Table of Contents
Definition and Overview of Chlamydia
Chlamydia — gram negative bacteria
The family of Chlamydiaceae contains 3 human pathogens:
Chlamydia are immobile, gram negative bacteria. The cell wall does not contain a peptidoglycan layer, but lipopolysaccharides. Common to all chlamydia is their complex reproduction cycle. Due to a defect in their own energy metabolism, chlamydia is dependent on that of its host.
Chlamydiae have the ability to establish long-term associations with host cells. When an infected host cell is starved for various nutrients such as amino acids (for example, tryptophan), iron, or vitamins, this has a negative consequence for Chlamydiae since the organism is dependent on the host cell for these nutrients. Long-term cohort studies indicate that approximately 50% of those infected clear within a year, 80% within two years, and 90% within three years.
The starved chlamydiae enter a persistent growth state wherein they stop cell division and become morphologically aberrant by increasing in size. Persistent organisms remain viable as they are capable of returning to a normal growth state once conditions in the host cell improve.
|Chlamydophila trachomatis||Chlamydophila psittaci||Chlamydophila pneumoniae|
|Host||Human||Birds (especially parrots, pigeons and budgies)||Human|
|Diseases||Serotypes A-C: Trachoma (chronic recurrent disorder of the conjunctivae and cornea of the eye)||Ornithosis/Psittacosis||Respiratory infections|
|Serotypes D-K: sexually transmitted urogenital infections and infections of the conjunctiva, perinatal infections|
|Serotypes L1, L2, L3: Lymphogranuloma venereum|
Epidemiology of Chlamydia
Globally, as of 2013, sexually transmitted chlamydia affects approximately 141 million people (3.1% of the population). It is more common in women (3.8%) than men (2.5%). In 2013 it resulted in about 1,100 deaths down from 1,500 in 1990.
In the United States about 1.4 million cases were reported in 2014. The CDC estimates that if one includes unreported cases there are about 2.8 million each year. It affects around 2% of young people. Infections are most common among those between the ages of 15 and 25 and are more common in women than men. In 2013 infections resulted in about 1,100 deaths. Chlamydial infection is the most common bacterial sexually transmitted infection in the UK.
Chlamydia causes more than 250,000 cases of epididymitis in the U.S. each year. Chlamydia causes 250,000 to 500,000 cases of PID every year in the United States. Women infected with chlamydia are up to five times more likely to become infected with HIV, if exposed.
Epidemiology of Chlamydophila trachomatis
- 30 – 50 % of all sterility is caused by chlamydia
- 90 % of all sterility caused by tube closure are caused by infections with Chlamydophila trachomatis
- every fourth woman infected with chlamydia is affected by subsequent sterility
Chlamydophila trachomatis is one of the most common pathogens of sexually transmitted diseases worldwide. According to WHO (2001), 89 million new infections with genital chlamydia occur worldwide per year. In Germany, the incidence is annually at 300,000 new infections. Particularly affected are persons with frequently changing sexual partners and children of infected mothers.
“In epidemiological studies using molecular biology methods, up to 13 % of the sexually active adolescent women were identified as infected in Germany. This infection rate varies regionally and decreases with increasing age and entry into a stable partnership relationship “(source: Robert Koch Institute)
In pregnant women, 2-3 % are populated with C. trachomatis. The infant is at risk of 50 % at birth.
The incidence of lymphogranuloma venereum has decreased worldwide, but this sexually transmitted infection is still endemic in Asia, Africa, South America and parts of the Caribbean. In Germany it is an absolute rarity with an occurrence of 1/1 million inhabitants.
Trachoma occurs almost exclusively in tropical countries under poor hygienic conditions. After cataract, trachoma is the second most common cause of blindness in the world.
Age group: Young adults (15-22 years)
Epidemiology of Chlamydophila psittaci
The disease is very rare in Germany: in 2007: 72 diseases, in 2008: 86 diseases. Risk groups are:
- Bird owners
- Animal keepers and vets
- Employees in pet shops, poultry farms or slaughterhouses
The transmission takes place by direct contact or by inhalation of dust particles or feces. A human-to-human transmission has not yet been demonstrated.
Epidemiology of Chlamydophila pneumoniae
“C. Pneumoniae is a very common worldwide cause of respiratory infections of humans. According to seroepidemiological investigations, the prevalence begins at the preschool age and is above 50% for men and over 70 % for men in the 6th decade. There is little known about the distribution of C. pneumoniae infections in Germany. ”
A high prevalence of seropositivity is to be expected: Everyone has probably contact with C. pneumoniae once in a lifetime. 5 -15 % of all outpatient acquired pneumonia are caused by C. pneumoniae.
Age group: 60-80 years
Etiology and Pathogenesis of Chlamydia
Etiology and pathogensis of Chlamydophila trachomatis
|Serotypes A-C:||Infectious eye secret, contaminated hands, towels (smear infection), flies|
|Serotypes D-K:||Sexually transmitted, perinatal|
|Serotypes L1-L3:||Sexually transmitted, causes Lymphogranuloma venereum perinatal|
The incubation period is approximately 1-3 weeks.
Etiology and pathogensis of Chlamydophila psittaci
Psittaci is the only zoonotic human pathogen from the Chlamydiaceae family. The excitation sources are mainly birds (chickens, ducks, pigeons, exotic birds).
The transfer takes place by direct contact or by inhalation of dust particles or faeces containing pathogens.
The pathogens are partly infectious even after drying out for up to 4 weeks. The incubation period of the ornithosis is about 1-4 weeks.
Etiology and pathogenesis of Chlamydophila pneumoniae
Pneumoniae is transmitted from person to person in an aerogenic pathway and by salivary contact.
The incubation time is estimated to be about 1-4 weeks.
Pneumoniae may remain persistent for a long time in the upper respiratory tract. (It is likely that the infected person will infect others over a long period of time).
Clinical Findings of Chlamydia
Symptoms of Chlamydophila trachomatis infection
Urogenital chlamydia infection
The pathogens can persist for years undetected in the body and possibly even become chronic.
Clinical manifestation of Chlamydophila trachomatis in men and women
|Primary stage||Herpetiform papules, ulcer, rapid scalp-free healing|
|Secondary stage||inguinal, painful lymphadenopathy (Bubo)|
|Tertiary stage||Fibrotic transformation of the lymph nodes, inflammation with ulceration, obliteration of the lymphatics, edema of the genital / extremity (elephantiasis), fever, arthralgia, splenomegaly, erythema nodosum|
The newborn chlamydiosis appears as conjunctivitis (60 %) or pneumonia (40 %).
Typical symptoms of inclusion body conjunctivitis are:
- purulent, mucopurulent, hemorrhagic inflammation of the conjunctiva
- eyelid edema
- follicular infiltration of the inner lid side
- first on one, then on both sides
- mostly inconsequential healing
Typical symptoms of neonatal pneumonia are:
- Increased respiratory effort
- Snorkeling breathing sounds
- Refusal of food
- In severe cases cyanosis
The follicular keratoconjunctivitis is caused by an initial infection in the child’s age. Repeated infections and, among others, bacterial superinfections lead to the formation of granulomas. The result of the granulomas are scarred shrinkages of the conjunctiva of the eyelids and an entropion. In the course of time, the cornea changes and becomes turbid.
Symptoms and Clinical Findings of Chlamydophila psittaci infection
The typical symptoms of ornithosis include:
Fever, chills, headaches
- atypical and interstitial pneumonia
- dry, persistent, non-productive cough
- extrapulmonary manifestations: hepatosplenomegaly (70% of patients), myocarditis, encephalitis, and exanthema
Symptoms of Chlamydophila pneumoniae infection
Frequently, the course of C. pneumoniae infections is asymptomatic.
- acute and chronic infections of the upper respiratory tract (pharyngitis, sinusitis, bronchitis)
- Outpatient pneumonia
- All symptoms of infection with C .psittaci can also occur in C. pneumoniae
Complications of Chlamydia
Possible complications of chlamydia infection
|C. trachomatis||C. psittaci||C. pneumoniae|
|Disorders of the arthrotic circle: joint inflammation (knee, ankle joint, …)||Myocarditis, pericarditis, endocarditis, thrombophlebitis, CNS involvement||Carditis, meningoradiculitis, erythema nodosum, reactive arthritis|
Diagnostics of Chlamydia
Smear for the determination of the chlamydial pathogens
The detection of the pathogen is carried out by taking smear of:
- Trachoma: Conjunctiva smear
- Eye infection: Conjunctiva smear
- Urogenital infections: cervical or vaginal smear, possibly urethral smear
- Lymphogranuloma venereum: Lymph node aspirate, ulcer smear
The direct detection of chlamydial antigens is carried out by means of fluorescence-labeled antibodies or ELISA. An alternative is the PCR with high specificity and sensitivity.
The pathogen is detected indirectly by serum antibody determinations. It must be specifically investigated for the appropriate species, i.e. Chlamydophila trachomatis, C. pneumoniae or C. psittaci. The diagnosis of genital chlamydial infections evolved rapidly from the 1990s through 2006. Nucleic acid amplification tests (NAAT), such as polymerase chain reaction (PCR), transcription mediated amplification (TMA), and the DNA strand displacement amplification (SDA) now are the mainstays.
Differential Diagnosis of Chlamydia
Chlamydia infection — similar medical conditions
|C. trachomatis||C. psittaci||C. pneumoniae|
|Pathogens that trigger atypical pneumonia:
||As in C. psittaci|
Therapy of Chlamydia
Antibiotic against chlamydia
Drug of choice in chlamydia is antibiotic.
|C. trachomatis||C. pneumoniae, C. psittaci|
|Tetracyclines (Doxycyclin)||Tetracyclines (Doxycyclin)|
||Makrolides (erythromycin, azithromycin)|
|Duration of treatment: at least 14 days.||Duration of treatment: 10-21 days.|
Prevention of Chlamydia
Prevention measures for Chlamydophila trachomatis
- Following the principles of preventing sexually transmitted infections
- Since January 1, 2008, sexually active women under 25 years of age is offered~ a chlamydia screening (reimbursement by the health insurance takes place under certain conditions).
- In Germany screening for chlamydia in pregnant women since 1995 has been part of maternity insurance for statutory health insurance.
- Trachoma: SAFE-Strategy in Global Programme for the Elimination of Trachoma. WHO:Surgery + Antibiotics + Facial cleanliness + Environmental improvement
Prevention measures for Chlamydophila psittaci
- Compulsory reporting: Compliance with the veterinary rules of disease control
- Early onset of diagnosis and therapy in case of suspicion
Which chlamydia infection is notifiable?
- trachomatis: In Germany there is no disease or pathogen specific reporting obligation according to Infection Protection Act IfSG. The disease, once diagnosed, must be reported to the CDC in the US.
- psittaci: The Infection Protection Act(§ 7) stipulates that the pathogen detection of Cp. Psittaci is notifiable, if there is evidence of an acute infection.
- pneumoniae: In Germany there is no disease or pathogen specific reporting obligation according to Infection Protection Act IfSG.
The correct answers can be found below the references.
1. At what age the chlamydia screening is covered by the statutory health insurance in certain cases?
- from 16
- from 18
- from 25
- from 30
- from 35
2. A young woman has a new boyfriend recently. Since she has been suffering from itching and pain in the vulva for a week, she is looking for her practiced gynecologist. The physician observes swollen lymph nodes and flat ulcers in vulvar area. Upon asking, the patient states that she has not used any protection in sexual intercourse. What infection is the most likely?
- Chlamydia infection
- HPV infection
- Herpes simplex virus infection
- HIV infection
- Measles infection
3. Which statement about chlamydia is true?
- Chlamydia psittaci is notifiable
- Chlamydia pneumoniae is notifiable
- Chlamydia trachomatis is notifiable
- Chlamydia psittaci is not notifiable
- All Chlamydia groups are not notifiable