Non gonococcal urethritis
- 1. By Dr. Ruqaiya Nadeem
- 2. Introduction Urethritis – is inflammation of urethra. Most episodes are caused by infection caused by pathogen that enter urethra from skin around urethral opening. Commensal flora of urethra- Enterobacteriaceae α/ɣ streptococci Enterococcus spp Diphtheroids CONS
- 4. Bacteria • Chlamadia trachomati s • Ureaplasm a urealyticus • Mycoplasm a hominis • Gardnerell a vaginalis • Acinetobac ter wolfii • Acinetobac ter caloaceticu s Virus • Herpes virus • CMV Fungus • Candida albicans Protozoa • Trachomon as vaginalis Mechanical or Chemical irritation NON-GONOCOCCAL URETHRITIS (Causative agent)
- 5. Non-gonococcal urethritis/ non specific urethritis Chronic urethritis where gonococci cannot be demonstrated. Or cocci persisting in L form and hence undetectable NGU is 2.5 times more common
- 6. Pre-disposing risk factors Sexual contact in which exchange of body fluid may occur May report multiple sexual partners Non-STI: secondary to catheterization or other instrumentation of the urethra, in association with other factors that contribute to urinary tract infection.
- 7. Incubation period- 7-21 days Clincal features- Variable dysuria Urethral itching Discharge- typically mucoid to watery, white 10% NGU are asymptomatic
- 8. Diagnosis Failure to demonstrate gonococci in gramstain & culture >/= 4 PML/oif in urethral smear or first voided urine sample immunoflourescence
- 9. Complications Epididymitis Urethral strictures Transmission Treatment Doxycycline 100mg B.D Azithromycin 1g once Ofloxacin 400mg B.D × 7days Whenever possible sexual partners should be treated simultaneously
- 10. Chlamydia trachomatis It accounts for 30-50% NGU Genital infections are caused by serovars D-K Infection in men Urethritis, epididymitis, proctitis, conjunctivitis, and Reiters syndrome Assoc. Symptoms – rectal pain, bleeding, mucopurulent discharge & diarrhoea
- 11. Infection in female Most infections are asymptomatic(80%) Urethritis Bartholinitis Mucupurulent cervicitis Vaginitis, vaginal discharge Endometritis Salpingitis PID Reiters Syndrome Genital chlamydiasis may cause infertility, ectopic pregnancy, premature deliveries, perinatal morbidity
- 12. Lab diagnosis 1. Specimen collection Urethral scraping Cervical scraping Urine Other specimens- semen, aspirates from fallopian tube/ epididymus
- 13. 2. Specimen transportation Swabs should be immediately placed into transport medium, sucrose phosphate saline (2SP) containing gentamicin, vancomycin, amphotericin B Heat inactivated fetal calf or bovine serum (5%) must be added to protect during freezing If transport is delayed- store at 4°C upto 24hrs -60 °C/ liquid nitrogen for longer delay
- 14. 3. MICROSCOPY They are gram negative Chlamydial elementary bodies & inclusions Better stained by Giemsa, Castaneda, Macchiavello, Giminez stains & lugol’s iodine Typical reniform inclusion bodies surrounding nucleus Immunoflourescence (IF) More sensitive & specific method of microscopy by using monoclonal antibodies Both inclusions & extracellular EB can be identified
- 17. 4 Isolation Inoculation into mice/ embryonated eggs Chlamydia can grow in yolk sac of 6-8 day old chick embryos First reported isolation was by Gordon & Quan in irradiated McCoy cells Cell lines supporting growth of chlamydiae McCoy cells HeLa 229 cell BHK cell BGM cell
- 18. 5. ANTIGEN DETCTION Immunoflourescence- Staining of smears by FITC-labelled antibodies against species specific MOMP or genus specific LPS Atleast 10 EBs should be seen for positive result Senstivity 90% specificity 95% ELISA- Detection of soluble genus-specific antigen Senstivity same as IF
- 19. DNA probes Radioactive DNA probes for detection of C.trachomatis in cell culture & cervical smears Chemiluminescence assay- Acridium-ester-labelled single stranded DNA probe complementary to RNA of C.trachomatis PCR Amplification targets- omp1 gene coding for MOMP - 16s rRNA gene
- 20. 6. ANTIBODY DETECTION Demonstration of group specific antibody by CFT or micro IF High level >64 of IgM and a rising titre of IgG is taken diagnostic IgM persists for 2months In neonatal chlamydial infection detection of IgM is taken diagnostic
- 21. Treatment DOC – doxycycline in adults & erythromycin in infants Since chlamydia have long replication cycle hence short course will only suppress infection t/t should be given for a min of 7days/ 3 weeks in women with ascending & complicated genital infections Azithromycin provides sustained levels in tissue
- 22. Ureaplasma urealyticum & Mycoplasma Infections caused by Ureaplasma urealyticum NGU Epididymitis Vaginitis, cervicitis It may cause chorioamnionitis, prematurity, postpartum endometritis, chronic lung disease of premature infant Male and female infertility
- 23. Mycoplasma hominis Salpingitis, tubo-ovarian abscess, pelvic abscess, septic abortion, puerperal infection, Mycoplasma genitalium NGU PID Very difficult to recover from culture
- 24. LAB DIAGNOSIS of Mycoplasma & Ureaplasma 1. Specimen collection Urethral, vaginal, cervical swabs Semen, prostatic secretions Urine Biopsy specimen
- 25. 2. Specimen transportation Standard Mycoplasma broth medium dispensed in small vials – for swab specimens Other specimens – sterile screw-capped containers If there is delay in processing- store at 4°C for 24 hours Or -70°C for further delay Mycoplasma broth medium – penicillin, polymyxin B, amphotericin B, glucose, phenol red PPLO broth medium containing 20% horse serum, glucose, phenol red
- 26. 3. CULTURE Medium is inoculated and incubated at 37°C in an atmosphere of 95% N2 & 5% CO2 It usually takes 4-28 days Growth shows turbidity in the medium and then sub- cultured on agar medium & incubated for 5-7 days Colonies of mycoplasma show characteristic ‘fried egg’ appearance while ureaplasma colonies are small & lack peripheral zone.
- 27. Haemadsorption test Colonies growing on surface agar Flooded with 2ml of 0.2-0.4% suspension of washed guinea-pig erythrocytes in MBM Incubated at 35°C for 30mins Washed with 3ml MBM & gently rotated Wash fluid is removed Observed under 50-100x magnification
- 28. Tetrazolium reduction test Growth can be easily screened by TR test in which mycoplasma colonies reduce colourless tetrazolium to red coloured formazan
- 29. The colonies can be demonostrated by Dienes method. Diene’s stain- azure II, methylene blue, maltose, Na2CO3, benzoic acid & DW. The plate is flooded with this stain Then rinsed with DW Decolourised with 95% ethanol Observed under low power
- 33. Oculogenital syndrome NGU and conjunctivitis may be seen in 4% patients & responds to tetracyclines. Reiter’s syndrome( reactive arthritis) Some cases of NGU also present with arthritis, uveitis, and skin/ mucous membrane lesions Few cases suggest antibiotic associated colitis or cryptosporidiosis Post dysentric reiter’s syndrome More common in HLA-B27 positive patients
- 34. Clinical features NGU is initial manifestation w/i 14days of exposure Urethritis may be mild & unnoticed Other features develop after 1-5 weeks Arthritis develops in 4 weeks Knees-ankles-small joints are involved
- 35. Dactylitis- sausage shaped swelling of digits is characteristic & persistent feature Mild B/L conjunctivitis, iritis, keratitis, uveitis for few days Dermatologic manifestation occur in 50% pts It includes waxy papules, central yellow spot, mostly on soles, palms, nails, scrotum, scalp, trunk the initial episode of RS lasts 2-6 months
- 36. Lab diagnosis Anaemia ESR Synovial fluid 1000-200,000 WBCs/ml >2/3 rds are PMNs Glucose in joint fluid Therapy Anti chlamydial treatment Tetracycline/erythromycin NSAIDS- indomethacin