Perinatal/Neonatal Case Presentation &&&&&&&&&&&&&& Urinary Tract Infection With Trichomonas vaginalis in a Premature Newborn Infant and the Development of Chronic Lung Disease

David J. Hoffman, MD vaginal bleeding with suspected abruption resulted in delivery of Gerard D. Brown, DO the infant by Cesarean section. The Apgar scores were 1, 5, and 9 Frederick H. Wirth, MD at 1, 5, and 10 minutes of life, respectively. Betsy S. Gebert, CRNP After delivery, the infant was managed with mechanical Cathy L. Bailey, MS, CRNP ventilation with pressure support and volume guarantee for Endla K. Anday, MD respiratory distress syndrome. She received exogenous surfactant

We report a case of a low-birth-weight infant with an infection of the urinary tract with Trichomonas vaginalis, who later developed cystic chronic lung disease suggestive of Wilson-Mikity syndrome. Although she had mild respiratory distress syndrome at birth, the extent of the chronic lung disease was out of proportion to the initial illness. We speculate that maternal infection with this organism may have resulted in an inflammatory response that led to its development. Journal of Perinatology (2003) 23, 59 – 61 doi:10.1038/sj.jp.7210819

CASE PRESENTATION A 956-g, appropriate-for-gestational-age, African–American female was delivered by Cesarean section following 27 5/7 weeks of gestation in breech presentation after a period of advanced cervical dilatation and uterine contractions. Her mother was a 20-year-old gravida 5, para 2022 woman whose prenatal laboratory data were significant for vaginal colonization with Streptococcus agalactiae, treatment for Chlamydia trachomatis, and a history of cocaine and marijuana usage confirmed by urine toxicology. The amniotic membranes were ruptured for 23 days prior to delivery. On admission to the hospital, she was treated with betamethasone and ampicillin/sulbactam prior to delivery. A nonreassuring biophysical profile of 4/10 (0 for fluid; 0 for nonstress test; +2 for gross movements; +2 for fine movements; and 0 for breathing) and

Section of Neonatology ( D.J.H., G.D.B, F.H.W., B.S.G., C.L.B. ), The Reading Hospital and Medical Center, West Reading, PA, USA; and Section of Neonatal Medicine ( E.K.A. ), St. Christopher’s Hospital for Children, Philadelphia, PA, USA.

Address correspondence and reprint requests to David J. Hoffman, MD, College of Medicine, Pennsylvania State University, Section of Neonatology, The Reading Hospital and Medical Figure 1. Supine radiograph of the chest at 10 days of life. The lung fields Center, Sixth Avenue and Spruce Street, West Reading, PA 19611, USA. show 9 1/2 rib expansion. Focal abnormalities are absent.

Journal of Perinatology 2003; 23:59 – 61 # 2003 Nature Publishing Group All rights reserved. 0743-8346/03 $25 www.nature.com / jp 59 Hoffman et al. Urinary Tract Infection With Trichomonas vaginalis in a Premature Infant

therapy. On the third day of life, she was extubated, at which time she Metronidazole therapy was initiated after discussion with a was placed on nasal continuous positive airway pressure. She was pediatric infectious disease specialist. Urinalysis was obtained on weaned to supplemental oxygen delivered by nasal cannula on the the infant’s 19th day of life, which showed absence of the following day. The lung fields showed resolution of the acute lung Trichomonas. disease (Figure 1). Apnea of prematurity was treated with The initial blood urea nitrogen and creatinine values were 24 and methylxanthines. Echocardiography failed to reveal a patent ductus 1 mg/dl, respectively, on the second day of life, and 6 and 0.6 mg/dl arteriosus. Parenteral nutrition, antibiotics, and fluid therapy were on the 18th day of life. On the infant’s 18th day of life, hyponatremia provided. Ampicillin and gentamicin were discontinued after developed. Sodium chloride therapy was initiated. Urine electrolytes 72 hours because the sepsis screen, consisting of a C-reactive protein, revealed sodium 26 mEq/l, potassium 29 mEq/l, chloride 28 mEq/l, complete blood cell count with differential, and blood culture and the urine creatinine value was less than 10 mg/dl. The were not supportive of infection. A sample of sputum obtained on fractional excretion of sodium was 1.1 and the ratio of urine the second day of life through the endotracheal tube was negative creatinine to plasma creatinine was 35, the latter value consistent for C. trachomatis, Mycoplasma hominis, and Ureaplasma with a prerenal state. The fractional excretion of sodium calculation urealyticum. The placental pathology report, however, was equivocal because the urine creatinine was reported as less than documented an immature placenta consistent with 27 weeks 10 mg/dl and, therefore, could not be accurately calculated. of gestation with acute amnionitis and funisitis. Ultrasonography had been performed on the infant’s fifth day of life On the infant’s 15th day of life, a urinalysis was obtained to due to the presence of hematuria and excluded the presence of renal determine the etiology of leukocytes detected by a routine urine vein thrombosis or other abnormalities. Urinalysis at that time dipstick. A urinalysis collected in a bag was within normal limits revealed a yellow but hazy appearance, negative glucose, negative except for the presence of numerable red blood cells and 8 to 12 bile, negative ketones, specific gravity 1.015, small blood, pH 5.5, white blood cells per high power field. A repeat sample obtained negative protein, negative nitrate, negative leukocyte esterase, by urethral catheterization revealed the presence of urine that was negative Clinitest test, occasional red blood cells per high power field, yellow in color and hazy in appearance with a specific gravity of two to four white blood cells per high power field, and slight mucus, 1.020 and pH of 6. It was negative for glucose, bile, ketones, but no trichomonads. nitrates, and reducing substances, but it contained moderate On the infant’s 21st day of life, she was transferred to a tertiary blood, protein (100 mg/dl), moderate leukocyte esterase, 20 to 25 care pediatric hospital near her home in order to facilitate parental red blood cells per high power field, 8 to 10 white blood cells per visitation. Renal ultrasonography and a voiding cystourethrogram high power field, occasional bacteria, moderate calcium oxalate were within normal limits. Although she had minimal lung crystals, and trichomonads (unspun specimen). The bacterial disease and was tolerating enteral feedings at the time of transfer, culture was negative and the infant was otherwise asymptomatic. she developed cystic chronic lung disease suspicious for the

Figure 2. Supine and lateral radiographs of the chest at 65 days of life. The lungs are less expanded (eight ribs). Infiltrates and cystic changes are evident in the lung fields, consistent with chronic lung disease.

60 Journal of Perinatology 2003; 23:59 – 61 Urinary Tract Infection With Trichomonas vaginalis in a Premature Infant Hoffman et al.

Wilson-Mikity Syndrome (Figure 2) and a persistent oxygen prospectively study its association with chronic lung disease in requirement delivered by nasal cannula. premature infants with and without respiratory distress syndrome.

DENOUEMENT AND DISCUSSION References Although infection of the vagina with Trichomonas vaginalis is 1. Danesh IS, Stephen JM, Gorbach J. Neonatal Trichomonas vaginalis common among pregnant women, it is not commonly cultured from infection. J Emerg Med 1995;13:51–4. neonates, nor is it a highly suspected pathogen in the intensive care 2. Schares T, Machtinger S, D’Harlingue AE, Maloney JR. Trichomonas vaginalis urinary tract infection in an infant. Pediatr Infect Dis 1982;1: nursery. However, infants with vaginal discharge have been reported 1–4 340–1. to be infected with T. vaginalis, and the organism has been 3. McLaren L, Davis LE, Healey GR, James CG. Isolation of Trichomonas cultured from tracheal aspirates in infants with respiratory diseases vaginalis from the respiratory tract of infants with respiratory disease. 5,6 such as pneumonia. In one series from Poland, it accounted for Pediatrics 1983;71:888–90. 17.2% of cases in infants less than 3 weeks of age who developed 4. Littlewood JM, Kohler HG. Urinary tract infection by Trichomonas vaginalis vaginal discharge.7 Despite its detection in urine samples, the in a newborn baby. Arch Dis Child 1966;41:693–5. ‘‘pyuria’’ most likely has its origin in the vagina. It is believed that 5. Hiemstra I, Van Bel F, Berger HM. Can Trichomonas vaginalis cause the effect of maternal estrogens on the vaginal epithelium may pneumonia in newborn babies? Br Med J 1984;289:355–6. predispose newborn female infants to infection.1 Successful treatment 6. Al-Salihi FL, Curran JP, Wang JS. Neonatal Trichomonas vaginalis: report has been reported with metronidazole.8,9 of three cases and review of the literature. Pediatrics 1974;53:196–200. We speculate that the development of a ‘‘bubbly’’ radiographic 7. Komorowska A, Kurnatowska A, Liniecka J. Occurrence of Trichomonas appearance of this patient’s lungs, together with persistent oxygen vaginalis (Donne) in girls in relation to hygienic conditions (Polish). Wiad Parazytol 1962;8:247–51. As quoted by Arvin AM, Maldonado YA. Protozoan requirement after several weeks of life following a relatively benign and helminth infections (including Pneumocystis carinii). In: Remington acute phase of her illness, is reminiscent of the condition described by JS, Klein JO, editors. Infectious Diseases of the Fetus and Newborn. 4th ed. 10 11 Wilson and Mikity in 1960, and later discussed by Hodgman et al. Philadelphia: Saunders; 1995. p. 757–804. This late-developing syndrome, characterized by cyanosis, retrac- 8. Robinson SC, Mirchandani G. Trichomonas vaginalis: V. Further observa- tions, and tachypnea in small premature infants, was reported to tions on metronidazole (Flagyl) (including infant follow-up). Am J Obstet have its onset after several weeks of life in infants without respiratory Gynecol 1965;93:502–505. distress at birth. The ‘‘bubbly’’ radiographic appearance of the lungs 9. Sokol AB, Min DS. Trichomonas cystitis in a six-week-old infant — may initially contain cysts and streaky infiltrates that later resolve effective treatment with metronidazole. J Indiana State Med Assoc 1972;10: and develop basilar hyperinflation and apical atelectasis. Respiratory 1084–86. mechanics are also altered,12 though not determined in this patient. 10. Wilson MG, Mikity VC. A new form of respiratory disease in premature Although this infant did manifest respiratory distress syndrome, the infants. Am J Dis Child 1960;99:489–99. degree of lung disease as the infant aged appeared out of proportion 11. Hodgman JE, Mikity VG, Tatter D, Cleland RS. Chronic respiratory distress in the premature infant: Wilson-Mikity syndrome. Pediatrics 1969;44: to the acute phase of her illness. Although T. vaginalis was not 179–95. isolated from this infant’s airway, it is plausible that it contributed to 12. Krauss AN, Levin AR, Grossman H, Auld PAM. Physiologic studies on infants her chronic lung disease by inflammation or other unexplained with Wilson-Mikity syndrome. J Pediatr 1970;77:27–36. phenomenon. As maternal infection with this organism is common 13. Cotch MF, Pastorek JG, Nugent RP, et al. Trichomonas vaginalis associated and is associated with premature rupture of membranes and with low birth weight and preterm delivery. The Vaginal Infections and premature birth in some populations,13 it may be worthwhile to Prematurity Study Group. Sex Transm Dis 1997;24:353–60.

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