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Asthma and Chlamydial Infection: a Case Series David L Asthma and Chlamydial Infection: A Case Series David L. Hahn, MD, and Rjurik Golubjatnikov, PhD, MPH Madison, Wisconsin Background. Adult-onset asthma is frequently associ­ asthma for the first time during the study period. ated with antecedent respiratory symptoms that could Thirty' (22.9%) patients were classified with acute asth­ represent either previously undiagnosed asthma or pre­ matic bronchitis, and 89 (67.9%) had nonwheezing ill­ vious lung infections that result in subsequent asthma. ness. Two of the newly diagnosed asthmatics met sero­ To further investigate a reported association of Chla­ logic criteria for acute C pneumoniae infection, and one mydia pneumonias infection and adult reactive airway had serologic evidence for acute M pneumoniae infec­ disease, we looked for evidence o f atypical infections in tion. Compared with patients with nonwheezing respi­ patients with acute wheezing and nonwheezing respira­ ratory' illnesses, C pneumoniae seroreactivity was signifi­ tory illnesses. cantly (P < .001) associated with both chronic asthma and with acute asthmatic bronchitis. Methods. Pharyngeal cultures and acute and convales­ cent serology for C pneumoniae and Mycoplasma pneu­ Conclusions. Acute wheezing illness was encountered moniae were obtained from 131 primary care outpa­ frequendy in this primary care setting. Although most tients (mean age, 36 years) with acute wheezing or acute wheezing respiratory' illness resolved without ob­ nonwheezing respiratory illnesses. Peak flow measure­ vious chronic sequelae, some patients had persistent ments were obtained in patients with cough or wheeze. symptoms and were diagnosed with chronic asthma. C Spirometry before and after bronchodilator use was pneumoniae seroreactivity was associated with both obtained to substantiate the diagnosis of chronic acute and chronic wheezing, suggesting that pulmo­ asthma in patients who had persistent wheezing and nary' infection with this intracellular pathogen plays a dyspnea after enrollment. role in the natural history of reactive airway disease. Results. Twelve (9.2%) of 131 patients were classified Key words. Asthma; bronchitis; Chlamydia pneumoniae; as having chronic asthma, 5/12 developed chronic Mycoplasma pneumoniae. (/ Fam Pract 1994; 38:589-595) The cause of asthma, a common chronic inflammatory bacteria (Mycoplasma pneumoniae and Chlamydia pneumo­ airway condition, is not well understood. It was once niae) may play a role in these reported associations.5-9 thought that infection played an important causative role Given these preliminary' results and our limited under­ in asthma,1"3 but there are no convincing scientific stud­ standing of asthma etiology, it is worthwhile to investi­ ies documenting “bacterial allergy” as a cause.4 More gate further the possibility that atypical infections arc- recent epidemiologic studies and clinical reports have involved in the initiation and exacerbation o f asthma, or documented that respiratory diagnoses including bron­ even the promotion of asthma in persistently infected, chiolitis,5 acute bronchitis,6 chronic bronchitis7 and susceptible individuals. pneumonia8 are associated with the development of sub­ Mycoplasma pneumoniae infection is a recognized sequent asthma in both adults and children. Some re­ cause of acute respiratory illnesses, including atypical ports have presented preliminary evidence that atypical pneumonia and tracheobronchitis, and may also cause asymptomatic infection in about 20% of cases.10 M pneu­ moniae infection is more common in children than in Submitted, revised, December 30, 1993. adults,11 and has been associated with varying propor­ From the Arcand Park Clinic, Division o f Dean Medical Center (D.L.H.), and tions of acute infectious exacerbations of asthma, usually Wisconsin State Laboratory o f Hygiene (R.G.), Madison, Wisconsin. Requests for reprints should be addressed to David L. Hahn, MD, Arcand Park Clinic, 3434 East in children12-14 but also sometimes in adults.15 A pro­ Washington Ave, Madison, W I 53704. longed carrier state beyond several months postinfection ® 1994 Appleton & Lange ISSN 0094-3509 The Journal of Family Practice, Vol. 38, No. 6(Jun), 1994 5 8 9 Asthma and Chlamydial Infection H ahn and Golubjatnikov in immunocompetent patients has not been document­ study are greater, therefore, than comparable figures ed,16 making it unlikely that persistent M pneumoniae (13% and 3%, respectively) from our previous study infection frequently promotes chronic asthma.5 which enrolled all patients systematically.9 Another atypical respiratory pathogen, Chlamydia Our definition of “asthmatic bronchitis” differs from pneumoniae, has emerged as an important cause of acute that used in some standard references of pulmonary med­ respiratory illness, including bronchitis and pneumo­ icine. Thus, asthmatic bronchitis has been used to de­ nia.17 Like M pneumoniae, most primary infections occur scribe patients in whom the diagnoses of chronic bron­ in younger age groups. Unlike M pneumoniae, however, chitis and asthma coexist, or are difficult to distinguish.^ the majority of patients with Cpneumoniae infections are The term “wheezy bronchitis,” as used in another refer­ asymptomatic or only mildly symptomatic,18 and repeat ence,27 denotes episodes of wheezing during acute bron­ infections are common and occur throughout adult­ chitis, occuring mainly in children. Acute asthmatic hood.19 Chronic intracellular infection is typical for chla- bronchitis, as used in this paper, refers to the latter type mydiae.20 Persistent infection has been documented for of wheezing during acute bronchitis but is not limited to C pneumoniae21 and has been implicated in some chronic children, since there is mounting evidence that a signif­ cardiopulmonary diseases including sarcoidosis,22 coro­ icant proportion (15% to 30%) of episodes of acute nary artery disease,23-25 and adult-onset asthma.9 bronchitis in adult outpatients from primary care settings In a previous prospective study designed to assess may involve bronchospasm or wheezing.6'9-28'29 the role o f acute C pneumoniae infection in bronchitis and atypical pneumonia, we found post hoc associations of C Pulmonary Function Measurement and pneumoniae scroreactivity with wheezing, asthmatic Diagnosis of Asthma bronchitis, and adult-onset asthma.9 We now report re­ sults of culture and serology for M pneumoniae and C Patients with acute asthmatic bronchitis had peak expi­ pneumoniae in a series of patients with asthma confirmed ratory flow measurements documented (best of three by pulmonary function testing, studied during a M pneu­ values) using a Wright peak flow meter (Armstrong moniae epidemic. Asthma patients arc compared with Industries, Inc, Northbrook, 111). Standardized normal patients who had acute asthmatic bronchitis or acute values for age, sex, and height were also recorded. Pa­ nonwheezing respiratory illnesses. tients with persistent wheezing and dyspnea in whom a diagnosis of asthma was suspected had spirometric test­ ing performed using a spirometer (System 21, Gould Methods Medical Products Inc, Dayton, OH). This study em­ ployed American Thoracic Society (ATS) guidelines for Study Setting the diagnosis of asthma and chronic obstructive pulmo­ One hundred thirty-one patients who visited a primary nary disease (COPD).30-31 care office with complaints o f respiratory illness between Clinical diagnoses of acute asthmatic bronchitis and October 1989 and January 1991 (16 months) were en­ asthma and serologic results o f patients (n = 50) enrolled rolled in the study. The study site was a community- between October and December 1989 were included in based, four-physician family practice office affiliated with our first report associating C pneumoniae infection with a large multispecialty, multisite group practice located in reactive airway disease.9 The resuits of pulmonary func­ a metropolitan area of south central Wisconsin (Dane tion testing for this group have not been published County), with a predominantly white, middle-class pop­ previously. When these original patients were compared ulation. with the 81 patients enrolled after December 1989, there were no significant differences in mean age, sex, history Enrollment Criteria of smoking, Cpneumoniae seroreactivity, titer category' ot acute antibody, or diagnoses of acute asthmatic bronchi­ Enrollment was offered to all patients who were encoun­ tis, asthma, or COPD. tered by the clinician-investigator during the course of usual practice and who had laryngitis, biphasic illness (pharyngitis and/or laryngitis, followed by bronchitis or Bacteriologic and Serologic Data pneumonia), wheezing, or atypical pneumonia. Patient Acute sera for microimmunofluorescence (MIF) testing refusal was not documented but is believed to be mini­ for C pneumoniae and complement fixation (CF) testing mal. Enrollment of patients with other respiratory ill­ for At pneumoniae and oropharyngeal culture for C pneu­ nesses was less systematic. The proportions of acute moniae and M pneumoniae were obtained at the time of asthmatic bronchitis (23%) and asthma (9%) in this study enrollment for all patients. Because 17 patients 5 9 0 The Journal of Family Practice, Vol. 38, No. 6(Jun), 1994 \sthma and Chlamydial Infection Hahn and Golubjamikov failed to return for follow-up testing, convalescent sera Respirator)^ diagnoses at enrollment and for the were available from only 114 patients (87%). Serologic 6 -month period before and after enrollment were tabu­ criteria for acute
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