non-gonococcalurethritis.Chronic urethritis where gonococci cannot be demonstrated

Urethritis – is inflammation of urethra.
Most episodes are caused by infection caused by pathogen that enter urethra from skin around urethral opening.Commensal flora of urethra-
Enterobacteriaceae
α/ɣ streptococci
Enterococcus spp
Diphtheroids
CONS
Non-STI: secondary to catheterization or other instrumentation of the urethra, in association with other factors that contribute to urinary tract infection.
Non-STI: secondary to catheterization or other instrumentation of the urethra, in association with other factors that contribute to urinary tract infection.

1. Non- gonococcal urethritis

2. Introduction Urethritis – is inflammation of urethra. Most episodes are caused by infection caused by pathogen that enter urethra from skin around urethral opening. Commensal flora of urethra- Enterobacteriaceae α/ɣ streptococci Enterococcus spp Diphtheroids CONS

3. NON-GONOCOCCAL URETHRITIS (Causative agent)

4. Non- gonococcal urethritis / non specific urethritis Chronic urethritis where gonococci cannot be demonstrated. Or cocci persisting in L form and hence undetectable NGU is 2.5 times more common

5. Pre-disposing risk factors Sexual contact in which exchange of body fluid may occur May report multiple sexual partners Non-STI: secondary to catheterization or other instrumentation of the urethra, in association with other factors that contribute to urinary tract infection.

6. Incubation period - 7-21 days Clincal features- Variable dysuria Urethral itching Discharge- typically mucoid to watery, white 10% NGU are asymptomatic

7. Diagnosis Failure to demonstrate gonococci in gramstain & culture >/= 4 PML/ oif in urethral smear or first voided urine sample immunoflourescence

8. Complications Epididymitis Urethral strictures Transmission Treatment Doxycycline 100mg B.D Azithromycin 1g once Ofloxacin 400mg B.D × 7days Whenever possible sexual partners should be treated simultaneously

9. Chlamydia trachomatis It accounts for 30-50% NGU Genital infections are caused by serovars D-K Infection in men Urethritis , epididymitis , proctitis , conjunctivitis, and Reiters syndrome Assoc. Symptoms – rectal pain, bleeding, mucopurulent discharge & diarrhoea

10. Infection in female Most infections are asymptomatic(80%) Urethritis Bartholinitis Mucupurulent cervicitis Vaginitis , vaginal discharge Endometritis Salpingitis PID Reiters Syndrome Genital chlamydiasis may cause infertility, ectopic pregnancy, premature deliveries, perinatal morbidity

11. Lab diagnosis Specimen collection Urethral scraping Cervical scraping Urine Other specimens- semen, aspirates from fallopian tube/ epididymus

12. Specimen transportation Swabs should be immediately placed into transport medium, sucrose phosphate saline (2SP) containing gentamicin , vancomycin , amphotericin B Heat inactivated fetal calf or bovine serum (5%) must be added to protect during freezing If transport is delayed- store at 4°C upto 24hrs -60 °C/ liquid nitrogen for longer delay

13. MICROSCOPY They are gram negative Chlamydial elementary bodies & inclusions Better stained by Giemsa , Castaneda, Macchiavello , Giminez stains & lugol’s iodine Typical reniform inclusion bodies surrounding nucleus Immunoflourescence (IF) More sensitive & specific method of microscopy by using monoclonal antibodies Both inclusions & extracellular EB can be identified

14. Isolation Inoculation into mice/ embryonated eggs Chlamydia can grow in yolk sac of 6-8 day old chick embryos First reported isolation was by Gordon & Quan in irradiated McCoy cells Cell lines supporting growth of chlamydiae McCoy cells HeLa 229 cell BHK cell BGM cell

15. ANTIGEN DETCTION Immunoflourescence - Staining of smears by FITC-labelled antibodies against species specific MOMP or genus specific LPS Atleast 10 EBs should be seen for positive result Senstivity 90% specificity 95% ELISA- Detection of soluble genus-specific antigen Senstivity same as IF

16. DNA probes Radioactive DNA probes for detection of C.trachomatis in cell culture & cervical smears Chemiluminescence assay- Acridium -ester-labelled single stranded DNA probe complementary to RNA of C.trachomatis PCR Amplification targets- omp1 gene coding for MOMP - 16s rRNA gene

17. ANTIBODY DETECTION Demonstration of group specific antibody by CFT or micro IF High level >64 of IgM and a rising titre of IgG is taken diagnostic IgM persists for 2months In neonatal chlamydial infection detection of IgM is taken diagnostic

18. Treatment DOC – doxycycline in adults & erythromycin in infants Since chlamydia have long replication cycle hence short course will only suppress infection t/t should be given for a min of 7days/ 3 weeks in women with ascending & complicated genital infections Azithromycin provides sustained levels in tissue

19. Ureaplasma urealyticum & Mycoplasma Infection s caused by Ureaplasma urealyticum NGU Epididymitis Vaginitis , cervicitis It may cause chorioamnionitis , prematurity, postpartum endometritis , chronic lung disease of premature infant Male and female infertility

20. Mycoplasma hominis Salpingitis , tubo -ovarian abscess, pelvic abscess, septic abortion, puerperal infection, Mycoplasma genitalium NGU PID Very difficult to recover from culture

21. LAB DIAGNOSIS of Mycoplasma & Ureaplasma Specimen collection Urethral, vaginal, cervical swabs Semen, prostatic secretions Urine Biopsy specimen

22. Specimen transportation Standard Mycoplasma broth medium dispensed in small vials – for swab specimens Other specimens – sterile screw-capped containers If there is delay in processing- store at 4°C for 24 hours Or -70°C for further delay Mycoplasma broth medium – penicillin, polymyxin B, amphotericin B, glucose, phenol red PPLO broth medium containing 20% horse serum, glucose, phenol red

23. CULTURE Medium is inoculated and incubated at 37°C in an atmosphere of 95% N 2 & 5% CO 2 It usually takes 4-28 days Growth shows turbidity in the medium and then sub-cultured on agar medium & incubated for 5-7 days Colonies of mycoplasma show characteristic ‘fried egg’ appearance while ureaplasma colonies are small & lack peripheral zone.

24. The serial dilutions of patients serum are mixed with an equal serum are mixed with an equal volume of 0.2% washed volume of 0.2% washed human O group erythrocytes at low temperature The clumping is observed at 4 °C overnight. However the clumping is dissociated at 37°C dissociated A titer of 1:32 or > is suggestive A raised titer in paired serum sample is more suggestive of infection.

25. Haemadsorption test Colonies growing on surface agar Flooded with 2ml of 0.2-0.4% suspension of washed guinea-pig erythrocytes in MBM Incubated at 35°C for 30mins Washed with 3ml MBM & gently rotated Wash fluid is removed Observed under 50-100x magnification

26. Tetrazolium reduction test Growth can be easily screened by TR test in which mycoplasma colonies reduce colourless tetrazolium to red coloured formazan

27. The colonies can be demonostrated by Dienes method. Diene’s stain- azure II, methylene blue, maltose, Na2CO3, benzoic acid & DW. The plate is flooded with this stain Then rinsed with DW Decolourised with 95% ethanol Observed under low power

28. PCR- Using target gene- 16S rRNA Treatment DOC- erythromycin & tetracycline Resistance to both of these drugs is fairly common

29. Oculogenital syndrome NGU and conjunctivitis may be seen in 4% patients & responds to tetracyclines . Reiter’s syndrome( reactive arthritis) Some cases of NGU also present with arthritis, uveitis , and skin/ mucous membrane lesions Few cases suggest antibiotic associated colitis or cryptosporidiosis Post dysentric reiter’s syndrome More common in HLA-B27 positive patients

30. Clinical features NGU is initial manifestation w/ i 14days of exposure Urethritis may be mild & unnoticed Other features develop after 1-5 weeks Arthritis develops in 4 weeks Knees-ankles-small joints are involved

31. Dactylitis - sausage shaped swelling of digits is characteristic & persistent feature Mild B/L conjunctivitis, iritis , keratitis , uveitis for few days Dermatologic manifestation occur in 50% pts It includes waxy papules, central yellow spot, mostly on soles, palms, nails, scrotum, scalp, trunk the initial episode of RS lasts 2-6 months

32. Lab diagnosis Anaemia ESR Synovial fluid 1000-200,000 WBCs/ml >2/3 rds are PMNs Glucose in joint fluid Therapy Anti chlamydial treatment Tetracycline/erythromycin NSAIDS- indomethacin

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