Mucopurulent cervicitis and Mycoplasma genitalium

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Mucopurulent cervicitis and Mycoplasma genitalium

• Manhart LE, Critchlow CW, Holmes KK, Dutro SM,
  Eschenbach DA, Stevens CE, Totten PA.
• J Infect Dis. 2003 Feb 15187(4)650-7.

Catherine Wetmore EPI 507 HIV/STIs in Women and
Children May 18, 2006
Pollack JD. Trends Microbiol. 1997 5413-9.
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Background

• Mucopurulent cervicitis
• Inflammation of the cervix
• Recognized pathogens
• GC, CT, HSV, Trich
• Many idiopathic cases
• Mycoplasma genitalium
• Fastidious bacterium
• Recently recognized cause of idiopathic NGU

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Rationale for Study

• Given a strong association between M. genitalium
  and NGU in men
• Manhart et al hypothesized this organism might
  also be associated with MPC, the corresponding
  reproductive tract syndrome in women.

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Study Design

• Design Clinic-based case-control study
• Study population 779 randomly-selected women
  aged 16-45 attending PHSKC STD clinic for new
  problem
• Case Presence of visible yellow mucopus or ? 30
  PMNLs/1000X microscopic field in cervical mucus
• Control No evidence of MPC based on clinical or
  microscopic examination

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Methods

• Recruited 779 subjects between 1984-1986
• Original study established role of GC, CT and HSV
  in MPC
• Collected detailed info on demographics, medical
  and sexual history, symptoms, clinical signs
• Standard pelvic exam
• Obtained and archived cervical and vaginal
  specimens
• PCR assay to detect presence of M. genitalium
• Multivariate logistic regression used to estimate
  association between MPC and M. genitalium,
  adjusting for relevant confounding factors

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Results (1)
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Results (2)

• Correlates of M. genitalium infection
• Higher cervical and vaginal PMNL counts
• Cervical mucopus
• Easily induced cervical bleeding
• Abnormal vaginal discharge
• Complaints of abdominal pain
• Complaints of diarrhea and vomiting
• Proliferative phase of the menstrual cycle
• Young age
• Young age at sexual debut
• Multiple recent partners
• Prior miscarriage
• Smoking
• Douching
• BV and cunnilingus are negatively associated

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Conclusions

• M. genitalium is associated with MPC
• Correlates of infection suggest a sexual mode of
  transmission
• Correlates of infection suggest possible role in
  upper reproductive tract disease

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Strengths

• Large sample
• Detailed covariate information
• One experienced clinician performed all clinical
  and microscopic exams, and recorded all observed
  abnormalities
• Great lab methods
• PCR inhibition controls
• Repeat PCR testing of second aliquot to confirm
  () results and rule out contamination

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Limitations

• No firm cytological definition for MPC
• ?10, 20, or 30 PMNLs/1000X microscopic field
• May have missed some cases
• Association ? Causation
• Can not assess temporal relationship between
  infection and disease manifestation
• M. genitalium may be harmless commensal organism
  that travels in association with a still
  unrecognized pathogenic organism
• Reliance on archived specimens
• Should confirm association in contemporary
  populations

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Future Directions for Research

• Assessing causality using epidemiologic data is
  challenging
• Inoculation of human subjects with clinical
  isolates is not ethical (nor feasible!)
• Treatment trials (ideally placebo-controlled)
  demonstrating correlation between microbiologic
  eradication and clinical cure would support
  causal relationship
• Effective treatment option is also prerequisite
  for initiating screening interventions to prevent
  serious sequelae