in RCMV-infected immunosuppressed BN rats after allogeneic bone marrow transplantation. IP was characterized by infiltration of mononuclear cells and diffuse thickening of the alveolar septal wall. DHPG reduced virus titers in the lungs but had no effect on IP. In contrast, HIS significantly reduced both virus titers and histopathologic changes in the lungs. Combined DHPG and HIS treatment minimized virus titers in internal organs and CMV-induced IP. Likewise, combined DHPG and control immune serum treatment significantly reduced immunopathologic changes in the lungs.

Prevention of bacteraemia by systemic ciprofloxacin treatment in rat cytomegalovirus-infected immunocompromised rats.

After total body irradiation (TBI) and subsequent rat cytomegalovirus (RCMV) infection rats developed severe neutropenia and in 90% of these animals Gram-negative bacteraemia was observed. Neutropenia was less severe (P < 0.01) and bacteraemia was not recorded (P < 0.01) in uninfected irradiated control groups. The effect of selective bowel decontamination (SBD) on the bowel flora and the incidence of bacteraemia in RCMV-infected irradiated rats was studied. Animals received ciprofloxacin 2 mg/kg/day, administered by either the oral or the subcutaneous route. After either treatment regimens the numbers of Enterobacteriaceae in the caecum and colon were reduced significantly (from 10(7) to < 10(2) g of faeces), while the total numbers of facultatively aerobic and obligatory anaerobic bacteria and the number of enterococci in the faeces was unaffected when measured 1, 3 and 7 days after the onset of treatment. The effect of ciprofloxacin treatment on the incidence of bacteraemia was recorded in RCMV-infected irradiated groups. Blood and organ cultures were taken 10 days after virus inoculation. The rate of bacteraemia decreased from 80% in untreated RCMV-infected irradiated rats affected by severe RCMV disease to < 10% in the ciprofloxacin treated groups (P < 0.01). The route of treatment did not influence these results. The uninfected irradiated and infected non-irradiated control groups showed no bacteraemia. It is concluded that symptomatic RCMV infection induces severe neutropenia, which predisposes to a high rate of Gram-negative bacteraemia, which can be prevented by eradication of the Gram-negative aerobic bacteria by means of SBD with ciprofloxacin. Systemic treatment seems to be superior for the control of Enterobacteriaceae. This may be especially useful for patients, who cannot be treated effectively by the oral route because of intestinal stasis.

Chlamydia trachomatis antibody testing is more accurate than hysterosalpingography in predicting tubal factor infertility.

OBJECTIVE: To compare the likelihood of abnormal Chlamydia trachomatis antibody test results with that of abnormal hysterosalpingography (HSG) test results in patients with tubal factor infertility. DESIGN: Anti-C. trachomatis immunoglobulin G antibodies were determined prospectively in 211 consecutive infertility patients by means of an indirect fluorescent antibody technique. The results were compared with the results of HSG with respect to their predictive value of tubal factor infertility. Likelihood ratio calculations were used. SETTING: University hospital-based, tertiary care infertility clinic. PATIENTS: A series of 211 consecutive infertility patients. INTERVENTIONS: C. trachomatis antibody testing, HSG, laparoscopy. MAIN OUTCOME MEASURES: Likelihood ratios for abnormal C. trachomatis antibody test results and abnormal HSG results in infertility patients, as assessed by laparoscopy. RESULTS: The positive likelihood ratio for C. trachomatis antibody testing was 9.1, indicating a patient with tubal factor infertility to be 9.1 times more likely to have abnormal serology results than a patient without tubal factor infertility. This was superior to HSG, which had a positive likelihood ratio of 2.6 in our study and of 1.6 to 6.1 in the literature. The odds ratio of C. trachomatis antibody testing was 31.5 in our study. Its 90% confidence interval (8.3 to 138.5) did not overlap that of HSG as calculated from a meta-analysis of literature reports (5.3 to 7.9). CONCLUSIONS: C. trachomatis antibody testing is simple, inexpensive, and causes minimal inconvenience to the patient. It is more likely than HSG to be abnormal in patients with tubal factor infertility. C. trachomatis antibody testing deserves to become an integral component of the initial fertility work-up.

Tumor necrosis factor alpha promotes replication and pathogenicity of rat cytomegalovirus.

We investigated the role of tumor necrosis factor alpha (TNF-alpha) in the pathogenesis of rat cytomegalovirus (RCMV) infection. TNF-alpha levels found in the sera of radiation-immunosuppressed rats in the course of infection (> 350 pg/ml) correlated with the development of RCMV disease. Administration of anti-TNF-alpha antibodies strongly reduced the severity of pneumonia and led to a reduction in virus titers. In immunocompetent rats, anti-TNF-alpha antibodies also significantly suppressed viral replication. Conversely, administration of TNF-alpha augmented RCMV replication and aggravated the disease signs. In vitro, TNF-alpha enhanced RCMV replication in the macrophage, whereas a reduction of viral replication was observed in fibroblasts, indicating that the effect on viral replication is cell type specific. Besides activation of viral replication and exacerbation of RCMV disease, TNF-alpha also favored lymphoid and hematopoietic tissue reconstitution after irradiation, which may contribute to antiviral resistance and survival. This finding demonstrates the protean nature of TNF-alpha, with both beneficial and adverse effects for the host. Our results suggest that TNF-alpha plays an important role in modulating the pathogenesis of RCMV infection.

Suppression of rat cytomegalovirus replication by antibodies against gamma interferon.

The role of gamma interferon (IFN-gamma) in the resolution of rat cytomegalovirus (RCMV) infection was investigated. In the spleen, IFN-gamma-producing cells reached maximum numbers on day 7 after infection. Prophylactic treatment with high doses of recombinant rat IFN-gamma exerted antiviral activity in fibroblasts and protected immunosuppressed rats against a lethal RCMV challenge. Remarkably, in immunocompetent rats, neutralization of endogenous IFN-gamma activity significantly reduced the numbers of RCMV antigen-expressing cells in the spleen, the predominant site of viral replication. Moreover, protection of radiation-immunosuppressed infected rats by transferred immune T cells was enhanced by coinjection of IFN-gamma neutralizing antibodies. The observations were paralleled by in vitro findings: low concentrations of IFN-gamma enhanced viral replication in both macrophages and fibroblasts. These data suggest that IFN-gamma can play different and even opposite roles in the regulation of RCMV replication in vivo; T lymphocytes may contribute to the progression of RCMV infection by secreting IFN-gamma.

Enhancement of transplantation-associated atherosclerosis by CMV, which can be prevented by antiviral therapy in the form of HPMPC.

Effects of acute cytomegalovirus (CMV) infections on transplantation-associated atherosclerosis (TxAA) were studied in a rat model for chronic vascular rejection. Rats underwent orthotopic abdominal allogeneic aorta transplantation. Neo-intima formation and media thinning was quantitated by measurement of cross-sectional surface areas (CSA) at day 50 post transplantation (Tx). Acute rat cytomegalovirus (RCMV) infection, established at the moment of maximum intimal proliferation and influx of inflammatory cells in the adventitia, resulted in enhanced neo-intima formation, accompanied by increased influx and proliferation of smooth muscle cells (smc) in the intima. This effect was completely inhibited by HPMPC, a very potent and selective inhibitor of CMV replication, indicating the virus specificity of the measured effects. Despite increased neointima formation, media thinning ("necrosis") was not affected by RCMV infection.

[A child with Chlamydia trachomatis pneumonia]. / Een kind met een Chlamydia trachomatis-pneumonie.

A six week old boy is presented with a Chlamydia trachomatis pneumonia. This pneumonia is seldom diagnosed because of the mild clinical symptoms and the good prognosis, even without therapy. Diagnosing the Chlamydia trachomatis infection of the neonate is of importance for the mother and the child. Chlamydia trachomatis infections in neonates are an underestimated problem.

Cytomegalovirus IgM antibody detection: comparison of five assays.

Human Cytomegalovirus (CMV) infection can result in a dramatic disease in immunosuppressed patients. For effective treatment sensitive and specific procedures are required for prompt and early diagnosis of active CMV infection. In the present study five different serological assays were used for detection of CMV-specific immunoglobulin M antibodies (IgM) in 78 sera, obtained from patients with a clinical suspicion of CMV infection. In addition, sequential sera, obtained from renal transplant recipients who experienced a primary CMV infection, were analysed by the five IgM detection assays. The assays used were two enzyme-linked immunosorbent assays (ELISA): the Vironostika CMV ELISA from Organon Teknika (ELISA-1) and the Monosan CMV ELISA from Sanbio (ELISA-2), the CMV microparticle enzyme immunoassay (MEIA) from Abbott and two Western-(immuno)blotting techniques using purified CMV structural viral proteins of the AD169 strain (IB-AD169) and the major non structural DNA binding protein of 52 kiloDalton (IB-Rp52) as antigenic material. The results of the assays were compared to each other with respect to sensitivity, specificity and overall agreement, as well as incidence of false positive and false negative results. Although the MEIA gave the highest sensitivity, the ELISA-1 combined a high sensitivity with a high specificity and therefore appears the most suitable method for determination of active CMV infection.