chlamydia%20-%20uncomplicated%20anogenital%20infection
CHLAMYDIA - UNCOMPLICATED ANOGENITAL INFECTION

Chlamydia is a gram negative obligate intracellular bacteria that causes sexually-transmitted infection.

Chlamydia trachomatis is the primary cause of pelvic inflammatory disease (PID) in women which may lead to ectopic pregnancy, infertility, or chronic pelvic pain.
Most infected females are asymptomatic.
But some females may experience vaginal discharge, dysuria, lower abdominal pain, abnormal vaginal bleeding (postcoital or intermenstrual) or breakthrough bleeding, dyspareunia, conjunctivitis, proctitis and reactive arthritis.

Diagnosis

  • Clinical signs and symptoms as described above
  • Bubo aspiration
    • Milky fluid in aspirate
    • May require sterile saline injection for aspiration
  • Direct detection by NAAT, culture, or direct immunofluorescence
    • Genital lesion swab, rectal swab or bubo aspirate may be used
    • Culture is the most specific test but may not be widely available
  • Serology
    • High antibody titers are suggestive of LGV in a patient with symptoms consistent with LGV, but low titers do not rule out the diagnosis
    • Complement fixation titer of ≥1:64 in the relevant clinical setting is consistent with LGV
  • Exclusion of other causes of inguinal lymphadenopathy
    • Non-sexually transmitted local and systemic infections (eg those of the lower limb or TB lymphadenopathy) can also cause inflammation of the inguinal lymph nodes
  • Because definite diagnostic testing is lacking, patients with symptoms consistent with LGV (ie proctocolitis or genital ulcer with lymphadenopathy) should receive treatment for LGV
Clinical Assessment of Patient with Inguinal Swelling
  • Lymphogranuloma venereum (LGV) is a systemic disease caused by L1, L2, L3 serovars of C trachomatis 

Clinical Manifestation of LGV

Primary LGV

  • Incubation period of 3-30 days
  • Painless papule (1-6 mm) at inoculation sites (eg vulva, vagina, penis, rectum, oral cavity, cervix)
    • These papules may ulcerate but are self-limited
    • Genital ulcer may occur at the site of inoculation but is usually healed by the time patients are seen in the clinic

Secondary LGV

  • Occurs 2-6 weeks from appearance of primary lesion
  • Accompanying symptoms may be present (eg fever, chills, malaise, myalgia, arthralgia, arthritis, pneumonitis or hepatitis)
    • Cardiac symptoms, meningitis and ocular inflammation may also be present
  • Abscesses and draining sinuses occur in <1/3 of patients
  • Lymph node, anus and/or rectum may be involved
    • Lymphadenopathy is characterized by a “groove sign” (ie swollen inguinal nodes above and femoral nodes below the level of the inguinal ligament)
    • Anorectal involvement is characterized by acute hemorrhagic proctitis/proctocolitis

Tertiary/Chronic LGV

  • More common in females
  • Lymphatic obstruction may cause genital elephantiasis
  • Genital and rectal strictures and fistula may occur at this stage
  • Clinical signs and symptoms as described above
  • Bubo aspiration
    • Milky fluid in aspirate
    • May require sterile saline injection for aspiration
  • Direct detection by NAAT, culture, or direct immunofluorescence
    • Genital lesion swab, rectal swab or bubo aspirate may be used
    • Culture is the most specific test but may not be widely available
  • Serology
    • High antibody titers are suggestive of LGV in a patient with symptoms consistent with LGV, but low titers do not rule out the diagnosis
    • Complement fixation titer of ≥1:64 in the relevant clinical setting is consistent with LGV
  • Exclusion of other causes of inguinal lymphadenopathy
    • Non-sexually transmitted local and systemic infections (eg those of the lower limb or TB lymphadenopathy) can also cause inflammation of the inguinal lymph nodes
  • Because definite diagnostic testing is lacking, patients with symptoms consistent with LGV (ie proctocolitis or genital ulcer with lymphadenopathy) should receive treatment for LGV

Physical Examination

  • Perform general assessment and look for signs of sexually transmitted infection (STI)
  • Examine mucocutaneous regions including the pharynx
  • External genitalia should be inspected for anatomical irregularities, cutaneous lesions, inflammation, and urethral discharge
  • Perianal inspection
    • Digital rectal exam and anoscopy should be considered if patient has practiced receptive anal intercourse or has rectal symptoms
  • Inguinal lymph nodes should be palpated

Illuminated Speculum Exam

  • Visualize cervix and vaginal walls
  • Evaluate vaginal and endocervical discharges
  • Observe for cervical mucopus, ectropion, friability
  • If resources are available, obtain specimens
    • Cervical swab may be sent for Chlamydia test, gonorrhea culture
    • Vaginal swab may be sent for Chlamydia test, for Gram stain and Trichomonas slide

Bimanual Pelvic Exam

  • Detect uterine or adnexal masses, tenderness or cervical motion tenderness

Assessment

Risk Assessment

  • In some settings, certain demographic and behavioral risk factors have been frequently associated with cervical infection (the following should be adjusted for local, social, behavioral and epidemiological situations)
  • Women at risk for cervicitis have a higher likelihood of cervical infection than those who are risk-negative
  • Women with vaginal discharge and positive risk assessment should, therefore, be offered treatment for gonococcal and chlamydial cervicitis
  • Annual screening of Chlamydia infection is advised for all sexually active nonpregnant women ages ≤24 years and older nonpregnant women with risk factors
  • Pregnant women at risk should be screened at 1st prenatal visit and at 3rd trimester if she continues to be at high risk

Women at Higher Risk for Infection

  • Age ≤24 years (>5x higher risk than age 30 years)
  • Sexual contact with known case of STI
  • IV drug users
  • Street involvement (youth on the streets, sex workers)
  • New or ≥2 sex partners in the past year
  • Previous STI
  • Lack of barrier contraception

Evaluation

  • Finding of lower abdominal tenderness or cervical motion tenderness should prompt the attending physician to evaluate the patient for salpingitis and/or endometritis which are part of PID
    • Treat patient accordingly (See Pelvic Inflammatory Disease Management Chart for details) 
  • Differential diagnoses may also include other surgical or gynecological conditions

Laboratory Tests

  • If resources permit, lab tests to screen women with vaginal discharge should be considered
    • In patients who undergo a speculum exam, endocervical or vaginal swabs may be sent for testing
    • If a speculum exam is not done, consider sending self-obtained low vaginal swab or 1st-void urine for testing 
  • Urine or rectal swab specimen may also be used, if appropriate
  • Test utilized will depend on available resources
  • Diagnosis is confirmed if C trachomatis is isolated by culture or demonstrated in a specimen through antigen or nucleic acid detection

Lab Exams for C trachomatis

  • Nucleic acid amplification tests (NAAT)
    • Recommended test for detection of chlamydial infection of genital tract
    • Most sensitive (90-95%) and specific
    • Test of choice for cervical, urethral, 1st-void urine specimens
      • Recommended specimen from women is a self- or physician-obtained vaginal swab
  • Cell culture
    • Recommended for throat and rectal specimens
    • May be used when blood and mucus interfere with NAAT result
    • Though highly specific, high cost and low sensitivity (60-80%) preclude routine use
  • Routine use of the following lab tests is not recommended:
    • Direct fluorescent antibody test: Not to be used for routine testing of specimen from the genital tract
    • Nucleic acid hybridization or probe test: Assays are not widely available
    • Enzyme immunoassays: False-positive results may occur due to cross-reactivity among chlamydial species
    • Serological test: Not to be used for screening since prior chlamydial infection may or may not generate a systemic antibody response
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