Clarification of Answer by
tehuti-ga
on
09 Jul 2003 15:36 PDT
Hello gravettibros,
While looking for further material to answer your clarification
request, I’ve actually found the situation is far less simple than
given in my answer. I must beg your patience for this very long and
complex clarification, but I have found some contradictory statements
about this topic and I feel I need to describe both sides in detail.
As I mentioned in my answer, there are different strains of C.
trachomatis.
The web page http://www.pathoplus.com/curecanc.htm (the last item on
the page) produced by
Dr Zwolski, Professor of Nursing, College of New Rochelle lists the
following differences between the strains:
Strains A, B, Ba, C are transmitted by fomites (any object that
carries the bacteria) and flies and cause trachoma
Strains D, E, F, G, H, I, J, K are transmitted by direct sexual
contact or at the time of birth and cause nongonococcal urethitis,
cerviciits, epidydimitis, PID, conjunctivitis, Reiter’s syndrome,
perinatally transmitted pneumonia.
Strain L1,L2,L3 are transmitted by direct sexual contact and cause
lymphogranuloma venereum.
And it goes on to make the following distinctions:
“Chlamydia trachomatis can cause two types of eye problems. The first
is caused by C. trachomatis, strains D-K. It is a type of
conjunctivitis (opthalmia neonatorum) that is transmitted from an
infected mother to her infant during the perinatal period….
Chlamydial conjunctivitis of this nature often does not become
apparent until 2- 20 weeks. The second type of eye problem is
trachoma. This is caused by infection with C. trachomatis, strains A,
B, Ba or C. Unlike opthalmia neonatorum it is not transmitted
perinatally. It is transmitted by fomites (e.g. washcloths that an
infected person has used to clean their eyes, which are then used by a
non-infected person) and by flies. Trachoma is a distinctive ocular
disease and a major health problem in areas such as sub Sahara Africa.
It causes scarring of the eye that often results in blindness…. The
same strain that causes opthalmia neonatorum…. can also cause
pneumonia in infants so exposed. This is a distinctive pneumonia that
appears between ages 1 – 4 months. It is distinctive because there is
no fever associated with it. There is a distinctive staccato cough,”
“Strains L1, L2 and L3 of Chlamydia trachomatis cause a venereal
disease, Lymphogranuloma venereum. This disease occurs worldwide but
has a low incidence in the United States. It occurs mostly in tropical
regions of the world. The symptoms of Lymphogranuloma venereum include
the development of large, tender inguinal lymph nodes, called buboes.”
So he seems to imply that the strain that causes trachoma does not
cause the other complicaations, nor is it transmitted from mother to
infant.
On the other hand, an article I found on Medline seems to disagree:
“Systemic infections with Chlamydia trachomatis are known to occur
with the agents of lymphogranuloma venereum but are not generally
recognized to occur with the trachoma and inclusion conjunctivitis
(TRIC) agents, i.e., immunotypes A-K. The clinical spectrum of TRIC
agent infections has expanded, however, and now includes deep-seated
genital infections such as epididymitis and salpingitis, as well as
infections in neonates. Endocarditis, pneumonia in adults, otitis
media, choroiditis and erythema nodosum are unusual manifestations of
C. trachomatis infections that may be seen.”
Scandinavian Journal of Infectious Diseases Supplement 1982, Volume 32
pages 122-6.
Unusual manifestations of Chlamydia trachomatis infections.
By Myhre EB, Mardh PA.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=6958008&dopt=Abstract
So, 20 years ago, these authors were already not making a distinction
between complications caused by strains A-C (trachoma agents) and
strains D-K (conjunctivitis agents). They were also arguing that both
these groups could cause systemic infection as well, although this had
been thought to be a feature of the L strains.
Further down in this clarification, I cite a statement that the
“ordinary” chlamydia infection (ie strains D-K) can result in pelvic
inflammatory disease, which, in rare circumstances of abscess rupture
can lead to systemic infection, ie that it is not only the L group
which can lead to systemic infection.
Also, while Ken Zwolski says that trachoma (as opposed to inclusion
conjunctivitis) is NOT transmitted from mother to child, a 1978 paper
in the Journal of the American Medical Association reported that it
is!
“During ten years of study of Chlamydia trachomatis eye infections,
trachoma was diagnosed in 14 Danish patients with onset during
childhood. Clinical findings in the eye were characteristic of
classical trachoma…. In five young girls the disease was extremely
severe…. The source of initial eye infection with C trachomatis
organisms in these cases was thought to be the birth canal. It was
further postulated that reinfection of the eyes of these children
occurred either from a reservoir in their own or their mother's
genital tract.”
“Childhood trachoma in a nonendemic area. Danish trachoma patients and
their close contacts, 1963 to 1973”
C. H. Mordhorst, S. P. Wang and J. T. Grayston
JAMA 1978, Volume 239, pages 1765-1771.
http://jama.ama-assn.org/cgi/content/abstract/239/17/1765?ijkey=c48f835d36106aee775716651678a5e2b7ea5c9d&keytype2=tf_ipsecsha
The Chlamydiae web site groups C. trachomatis into 2 main groups, the
L strains and strains A-K, but says that even these two groupings each
contain strains that can cause some similar pathology:
“The first chlamydial agent to be discovered. C. trachomatis is
comprised of two human biovars: the trachoma and lymphogranuloma
venereum (LGV). The mouse and swine strains that were previously
grouped with this species now belong to separate species (C. muridarum
and C. suis, respectively). Serovars in both C. trachomatis biovars
cause trachoma, sexually transmitted disease, some forms of arthritis,
and neonatal inclusion conjunctivitis and pneumonia”
http://www.chlamydiae.com/docs/Chlamydiales/genus_chlamydia.htm
I’m sorry if this has confused you, but I thought it important to put
these contradictory views forward.
In what follows below, I am working on the same assumptions as held by
the Chlamydiae site and the two Scandinavian groups, namely not making
the very specific distinctions between strains that are made by
Zwolski, and referring to all as C. trachomatis. I would anyway
assume that immigrants coming from all over the world would have
brought all these strains to Ellis Island, and, in those days, the
appropriate laboratory tests did not exist to distinguish between
them.
It is important to remember in all this that we are talking about very
rare manifestations.
A child infected with C. trachomatis from the mother might possibly
develop endocarditis as a complication, especially later on in life.
Endocarditis is more common in adults than in children, and it is
thought to have a greater possibility of developing where some form of
heart damage is already present. For this reason, it is more common
in the elderly, who are more likely to have heart disease already.
According to an article by NC Joshi, only a few cases occur in
children with no pre-existing heart disease. Incidentally, he does
not list Chlamydia among the responsible organisms, because other
types of bacterial infection are more likely to result in
endocarditis.
http://www.pediatriconcall.com/fordoctor/DiseasesandCondition/infective_endocarditis.asp
One scenario could be that the mother had had a chronic Chlamydia
infection with subacute endocarditis, which, over the years, had
weakened her heart. She might then die as a result of heart failure
from the stresses of pregnancy and labour. Alternatively, a more
acute endocarditis could have manifested and ran a more serious course
over a shorter period.
In these situations, the baby could well not become infected from the
mother at all, unless bacteria were also still present in the mother’s
cervix, in which case the baby could be infected during the birth
process.
A paper on this topic, “Perinatally acquired Chlamydia trachomatis
associated morbidity in young infants” by S Jain was published in
Maternal and Fetal Medicine, May-Jun 1999, Volume 8(3) pages 130-3.
“… 530 symptomatic infants < or =12 weeks of age … tested for
Chlamydia trachomatis infection in the upper respiratory tract … from
January 1993 to December 1994. RESULTS: During the study period,
70/530 (13.2%) patients tested positive for Chlamydia trachomatis from
the conjunctiva and/or the nasopharynx. Complete medical records of 66
of these infants were available for review. Forty-eight of 66 (73%)
infants had conjunctivitis, 13/66 (20%) had pneumonia, 5/66 (7%) had
both conjunctivitis and pneumonia. Thirteen of 66 (20%) infants were
hospitalized, 7 for pneumonia and 6 for ophthalmia, accounting for 68
hospital days. In 55/66 (83%), maternal records were available for
review. Nineteen of 55 (35%) mothers had documented Chlamydia
trachomatis infection at delivery or during pregnancy that had not
been treated; 16/55 (29%) mothers tested negative for Chlamydia
trachomatis sometime during pregnancy but were not retested at
delivery, 8/55 (14%) were treated for Chlamydia trachomatis during
pregnancy but status at delivery regarding reinfection was not
evaluated. In 12/55 (22%) mothers, no prenatal testing was documented”
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10338068&dopt=Abstract
However, the consequences need not be so immediate:
Here is an article which describes such “vertical transmission” with
resulting eye infection. Note that the child showed hardly any
symptoms for the first six years of life.
“A family cluster of Chlamydia trachomatis infection “
C Thompson, M Macdonald, and S Sutherland
British Medical Journal 16th June, 2001, Volume 322, pages 1473-1474.
http://bmj.com/cgi/content/full/322/7300/1473
While the uterus is normally a sterile environment, there is always a
possibility that bacteria will invade it by ascending up from the
cervix. I have found a paper about this topic:
“The role of infection in preterm labour and delivery” by Roberto
Romero and colleagues
Paediatric and Perinatal Epidemiology, 2001, Volume 15 (suppl. 2),
pages 41-56.
http://209.10.141.228/files/Role_of_infection.pdf
The paper makes the following relevant points:
Once the bacteria are in the amniotic cavity inside the uterus, they
can cause a local infection at points of contact with the baby, which
would lead to conjunctivitis amongst other things. If the baby draws
the infected amniotic fluid into its lungs, this can cause it to
develop pneumonia even while still in the womb. Finally, if the
bacteria are able to “seed” themselves from any of these sites into
the fetal circulation, this will result in bacteremia and fetal
sepsis, which the authors report to result in death rates of anything
between 20% and 95% (remember though that is today, when the babies
can be treated with antibiotics!). The authors say it is not yet
clear whether this scenario happens with Chlamydia trachomatis.
However, they refer to a case of congenital pneumonia (ie occurring
before birth) that was found due to C. trachomatis, and they consider
this evidence that this bacterium could indeed be capable of
intra-amniotic infection.
Another point of relevance is that intrauterine infection is
associated with pre-term labour, and that a premature infant also has
an increased risk of death, which would have been even greater in the
days before incubators were available.
A very acute situation could occur in the mother if the infection has
resulted in pelvic inflammatory disease. “The most serious
complication of PID, requiring immediate medical attention, is rupture
of an abscess or of the walls of one of the infected organs. This may
cause bacteria to pour out into the abdominal cavity, causing a
general abdominal infection, known as peritonitis. This can kill.
Bacteria can also get into the bloodstream, a condition known as
sepsis, which can also be fatal. Rupture of an abscess will cause a
sharp increase in symptoms. Intense lower abdominal pain will be
followed by nausea, then weakness and possibly fainting as the blood
pressure drops. This last symptom is sometimes called septic shock,
and it can kill.”
http://www.mediresource.com/zellers/health/PatientInfo.asp?DiseaseID=103
(Zellers Pharmacy web site).
In this sort of acute situation, at a time when no antibiotics were
available, it is unlikely that either the mother or the baby would
survive.
,
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