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Home , Neisseria, Neisseria flavescens, Neisseria lactamica, Neisseria mucosa, Neisseria sicca

Al-Dorri (2020): Isolation of N sicca from genital tract Dec, 2020 Vol. 23 Issue 24

Isolation of sicca from genital tract

Alaa Zanzal Ra'ad Al-Dorri1*

1. Department of Medical Microbiology, Tikrit University/ College of Medicine (TUCOM), Iraq.

*Corresponding author:[email protected] (Al-Dorri)

Abstract In the last few decades some researchers has focused on N. meningitidis and N. gonorrhoeae in attempts to understand the pathogenesis of the diseases produced by these organisms. Although little attention has been paid to the other neisseria species since they are considered harmless organisms of little clinical importance although they can cause infections. In this paper, pathological features and the clinical of high vaginal and cervical infections caused by are described, which are normal inhabitants of the human respiratory tract as in oropharynx and can act as opportunistic when present in other sites such as female genital tract. We note they usually infect married women at a young age group who were multipara and active sexual women. N.sicca was resistant to most antibiotics that were used while the doxycycline was the most effective antibiotic against N.sicca.

Keywords: Neisseria sicca,genital tract infection, pharyngeal carriage, colonization, How to cite this article: Al-Dorri AZR (2020): Isolation of Neisseria sicca from genital tract, Ann Trop Med & Public Health; 23(S24): SP232417. DOI:http://doi.org/10.36295/ASRO.2020.232417

Introduction: Neisseria is considered as a genus of b-, which are absolute symbionts in human mucosal surfaces. 8 species of Neisseria have been reported and they normally colonize the mucosal surfaces of humans [1, 2]. Although some studies have described eleven other species that colonizes humans, only two are pathogens, N.gonorrhoeae and N.meningitidis oftentimes cause infections [3]. Neisseria meningitides cause septicemia and , whilst causes transmitted sexual disease. For of their importance to public global health, the former researches completed have focused fundamentally on the two pathogens, leading to the identification of large factor virulence that is substantial for humans in infection. Neisseria species are Gram-negative , diplococci resemble coffee beans, sometimes appear as tetrads, and they grow at 37°C when viewed microscopically. Neisseria is positive for both and oxidase [3]. Several Neisseria could be diagnosed via fermentation of sugars from which they will products acid. For like, N.gonorrheae products acid from only glucose, but N.meningitidis produces acid from maltose and glucose [3].

New reports show that commensal Neisseria as well has the genes associated with virulence.N. meningitidisand N. gonorrhoeae cause important diseases distributed world-wide, the dominance of which is subordinate on the availability and widespread utilizer of gonococcal vaccines and meningococcal. The nature of the organism’s heterogeneity, variability, poor immunogenicity onto components surface should be affected the development of Neisseria vaccines [4, 5, 6]. Therefore, the study focused each on a fixed number of genes virulence or only one commensal genome. The total virulence gene content of the Neisseria genus is unknown. Neisseria sicca differs from other commensal Neisseria because it causes disease in healthy individuals [6]. One of the protective

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232417 Al-Dorri (2020): Isolation of N sicca from genital tract Dec, 2020 Vol. 23 Issue 24

mechanisms of N. meningitidis is the presence of a polysaccharide capsule that surrounds the outer membrane of the bacterium and protects the bacteria against immune defense mechanisms, while N. does not possess such capsule. Both commensal and pathogenic Neisseria have lipooligosaccharide (LOS) consisting of a core polysaccharide and instead of (LPS) and play an important role in the pathogenesis of pathogenic species. Commensal Neisseria also has LOS but can express additional structures not found in the pathogenic strains.N. sicca was responsible for a fatal case of endocarditis in healthy adult males, this isolate from commensal species represents an increase in virulence of this organism to invade the host and survive in the blood [7]. LOS acts as an endotoxin against antibiotics, and it is a high stimulator to the human [8].

Regarding the cultural features of N. sicca are Gram-negative bacteria, while colonies appear as dry, wrinkled, adherent colonies but smooth colonies may form catalase positive. Most N. sicca strains are not pigmented while others strains can be pigmented, for differentiation among N. subflava and N. sicca we can use the characteristic of lacking pigmentation. N.sicca produces acid from glucose, maltose, sucrose, and fructose but not for lactose [9]. For the past 70 years, antibiotics were used successfully for the treatment of the pathogenic Neisseria (N. gonorrhea and N. meningitides) infections. Although resistance to antibiotics is increasing. The mechanisms of antibiotic resistance in gonococci and meningococci should be elucidated in order todesign novel antimicrobials to avoid this problem [10].

Neisseria sicca/subflava are considered as one of normal flora are found in the greater tract respiratory and oral cavity of humans and rarely cause meningitis, endocarditis, urethritis, , spondylitis, and bacteremia. There is little literature that explains the clinical features and management of iatrogenic meningitis caused by N. sicca/subflava[11, 12]. The human mucosal surfaces have variation in the Neisseria species which leads to the increase in the probability of genetic exchange between the bacteria [13, 14]. Because these infections are more associated with gonococci and meningococci, we should be careful during identification of all Neisseria recovered from blood, cerebrospinal fluid, and gynecologic specimens. The aim of this work: to investigate the pathological features and the clinical of high vaginal and cervical infections caused by Neisseria sicca are described, which are normal inhabitants of the human respiratory tract as in oropharynx and can act as opportunistic pathogens when present in other sites such as female genital tract.

Methods and materials Study the population was composed of (215) married women, at aged among 15–49 years old, who attending the outpatient of gynecological and obstetric clinic in Tikrit Teaching Hospital and private clinics in Tikrit province. Most of the patients were suffering from colored vaginal discharge, itching or irritation, and sometimes bad odor, dysuria (pain during urination), and dyspareunia (pain during intercourse). All patients were interviewed and careful history taken from them by special questioners of parity, bad obstetric history, used contraceptive, drugs, level of education, resident, and husband occupation. The patients excluded from this study included presenting with diabetes mellitus (DM), received corticosteroids (CS) drug, malignancy, vaginal bleeding, and menstrual bleeding and received antimicrobial or antibiotic drugs less than one week.

By using unlubricated sterile Cusco's speculum was inserted into vaginal women in the lithotomy position. The lateral, posterior vaginal fornix and cervix were swabbed with two sterile cotton-tipped applicators. One of the

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232417 Al-Dorri (2020): Isolation of N sicca from genital tract Dec, 2020 Vol. 23 Issue 24

swabs was put in the tube with 1 – 2 ml of sterile Amies transport media and transported to the microbiological laboratory in TUCOM, were cultured and another swab for microscopic examination (wet mount and ). A pH strip placed in contact with the secretions on the speculum for measuring vaginal pH. Bacterial infection was clinically diagnosed when the vaginal pH > 4.5 this indicates dimensioned in normal Lactobacilli flora, while in candida vaginitis there is no elevated in pH. Gram stain usually used to determine the vaginal flora, clue cells, leukocyte counts, which were evaluated in five different fields. The vaginal discharge present on the swab directly transferred to the glass slide, the smear was fixing by heating, and then Gram staining was done.

Swabs were inoculated directly on to selective media such as Columbia blood agar base (Himedia/India), with supplement FD 056 (Himedia/India) vial contains antibiotics (Nalidixic acid 15 mg, Gentamicin sulfate 2 mg and Amphotericin B 1 mg) each one vial added to cooled (45-50 OC) of 500 ml of sterilized this media along with 5% human blood mixed well. Plates were incubated anaerobically at 37 OC for 48 hours in candle jar to provide 5- 10% CO2 tension. Another swab streaked the Blood agar, and MacConkey's agar, which were incubated at the microaerophilic atmosphere. Catalase and oxidase tests were positive, also the suspicious colonies investigated by further biochemical testing and usage of Api System (analytical profile index) for identification of bacteria including RapIDTM NH ONE System (remel) was used for diagnosis and identification of Neisseria sicca [15].

Disk diffusion method (Kirby Bauer test) The susceptibility of Neisseria sicca against various antibiotics was studied, using the Kirby-Bauer method. The used disk in this method was 5 mm in diameter and the inhibition zone around the disk was measured in mm. A sterile swab placed on the broth culture of Neisseria sicca. The inoculate was transferred to the Muller-Hinton by streaking in three directions. The plate left 5 minutes, and antibiotic discs were dispensed onto the agar using flame-sterilized forceps. Plates should be incubated at 37 OC for 48 hours. The antibiotics used including Tetracycline, Erythromycin, Norfloxacillin, Ciprofloxacillin, Doxycycline, G and Cefixime.

Results

[CATEGORY N. sicca +ve N. sicca -ve NAME]; [VALUE]( [VALUE].29%)

[CATEGORY NAME]; [VALUE](92.70% )

Fig. 1: Distribution of N.sicca in patient with genital infection

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232417 Al-Dorri (2020): Isolation of N sicca from genital tract Dec, 2020 Vol. 23 Issue 24

Table 1: Distribution of N. sicca infection in patient with genital infection according to age group

Age group (yr.) N. sicca +ve No. % N. sicca –ve No. % 15 - 19 2 28.57 8 8.98 20 - 24 3 42.85 19 21.34 25 - 29 2 28.57 23 25.84 30 - 34 0 0 20 22.47 35 - 39 0 0 11 12.35 40 - 44 0 0 8 8.98 Total 7 100 89 100

Table 2: Distribution of N. sicca infection in women with genital infection according to parity.

Parity N. sicca +ve No. % N. sicca –ve No. % Nullipara 1 14.28 18 20.22 Para 1 0 0 15 16.85 Para =< 3 3 42.85 27 30.33 Multipara > 3 3 42.85 29 32.58 Total 7 100 89 100

Table 3: Frequency of N. sicca infection in women with genital infection according to residence

Residence N. sicca +ve No. % N. sicca –ve No. % Urban 2 28.57 28 31.46 Rural 5 71.42 61 68.53 Total 7 100 89 100

Table 4: Susceptibility of N. sicca to antibiotics.

Antibiotics N.sicca1 N.sicca2 N.sicca3 N.sicca4 N.sicca5 N.sicca6 N.sicca7 Tetracycling R - R S S S R Erythromycin 5 g R ------Norfloxacillin 10 g R - R - R S - Cefixime 5 g R - - R R S - Doxycycline 30 g S S S R S S - Ciprofloxacillin5 g R R R - R S - Penicillin G 10 I.U. S R R S R - S *S= sensitive *R= resistant

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232417 Al-Dorri (2020): Isolation of N sicca from genital tract Dec, 2020 Vol. 23 Issue 24

Discussion In the beginning, Von Lingelsheim described N. sicca in 1906, also in 1909 Elser and Huntoon recognized N.sicca. In addition, Berger and co-workers demonstrated there was differentiation among N.subflava serologically and N. sicca (9). Neisseria sicca is detected in the upper respiratory tract and considered as harmless commensal bacteria(16). Neisseria species like N. sicca are obligate human pathogens the organism was recovered from a vertebral biopsy specimen and from the blood of the culture. N. sicca has been reported once already as the occasion of intervertebral disc space infection (18). Numerous Neisseria commensal types asymptomatically colonize nasal cavity sites and oral and are only scarcely linked with disease. Shotgun metagenome sequencing has shown that different commensal types have tropism for several sites in the oropharynx and oral cavity.Neisseria sicca/ subflava is enriched of the surface dorsal on the tongue whilst is diffuse in buccal mucosa and on gingival plaque (19). While Bennett et al demonstrated with sequence multilocus that N.flavescens and N. subflavaare phylogenetically the same type. Comparable data substantiate the reclassification of both N. macacae as N. mucosa and N. sicca (20).

This present study shows N. sicca infect female genital tract in 7(7.29%) case, while 89(92.70%) case of genital tract infection with other causes. This is consistent with a report of (21), who mentioned the prior gynecologic history was limited to spontaneous abortion in 1985 and successful medical therapy for a left Bartholin's gland abscess in the patient was not known to be immunosuppressed. Arecurrent left Bartholin's gland abscess was identified.A Gram stain of surgical drainage material revealed large numbers of polymorphonuclear leukocytes and gram-negative diplococci.

Abundant growth of dry and oxidase- and catalase-positive colonies was noted on chocolate agar, identified as N.sicca. Also, this present study is corresponding with (22) mentioned that different types of Neisseria than the gonococcus had been isolated from the tract genitals such as N. subflava, N. sicca, and N. catarrhalis. Also, others reported Neisseria spp., other than Neisseria gonorrhea can be presented as a in female genital tract such as N. meningitides which are considered as normal flora of oropharynx in some people (23) so that this is consistent with this result in which N. sicca is considered as normal flora in the oropharynx. In addition to that other researcher (24) examined 1,014 female inmates of a mental institution. Gram-negative intra- and extra-cellular diplococci were found in the secretions of twelve girls with vulvovaginitis. These organisms were identified as N. sicca. In other papers (Wax, 1950), the results were given a more detailed study of 57 of these non-gonococcal strains. Thirty-seven were identified as N. sicca (25).

Also, in the other study (26) reported that N. sicca/ subflava, an organism that is harmless in the human oropharynx, cause infection invasive in immunocompetent adults when inserted immediately into the space subarachnoid. Prevention is essential; so, wearing masks face should be compulsory for all personnel sitting through lumbar punctures and each other sterile procedures. From all above, we can conclude that N. sicca may produce infection or diseases when presented in site other than oropharynx area such as female genital tract, and this is maybe attributed to sexual behavior, from the oropharyngeal secretion of husband or partners during sexual intercourse.

Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232417 Al-Dorri (2020): Isolation of N sicca from genital tract Dec, 2020 Vol. 23 Issue 24

The present study as shown in table 1 highlights the distribution of N. sicca infection in a patient with genital infection according to age group in which the affected age group was 20 – 24 year 3(42.85%) case from rural area especially in multipara, while another age group was 2(28.57%) case. This is maybe attributed to act sexually in this age group, marriage and use of different ways of sex. Genital tract infection may be asymptomatic and may be isolated the organism from these patients as a pathogen.

In the present study, the Kirby-Bauer method several drugs for the organism improved from high vaginal and cervical swab specimen were as follows: Penicillin G 10 I.U, ciprofloxacin 5g, cefixime 5g, doxycycline 30g, norfloxacin 10g, tetracyclin 30g, and erythromycin 5g. The most effective antibiotic was doxycycline then followed by tetracycline and penicillin G, which shows the doxycycline is the most effective antibiotic against N.sicca. This is identical with and participates in almost regions in the transpeptidase-encoding field in this penA gene was analogous to the in the penA genes of N.cinerea, Neisseria per lava (N. sicca), N. meningitides and . The results appear that a structure mosaic-like in the penA gene conferred a decrease in the levels of susceptibility of N. gonorrhea to cephems and penicillin in a way like the foundation for Streptococcus pneumonia and N. meningitides (27). Although other reports mentioned ciprofloxacin was used as prophylaxis in a single dose was given (28, 29).

In conclusion, we describe the clinical samples of high vaginal and cervical infections were caused by N. sicca/ subflava, which is normal inhabitants of the human respiratory tract and is reinforced onto the dorsal surface of the tongue. Microscopical examination (stained smear) should be done in the diagnosis of Neisseria to demonstrate an excess of PMNLs in addition to the biochemical tests to recognize Neisseria species, especially in genital tract infections. Neisseria sicca was resistant to most antimicrobial therapies were used in this report, while doxycycline was sensitive against it. For all above, we need to lessen the dissemination of resistance antimicrobial especially for normal flora in reservoirs respiratory and in another system.

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Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232417 Al-Dorri (2020): Isolation of N sicca from genital tract Dec, 2020 Vol. 23 Issue 24

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Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232417 Al-Dorri (2020): Isolation of N sicca from genital tract Dec, 2020 Vol. 23 Issue 24

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Annals of Tropical Medicine & Public Health http://doi.org/10.36295/ASRO.2020.232417