History

Fact Explanation
Vaginal discharge.[1] Chlamydia causes cervicitis which usually gives rise to a yellow or cloudy mucoid and odorless discharge. [1] The discharge maybe blood stained in cases of chronic endometritis caused by ascending Chlamydia infection. [4]
Urethral discharge and dysuria in men. [1] Due to urethritis.
Fever, lower abdominal pain/ chronic pelvic pain, deep dyspareunia [1][5] Ascending chlamydial infection causes endometritis and pelvic inflammatory disease (PID) which causes these symptoms. [1]
Irregular per vaginal bleeding. [4] This is caused by an easily friable inflamed endometrium caused by Chlamydia endometritis. [4]
Sub fertility. [2][3] Ascending chlamydial infection causes endometritis and acute salpingitis which are usually asymptomatic thus, not diagnosed and treated leading to sub fertility. Also Chlamydia spreads further and result in PID which also contributes to sub fertility. [2][3]
Ectopic pregnancy which presents with vaginal bleeding with period of amenorrhoea. Ectopic pregnancy occurs due to PID caused by Chlamydial infection. [5]
Pregnant women may present with early rupture of membranes associated with gush of amniotic fluid expulsion. Chlamydia complicates pregnancy by causing premature rupture of membrane and and premature delivery.[6]
Being of adolescents or of younger age group, history of having multiple sexual partners in the last year [5] These are known risk factors for Chlamydial infection. Both young men and women are at higher risk than older population to have the infection. Also high number of sexual partners in the lifetime do not seem to increase the risk, this is thought to be due to development of immunity due to repeated exposure. [5]
May present with triad of symptoms of urethritis (cervicitis in women), conjunctivitis, and arthritis with asymmetric and multiple joint involvement. Painless mucocutaneous lesions may also occur.[1][7] This is known as Reiter syndrome, occur as a complication of untreated Chlamydial infection.[1]
Right upper abdominal pain. Transperitoneal spread of PID will result in peri hepatitis results in this symptom. Presence of peri hepatitis and PID is know as Fitz-Hugh-Curtis syndrome. [8]
References
  1. MILLER KARL E.Diagnosis and Treatment of Chlamydia trachomatis Infection. American Family Physician. 2006 Apr 15. Volume 73, Issue 8, pages 1411-1416. Viewed on 27/03/2014 http://www.aafp.org/afp/2006/0415/p1411.html
  2. MALIK Abida, JAIN S, HAKIM S, SHUKLA I, RIZVI M, Chlamydia trachomatis infection & female infertility. Indian Journal of Medical Research, June 2006, Volume 123, Pages 770-775. Viewed on 27/03/2014 http://icmr.nic.in/ijmr/2006/june/0610.pdf?origin=publication_detail
  3. PAAVONEN J, AINE R, TEISALA K et al. Journal of Clinical Pathology. July 1985; Volume 38, Issue 7, Pages 726–732. Chlamydial endometritis. PMCID: PMC499293. Viewed on 27/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC499293/?page=1
  4. MARDH PA, MOLLER BR, INGERSELV HJ et al. Endometritis caused by Chlamydia trachomatis. British Journal of Venereal Diseases. Jun 1981; Volume 57, Issue 3, Pages 191–195. PMCID: PMC1045915. Viewed on 28/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1045915/?page=1
  5. NAVARRO Christine, JOLLY Anne, NAIR Rama, CHEN Yue. Risk factors for genital chlamydial infection. Canadian Journal of Infectious Diseases. 2002 May-Jun; Volume 13, Issue 3, Pages 195–207. PMCID: PMC2094865 Viewed on 28/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2094865/
  6. BLAS Magaly M, CANCHIHUAMAN Fredy A, ALVA Isaac E, HAWES Stephen E. Pregnancy outcomes in women infected with Chlamydia trachomatis: a population‐based cohort study in Washington State. Sexually Transmitted Infections. Jul 2007; Volume 83, Issue 4, Pages 314–318. Available from: doi: 10.1136/sti.2006.022665 PMCID: PMC2598687 Viewed on 28/03/2014 http://pubmedcentralcanada.ca/pmcc/articles/PMC2598687/
  7. MARTIN DH, POLLOCK S, KUO CC, WANG SP, BRUNHAM RC, HOLMES KK. Annals of Internal Medicine. 1984 Feb;Volume 100, Issue 2, Pages 207-13. Chlamydia trachomatis infections in men with Reiter's syndrome. Viewed on 28/03/2014 http://www.ncbi.nlm.nih.gov/pubmed/6691663
  8. McSHERRY JA, Chlamydia Trachomatis and the Fitz-Hugh-Curtis Syndrome. Canandian Family Physician. Jul 1985; Volume 31: Pages 1415–1416. PMCID: PMC2327308 Viewed on 28/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2327308/

Examination

Fact Explanation
Lower abdominal tenderness, Right upper abdominal tenderness.[1] Lower abdominal tenderness maybe due to PID and right upper abdominal tenderness occur due to Fitz-Hugh-Curtis.[1]
Vaginal discharge will be visible. [3] Mucopurulent discharge, yellow to cloudy in nature. [2][3]
Urethral discharge maybe expressed by compressing the urethra. [3] Especially in male patients, this can be used as a sample for investigations.
Uterine, adenexial tenderness maybe elicited by bimanual palpation. [2]Cervical motion tenderness maybe present. [2][3] This maybe due to PID caused by ascending Chlamydial infection.
Speculum examination may reveal erythematous and oedemaous cervix. Due to Chlamydial cervicitis.
Contact bleeding is present and elicited in vaginal and speculum examination. [2][3][4] Due cervicitis caused by Chlamydia the cervix becomes easily friable, [3] thus results in contact bleeding.
References
  1. McSHERRY JA, Chlamydia Trachomatis and the Fitz-Hugh-Curtis Syndrome. Canandian Family Physician. Jul 1985; Volume 31: Pages 1415–1416. PMCID: PMC2327308 Viewed on 28/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2327308/
  2. GEISLER WM, CHOW JM, SCHACHTER J, McCORMACK WM. Pelvic examination findings and Chlamydia trachomatis infection in asymptomatic young women screened with a nucleic acid amplification test. Sexually Transmitted Disease. 2007 Jun; Volume 34, Issue 6, Pages 335-8. Viewed on 27/03/2014 . http://www.ncbi.nlm.nih.gov/pubmed/17028510
  3. MILLER KARL E.Diagnosis and Treatment of Chlamydia trachomatis Infection. American Family Physician. 2006 Apr 15. Volume 73, Issue 8, pages 1411-1416. Viewed on 27/03/2014 http://www.aafp.org/afp/2006/0415/p1411.html
  4. CASEY Petra M., LONG Margaret E., MARNACH Mary L. Abnormal Cervical Appearance: What to Do, When to Worry? Mayo Clinic Proceedings. Feb 2011; Volume 86, Issue 2, Pages 147–151. Available from: doi: 10.4065/mcp.2010.0512 Viewed on 27/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031439/

Differential Diagnoses

Fact Explanation
Bacterial vaginosis [1] Also presents with vaginal discharge. Can be excluded by measuring the pH of the discharge/ positive whiff test/ presence of clue cells in microscopy. [2][3]
Urinary tract infection (UTI) [1] Urine full report will reveal leukocytes as in Chlamydial infection but the urine culture will show UTI specific organisms unlike in Chlamydia. [1]
Trichomoniasis [1] Also causes cervicitis, urethritis and PID. Presence of frothy green discharge is characteristic of Trichomoniasis but may not be seen always. "Strawberry cervix" is visible on speculum examination. Wet mount under microscopy will demonstrate the organism. [4]
Vaginal candidiasis. The discharge will have thick curd like appearance [5]
References
  1. MILLER KARL E.Diagnosis and Treatment of Chlamydia trachomatis Infection. American Family Physician. 2006 Apr 15. Volume 73, Issue 8, pages 1411-1416. Viewed on 27/03/2014 http://www.aafp.org/afp/2006/0415/p1411.html
  2. THULKAR J, KRIPLANI A, AGARWAL N. Utility of pH test & Whiff test in syndromic approach of abnormal vaginal discharge. Indian Journal of Medical Researches. 2010 Mar; Volume 131, Pages 445-8. Viewed on 28/03/2014 http://www.ncbi.nlm.nih.gov/pubmed/20418561
  3. DISCACCIATI MG, SIMOES JA et al. Presence of 20% or more clue cells: an accurate criterion for the diagnosis of bacterial vaginosis in Papanicolaou cervical smears. Diagnostic Cytopathology. 2006 Apr; Volume 34, Issue 4, Pages 272-6. Viewed on 28/03/2014 http://www.ncbi.nlm.nih.gov/pubmed/16544334
  4. SWYGARD H, SENA AC, HOBBS MM, COHEN MS. Tropical medicine series, Trichomoniasis: clinical manifestations, diagnosis and management Sexually Transmitted Infections 2004; Volume 80, Pages 91-95. Available from: doi:10.1136/sti.2003.005124 Viewed on 28/03/2014 http://sti.bmj.com/content/80/2/91.full
  5. ACHKAR Jacqueline M., FRIES Bettina C. Candida Infections of the Genitourinary Tract, Clinical Microbiol Review. Apr 2010; Volume 23, Issue 2, Pages 253–273. Available from: doi: 10.1128/CMR.00076-09 Viewed on 28/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2863365/

Investigations - for Diagnosis

Fact Explanation
Microscopic examination and culture of urethral discharge. [1] There will be more than 5 white cells per high power field. Culture would not yield any organisms. [1]
Culture of an endocervical sample and ABST (Antibiotic sensitivity test) Culture on an appropriate culture plates (McCoy cell culture media), will result in inclusion bodies in the infected cells which can be visualized by staining them, usually with specific fluorescein-conjugated monoclonal antibodies. Fluorescein based detection is more specific than iodine or Giemsa based inclusion detection. [2][3]
Nucleic acid amplification(NAAT) test of samples from endocervical swabs of women, urethral swabs of men, and urine of both sexes. [2] This test is mainly used in screening due to high sensitivity.
Nucleic Acid Hybridization (Nucleic Acid Probe) Tests [2] Samples need not be refridgerated but should be processed on or before 7 days from collection. [2]
Enzyme Immunoassays (EIA) *Should not be used on samples obtained from rectum.[2] The sample need not be refridgerated but have to be processed before the time mentioned by the manufacturer of the EIA kit.[2] Enzyme labeled antibody detects LPS (lipopolysaccharide) which is not species-specific of Chlamydia. Samples obtained from rectum will cause cross reaction thus should not be used. [2]
Direct fluorescent antibody- specimen from endocervical swab or brush [2] Sample is used to prepare a slide and then processed within 7 days. The slides are stained with flouroscein monoclonal antibodies and visualised under flouroscent microscopy. Some kits contain MOMP (major outer membrane protein) antibodies which are more specific than LPS (lipopolysaccharide) antibody containing kits. [2]
Chlamydia rapid test.[2] This is a less specific test and is not recommended where other tests are feasible. [2]
References
  1. MILLER KARL E.Diagnosis and Treatment of Chlamydia trachomatis Infection. American Family Physician. 2006 Apr 15. Volume 73, Issue 8, pages 1411-1416. Viewed on 27/03/2014 http://www.aafp.org/afp/2006/0415/p1411.html
  2. Centers for Disease Control and Prevention. Screening Tests To Detect Chlamydia trachomatis and Neisseria gonorrhoeae Infections — 2002. MMWR (Morbidity and Mortality Weekly Report) 2002; Volume 51(No. RR-15). Pages 3-6. Viewed on 28/03/2014. Available from: http://www.cdc.gov/std/labguidelines/rr5115.pdf
  3. STAMM Walter E., TAM Milton, KOESTER Mark, CLES Linga. Detection of Chlamydia trachomatis Inclusions in McCoy Cell Cultures with Fluorescein-Conjugated Monoclonal Antibodies, Journal of clinical microbiology. Apr. 1983, page 666-668 Vol. 17. No. 4. Viewed on 28/03/2014 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC272712/pdf/jcm00141-0120.pdf

Investigations - Followup

Fact Explanation
Follow up investigation is recommended in pregnant women, in those who symptoms persist or when reinfection is suspected. [1] Screening test is done 3 to 4 weeks after completion of therapy. [1]
A follow up should be done in 3 months time, if not whenever patient seeks next medical care within the first 12 months of treatment. [1] Reinfection rates are high in those who are not re-treated within several months. This is usually due to new sexual partners or untreated sexual partners. [1]
References
  1. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. Page last reviewed: January 28, 2011. Viewed on 28/03/2014. Available from: http://www.cdc.gov/std/treatment/2010/chlamydial-infections.htm

Investigations - Screening/Staging

Fact Explanation
DNA amplification test is used on endocervical swabs in women, urethral swabs in men, or first-void urine specimens from both sexes. [1] All sexually active nonpregnant and pregnant women who are 24 years or younger should be screened.[2] (Reduce rate of PID and reduces the prevelece of Chlamydia) If more than 24 years of age, regardless of the fact whether they are pregnant or not, screen only if they are high risk[2] Evidence on whether to screen asymptomatic men is lacking. [1][2]
References
  1. NELSON HD, HELFAND M. Screening for chlamydial infection. American Journal of Preventive Medicine. 2001 Apr; Volume 20, Issue 3, Pages 95-107. Viewed on 28/03/2014. http://www.ncbi.nlm.nih.gov/pubmed/11306238
  2. U.S. Preventive Services Task Force. Screening for chlamydial infection: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine. 2007 Jul 17; Volume 147. Issue 2, Pages 128-34. [Viewed on 28/03/2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17576996

Management - General Measures

Fact Explanation
Tracing and treating the sexual partner is indicated. [1] This prevents reinfection as well as infection from spreading on to other sexual contacts. [1]
References
  1. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. Page last reviewed: January 28, 2011. Viewed on 28/03/2014. Available from: http://www.cdc.gov/std/treatment/2010/chlamydial-infections.htm

Management - Specific Treatments

Fact Explanation
Single dose azithromycin 1g orally or oral doxycycline 100 mg bd for seven days. [1][2] Alternatively, oral erythromycin base 500 mg qds 7 days or oral erythromycin ethylsuccinate 800 mg qds for 7 days or oral levofloxacin 500 mg od for 7 days or oral ofloxacin 300 mg bd for 7 days are also used.
For pregnant mothers-erythromycin 200 mg qds for 7 days or base or amoxicillin 500mg tds for 7 days. [1][2] Treatment of pregnant mothers reduces risk of transmission of infection to the baby during child birth. [2] Doxycycline, ofloxacin, and levofloxacin should not be used in pregnancy. [2]
Erythromycin base 250 mg orally four times a day for 14 days. [2] This regimen is used if gasterointestinal side effects occur to higher dose regimen erythromycin, usually in pregnancy. [2]
If patient is suspected of having PID with has high fever associated with nausea and vomiting hospital admission maybe necessary. When oral regime is not tolerated by the patient iv regime might have to be started. Also underlying tubo ovarian abscess/ surgical conditions should be excluded.
References
  1. MILLER KARL E.Diagnosis and Treatment of Chlamydia trachomatis Infection. American Family Physician. 2006 Apr 15. Volume 73, Issue 8, pages 1411-1416. Viewed on 27/03/2014 http://www.aafp.org/afp/2006/0415/p1411.html
  2. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. Page last reviewed: January 28, 2011. Viewed on 28/03/2014. Available from: http://www.cdc.gov/std/treatment/2010/chlamydial-infections.htm