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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~  References
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  Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 31  |  Issue : 2  |  Page : 190-192
 

Co-infections with Ureaplasma parvum, Mycoplasma hominis and Chlamydia trachomatis in a human immunodeficiency virus positive woman with vaginal discharge


1 Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi, India

Date of Submission29-Sep-2012
Date of Acceptance28-Apr-2013
Date of Web Publication19-Jul-2013

Correspondence Address:
Benu Dhawan
Department of Microbiology, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.115231

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 ~ Abstract 

A 30-year-old human immunodeficiency virus (HIV)-1 infected woman presented with vaginal discharge and associated vulval irritation. The vaginal swabs tested positive for Ureaplasma parvum and Mycoplasma hominis by both culture and polymerase chain reaction (PCR). The specimen also tested positive for Chlamydia trachomatis deoxyribonucleic acid (DNA) by cryptic plasmid and omp1 gene PCR assays. The patient was successfully treated with azithromycin based on the antibiotic susceptibility testing results of U. parvum and M. hominis by microbroth dilution. Since sexually transmitted infections enhance the transmission of HIV, HIV-positive patients should be screened routinely for these pathogens.


Keywords: HIV, mycoplasma, chlamydia, co-infection


How to cite this article:
Ghosh A, Rawre J, Khanna N, Dhawan B. Co-infections with Ureaplasma parvum, Mycoplasma hominis and Chlamydia trachomatis in a human immunodeficiency virus positive woman with vaginal discharge. Indian J Med Microbiol 2013;31:190-2

How to cite this URL:
Ghosh A, Rawre J, Khanna N, Dhawan B. Co-infections with Ureaplasma parvum, Mycoplasma hominis and Chlamydia trachomatis in a human immunodeficiency virus positive woman with vaginal discharge. Indian J Med Microbiol [serial online] 2013 [cited 2019 Sep 23];31:190-2. Available from: http://www.ijmm.org/text.asp?2013/31/2/190/115231



 ~ Introduction Top


Coexisting sexually transmitted infections (STIs) facilitate the transmission and acquisition of other STIs, including human immunodeficiency virus (HIV). The non-ulcerative STIs caused by Chlamydia trachomatis and genital mycoplasmas viz. Ureaplasma spp., Mycoplasma hominis and Mycoplasma genitalium potentially increase the susceptibility of acquiring and transmitting HIV. [1]

An increased frequency of Ureaplasma spp. and M. hominis genital infections in HIV-infected patients has previously been reported. [2],[3] In addition, studies have suggested that certain genital mycoplasmas such as M. genitalium, M. hominis, Mycoplasma penetrans and Mycoplasma fermentans are candidate "co-factors" in the pathogenesis of acquired immune deficiency syndrome (AIDS) or in other words, these mycoplasmas act in synergy with HIV to exacerbate the retroviral disease. [3],[4],[5] Chlamydia trachomatis is also associated with increased genital HIV shedding. [1] Moreover, infections with C. trachomatis and genital mycoplasmas among HIV-infected individuals are important markers of sexual behaviour that may expose others to HIV. Hence, early detection and treatment of these sexually transmitted pathogens in HIV-infected patients is an effective strategy for HIV prevention.

We report a case of co-infections with C. trachomatis, Ureaplasma parvum and M. hominis in a HIV-1 infected woman with lower genital tract symptoms.


 ~ Case Report Top


A 30-year-old HIV-1 infected woman presented to the sexually transmitted disease (STD) clinic in June, 2012 with complaints of vaginal discharge and associated irritation of the vulva of 2 weeks duration. She was diagnosed as seropositive for HIV-1 in January, 2012. The patient was employed as a nurse in a hospital and lived with her spouse who was seronegative for HIV. Sexual history did not reveal any non-marital or casual or accidental exposure. However, she maintained an active sex life with the spouse in the form of protected vaginal intercourse. There was no history of blood transfusion, surgical intervention or intravenous drug abuse. The HIV transmission category of the patient was considered as unknown.

Medical history did not reveal any significant systemic abnormalities. Drug history revealed that the patient was not receiving antiretroviral therapy. However, she had received oral valacyclovir for 1 week 3 months ago on the advice of a local practitioner for painful vesicular erythematous lesions over her cheeks. She had no history of oral contraceptive intake and intrauterine device insertion.

Review of laboratory records revealed that the patient had a CD 4+ lymphocyte count of 342/μl. She was non-reactive for Venereal Disease Research Laboratory and seronegative for both hepatitis B surface antigen and anti-hepatitis C virus antibodies.

The patient was afebrile and had no complaints of dysuria and lower abdominal pain. Speculum examination revealed an odorless, mucoid non-bloody white vaginal discharge. No ulcer, erosion or warts were observed on vaginal examination. The perineal and perianal area was normal on examination. On palpation, there was no inguinal lymphadenopathy or suprapubic tenderness. Systemic examination was within normal limits.

The vaginal discharge was further examined by diluting it in two drops of 0.9% normal saline solution on a clean glass slide and in 10% potassium hydroxide (KOH) solution on another. No amine odor was detected immediately after applying KOH. Microscopic examination under low and high power objectives was negative for any motile trophozoites, yeast cells and pseudohyphae. Microscopic examination of gram stained smear of the discharge under oil-immersion objective revealed 20-30 pus cells per field. No Gram negative intracellular diploccoci were seen. Culture of the discharge on gonococci agar with vancomycin, colistin, nystatin and trimethoprim sulfate was negative for  Neisseria More Details gonorrhoeae.

Three dacron swab specimens of the discharge were collected from the patient. Two swabs were inoculated into Pleuropneumonia-like organism (PPLO) broth containing urea and PPLO broth containing arginine for isolation of Ureaplasma spp. and M. hominis respectively. Serial 10-fold dilutions starting from 1:10 to 1: 10 5 were prepared and the broths were incubated at 37°C under 5% CO 2 and were inspected twice daily in absence of turbidity. The semi-quantitative cultures were positive for both Ureaplasma spp. and M. hominis at a concentration of ≥10 5 colour changing units per ml within 48 hours of incubation. Both Ureaplasma spp. and M. hominis were uniformly susceptible to azithromycin, doxycycline, ofloxacin, ciprofloxacin, levofloxacin and josamycin by microbroth dilution method. [6]

The third swab was transported to the laboratory in 0.2 M sucrose phosphate buffer, subjected to DNA extraction by QIAamp Mini Kit (QIAGEN, Hilden, Germany) and polymerase chain reaction (PCR) assays. The sample tested positive for C. trachomatis by both cryptic plasmid and omp1 gene PCR [Figure 1]. Multiplex PCR targeting the urease gene of Ureaplasma spp. and 16S ribosomal DNA of M. hominis was positive for both the organisms. The ureaplasma isolate was further biotyped. It belonged to biovar 1 (U. parvum). The PCR assay targeting the adhesin gene of M. genitalium was negative. Details of the PCR assays performed on the specimen have been summarized in [Table 1].
Table 1: Summary of the PCR assays for detection of C. trachomatis and genital mycoplasmas

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Figure 1: Polymerase chain reaction for cryptic plasmid and omp1 gene amplifi cation. Lane 1 and 9: DNA Molecular size marker (100bp-1kb). Lane 2: Cryptic plasmid positive control. Lane 3: Negative control. Lane 4: Positive clinical sample (Cryptic plasmid). Lane 5 and 10: Blank . Lane 6: Omp 1 gene positive control. Lane 7: Negative control

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First-void urine sample of the partner was also collected, subjected to culture for Ureaplasma spp. and M. hominis and PCR assays for C. trachomatis, Ureaplasma spp., M. hominis and M. genitalium. The sample tested negative for all the above pathogens.

The patient was treated with azithromycin (1.0 gm) single dose and evaluated one week after treatment. She reported cessation of vaginal discharge and itching. Post-treatment culture and PCR assays for C. trachomatis, Ureaplasma spp. and M. hominis of the vaginal swabs collected were also negative. Both the patient and the partner were counseled for safe sex practices and advised for regular follow-ups at interval of 2 weeks.


 ~ Discussion Top


Genital mycoplasmas such as Ureaplasma spp., M. hominis and M. genitalium have been implicated as co-pathogens in HIV-infected patients. Risk of retroviral transmission is increased in presence of co-infections with organisms like C. trachomatis. [7] In a study from our hospital, we observed genital mycoplasma and C. trachomatis infections in 14% of HIV-infected adults. However, co-infection with these pathogens was not observed in our patients. [8] To our knowledge, this is the first case report of co-infections with C. trachomatis, U. parvum and M. hominis in an HIV-infected woman.

The HIV-1 positive woman in our report had a CD4 cell count of 342/μl and was not suffering from AIDS. Previous studies also could not find any significant association between isolation of genital mycoplasmas and C. trachomatis from the genital tract of HIV infected adults and CD4 cell count. [9],[10] Hence, screening for these organisms of HIV patients should be carried out irrespective of their CD4 cell counts.

This case report also highlights that fact that HIV-positive STD clinic attendees need to be screened for multiple co-pathogens colonizing the genital tract of these patients. Since these organisms have been associated with increased HIV transmissibility, screening guidelines in HIV-positive adults should include simultaneous testing and treatment of these STIs simultaneously, which might prove prudent to control the retroviral transmission.

 
 ~ References Top

1.Ghys PD, Fransen K, Diallo MO, Ettiègne-Traoré V, Coulibaly IM, Yeboué KM, et al. The associations between cervicovaginal HIV shedding, sexually transmitted diseases and immunosuppression in female sex workers in Abidjan, Côte d'Ivoire. AIDS 1997;11:F85-93.  Back to cited text no. 1
    
2.Martinelli F, Garrafa E, Turano A, Caruso A. Increased frequency of detection of Ureaplasma urealyticum and Mycoplasma genitalium in AIDS patients without urethral symptoms. J Clin Microbiol 1999;37:2042-4.  Back to cited text no. 2
[PUBMED]    
3.Cordova CM, Blanchard A, Cunha RA. Higher prevalence of urogenital mycoplasmas in human immunodeficiency virus-positive patients as compared to patients with other sexually transmitted diseases. J Clin Lab Anal 2000;14:246-53.  Back to cited text no. 3
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4.Blanchard A, Montagnier L. AIDS-associated mycoplasmas. Annu Rev Microbiol 1994;48:687-712.  Back to cited text no. 4
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5.Napierala Mavedzenge S, Weiss HA. Association of Mycoplasma genitalium and HIV infection: A systematic review and meta-analysis. AIDS 2009;23:611-20.  Back to cited text no. 5
[PUBMED]    
6.Waites KB, Duffy LB, Shwartz S, Talkington DF. In: Isenberg H, editor. Mycoplasma and Ureaplasma. Clinical Microbiology Procedures Handbook. 3 rd ed. Washington, D.C.: ASM Press; 2010. p. 3.15.1-3.15.17.  Back to cited text no. 6
    
7.Mayer KH, Venkatesh KK. Interactions of HIV, other sexually transmitted diseases, and genital tract inflammation facilitating local pathogen transmission and acquisition. Am J Reprod Immunol 2011;65:308-16.  Back to cited text no. 7
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8.Ghosh A, Dhawan B, Chaudhry R, Vajpayee M, Sreenivas V. Genital mycoplasma and Chlamydia trachomatis infections in treatment naïve HIV-1 infected adults. Indian J Med Res 2011;134:960-6.  Back to cited text no. 8
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9.Lanzafame M, Delama A, Lattuada E, Faggian F, Padovani GC, Concia E, et al. Prevalence and clinical significance of Ureaplasma urealyticum and Mycoplasma hominis in the lower genital tract of HIV-1-infected women. Infez Med 2006;14:213-5.  Back to cited text no. 9
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10.Page KR, Moore RD, Wilgus B, Gindi R, Erbelding EJ. Neisseria gonorrhoeae and Chlamydia trachomatis among human immunodeficiency virus-infected women. Sex Transm Dis 2008;35:859-61.  Back to cited text no. 10
    


    Figures

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