Atypical presentation of herpes simplex virus 2 primary infection: a case report.

BACKGROUND: Cervicitis, an infectious or noninfectious inflammation of the cervix, encompasses a wide range of clinical conditions, from asymptomatic infections to severe lesions, making its diagnosis difficult. Acute cervicitis may develop into pelvic inflammatory disease. In patients with cervicitis, current guidelines recommend testing for herpes simplex virus when external genital lesions are present. Here, we present the case of a patient with an atypical primary herpes simplex virus 2 infection manifesting as cervicitis without genital lesions. CASE PRESENTATION: A 29-year-old Caucasian woman was hospitalized for pelvic inflammatory disease. The patient complained of severe suprapubic pain, fever, and heavy vaginal discharge. The external genitalia were unremarkable, so empirical antibiotic treatment was initiated. Despite 48 hours of well-administered antibiotic therapy, her complaints persisted. Polymerase chain reaction for possible microbial causes was negative for Chlamydia trachomatis and Neisseria gonorrhoeae. There was no bacterial vaginosis. Repeat gynecological examinations with endovaginal ultrasound revealed an enlarged cervix, and pelvic magnetic resonance imaging supported a diagnosis of cervicitis. At this point, additional screening for other sexually transmitted infections and infectious disease-related etiologies of cervicitis was performed, and the polymerase chain reaction analysis of newly isolated samples was positive for herpes simplex virus 2. No antiviral treatment was initiated given the delay in diagnosing herpes simplex virus 2 infection and the slow but spontaneous abatement of symptoms. CONCLUSION: Herpes simplex virus infection should be considered as a possible cause of cervicitis, even in the absence of typical genital lesions. Early detection of herpes simplex virus allows early treatment, helping to reduce the duration and severity of symptoms and therefore potentially reducing recurrences and improving disease control. These data and data from future cases might spur changes in the guidelines on cervicitis testing and treatment.

Vaginal anaerobes are associated with cervicitis: A case-control study.

OBJECTIVES: Cervicitis is associated with important reproductive sequelae. Primary causes include chlamydia and gonorrhoea, but a known sexually transmitted infection (STI) is not identified in >50% of cases (i.e. STI-negative cervicitis). Bacterial vaginosis (BV) and specific BV-associated bacteria have also been associated with cervicitis, but data are limited. We investigated the association between STI-negative cervicitis and vaginal microbiota composition. METHODS: This was a case-control sub-study of the OhMG study conducted at the Melbourne Sexual Health Centre. Cases were women with cervicitis who tested negative for STIs (STI-negative cervicitis, n = 64). Controls were STI-negative asymptomatic women attending for STI-screening (n = 128). The vaginal microbiota was characterised using 16S rRNA gene sequencing. Vaginal community state types were compared between cases and controls using logistic regression. Differential abundance analysis was performed to identify taxa associated with STI-negative cervicitis. RESULTS: STI-negative cervicitis cases were more likely than controls to have a Lactobacillus-deficient non-optimal microbiota (adjusted-odds-ratio 2.55, 95% CI 1.18-5.50). Compared to controls, cases had increased abundance of four BV-associated bacteria (Gardnerella, Fannyhessea vaginae, Prevotella bivia, Dialister micraerophilus) and decreased abundance of optimal lactobacilli. CONCLUSIONS: We report a positive association between non-optimal vaginal microbiota composition and STI-negative cervicitis. Specific anaerobic BV-associated bacteria may represent infectious causes of cervicitis.

Qualitative and Quantitative Detection of Multiple Sexually Transmitted Infection Pathogens Reveals Distinct Associations with Cervicitis and Vaginitis.

Many diverse pathogens have been discovered from reproductive-tract infections, but the relationship between the presence and abundance of particular pathogen species and disease manifestations is poorly defined. The present work examined the association of multiple common pathogens causing sexually transmitted infections (STIs) with cervicitis and vaginitis. The presence and abundance of 15 STI pathogens and the genotypes of human papillomavirus were determined in a cohort of 944 women that included 159 cervicitis patients, 207 vaginitis patients, and 578 healthy controls. Logistic regression and random forest models were constructed and validated in a separate cohort of 420 women comprising 52 cervicitis patients, 109 vaginitis patients, and 259 healthy controls. The frequency of individual STI pathogen species varied among the symptomatic patients and healthy controls. Abundance determination was necessary for most pathogens that were associated with the studied diseases. STI pathogens were more commonly associated with cervicitis than with vaginitis. Pathogen identification- and quantification-based diagnosis was observed for cervicitis with high sensitivity and specificity, but for vaginitis, the assay results would need to be combined with results of other diagnostic tests to firmly establish the pathogen-disease correlation. Integrated qualitative and quantitative detection of a selected panel of common STI pathogens can reveal their association with cervicitis and vaginitis. STI pathogen identification and quantification can be used to diagnose cervicitis and also help improve correct diagnosis of vaginitis. IMPORTANCE Scarce information exists with regard to whether STI pathogens can be defined as valid microbiological predictive markers for the diagnosis of cervicitis and vaginitis. We therefore conducted this study to assess the presence and abundance of a wide range of STI pathogens among patients having these two diseases and healthy controls as well. High sensitivity and specificity were observed for cervicitis by pathogen identification- and quantification-based diagnosis. In contrast, the assay results obtained for vaginitis would need to be combined with test results obtained by other diagnostic methods to decisively establish the pathogen-disease correlation. Simultaneous qualitative and quantitative detection of a selected panel of common STI pathogens and further coupling with machine learning models is worthwhile for establishing pathogen-based diagnosis of gynecological inflammations, which could be of great value in guiding the rational use of antimicrobials to control the spread of STIs.

The clinical indications for testing women for Mycoplasma genitalium.

BACKGROUND: While the contribution of Mycoplasma genitalium (MG) to symptoms in men is well described, less is known about its association with common genital symptoms in women. We aimed to determine the prevalence of MG and macrolide resistance, and its association with common genital symptoms in women attending a sexual health service, to inform indications for testing and clinical practice. METHODS: We undertook a cross-sectional study of symptomatic and asymptomatic women attending Melbourne Sexual Health Centre (MSHC), between April 2017 and April 2019. Women were tested for MG and macrolide resistance, Chlamydia trachomatis (CT), Neisseria gonorrhoeae, Trichomonas vaginalis, bacterial vaginosis and vulvovaginal candidiasis. Women completed a questionnaire on symptoms, and symptomatic women underwent examination. The prevalence of MG (and macrolide resistance) and other genital infections was calculated with 95% CIs, and associations between these outcomes and specific genital symptoms were examined using logistic regression. RESULTS: Of 1318 women, 83 (6%, 95% CI: 5% to 8%) had MG, of which 39 (48%, 95% CI: 36% to 59%) had macrolide-resistant MG; 103 (8%, 95% CI: 6% to 9%) women had CT. MG prevalence was similar in asymptomatic (10 of 195; 5%) and symptomatic (73 of 1108; 7%) women, p=0.506. MG was associated with mucopurulent cervicitis on examination (adjusted OR=4.38, 95% CI: 1.69 to 11.33, p=0.002), but was not associated with other specific genital symptoms or signs. CONCLUSIONS: MG was as common as CT among women attending MSHC. MG was not associated with genital symptoms, but like CT, was significantly associated with cervicitis. These data provide evidence that routine testing for MG in women with common genital symptoms is not indicated. The presence of macrolide resistance in 48% of women supports use of resistance-guided therapy.

Cervical Cytology of Samples with Ureaplasma urealyticum, Ureaplasma parvum, Chlamydia trachomatis, Trichomonas vaginalis, Mycoplasma hominis, and Neisseria gonorrhoeae Detected by Multiplex PCR.

INTRODUCTION: Despite increasing application of molecular diagnostic methods for the detection of sexually transmitted infections, the cytological findings in pap smears of patients with pathogens that can be identified only by PCR are not yet well described. The aim of this study was to describe the most common cytological features in cervical pap smears of patients with Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, Trichomonas vaginalis, Mycoplasma hominis, Ureaplasma urealyticum, and Ureaplasma parvum detected by multiplex PCR. METHODS: Cervical samples for conventional and liquid-based cytology and for multiplex PCR were collected from women ranging from 23 to 54 years old, who underwent routine screening at a gynecological Unit. RESULTS: Multiplex PCR was positive in 36.2% of the samples: Ureaplasma parvum 14.9%, Chlamydia trachomatis 10.6%, Trichomonas vaginalis 10.6%, Mycoplasma hominis 8.5%, Ureaplasma urealyticum 4.2%, Neisseria gonorrhoeae 2.1%, and Mycoplasma genitalium (0). Multiple pathogens were observed in 12.8% of samples. Microscopic cervicitis (≥10 polymorphonuclear leukocytes/epithelial cell) and normal (predominantly lactobacillary) microbiota were the most frequent findings in the samples in which the pathogens were detected alone or in multiple infections, except for samples with Trichomonas vaginalis in which the coccobacillary microbiota was the most common. In samples with microscopic cervicitis and normal microbiota, those with at least one pathogen identified by multiplex PCR were significantly more frequent than those with no pathogen, 66.6% versus 33.3%. CONCLUSION: Failure to identify an inflammatory agent in pap smear with intense neutrophil exudate may suggest the presence of Ureaplasma parvum, Ureaplasma urealyticum, Chlamydia trachomatis, or Trichomonas vaginalis. A remark on the intensity of inflammation should be made in the reports of cervical pap smears so that this cytological finding can be correlated with clinical and PCR results.

Association of TLR4 and TLR9 gene polymorphisms and haplotypes with cervicitis susceptibility.

BACKGROUND: Cervicitis is one of the major health problems amongst women caused by infection of various pathogens including Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Trichomonas vaginalis (TV) as well as human papillomavirus (HPV), and persistent cervical inflammation is one of the etiologic agents of cervical cancer. Toll-like receptors (TLRs) play an important role in the recognition and subsequent elimination of these pathogens. Variations in the Toll-like receptor genes influence susceptibility to pathogens as well as disease progression independently. METHODS: Ten single nucleotide polymorphisms, five each of TLR4 and TLR9 genes were analyzed among 130 cervicitis patients and 150 controls either using polymerase chain reaction-restriction fragment length polymorphism or allele specific-PCR. RESULTS: T. vaginalis infection was found at the highest frequency (30.7%) as compared to C. trachomatis (1.5%), N. gonorrhoeae (2.3%) and HPV (4.6%) infections in cervicitis patients. TLR4 rs11536889 CC (age-adjusted OR, 2.469 [95% CI, 1.499 to 4.065]; p < 0.001) and TLR9 rs187084 TC (age-adjusted OR, 2.165 [95% CI, 1.267-3.699]; p = 0.005) genotypes showed the higher distribution in cervicitis patients compared to controls. In addition, TLR4 rs11536889 C allele was shown to increase the risk of cervicitis (age-adjusted OR, 1.632 [95% CI, 1.132 to 2.352]; p = 0.009) compared to controls. The TLR4 haplotype GCA (OR, 0.6 [95% CI, 0.38-0.95]; p = 0.0272) and TLR9 haplotype GTA (OR, 1.99 [95% CI, 1.14-3.48]; p = 0.014) were found to be associated with decreased and increased risk of cervicitis respectively. CONCLUSIONS: TLR4 and TLR9 polymorphisms, as well as haplotypes were shown to modulate the cervicitis risk.

The performance of a syndromic algorithm in diagnosing cervicitis in Jamaica.

A cross-sectional survey of 295 persons attending a major sexually transmitted infection clinic in Jamaica's capital city showed that the Ministry of Health's syndromic algorithm has moderate sensitivity and negative predictive value for diagnosing cervicitis. In the absence of diagnostic tests for sexually transmitted infections, a syndromic algorithm continues to be useful for diagnosing sexually transmitted infections.

Syphilitic Cervicitis with Cervical Cancer Presenting as Oropharyngeal Syphilis.

We herein report a patient with syphilitic cervicitis and cervical cancer presenting as oropharyngeal syphilis. A 31-year-old Japanese woman with a history of unprotected vaginal and oral sex visited our hospital with right submandibular adenomas and erythema in the extremities. The fornix uteri was red, with a nodule noted. The rapid plasma reagin ratio was 1:3. She was diagnosed with syphilitic cervicitis and treated with amoxicillin for four weeks. Initial cervical cytology showed cells with mild nuclear enlargement, which was thought to be metaplasia associated with syphilis. Repeated cytology a month later showed a high-grade squamous intraepithelial lesion. A punch biopsy of the lesion led to the pathological diagnosis of cervical carcinoma in situ. We performed cervical conization, and no recurrence occurred. Human papillomavirus (HPV) immunostaining was positive in the lesion. Mucosal lesions are an infrequently reported symptom of syphilis. When oropharyngeal lesions are found, the sexual history should be ascertained, and the patient should be screened for sexually transmitted diseases. HPV is especially significant because of its association with cervical cancer. Coinfection of HPV with cervical cancer must be ruled out during follow-up for women when oropharyngeal syphilis involves genital lesions.

Predominance of cervicitis agents with minimal testing rate within the student population in Benin city, Nigeria.

Here, we aimed to investigate the predominance of cervicitis agents with minimal testing rates among asymptomatic students in a Tertiary Institution and its associated risk factors. Endocervical swabs were collected from randomly selected 133 female students (15-34 years of age) in Benin City, Nigeria and screened for six genital pathogens (Chlamydia trachomatis, Mycoplasma hominis, M. genitalium, Ureaplasma urealyticum, U. parvum and Trichomonas vaginalis) using multiplex PCR. Out of the 133 subjects, 80 were positive for cervicitis with 46.3% of its agents. Five different species of the pathogens were identified with highest and lowest prevalence as: T. vaginalis (71.0%) and U. urealyticum (6.45%). Co-infection had predominance of 19.35 and 9.67% for three-organism and two-organism colonisation respectively. Strong associations were observed between the presence of cervicitis and co-infection with other genital pathogens, abortion, inconsistent condom use (p < .05). The high occurrence of cervicitis agents in our study combined with asymptomatic outcome among the subjects justifies screening for these pathogens in this population. Impact statement What is already known on this subject? Cervicitis is a genital condition among reproductive age women. It is characterised by inflammation of the uterine cervix which subsequently promotes the acquisition of certain genital conditions such as infertility and sexually transmitted infections. In various studies, there have been reports on 30-40% of cervicitis cases associated with known pathogens but left undetected within the general population. Studies have shown that majority of the cervicitis cases presents in an asymptomatic state. What the results of this study add? There may be some risk associated factors promoting the acquisition of cervicitis agents within the student population since the prevalence of these agents in this population which is underrated was relatively high. What the implication are of these findings for clinical practice and/or further research? Further investigation is needed to define the prospective influence of microbial load in colonisation of the organism and the association of new and higher sexual partners as their prevalence are not fully understood. Furthermore, our finding recommend inclusion of screening exercise for cervicitis agents within the student population which will control the infection, thereby improving female reproductive health, consequently limiting spread and serious sequelae.

Current status of Neisseria gonorrhoeae cervicitis in pregnant women in Japan.

We evaluated the current prevalence of gonococcal cervicitis among pregnant women in institutes that either do or do not routinely screen for gonococcal infection in Japan. We requested 2,330 obstetrical facilities to provide information on Neisseria gonorrhoeae cervicitis in pregnant women. A total of 1,876 (80.5%) of them responded. The universal screening test for gonococcal cervicitis, involving nucleic acid amplification for all pregnant women, was performed in 281 institutes (13.9% of institutes across Japan). The total rate of pregnant women with gonococcal cervicitis was 1.3% in the institutes performing the screening test during pregnancy, while it was only 0.2% (p < 0.01) in those not performing it. This suggests that 84% of infected women may have been missed in the institutes that do not routinely perform the screening test for gonococcal cervicitis. It may be time to examine the cost-effectiveness of providing gonococcal screening for all pregnant women in Japan.

Gonococcal infection: An unresolved problem. / Infección gonocócica: un problema aún sin resolver.

Gonococcal infection is a current public health problem worldwide, being the second most prevalent bacterial sexually transmitted infection. The etiologic agent is Neisseria gonorrhoeae, a gram-negative diplococcus, and mainly causes urethritis in men. In women up to 50% of infections can be asymptomatic. N. gonorrhoeae has a great ability to develop antibiotic resistance, so the last remaining therapeutic option are extended spectrum cephalosporins. Many guides recommend dual therapy with ceftriaxone and azithromycin, but in recent years the resistance to azithromycin is also increasing, so that dual treatment is being questioned by scientific societies.

Cervicitis: Etiology, diagnosis and treatment. / Cervicitis: etiología, diagnóstico y tratamiento.

Cervicitis is the inflammation of the cervix. It is usually caused by an infectious agent, usually sexually transmitted. Cervicitis is frequently asymptomatic and silent infection can cause complications of the upper genital tract. The symptoms are usually nonspecific, the most significant being an increase in vaginal discharge and/or intermenstrual bleeding. For its diagnosis, there are commercial systems based on molecular techniques that include almost all of the known pathogens associated with cervicitis, although cultures should not be abandoned due to the need to conduct studies of susceptibility to antibiotics. It is recommended to initiate an empirical antibiotic therapy that covers C.trachomatis and N.gonorrhoeae in the case of women at high risk of infection by these pathogens, especially if the follow-up is not assured or adequate diagnostic tests are not available. In women with low risk of sexually transmitted infection, antibiotic therapy should be adjusted to the results of the microbiological results.

Identification of a new variant of Chlamydia trachomatis in Mexico.

INTRODUCTION: Chlamydia trachomatis is one of the main etiological agents of sexually transmitted infections worldwide. In 2006, a Swedish variant of C. trachomatis (Swedish-nvCT), which has a deletion of 377bp in the plasmid, was reported. In Latin America, Swedish-nvCT infections have not been reported. We investigated the presence of Swedish-nvCT in women with infertility in Mexico. METHODS: Swedish-nvCT was searched in 69C. trachomatis positive samples from 2339 endocervical specimens. We designed PCR primers to identify the deletion in the plasmid in the ORF1, and the presence of a repeated 44bp in the ORF3. The sample with the deletion was genotyped with the genes of the major outer membrane protein A (ompA) and the polymorphic membrane protein (pmpH). RESULTS: The deletion was detected in one of the 69 samples positive C. trachomatis of 2339 endocervical exudates. The nucleotide sequence analysis of the ompA shows a high degree of similarity with the Swedish nvCT (98%), however the variant found belongs to serovar D. The nucleotide sequence of the pmpH gene associates to the variant found in the genitourinary pathotype of the Swedish-nvCT but in different clusters. CONCLUSIONS: Our results revealed the presence of a new variant of C. trachomatis in Mexican patients. This variant found in Mexico belongs to serovar D based on the in silico analysis of the ompA and pmpH genes and differs to the Swedish-nvCT (serovars E). For these variants of C. trachomatis that have been found it is necessary to carry out a more detailed analysis, although the role of this mutation has not been demonstrated in the pathogenesis.

A Clinical Conundrum: Chronic Cervicitis.

BACKGROUND: Cervicitis is most commonly caused by sexually transmitted infections. "Normal vaginal flora" are rarely responsible for inflammation of the cervix. CASE: We describe a 22-year-old female patient with chronic cervicitis who had negative test results for bacterial and viral pathogens most commonly responsible for cervicitis. After 21 months of symptoms and multiple courses of empiric antibiotics addressing the most common causes of cervicitis, a course of antibiotics targeting group B streptococcus found on a genital culture resolved the patient's illness. SUMMARY AND CONCLUSION: Bacteria considered to be "normal vaginal flora" in a nonpregnant young female adult should be considered as a potential pathogen when test results for more routine pathogens associated with cervicitis are negative.

Identifying acute cervicitis in an era of less-frequent routine gynecologic examinations.

Acute inflammation of the uterine cervix can lead to serious problems such as pelvic inflammatory disease (PID), endometritis, and complications of pregnancy and childbirth. As intervals for routine gynecologic screening examinations lengthen, cervical infections, especially if asymptomatic, may be missed. Annual wellness examinations and other patient visits outside routine gynecologic cancer screening visits should include brief evaluation with sexual risk assessment and a gynecologic examination if indicated. If cervicitis persists after standard treatment for sexually transmitted infections (STIs), consider Mycoplasma genitalium. Clinicians should be sensitive to the fact that the unexpected presence of infection may cause distress.

Should we screen for the sexually-transmitted infection Mycoplasma genitalium? Evidence synthesis using a transmission-dynamic model.

There is increasing concern about Mycoplasma genitalium as a cause of urethritis, cervicitis, pelvic inflammatory disease (PID), infertility and ectopic pregnancy. Commercial nucleic acid amplification tests (NAATs) are becoming available, and their use in screening for M. genitalium has been advocated, but M. genitalium's natural history is poorly-understood, making screening's effectiveness unclear. We used a transmission-dynamic compartmental model to synthesise evidence from surveillance data and epidemiological and behavioural studies to better understand M. genitalium's natural history, and then examined the effects of implementing NAAT testing. Introducing NAAT testing initially increases diagnoses, by finding a larger proportion of infections; subsequently the diagnosis rate falls, due to reduced incidence. Testing only symptomatic patients finds relatively little infection in women, as a large proportion is asymptomatic. Testing both symptomatic and asymptomatic patients has a much larger impact and reduces cumulative PID incidence in women due to M. genitalium by 31.1% (95% range:13.0%-52.0%) over 20 years. However, there is important uncertainty in M. genitalium's natural history parameters, leading to uncertainty in the absolute reduction in PID and sequelae. Empirical work is required to improve understanding of key aspects of M. genitalium's natural history before it will be possible to determine the effectiveness of screening.