Acute Salpingitis Research Articles

Transvaginal intratubal insemination by tactile sensation: a preliminary report

Transvaginal catheterization of the fallopian tube has gained increased popularity for transfer of embryos and gametes. Forty-five ITIs were performed on 32 patients using the novel approach of tubal transfer via tactile sensation. This group of patients had undergone an average of 5.2 IUIs before ITI. There were a total of 11 pregnancies, 6 occurring with hMG stimulation and 5 with CC-stimulated cycles (34% PR per patient). Three pregnancies ended with spontaneous abortion, and one patient developed acute salpingitis necessitating laparotomy. These data suggest ITI may be effective in assisted reproduction but, as other invasive procedures, is not without risk.

Acute Chlamydial Salpingitis With Ascites and Adnexal Mass Simulating a Malignant Neoplasm

Chlamydia trachomatis is a well-known cause of acute and chronic salpingitis, accounting for approximately half of all cases of pelvic inflammatory disease. Typically, patients with acute chlamydial salpingitis present with acute lower abdominal pain, tenderness on bimanual pelvic examination, or vaginal discharge. We describe a case of acute chlamydial salpingitis with marked ascites and an adnexal mass that simulated a malignant neoplasm. Microscopically, a severe lymphofollicular salpingitis and a marked lymphofollicular hyperplasia of the omentum and retroperitoneal lymph nodes were found. Chlamydial inclusions in the fallopian tube epithelium were demonstrated by immunohistochemistry using a mouse monoclonal antibody to a genus-specific outer membrane lipoprotein. Chlamydial infection may cause marked ascites and a palpable adenexal mass and should be considered whenever marked chronic inflammation with a lymphofollicular hyperplasia involves the fallopian tube or other female genital tract sites.

Neisseria meningitidis in Specimens From Urogenital Sites

Neisseria meningitidis serogroups B type 2 and Y were isolated from urogenital specimens from three heterosexual patients. The first patient was a young man with the clinical signs and microscopic findings of a typical gonococcal urethritis. The second was a middle-aged woman with cervicitis, in whom neither Neisseria gonorrhoeae nor Chlamydia trachomatis were demonstrated by culture. In the third patient, a young woman, N. meningitidis was associated with cervicitis, acute salpingitis, and peritonitis. The patients' clinical symptoms responded quickly to antibiotic treatment. Meningococci of the same serogroup/serotype as the index cases were demonstrated in two of the sexual consorts in pharyngeal specimens but not in genitourinary specimens. Orogenital sexual practice seemed to be the most likely route of transmission. During the period of this study (August 1989-March 1990), the three meningococcal strains observed at the authors' laboratory represented 20% of the total number of urogenital isolates of pathogenic Neisseria. A greater awareness of this problem from medical, diagnostic, epidemiologic, and legal viewpoints is therefore needed.

Surgical Considerations in the Diagnosis and Treatment of Pelvic Inflammatory Disease

Pelvic inflammatory disease continues to be a common finding in young women with lower abdominal pain. Typical emergency room pelvic inflammatory disease, with classic symptoms of pain, fever, and a history of high-risk sexual behavior, is easily diagnosed with a high degree of specificity. However, the majority of patients with pelvic inflammatory disease have atypical symptoms, and their condition may be incorrectly diagnosed and treated. Careful attention to the physical signs of pelvic infection and the evaluation of the vaginal secretions for leukocytes improves diagnostic accuracy. Liberal use of diagnostic laparoscopy to confirm the possibility of acute salpingitis is recommended in young women, who have much to lose from a case of untreated salpingitis. Outpatient treatment with a beta-lactam antibiotic followed by a course of doxycycline adequately treats patients with N. gonorrhoeae and C. trachomatis infections. However, patients with suspected anaerobic upper genital tract infection such as those infections associated with tubo-ovarian abscess or IUD use should be admitted for parenteral antibiotic therapy and observation. Laparotomy and extirpative surgery should be reserved for seriously ill patients with generalized peritonitis associated with rupture of a tubo-ovarian abscess and for patients who do not respond to antibiotic therapy. Sound judgment regarding the extent of extirpative surgery, taking into consideration the wishes of the patient with respect to future fertility and hormone production, will lead to an acceptable outcome.

Recurrence of ectopic pregnancy: The role of salpingitis

We evaluated the role of salpingitis on the recurrence of ectopic pregnancy from a historical cohort of 2501 women who had undergone laparoscopic examination for acute salpingitis. We used pregnancy (N = 2899) as the unit of analysis and a modified conditional logistic regression to estimate a pairwise odds ratio as a measure of the recurrence of ectopic pregnancy. Among the second or higher order of pregnancy, the recurrence was 21.7%. For pregnancies with a prior uterine pregnancy, the ectopic pregnancy rate increased with prior salpingitis scores constructed from a combination of prior salpingitis episodes and severity (0 score, 2.7%; 1 to 2 scores, 4.8%; and greater than or equal to 3 scores, 12.1%). For those with a prior ectopic pregnancy, the rate did not increase with prior salpingitis scores (score 0, 20.0%; score 1 or 2, 19.2%; and score greater than or equal to 3, 26.9%). The adjusted pairwise odds ratio was 2.2 and was practically unchanged (2.1) after additional adjustment with prior salpingitis scores. These findings confirm salpingitis as a risk factor for first ectopic pregnancy, but once a woman had an ectopic pregnancy, previous salpingitis might not add any incremental risk.

A randomized trial of ofloxacin versus cefoxitin and doxycycline in the outpatient treatment of acute salpingitis

The object of this randomized study was to compare the safety and efficacy of oral ofloxacin, 400 mg twice daily for 10 days, versus intramuscular cefoxitin, 2 gm, plus oral probenecid, 1 gm, followed by oral doxycycline, 100 mg twice daily for 10 days, in the outpatient treatment of uncomplicated acute salpingitis. Thirty-eight women (53%) had Neisseria gonorrhoeae from their pretreatment endocervical or endometrial cultures, and 18 had Chlamydia trachomatis (25%). Thirty-five of 37 women (95%) treated with the ofloxacin regimen were clinically cured, and 34 of 35 (97%) were cured with the cefoxitin-doxycycline regimen (p = 0.52). One clinical failure occurred in each group with N. gonorrhoeae infection, and one failure occurred in the ofloxacin group because of side effects. The bacteriologic response for N. gonorrhoeae in both groups was 100%. The eradication of C. trachomatis was 100% (10/10) for the cefoxitin/doxycycline group and 86% (6/7) for ofloxacin. The side effects were similar in both groups of subjects. In this study both regimens were effective for the outpatient treatment of uncomplicated acute salpingitis.

Comparison of Cefotetan Plus Doxycycline With Cefoxitin Plus Doxycycline in the Inpatient Treatment of Acute Salpingitis

Pelvic inflammatory disease (PID), one of the major sequelae of the current epidemic of sexually transmitted diseases, has been shown to be a polymicrobial infection. This study compares the efficacy and safety of two broad-spectrum combination drug regimens, cefotetan with doxycycline and cefoxitin with doxycycline, in the treatment of PID. A total of 108 patients with acute salpingitis were hospitalized and randomized into two treatment groups: cefotetan/doxycycline (N = 54) and cefoxitin/doxycycline (N = 54). Before antibiotic administration, Chlamydia trachomatis was identified in 17 (16%) of the patients, Neisseria gonorrhoeae from 72 (67%), and anaerobic and aerobic bacteria were identified from the endometrial cultures of 86 (80%). There were seven tubo-ovarian abscesses (TOAs) that were diagnosed in the cefotetan group, and six in the cefoxitin group. Clinical cure was achieved in 51 of 54 (94%) patients in each group. Of the six patients whose treatment failed, all had positive cultures for N. gonorrhoeae and facultative/anaerobic bacteria, whereas none had C. trachomatis. Two patients from each study arm whose treatment failed were diagnosed with TOAs and responded subsequently to clindamycin plus an aminoglycoside. Cultures that were obtained after the completion of inpatient treatment showed the eradication of C. trachomatis and N. gonorrhoeae in all patients. Also, both regimens were effective in reducing aerobic and anaerobic pathogens. Finally, both regimens were well tolerated, with few side-effects.

Roxithromycin treatment of mouse chlamydial salpingitis and protective effect on fertility

We used a mouse model of acute chlamydial salpingitis to evaluate the efficacy of roxithromycin in preventing irreversible inflammatory damage leading to tubal infertility. Female C3H/He mice were genitally inoculated with a human strain of Chlamydia trachomatis and then treated with roxithromycin glutamate subcutaneously. Treatment was initiated either 7 or 10 days postinfection (p.i.) and continued for 7 days at a dosage of 50 or 100 mg/kg of body weight per 24 h. The course of the disease was monitored serologically, bacteriologically, and histologically. At the end of the treatment, the mice were encaged with males and their reproductive capacity was recorded over a 19-week period. The protective effect of roxithromycin was assessed in terms of fertility parameters in comparison with values for noninfected control mice. When treatment was initiated on day 7 p.i. and given in twice-daily 25-mg/kg doses, all the mice remained fertile and the total number of offspring was similar to that of sham-infected mice (17.3 +/- 3.3 versus 17.2 +/- 2.3). When treatment was initiated on day 10 p.i. and given in a single daily dose of 50 or 100 mg/kg, 90 and 70% of the mice, respectively, remained fertile; however, in terms of total offspring, fertility was lower in the group treated with the lower dose (5.6 +/- 1.4 versus 13.0 +/- 3.8). Roxithromycin was found to be effective against C. trachomatis in the mouse genital tract, but fertility was only partially preserved when the time between infection and treatment was prolonged.

Epidemiology and aetiology of acute non-tuberculous salpingitis. A comparison between the early 1970s and the early 1980s with special reference to gonorrhoea and use of intrauterine contraceptive device.

More patients were hospitalised for acute salpingitis at the Department of Obstetrics and Gynaecology, Orebro Medical Centre, Orebro, Sweden, during the 5 year period 1970-1974 (period I) as compared with that of 1980-1984 (period II), 666 patients and 524 respectively, a decrease of 22%. The majority of cases, 92% in period I and 85% in period II, occurred among women 15-34 years of age, that is a relative increase of patients aged over 34 from 8% in period I to 15% in period II. Concomitant urogenital gonorrhoea occurred in 26.2% of the patients in period I compared with 12.0% in period II, a highly significant decrease (p less than 0.001) mainly confined to the age group 15-24, whereas there was no relative difference for the two periods in the age group 25-34 years. The number of patients using intrauterine contraceptive device (IUCD) was 96/666 (14.4%) in period I compared with 113/524 (21.6%) in period II (p less than 0.001). There were also relatively more IUCD users among the patients with gonorrhoea and acute salpingitis in period II (15.5%) compared with period I (10.4%) but this difference was not statistically significant. From 1981 to 1984 370/424 patients were cultured for Chlamydia trachomatis and 27.8% (103/370) were positive. Thus Chlamydia trachomatis is at present, at least in the Orebro area, the most frequently isolated STD agent among acute salpingitis patients while gonorrhoea is of much less importance.

Chlamydia trachomatis infection in primary unexplained infertility

In recent years Chlamydia trachomatis has emerged as a significant cause of acute salpingitis and reproductory failure. In this study, 85 women suffering from primary infertility and 85 parous women as control group were screened for C. trachomatis genital infection by means of cell culture and antigen detection on genital samples as well as the detection of anti-chlamydial antibodies in blood. C. trachomatis was detected in 31.8% of infertile women and 5.8% of fertile subjects. Isolation of C. trachomatis in cell culture proved to be the most reliable diagnostic tool when compared to immunofluorescence staining on smears and serology. Although the latter may be considered of great value in epidemiological researches, culture isolation should be associated for the diagnosis of active infection.

High hepatitis B carrier rate among non-Oriental patients with acute salpingitis

Hepatitis B surface antigen screening was performed on non-Oriental patients with the diagnosis of acute salpingitis. Six of 59 (10.17%) had hepatitis B surface antigenemia. We therefore recommend hepatitis B screening for all patients with salpingitis. The detection of covert hepatitis B helps to protect hospital staff and provides important information for the patient. Further, the administration of hepatitis B vaccine may be appropriate for those patients with acute salpingitis who are found to be hepatitis B surface antigen-negative.

Sexually Transmitted Diseases in Africa

Sexually transmitted diseases (STD) are defined as a group of communicable diseases which have in common that they are transmitted predominantly by sexual contact. The number of agents now known to be sexually transmitted include some 20 pathogens. Some of these agents (such as Chlamydia trachomatis, herpes simplex virus, human papilloma virus, hepatitis B. virus, human immunodeficiency virus) tend to replace the classical "venereal diseases" both in importance and frequency as these agents are often more difficult to detect, treat, and control. Sexually transmitted diseases are a major public health problem in most African countries on account of their frequency, their associated morbidity and mortality, their impact on maternal and infant health, as well as their economic costs in terms of health expenditure and lost productivity, and, last but not least, because of their social consequences. Recent epidemiological studies using sophisticated diagnostic technologies greatly extend our knowledge on the true spectrum of complications and sequelae associated with these infections. Nongonococcal urethritis - caused to 40% by Chlamydia trachomatis - and gonococcal infections are together the most frequent sexually transmitted diseases. The increasing importance of chlamydial infections, in contrast to a gradual decrease of gonococcal infections, is related to the fact that these infections Sexually transmitted diseases (STD) are defined as a group of communica- ble diseases which have in common that they are transmitted predominantly by sexual contact. The number of agents now known to be sexually trans- mitted include some 20 pathogens. Some of these agents (such as Chlamydia trachomatis, herpes simplex virus, human papilloma virus, hepatitis Br virus, human immunodeficiency virus) tend to replace the classical "vene- real diseases" both in importance and frequency as these agents are often more difficult to detect, treat, and control. Sexually transmitted diseases are a major public health problem in most African countries on account of their frequency, their associated morbidity and mortality, their impact on maternal and infant health, as well as their economic costs in terms of health expenditure and lost productivity, and, last but not least, because of their social consequences. Recent epidemio- logical studies using sophisticated diagnostic technologies greatly extend our knowledge on the true spectrum of complications and sequelae asso- ciated with these infections. Nongonococcal urethritis - caused to 40% by Chlamydia trachomatis - and gonococcal infections are together the most frequent sexually transmitted diseases. The increasing importance of chlamydial infections, in contrast to a gradual decrease of gonococcal infections, is related to thefact that these infections frequently cause asymptomatic or mild disease and do not motivate patients to seek medical care, resulting in an extended period of infectivity and high risk of developing complications. Untreated gonorrhoea and chlamydial infections are the most common causes of epididymitis in males under the age of 35 years and may lead to decreased fertility. In some parts of sub-saharan Africa where urethritis often goes untreated, epididymitis is the leading course of male infertility. Also urethral strictures still from a large part of urogenital practice in some African countries. An estimated 8-16% of women with untreated endocervical gonococcal or chlamydial infections will develop acute salpingitis following an ascending spread of these pathogens. After one episode of acute salpingitis approximately 10% of women may become infertile due to complete tubal occlusion. Similarly, the risk for women to develop an ectopic pregnancy after salpingitis is 6-10 times greater than in controls. Ectopic pregnancies in areas with insufficient health services carry a high mortality risk. Maternal infections with STD may not only have adverse effects on pregnancy outcome but may cause serious morbidity and mortality in the newborn (e.g. congenital syphilis, ophthalmia neonatorum, herpes simplex virus infection of the neonate, chlamydial pneumonia, congenital HIV infection). AIDS is an example "par excellence" of a sexually transmitted disease of public health importance requiring extensive clinical services and posing enormous financial and social problems for the individual and the society at large. AIDS and the other viral STD have greatly increased the interest in primary prevention strategies such as health education and behavioral modification, for the control of sexually transmitted diseases.KEYWORDS: chancroid, chlamydia, gonorrhoea, HIV, infertility, sexually transmitted diseases, surveillance

Endometrial Histopathology in Patients with Culture-proved Upper Genital Tract Infection and Laparoscopically Diagnosed Acute Salpingitis

To define and quantitate histologic changes in the endometrium that best correlate with documented upper genital tract infection (UGTI) and laparoscopically diagnosed acute salpingitis, we studied endometrial biopsy specimens from 69 consecutive patients with clinically suspected acute pelvic inflammatory disease (PID) who underwent microbiological evaluation for UGTI and laparoscopic examination for acute salpingitis. Both UGTI and acute laparoscopically confirmed salpingitis were present in 37 patients (54%), UGTI without salpingitis in 1 (1%), salpingitis without UGTI in 11 (16%), and neither UGTI nor salpingitis in 20 (29%). Chlamydia trachomatis or Neisseria gonorrhoeae UGTI was found in 34 women, Escherichia coli in two patients, Peptococcus magnus in one woman, and with Streptococcus agalactiae in one woman. The following features were correlated both with UGTI and with salpingitis: presence of any neutrophils in the endometrial surface epithelium; neutrophils within gland lumens; dense subepithelial stromal lymphocytic infiltration; any stromal plasma cells; and germinal centers containing transformed lymphocytes. The simultaneous presence of five or more neutrophils per X 400 field in endometrial surface epithelium, together with one or more plasma cell per X 120 field in endometrial stroma, was the best predictor of UGTI plus salpingitis. This combination had a sensitivity of 92% and a specificity of 87% for predicting the diagnosis of both UGTI and laparoscopically confirmable acute salpingitis. Prospective studies are needed to assess the usefulness of these criteria.

Peritoneal Fluid Leukotriene B<sub>4</sub> and Prostaglandin E<sub>2</sub> in Acute Salpingitis

Concentrations of leukotriene B4 (LTB4) and prostaglandin E2 (PGE2) in peritoneal fluid were measured in 19 women with suspected acute pelvic inflammatory disease. Acute salpingitis was verified by laparoscopy in 16 cases; 11 of them had isolation of microbes from the peritoneal cavity. Means (+/- SD) levels of peritoneal fluid LTB4 and PGE2 in acute salpingitis were 506 +/- 288 and 378 +/- 330 pg/ml, respectively, and higher (p less than 0.001) than the levels in the peritoneal fluid of 20 healthy controls: LTB4 44 +/- 57, PGE2 11 +/- 2 pg/ml, respectively. An inflammatory cytologic pattern was found in the peritoneal fluid in all the cases with acute salpingitis, neutrophils being the prominent cells. These chemical mediators of inflammation in peritoneal fluid may have a role in the development of scarring and peritubal adhesions found after acute salpingitis.

Comparison of cefotaxime, cefoxitin and clindamycin plus gentamicin in the treatment of uncomplicated and complicated pelvic inflammatory disease

Patients with uncomplicated pelvic inflammatory disease (PID) (acute salpingitis and no pelvic masses) were randomly assigned for treatment with either cefotaxime or cefoxitin. A clinical cure was achieved in 17 of 20 cases (82%) and 19 of 22 cases (84%), respectively. Within the complicated PID group, patients were assigned to two subgroups: those with a tubo-ovarian complex (26 patients), and those with a tubo-ovarian abscess (32 patients), as confirmed by ultrasonography or surgery. Patients within each of these two subgroups were then randomly assigned for treatment with either cefotaxime or clindamycin plus gentamicin. Within the tubo-ovarian complex subgroup, a clinical cure was achieved in 11 of 13 cases (85%) treated with cefotaxime and 10 of 13 cases (77%) treated with clindamycin plus gentamicin. Within the tubo-ovarian abscess subgroup, a clinical cure was achieved in 12 of 16 cases (75%) treated with cefotaxime and 11 of 16 cases (69%) treated with clindamycin plus gentamicin. No differences in any category were statistically significant. Specimens for culture were obtained from the endocervix, endometrium, and when possible, the cul-de-sac, fallopian tubes, and abscess. Neisseria gonorrhoeae (33%) was isolated more frequently than Chlamydia trachomatis (12%) in patients with PID, and neither of these organisms was isolated with any increased frequency in patients with complicated PID. The majority of the patients were considered to have polymicrobial infection. Cefotaxime was as efficacious as cefoxitin and clindamycin plus gentamicin for the treatment of acute salpingitis, tubo-ovarian complex and tubo-ovarian abscess.

Comparison of parenteral ciprofloxacin with clindamycin-gentamicin in the treatment of pelvic infection

A prospective, randomized study of intravenous followed by oral ciprofloxacin compared with the combination of intravenous clindamycin and gentamicin was conducted in 122 women hospitalized with pelvic infections. Clinical diagnosis included endometritis (97 patients) and uncomplicated pelvic inflammatory disease (25 patients). Treatment successes for endometritis included 42 of 50 (84 percent) patients treated with ciprofloxacin compared with 35 of 47 (75 percent) treated with the clindamycin-gentamicin combination. Treatment successes for acute salpingitis included 10 of 10 (100 percent) treated with ciprofloxacin and 13 of 15 (87 percent) treated with clindamycin-gentamicin. Ciprofloxacin successfully eradicated Chlamydia trachomatis in 11 of 12 patients as did clindamycin-gentamicin in six of seven patients. In this study of pelvic infection, ciprofloxacin demonstrated efficacy comparable with the combination of clindamycin and gentamicin, and is effective against C. trachomatis.

High hepatitis B carrier rate among non-Oriental patients with acute salpingitis

Hepatitis B surface antigen screening was performed on non-Oriental patients with the diagnosis of acute salpingitis. Six of 59 (10.17%) had hepatitis B surface antigenemia. We therefore recommend hepatitis B screening for all patients with salpingitis. The detection of covert hepatitis B helps to protect hospital staff and provides important information for the patient. Further, the administration of hepatitis B vaccine may be appropriate for those patients with acute salpingitis who are found to be hepatitis B surface antigen-negative.

Second Look Laparoscopy

BRIHMER, CHRISTINA; KALLINGS, INGEGERD; NORD, CARL ERIK; BRUNDIN, JAN Author Information

Immune response to genital chlamydial infection and influence ofChlamydia pneumoniae (TWAR) antibodies

Chlamydial IgG antibodies at a titre of at least 32 were found to occur at approximately the same frequency (76-88%) in three groups of patients who had been treated for genital chlamydial infection. Twenty-four patients who had recovered from acute salpingitis, however, had a higher geometric mean titre (GMT; 176) than 59 pregnant women (GMT 44) or 61 patients with uncomplicated genital chlamydial infection (GMT 57). The chlamydial antibody titres thus seemed to reflect the severity of inflammatory involvement. Antibodies to the new species Chlamydia pneumoniae (previously known as Chlamydia TWAR), did not influence the frequency or titre of antibodies to Chlamydia trachomatis, arguing against the possibility of cross-reactivity or shared antigens. There was assumed to be no cross-immunity, since patients with Chlamydia trachomatis infection did not have a lower frequency of antibodies to Chlamydia pneumoniae.

Experimental Chlamydia trachomatis salpingitis in mice: initial studies on the characterization of the leukocyte response to chlamydial infection.

The murine biovar (mouse pneumonitis) of Chlamydia trachomatis was inoculated into the left oviduct of female Swiss Webster mice to establish acute salpingitis. Chlamydial inclusions were observed in secretory epithelial cells by both transmission electron microscopy and light microscopy using immunoperoxidase staining of deparaffinized sections. By days 5-8 after infection, a mixed polymorphonuclear and mononuclear cellular infiltrate was observed in the submucosa and mucosa. Epithelial cell deterioration occurred in the endosalpinx in areas of heavy mononuclear cellular infiltration. During the acute phase of the disease a cellular infiltrate consisting mainly of T cells was identified by staining frozen tissue sections with monoclonal antibodies to mouse lymphocyte antigens. Occasionally B lymphocytes were observed. Widespread deciliation of the mucosa was observed by scanning electron microscopy. No histopathologic or immunopathologic responses were observed in the control oviducts. These observations suggest an immunologic basis for the structural abnormalities seen in the infected oviducts.