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The Role of Mycoplasma Genitalium and Trichomonas Vaginalis

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The Role of Mycoplasma Genitalium and Trichomonas Vaginalis Research Etiology of urethral discharge in West Africa: the role of Mycoplasma genitalium and Trichomonas vaginalis Jacques Pe´ pin,1 Franc¸ois Sobe´la,2 Sylvie Deslandes,3 Michel Alary,4 Karsten Wegner,5 Nzambi Khonde,6 Fre´de´ric Kintin,7 Aloys Kamuragiye,8 Mohammed Sylla,9 Petit-Jean Zerbo,10 E´ nias Baganizi,11 Alassane Kone´,12 Fadel Kane,13 Benoit Maˆ sse,14 Pierre Viens,15 & Eric Frost16 Objective To determine the etiological role of pathogens other than Neisseria gonorrhoeae and Chlamydia trachomatis in urethral discharge in West African men. Methods Urethral swabs were obtained from 659 male patients presenting with urethral discharge in 72 primary health care facilities in seven West African countries, and in 339 controls presenting for complaints unrelated to the genitourinary tract. Polymerase chain reaction analysis was used to detect the presence of N. gonorrhoeae, C. trachomatis, Trichomonas vaginalis, Mycoplasma genitalium, and Ureaplasma urealyticum. Findings N. gonorrhoeae, T. vaginalis, C. trachomatis, and M. genitalium — but not U. urealyticum — were found more frequently in men with urethral discharge than in asymptomatic controls, being present in 61.9%, 13.8%, 13.4% and 10.0%, respectively, of cases of urethral discharge. Multiple infections were common. Among patients with gonococcal infection, T. vaginalis was as frequent a coinfection as C. trachomatis. M. genitalium, T. vaginalis, and C. trachomatis caused a similar clinical syndrome to that associated with gonococcal infection, but with a less severe urethral discharge. Conclusions M. genitalium and T. vaginalis are important etiological agents of urethral discharge in West Africa. The frequent occurrence of multiple infections with any combination of four pathogens strongly supports the syndromic approach. The optimal use of metronidazole in flowcharts for the syndromic management of urethral discharge needs to be explored in therapeutic trials. Keywords: urethral diseases, etiology; Gram-negative bacterial infections; Mycoplasma; Trichomonas vaginalis; Neisseria gonorrhoae; Chlamydia trachomatis; genital diseases, male; Africa, Western. Mots cle´s: ure`tre, maladies, e´ tiologie; infection bacte´rienne, Gram-ne´gatif; Mycoplasma; Trichomonas vaginalis; Neisseria gonorrhoeae; Chlamydia trachomatis; appareil ge´nital masculin, maladies; Afrique de l’Ouest. Palabras clave: enfermedades uretrales, etiologı´a; infecciones bacterianas gramnegativas; Mycoplasma;Tricho- monas vaginalis; Neisseria gonorrhoae; Chlamydia trachomatis; enfermedades de los genitales masculinos; Africa occidental. Bulletin of the World Health Organization, 2001, 79: 118–126. Voir page 125 le re´sume´ en franc¸ais. En la pa´ gina 125 figura un resumen en espan˜ ol. Introduction of human immunodeficiency virus (HIV) in sub- Saharan Africa (1). In most African countries, STD The control of sexually transmitted diseases (STDs) can lead to a substantial reduction in the transmission 8 National Coordinator, WAPCAS, Conakry, Guinea; currently 1 at UNICEF, Moroni, Comores. Director, Centre de sante´ internationale, Universite´ de Sherbrooke, 9 3001, 12e`me avenue Nord, Sherbrooke, Que´bec, J1H 5N4, Canada National Coordinator, WAPCAS, Bamako, Mali. (email [email protected]). Requests for reprints should 10 National Coordinator, WAPCAS, Dakar, Senegal. be addressed to this author. 11 2 National Coordinator, WAPCAS, Cotonou, Benin. Technical Adviser, West Africa Project to Combat AIDS and STD 12 (WAPCAS), Ouagadougou, Burkina Faso. Medical Officer, WAPCAS, Abidjan, Coˆ te d’Ivoire. 13 3 Research Officer, De´partement de microbiologie, Universite´de National Coordinator, WAPCAS, Abidjan, Coˆ te d’Ivoire; currently Sherbrooke, Sherbrooke, Que´bec, Canada. at Health Canada, Ottawa, Ontario, Canada. 14 4 Senior Epidemiologist, Centre de recherche, Hoˆ pital St-Sacrement, Senior Biostatistician, Centre de recherche, Hoˆ pital St-Sacrement, Que´bec, Que´bec, Canada. Que´bec, Canada. 15 5 Epidemiologist, Centre de sante´ internationale, Universite´de Director, Centre de coope´ration internationale en sante´et Sherbrooke, Sherbrooke, Que´bec, Canada; currently at the de´veloppement, Que´bec, Que´bec, Canada. German Navy Institute for Maritime Medicine, Kiel, Germany. 16 Associate Professor, De´partement de microbiologie, Universite´de 6 National Coordinator, WAPCAS, Accra, Ghana. Sherbrooke, Sherbrooke, Que´bec, Canada. 7 National Coordinator, WAPCAS, Ouagadougou, Burkina Faso. Ref. No. 99-0119 118 # World Health Organization 2001 Bulletin of the World Health Organization, 2001, 79 (2) Etiology of urethral discharge in West Africa control is based on the syndromic approach: patients country, we attempted to enrol 100 cases of urethral presenting with a genitourinary complaint are treated discharge and, as controls, 50 sexually active male with a combination of drugs that target the most patients who presented to some of these institutions frequent etiological agents of the corresponding with complaints unrelated to the genitourinary tract. syndrome, and there is no attempt to make a precise After obtaining verbal consent from the patients, a microbiological diagnosis (2–4). This approach is questionnaire was administered by the health care attractive, given the high cost and poor availability of provider (medical doctors, medical assistants or laboratory assays for sexually transmitted pathogens. nurses), and two urethral swabs were obtained. It does, however, require a proper understanding of These were put into the Amplicor Swab Specimen the most common etiological agents of a syndrome, Collection and Transport Kit (Roche Diagnostic and appropriate selection of drugs that are both Systems, Branchburg, New Jersey), kept in a cheapand effective against these pathogens. refrigerator, and later sent by air mail to a central Urethral discharge is by far the most common laboratory for polymerase chain reaction (PCR) syndrome seen in men with STD in sub-Saharan analysis. Patients were treated according to the Africa (5, 6). Non-ulcerative diseases play an im- national STD flowcharts. portant role in facilitating the spread of HIV, and gonococcal urethritis increases the seminal shedding PCR analysis of HIV several fold (7, 8). Studies of the etiology of PCR analysis was carried out for the following urethral discharge syndrome in Africa have shown potential pathogens: N. gonorrhoeae (NG), C. tracho- that Neisseria gonorrhoeae and Chlamydia trachomatis are matis (CT), Trichomonas vaginalis (TV), Mycoplasma involved in 53–80% and 3–16%, respectively, of genitalium (MG) and Ureaplasma urealyticum (UU). such cases (9, 10). Upto 40% of cases are of Specimens were prepared for PCR by adding an unknown etiology, so management of a significant equal volume of Amplicor Specimen Diluent, fraction of patients with urethral discharge remains followed by storage at 4 oC for at least three days empirical. Current WHO guidelines recommend the prior to analysis, to reduce the frequency of inhibition simultaneous administration of drugs that are (11). Inhibition was monitored using Amplicor effective against N. gonorrhoeae and C. trachomatis, Internal Control or home-made internal controls, but not against other potential pathogens (2). obtained by cloning the amplicon and removing or Development of protocols for the management of inserting a DNA fragment (12). For NG and CT, the patients in whom this therapy fails and in whom Roche Amplicor C. trachomatis/N. gonorrhoeae Test Kit reinfection is unlikely, is left to the discretion of each was used according to the manufacturer’s instruc- country. Proper laboratory investigation is advocated tions. Modifications of published procedures (13–16) but seldom available. To delineate better the etiology for the detection of MG, UU, and TV were used (a of urethral discharge syndrome in West Africa, we full description of the primers is available from the organized a regional study in which molecular authors). Each organism was detected separately diagnostic methods were used on specimens using PCR or semi-nested PCR (for MG and TV). obtained in a large number of primary health care Presence of the amplicon was determined by agarose facilities. gel electrophoresis. Prepared samples (25 ml) were added to a master mix (25 ml) composed of 2X buffer (20 mmol Methods TrisHCl pH 8.3, 100 mmol KCl), 400 mmol of Sample collection dNTPs, 1.25 units of Taq polymerase (Roche Diagnostic Systems), and 0.5 mmol primers. The Primary health care facilities (governmental health o centres, private non-profit or for-profit nursing posts amplification procedure comprised 5 min at 95 C and 40 cycles of denaturation (95 oC), annealing in urban areas of seven West African countries o o covered by a regional HIV/STD control programme (62 C), and extension (72 C) for 20 s at each step followed by a hold cycle at 72 oC for 15 min prior to were invited to participate. Between July 1996 and o December 1997, a total of 72 health care facilities cooling the reactions to 4 C. provided specimens from the following countries: After the first series of amplification, a semi- Benin (6 facilities in Cotonou), Burkina Faso (11 in nested series of PCR was undertaken for MG and TV Ouagadougou), Coˆte d’Ivoire (5 in Abidjan and four using 1 ml of the first series and 49 ml of a master mix in Bouake´), Ghana (5 in Accra), Guinea (18 in to give the final concentration of reagents as in the Conakry and 1 in Kamsar), Mali (6 in Bamako and 3 in initial series. Positive and negative controls were Koutiala)
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