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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~  References
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  Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 35  |  Issue : 3  |  Page : 429-431
 

A case of sterile pyuria caused by Chlamydia trachomatis and Mycoplasma hominis: A diagnostic challenge


1 Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication12-Oct-2017

Correspondence Address:
Benu Dhawan
Department of Microbiology, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmm.IJMM_17_125

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 ~ Abstract 

Sterile pyuria is a highly prevalent condition with a wide aetiological spectrum, which often challenges the diagnostician. We describe the case of a middle-aged female admitted to the medical Intensive Care Unit for acute gastroenteritis, whose urinalysis revealed persistent sterile pyuria. Polymerase chain reaction assay in urine was positive for Chlamydia trachomatis and Mycoplasma hominis. She responded to antimicrobial therapy. We hereby reflect on the approach to a case of sterile pyuria and review the available literature on this entity.


Keywords: Chlamydia trachomatis, doxycycline, genito-urinary tuberculosis, Mycoplasma hominis, sterile pyuria


How to cite this article:
Mian A, Sebastian S, Arif N, Soneja M, Dhawan B. A case of sterile pyuria caused by Chlamydia trachomatis and Mycoplasma hominis: A diagnostic challenge. Indian J Med Microbiol 2017;35:429-31

How to cite this URL:
Mian A, Sebastian S, Arif N, Soneja M, Dhawan B. A case of sterile pyuria caused by Chlamydia trachomatis and Mycoplasma hominis: A diagnostic challenge. Indian J Med Microbiol [serial online] 2017 [cited 2018 Oct 22];35:429-31. Available from: http://www.ijmm.org/text.asp?2017/35/3/429/216623



 ~ Introduction Top


Pyuria is defined as the presence of ten or more white blood cells (WBCs) per cubic millimetre in a urine specimen or a urinary dipstick that is positive for leucocyte esterase.[1] In the absence of associated positive urinary aerobic culture, the persistence of pyuria is termed as sterile pyuria. While bacterial infections of the genito-urinary tract are the most often underlying pathology, certain atypical organisms and non-infectious causes must also be kept in mind. A high index of suspicion and detailed clinical, laboratory or radiological evaluation is required to ascertain the cause.


 ~ Case Report Top


A 43-year-old female presented to the medical emergency with diarrhoea with severe dehydration for 2 days and altered mental status for last four hours. On examination, she was drowsy, with a Glasgow Coma Scale score of 10, had cold peripheries with a feeble pulse, tachycardia (130 beats/min) and blood pressure of 60/40 mmHg. Rest of general physical and systemic examination was normal. The patient had no prior co-morbidities. The patient was shifted to the Intensive Care Unit for the management of hypovolaemic shock secondary to acute gastroenteritis. Her laboratory parameters revealed WBC count of 17,000 cell/mm3, serum urea of 90 mg/dL and serum creatinine of 1.9 mg/dL, consistent with pre-renal acute kidney injury. The patient responded well to treatment with parenteral antibiotics (ceftriaxone) and fluid resuscitation. Deranged renal parameters also started resolving.

Culture of stool sample grew colonies of mixed commensal flora. As a part of routine screen, a urine sample was sent for microscopy and culture. Urinalysis demonstrated 50–60 WBCs per high power field but no organisms. Urine culture was sterile. Notably, subsequent urine samples sent on four separate occasions were sterile despite persistent pyuria. A diagnosis of sterile pyuria was made. Considering the patient's epidemiological risk factors (Indian origin), microbiological evaluation of genito-urinary tuberculosis (GU-TB) was done which was negative. Fungal culture of urine was also unrevealing. Ultrasonography of the abdomen and pelvis did not reveal any abnormality. Subsequently, urine sample was sent for polymerase chain reaction (PCR) for atypical organisms, which tested positive for Chlamydia trachomatis and Mycoplasma hominis and negative for Ureaplasma urealyticum and Mycoplasma genitalium. The patient was treated with tablet doxycycline 100 mg twice daily for 7 days. Repeat urine testing showed no pyuria, and PCR was negative after 6 weeks of treatment completion. Her partner could not be tested due to loss of follow-up.


 ~ Discussion Top


Sterile pyuria is not an uncommon laboratory finding. It is seen in both sexes although women (13.9%) are more commonly affected than men (2.6%) due to a higher incidence of pelvic infection.[2] It can be attributed to infectious and non-infectious causes [Table 1].[3] Commonly linked conditions include sexually transmitted infections, TB, interstitial cystitis, carcinoma in situ of the bladder and prolonged antibiotic use.[4]
Table 1: Causes of sterile pyuria

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Sterile pyuria is often encountered in medical outpatients and even in those hospitalised for an alternate cause as an incidental detection. The same was seen in our case and has been substantiated in a study, in which 15% of medical and surgical inpatients were detected to have pyuria with sterile cultures, in the absence of other evidence to suggest urinary tract infection (UTI).[5]

GU-TB is an important manifestation of extrapulmonary TB. Sterile pyuria and haematuria are most often the initial presentation,[4] advanced cases presenting with calyceal destruction and hydronephrosis. Isolation of acid-fast bacilli, solid culture and bladder biopsy with histopathology is limited by poor sensitivity. Overall, urinary PCR for Mycobacterium tuberculosis remains the most rapid and sensitive (94%) diagnostic method.[6] Treatment with anti-TB therapy is mandated.

Sexually transmitted bacterial and viral infections have an estimated annual worldwide incidence of over 125 million.[7] Atypical organisms such as chlamydia, mycoplasma and ureaplasma are common causes of sterile urine culture. Gonorrhoea has also been listed as a cause of sterile pyuria as diagnosis on routine culture is often missed. The nucleic acid amplification tests are considered gold standard for diagnosis. In a study by Nasser et al., on patients with sterile pyuria, C. trachomatis was detected in 10%, U. urealyticum in 5%, M. hominis in 3% and M. genitalium in 1% using PCR technique.[8] Globally accepted treatment for C. trachomatis infection includes azithromycin (1 g orally single dose) or doxycycline (100 mg orally twice daily for 7 days). Tetracyclines were the drug of choice for the treatment of mycoplasma and ureaplasma species, hitherto studies documented a microbiological failure rate of >68% for doxycycline and macrolide resistance of 13%–33% in M. genitalium.[9] The 2015 UK National Guideline for Management of non-gonococcal urethritis suggests a prolonged azithromycin course (500 mg stat followed by 250 mg daily for next 4 days) as first line for M. genitalium.[10] An alternative regimen is the use of ofloxacin (200 mg twice daily or 400 mg once daily) for 7 days.[10] Since our patient tested positive for C. trachomatis and M. hominis, we treated her with a standard 7-day course of oral doxycycline. Follow-up PCR was negative after 6 weeks, indicating a complete response.

Rarely, genital herpes (herpes simplex virus type 2), human papillomavirus and advanced untreated human immunodeficiency virus infection are also reported as of pyuria. Fungal infections can cause pyuria in the immunocompromised (Candida, Aspergillosis, Cryptococcus) and those associated with environmental exposure to dimorphic fungi. Urine microscopy may show budding yeast or hyphae, but special fungal culture requires up to 3 weeks.

Inflammatory conditions that are causes of sterile pyuria include interstitial cystitis, analgesic nephropathy, Kawasaki's disease and systemic lupus erythematosus. Symptoms suggestive of UTI with no response to antimicrobials, negative urine cultures, presence of systemic manifestations or relevant clinical history must raise suspicion for these aetiologies.

As observed in our case, the importance of identifying these infections is that definitive therapy [Table 2] with good cure rates can be instituted early, before the onset of complications such as pelvic inflammatory disease, recurrent urethritis/cystitis, infertility and ectopic pregnancy. Non-infectious causes are cured with the management of the underlying primary pathology.
Table 2: Antimicrobial regimens for common infectious causes of sterile pyuria

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Due to its vast possible aetiologies, it can pose a diagnostic challenge and warrant detailed evaluation. Sterile pyuria has historically been considered to be suggestive of GU-TB;[1] hence samples are not routinely screened for atypical organisms in laboratories in India. Our case underscores the importance for screening for these infections in asymptomatic individuals who serve as reservoirs. Resolution of symptoms, negative culture or a negative PCR assay can be considered to define successful treatment, as pyuria may outlast the infection due to local inflammatory changes. To conclude, this case is to sensitise the physicians to this 'common, but forgotten entity'.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ~ References Top

1.
Wise GJ, Schlegel PN. Sterile pyuria. N Engl J Med 2015;372:1048-54.  Back to cited text no. 1
    
2.
Alwall N, Lohi A. A population study on renal and urinary tract diseases. II. Urinary deposits, bacteriuria and ESR on screening and medical examination of selected cases. Acta Med Scand 1973;194:529-35.  Back to cited text no. 2
    
3.
Dieter RS. Sterile pyuria: A differential diagnosis. Compr Ther 2000;26:150-2.  Back to cited text no. 3
    
4.
Goonewardene S, Persad R. Sterile pyuria: A forgotten entity. Ther Adv Urol 2015;7:295-8.  Back to cited text no. 4
    
5.
Hooker JB, Mold JW, Kumar S. Sterile pyuria in patients admitted to the hospital with infections outside of the urinary tract. J Am Board Fam Med 2014;27:97-103.  Back to cited text no. 5
    
6.
Hemal AK, Gupta NP, Rajeev TP, Kumar R, Dar L, Seth P, et al. Polymerase chain reaction in clinically suspected genitourinary tuberculosis: Comparison with intravenous urography, bladder biopsy, and urine acid fast bacilli culture. Urology 2000;56:570-4.  Back to cited text no. 6
    
7.
De Schryver A, Meheus A. Epidemiology of sexually transmitted diseases: The global picture. Bull World Health Organ 1990;68:639-54.  Back to cited text no. 7
    
8.
Nassar FA, Abu-Elamreen FH, Shubair ME, Sharif FA. Detection of chlamydia trachomatis and mycoplasma hominis, genitalium and ureaplasma urealyticum by polymerase chain reaction in patients with sterile pyuria. Adv Med Sci 2008;53:80-6.  Back to cited text no. 8
    
9.
Seña AC, Lensing S, Rompalo A, Taylor SN, Martin DH, Lopez LM, et al. Chlamydia trachomatis, mycoplasma genitalium, and trichomonas vaginalis infections in men with nongonococcal urethritis: Predictors and persistence after therapy. J Infect Dis 2012;206:357-65.  Back to cited text no. 9
    
10.
Horner P, Blee K, O'Mahony C, Muir P, Evans C, Radcliffe K, et al. 2015 UK national guideline on the management of non-gonococcal urethritis. Int J STD AIDS 2016;27:85-96.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2]



 

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