PRESENTATION OUTLINE

• Introduction
• General Characteristics
• Epidemiology
• Host Response
• Virulence factors and pathogenesis
• Clinical Features
• Laboratory diagnosis
• Treatment
• Prevention
• References
 INTRODUCTION
• There are three species: Chlamydia trachomatis, which infects the eye and
the genital tract; and two respiratory pathogens, C. pneumonia and C.
psittaci.
• They are all obligate, intracellular bacteria.

SPECIES AND MEDICAL IMPORTANCE

SPECIES
Chlamydia trachomatis
serotypes A, B, & C
serotypes D through K
serotypes L1, L2, L3
Chlamydia psittaci
Chlamydia pneumoniae
DISESASE
Trachoma (a leading cause of
blindness in the world by repeated infection)
1. Inclusion conjunctivitis; ocular chlamydial
infection not resulting in blindness
2. Infant pneumonia
3. Cervicitis and PID
4. Non-gonococcal urethritis (NGU) in men
Lymphogranuloma venereum (LGV)
Atypical pneumonia (psittacosis)
Atypical pneumonia, Bronchitis, Pharyngitis
• Chlamydia is especially fond of columnar epithelial cells that line mucous
membranes. This correlates well with the types of infection that Chlamydia
causes, such as urethritis, conjunctivitis, cervicitis, and pneumonia.

• Chlamydia is extremely tiny about 0.2-1.oµ

• One would ask; Are these bacteria really viruses, since they are very tiny
and use the host's cell for their own reproduction???? A: Although
Chlamydia share a few characteristics with viruses (such as their small size
and being obligate intracellular parasites), they have both RNA and DNA
(while viruses have either DNA or RNA). Also, unlike viruses they
synthesize their own proteins and are sensitive to antibiotics.

• It is classified as gram negative because it stains red with Gram stain

technique and has an inner and outer membrane. Unlike other gram-
negative bacteria, the cell wall contains lipopolysaccharide, have no
peptidoglycan in their cell wall but have outer membrane similar to that of
Gram negative bacteria

• Metabolism: unable to produce their own ATP.

 EPIDEMIOLOGY
• Chlamydia trachomatis was first discovered in 1907 by Stanislaus
von Prowazek in Berlin. The first known case of infection with C.
pneumoniae was in Taiwan in 1950, while C. psittaci, was first
characterized in 1879 when seven individuals in Switzerland were
found to experience pneumonia after exposure to tropical pet birds.

• Chlamydia is the most frequently reported bacterial STI in the US.

In 2010, 1,307,893 chlamydia infections were reported to CDC from
50 states and the District of Columbia. In 2018, it increased to
1,758,668 cases.

• A large number of cases are not reported because most people with
chlamydia are asymptomatic and do not seek testing.

• An estimate of 2.86 million of infections occur annually.

• Chlamydia is most common among young people. Almost 2/3 of
new chlamydia infections occur among youth aged 15-24 years.

• Chlamydia is also common among homosexuals. Among

homosexuals screened for rectal chlamydial infection, positivity has
ranged from 3.0% to 10.5% and pharyngeal chlamydia infection,
positivity ranges from 0.5% to 2.3%

• In published prospective studies, chlamydial conjunctivitis has been

identified in 18-44% and chlamydial pneumonia in 3-16% of infants
born to women with untreated chlamydial cervical infection at the
time of delivery.

• Women infected with chlamydia are up to five times more likely to

become infected with HIV, if exposed.
 HOST RESPONSES
• C. trachomatis infection usually attracts different types of immune cells
such as lymphocytes, macrophages and dendritic cells to infiltrate the
epithelium.
• At the site of infection there is a strong inflammatory reaction mediated
mainly by CD4+ T cells to clear the infection. These cells produce
interferon-γ (IFN-γ) which is known to inhibit chlamydial reproduction.
However, there is evidence that the concentration of IFN- γ  is critical to
the outcome of infection; high levels of IFN- γ are associated with the
clearance of the infection whilst low levels can allow the bacteria to
persist without replicating. The infection can persist for several years and
reinfection is common.
• It has been shown that reinfection can result in a strong secondary
immune response and the increased inflammation may cause further
damage to the infected cell. This has been suggested to be the case in
chronic pelvic inflammatory disease.
• It remains unclear how much damage is caused by C.trachomatis and how
much by the host immune response.
The immune response against Chlamydia infection
 VIRULENCE FACTORS
1. Chlamydia has a unique cell wall; outer LPS membrane but NO
peptidoglycan. It contains cystine-rich proteins functionally
equivalent to peptidoglycan. This inhibits/prevents phagolysome
fusion; hence, evades phagocytic killing.

2. Chlamydia genome encodes for peptidoglycan biosynthesis

enzymes but PGs aren’t synthesized; Hence, resistance to beta-
lactam drugs. Chlamydia anomaly.

3. Intracellular replication; protected from host immune defense.

4. Contains LPS that causes septic shock.

5. Pili; adhesion to Salic acid receptors on host mucous membranes,

presence at sites inaccessible to phagocytes, T-cells & B-cells.
6. Antigenic variation resulting in 15 known serotypes with
different clinical manifestations.

7. 75% of the infection are sub-clinical but still infectious

though.

8. Pathogenicity islands coding for needle-like projection type

III secretion apparatus that injects proteins directly from the
bacteria into the host cell cytoplasm and avoid lysosomes.

9. Chlamydia infested host vacuole divert lipids to itself rather

than to another compartment of the host cell.

10. Repeated infections with C. trachomatis; results in cell

pathology.
 PATHOGENICITY

SPECIES SPREAD/TRANSMISSION
Chlamydia trachomatis Contaminated fingers, face cloths,
serotypes A, B, & C etc., direct contact.

serotypes D through K 1.Usually in newborns, contracted

while passing through the birth
canal.
In adults, via oral sex and its been
isolated in swimming pools
2. Sexually transmitted; multiple
partners. Recurrence rate is high.

serotypes L1, L2, L3 Sexually transmitted

Chlamydia psittaci (Inhalation from bird droplets)
occupational hazard

Chlamydia pneumoniae By droplets and direct contact.

PATHOGENESIS
• Chlamydia has two morphological forms; Elementary Body(EB) and
Reticulate Body (RB)

• ELEMENTARY BODIES: Small (0.3 – 0.4nano meter), Extracellular,

Rigid outer membrane, Resistant, non-replicating, non-metabolically
active, Infectious.

• RETICULATE BODIES: Large (0.8 – 1nano meter), Intracellular,

Fragile membrane, Metabolically active, Replicating, non-infectious.

It is the EB that binds to columnar epithelial cells/macrophages → Down

regulation of class 1 MHC → Infiltration of PMNS and lymphocytes →
Lymphoid follicle formation → Fibrosis → Disease results from destruction of
cells and host immune response → No long lasting immunity; reinfection
results in inflammatory response.
• LIFE CYCLE
 CLINICAL FEATURES
• The incubation period of Chlamydia is 7-21 days. In 60% women and at
least 25% of men, Chlamydia infection is asymptomatic while highly
infectious (silent injury).

• Clinical features of chlamydia depends on where it is found; endocervix,

rectum, peritoneal cavity, fallopian tubes, oropharynx and conjunctiva.

UROGENITAL INFECTION; Cervicitis, PID and Salpingitis

• Women may present with non-specific symptoms such as;

– Abnormal vaginal discharge and bleeding due to cervicitis
– Dysuria and Pyuria
– Abdominal/low back Pain, Nausea and Fever due to pelvic inflammatory
disease (PID), or from infection of the fallopian tubes or uterus.
– Dysperunia (pain with intercourse esp. in sexually active women)
– Vaginal bleeding between periods.
• In Men; Non Gonococcal Urethritis (NGU)
- Dysuria - Pyuria- Itching - Urethral/Penile discharge -
Frequency
- If rectally; Pain, blood, discharge from rectum
- Epididymitis (unilateral): pain and swelling of the testes. May
result in decreased fertility.

INFANT INCLUSION CONJUCTIVITIS

• Mucopurulent eye discharge
• Corneal scarring can occur
• Ear infection and rhinitis often accompany it.

INFANT PNEUMONIA
• Failure to thrive
• Wheezing and cough but no fever
• Often preceded by conjunctivitis
LYMPHOGRANULOMA VENEREUM (LGV); Sexually
transmitted
• Small painless lesion at infection site
• Fever, headache and myalgia.
Later, inflammation , Buboes, Proctitis,
ulcerations or Elephantiasis.

CHLAMYDIA PSITTACI; Atypical Pneumonia

• Usually asymptomatic
• Chills, fever (Parrot fever), headache and persistent cough
• Psittacosis/Ornithosis in avian and mammalian populations

CHLAMYDIA PNEUMONIAE
• Usually asymptomatic but bronchitis and pneumonia are main
symptoms
• Pneumonia more common in elderly than in persons less 20 years
• First symptoms; sore throat and hoarseness; Pharyngitis.
• A Persistent cough may develop. Also, sinusitis are seen in some
patients.
 COMPLICATIONS
• Premature Delivery
• Ectopic pregnancy
• Infertility
• Prostatitis
• Reiter’s Syndrome; reactive arthritis,
inflammation of joints and urethra and eyes,
mouth ulcers too. Sometimes GI inflammation
may also occur.
 LABORATORY DIAGNOSIS
The recommended test for Chlamydia are simple, painless, and generally very
reliable. They involve sending a sample of cells to a laboratory for analysis and
these samples collected can be done in two main ways; Using a swab or
Urinating into a container.
•Sample of choice in female is cervical pap smear
• Diagnosis based on clinical grounds because of cost and complexity of
culture
• Culture in McCoy Agar
• Test for NGU: leucocyte esterase test
• Enzyme immunoassays for detecting chlamydial antigens
• Immunofluorescence tests
- Microimmunofluoresecence for patients with eye infections to check tears
for the presence of anti-chlamydia antibody.
- Direct immunofluorescence of conjunctive cells with fluorescein.
Conjugated monoclonal antibody is sensitive and specific. Indicated in
neonatal conjunctivitis and early trachoma.
Giemsa stained smear of
cultured C.trachomatis on
McCoy cells.
 TREATMENT
• Doxycycline and Azithromycin are drugs of choice
• Ofloxacin, erythromycin are alternatives
• For PID: cefoxitin or other cephalosporins plus
doxycycline
• Erythromycin syrup administered orally for
inclusion conjunctivitis and pneumonia in infants
• Erythromycin and amoxicillin are recommended
for pregnant women.
 PREVENTION
• No vaccine yet
• Safe sex practice
– Barrier contraceptives
– Single sexual partners
• Topical antimicrobials
• Regular screening
• Good Hygiene
• Using Personal Protective Equipment (PPE) for those
who work with poultries.
• Educational programs
 REFERENCES
• CDC. Sexually Transmitted Disease Surveillance, 2018. Atlanta, GA:
Department of Health and Human Services; October 2019.4.
• Clinical microbiology made ridiculously easy; third edition.
• https://www.slideshare.net
• Medical microbiology and infection at a glance; Bamford, Kathleen, Gilliespie,
Stephen.
• Satterwhite CL et al, Sexually transmitted infections among US women and
men: prevalence and incidence estimates, 2008. STD 2013 Mar;40(30):187-
935. Centers for Disease Control and Prevention. Sexually Transmitted Disease
Surveillance, 2018. Atlanta, GA: US Department of Health and Human
Services; 2019. https://www.cdc.gov/std/stats18/default.htm (Accessed on
October 10, 2019).
• White JA. Manifestations and management of lymphogranuloma venereum.
Current opinion in infectious diseases 2009;22:57-66.3.