CLINICAL CASE

A 19-year-old woman presents for the evaluation of pelvic pain. The pain has
progressively worsened over the past week. She has also been having some burning
with urination and a vaginal discharge. She is sexually active, has had four lifetime
partners, takes oral contraceptive pills, and occasionally uses condoms. On
examination, she appears in no acute distress and does not have a fever. Her
abdomen is soft with moderate lower abdominal tenderness. On pelvic examination,
she is noted to have a yellow cervical discharge and significant cervical motion
tenderness. No uterine or adnexal masses are palpated, but mild tenderness is also
noted. A Gram stain of the cervical discharge reveals only multiple
polymorphonuclear leukocytes. A direct DNA probe test subsequently comes back
positive for Chlamydia trachomatis.

How does C. trachomatis enter a target cell?

What are the two stages of the C. trachomatis life cycle?
ANSWERS TO CASE 5: Chlamydia trachomatis
Summary: A 19-year-old woman with probable pelvic inflammatory disease has a
positive DNA probe assay for C. trachomatis.

How C. trachomatis enters a target cell: The elementary body of C.

trachomatis binds to receptors on the host and induces endocytosis.

Two stages of the C. trachomatis life cycle: The elementary body and the

reticulate body.

CLINICAL CORRELATION
Chlamydia trachomatis is the causative agent of the most common sexually
transmitted disease in the United States, and it is also the greatest cause of
preventable blindness around the world. Chlamydial disease affects women five
times more often than men, and approximately two-thirds of those affected lack
symptoms and thus, do not know that they are infected. Many of those infected
with gonorrheal disease are also infected with Chlamydia, as both organisms
infect the columnar epithelial cells of the mucous membranes. Chlamydial disease
usually affects those of lower socioeconomic standing and is prevalent in
underdeveloped countries. Children are also a main reservoir, transmitting the
disease by hand-to-hand transfer of infected eye fluids or by sharing contaminated

towels or clothing.

APPROACH TO SUSPECTED CHLAMYDIAL INFECTION

Objectives
1. Know the characteristics of the Chlamydia species. 
2. Know the virulence factors and diseases associated with Chlamydia bacteria. 

Definitions
Elementary body: Nondividing 300-nm infectious particle. This particle has an
outer membrane with disulfide linkages which allows it to survive extracellularly.
Chandelier sign: Cervical motion tenderness during the bimanual exam,
characteristic of pelvic inflammatory disease (PID).
Exudate: Material, such as fluids, cells or debris, which has extravasated from
vessels and has been deposited on tissue surfaces or in tissue.
Papule: Small palpable elevated lesion that is less than 1 cm.

DISCUSSION
Characteristics of Chlamydia trachomatis
Chlamydia trachomatis is a gram-negative obligate intracellular parasite with a
unique life cycle. It is coccoid in morphology and is very small, usually about 350
nm in diameter. Although C. trachomatis is classified as gram-negative bacteria, it
lacks a peptidoglycan layer and muramic acid, which are present in other gramnegative organisms. There are many disulfide linkages present in the outer
membrane which stabilize the organism. Its extracellular form is called the
elementary body, which has a small, spore-like structure. It attaches to columnar,
cuboidal, or transitional epithelial cells in structures lined by mucous membranes.
The elementary body binds to receptors on susceptible cells and induces endocytosis
into the host. These membrane-protected structures are known as inclusions. The
elementary body undergoes reorganization into a larger, more metabolically active
form known as the reticulate body. Reticulate bodies grow and multiply by binary
fission to create larger intracellular inclusions. Reticulate bodies transform back into
elementary bodies, which are released from the epithelial cell by exocytosis and
which can then infect other cells. The life cycle of C. trachomatis lasts
approximately 4872 hours. Table 5-1 lists in sequential order are the stages of the
life cycle.

Chlamydia trachomatis appears to be an obligate human pathogen with

approximately 15 serotypes. It is the most common bacterial cause of sexually
transmitted diseases in humans and also causes conjunctivitis and ocular
trachoma. Infection of the conjunctiva by C. trachomatis results in scarring and
inflammation. This fibrosis pulls the eyelid inward causing the eyelashes to rub
against the cornea. Because the eyelid is rolled inward, the individual is unable to
completely close the eye resulting in the inability to maintain moisture on the
surface of the eye. It is the combination of the lack of surface moisture and constant
abrasion by the eyelashes that causes corneal scarring and blindness. Ocular
trachoma is one of the leading causes of blindness worldwide.
Chlamydia trachomatis also causes other diseases including pneumonia, urethritis,
epididymitis, lymphogranuloma venereum, cervicitis, and pelvic inflammatory
disease. Lymphogranuloma venereum presents with a painless papule on the
genitalia that heals spontaneously. The infection is then localized to regional
lymph nodes where it resides for approximately 2 months. As time progresses, the
lymph nodes begin to swell, causing pain, and may rupture and expel an exudate.
Men with epididymitis present with fever, unilateral scrotal swelling, and pain.
Women with cervicitis present with a swollen, inflamed cervix. There may also be a
yellow purulent discharge present. PID occurs when the infection spreads to the
uterus, fallopian tubes, and ovaries. PID presents with lower abdominal pain,
dyspareunia, vaginal discharge, uterine bleeding, nausea, vomiting, and fever.
Cervical motion ten- derness during the bimanual exam is known as the
chandelier sign. Recurrent PID may scar the fallopian tubes, resulting in infertility
or ectopic pregnancy. Children may acquire chlamydial disease during birth via
passage through an infected birth canal. Inflammation of the infants conjunctiva
may occur with a yellow discharge and swelling of the eyelids within 2 weeks after
birth. The presence of basophilic intracytoplasmic inclusion bodies from the
conjunctiva is a helpful diagnostic clue. Neonatal pneumonia may also occur from
passage through an infected birth canal. An infected child may present 411 weeks
after birth with respiratory distress, cough, and tachypnea. The direct destruction of
host cells due to chlamydial infection and then hosts inflammatory response
produces the clinical symptoms associated with the various forms of chlamydial
disease.
Other Chlamydial species are known to cause disease in humans. Atypical
pneumonia is caused by Chlamydophila pneumonia, and presents with fever,
headache, and a dry hacking cough. Additionally, psittacosis is another atypical
pneumonia caused by Chlamydophila psittaci. This organism is acquired by
inhalation of feces from infected birds, which serve as the reservoir.

Diagnosis
Infection with C. trachomatis can be rapidly diagnosed by detection of the bacterial
nucleic acid in patient samples from the oropharynx, conjunctiva, urethra, or cervix.
Other specimens such as the conjunctiva can be cultured using McCoy cells in a
tissue culture assay. Diagnostic tests for nucleic acid detection include PCR
amplification or direct DNA hybridization assays, measuring for specific 16S
ribosomal RNA sequences can be performed on all of above specimens including
urine.

Treatment and Prevention

Currently, the best method of preventing chlamydial infection is education and
proper sanitation. Ocular infection of C. trachomatis can sometimes but not always
be prevented by administration of topical tetracycline drops. It is the lack of this
antibiotic in underdeveloped countries that makes C. trachomatis prevalent in these
areas. Chlamydia trachomatis, C. psittaci, and C. pneumonia are all treated with
tetracycline or erythromycin. Azithromycin is effective for cervicitis and urethritis.
Pelvic inflammatory disease is treated with ceftriaxone and 2 weeks of doxycycline.