Cultures: Is There a Correlation?

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Infectious DiseasesinObstetrics and Gynecology 3:3-6 (1995) (C) _{1995 Wiley-Liss,} Inc.

Chronic

Endometritis

and

Positive

Mycoplasma

Cultures:

Is

There

a

Correlation?

Ashwin

Chatwani,

Paul Nyirjesy, and Soheil Amin-Hanjani

Department

_of

Obstetrics, Gynecology, andReproductiveSciences, Temple University School

_of

Medicine, Philadephia, PA (A.C., P.N.), andDepartment

_of

Obstetrics andGynecology, Goddard

MedicalAssociates, Brockton, MA (S.A.-H.)

ABSTRACT

Objective: This studywas undertaken to assess the impact of mycoplasma strains (Mycoplasma hominisorUreaplasmaurealyticum)onthedevelopmentofchronicendometritis.

Methods: Fifty-eight patients withacutepelvic infectionwereenrolled in this prospective cohort study.Endometrialcultures and biopsieswereobtainedonadmissionand5-7 and 21-28 days after completion oftreatment.

Results: Of148samples, 40werepositive formycoplasmastrains(group A) and 58werepositive for mycoplasmawithother pathogens (group B). Twenty-seven samples werepositive forother pathogensonly (group C). Chronic endometritiswas seenin7 (17.5%),30(51.7%),and 10 (37%) in group A,B,andCpatients, respectively.

KEYWORDS

Pelvicinflammatory disease, Mycoplasmahominis,

_Ureatdasma

urealyticum, endometrial cavity

he precise role of mycoplasma organisms in

upper-genital-tract disease in women remains controversial. Thereisevengreatercontroversyon whetherornotmycoplasmainendometrialcultures

isassociated with endometritis.ThereportofHome et al. suggests that this association exists, while

Gump

and colleagues2

and Bercovici et al.3

re-portednoassociationbetween mycoplasma-positive

endometrial cultures and endometrial

inflamma-tion.The purpose of thepresentstudywasto exam-ine prospectively a group of patients presenting

withacutepelvicinfectionandtodeterminewhether the presence ofmycoplasma in the uterine cavity was correlated with histologically proven chronic endometritis.

SUBJECTS

AND METHODS

Fifty-eightpatientsadmitted withaclinical diagno-sis ofacute pelvic inflammatory disease were en-rolled in this study. Thediagnosis ofacute pelvic

infection was based on the presence of all of the

following: abdominal pain andtenderness, uterine tenderness, cervical motion tenderness, and ad-nexal tenderness. In addition, or more of the

following were present: elevated temperature

(>38C),

elevated WBC count

(>10,000),

ele-vated sedimentation rate

_(>20

_mm/h),

elevated

C-reactive protein

(>0.0625 mg/dl),

orthe pres-ence ofpurulentvaginal discharge. Atthe time of

admission, cervical andendometrial cultureswere obtained for Neisseria gonorrhoeae and Chlamydia

Address correspondence/reprintrequests toDr.Ashwin Chatwani, DepartmentofOB/GYN, TempleUniversity Hospital,

3401North BroadStreet,7OPD,Philadelphia,PA19140.

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CHRONIC ENDOMETRITISAND MYCOPLASMA CULTURES CHATWANI ET AL trachomatis. Endometrial cultures were also

ob-tained for Mycoplasma hominis, Ureaplasma ure-alyticum, facultative aerobes, and anaerobes.

An

endometrial biopsy forhistologic examination was

performed with an endometrial biopsy curette

(Pipelle

TM,

Unimar,

Inc.,

Wilton,

CT).

The en-dometrial cultures and biopsy were obtained after

cleansingthecervixwithbetadine solution.

Cultures for N. gonorrhoeae and C. trachomatis were placed on Thayer-Martin platesand Bartel’s medium, respectively. Forfacultativeaerobes, cul-tures wereinoculatedintoBBL port-a-culmedium

(BBL,

Lockeysville,

MD)

and then onto sheep

blood agar plates, MacConkey agar plates, choco-late agar plates, and

V-agar

plates. Foranaerobes, CDC anaerobe blood agar, CDC anaerobe blood agar with kanamycin and vancomycin, and prere-ducedPRASbrainheartinfusion brothwereused.

Mycoplasma cultures were placed into Shepard’s

10B broth and transferredtothe reference

labora-toryat -70Condryice.The brothwasincubated at

37C

under atmosphericconditions. Thegrowth

ofmycoplasma was suggested by an alkaline shift

duetoureaseactivityby U. urealyticumorarginine

hydrolysis by M. hominis. Thebroth cultureswere incubated for 5 days before theywerecalled

nega-tive.The positive broth cultureswereinoculatedon A-8 agar plates,just asthe

pH

indicatorbegan to turnfor morphologicidentification. The A-8 agar plates were incubated under 5% carbon dioxide. M.hominiscolonieswereidentifiedbytheirtypical

"fried

egg"

appearance andU. urealyticumbyblack

colonies.

After successful inpatienttreatmentwith antibi-otic

_{therapy (cefoxitin,}

2 g IV q 6 h, and doxycy-cline, 100mgIVororallyq 12huntil resolutionof the symptoms), the patients were discharged on oral medications. Forty-five patients returned for the 1st

follow-up

visit 5-7 days followingthe

com-pletion of oraltreatmentanda 2nd

follow-up

visit 21-28 daysafter thecompletionoftreatment. The 2nd and 3rd sets of specimens

(endometrial

cul-tures and biopsies) were obtained on both occa-sions.

Theendometrialbiopsieswereexaminedfor ev-idence of chronic endometritis. The diagnosis of

chronic endometritis was basedon the presence of any plasma cells. The culture results from each

visitwere correlated with the histological findings

from thebiopsy obtained atthe corresponding en-counter.

Statistical analyses were

performed

using Epi Info

(Centers

for Disease Control, Atlanta,

GA).

The Mantel-Haenszel chi-squared formula was used. When a cell value <5 was encountered, a 2-tailedPvaluewasobtained withtheFisherexact test.

RESULTS

Fifty-eight patients who presented with acute

pel-vicinfection wereenrolled inthestudy. Forty-five

of these patients returned for both

follow-up

visits. Their agesranged from 17 to39 years. The mean gravidity and parity were 2.1

+-

1.7 and 1.6 + 1.1, respectively. Eighty-one percentwere black,

10%werewhite, and the remaining 9%were

His-panic.

There were 148 biopsies and 148 sets of cul-tures. At the initial presentation, 7 cultures were positive for mycoplasma only, but only

corre-sponding biopsy showed chronic endometritis. All

together, 40 sampleswerepositive formycoplasma strains alone

(23

positive for bothM. hominisand

U. urealyticum, 12 positive for M. hominis only,

and 5 positive for U. urealyticumonly), butonly 7

had evidenceofchronic endometritis

(5

with both

M. hominband U. urealyticum, with M.hominis only, and with U. urealyticumonly).

Two

of23 biopsies with no _growth had evidence ofchronic endometritis. The difference in the incidence of

chronic endometritiswasnot_significant

_(P

_0.33)

between these 2 groups

(Table

1). Histologic evi-denceofchronic endometritiswas seenin 30 of the

58 patients with mycoplasma strains and other

pathogens and in 10 of the 27 patients with other

pathogensalone

(Table 1).

Theincidenceofchronic endometritis was not statistically different

(P

0.20)inthese2groupseither. Thepathogensother than mycoplasmaateach visitare presented in

Ta-ble2.

DISCUSSION

In 1966, Hirth et al.4

demonstrated that

myco-plasmawascapableof causingsalpingo-oophritisin cows. In 1977, Ruben and colleaguess demon-strated histologic evidence ofsevere inflammation of the fetal membranes in cows inoculated with mycoplasma. Gabridge6

produced histopathology

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TABLE I. Correlation ofmycoplasmacultures with chronic endometritis No.of biopsies Present Chronic endometritis Absent Mycoplasmaalone 40 7 33 0.33 Nogrowth 23 2 21

Mycoplasmawithotherpathogens 58 30 28

0.20

Otherpathogens only 27 10 17

TABLE 2. Pathogens otherthan mycoplasma

Organisms Admission First follow-up Second follow-up Neisseriagonorrhoeae 34 0 2 Chlarnydiatrachornatis 9 0 Non-gonococcal/non-chlamydia Aerobes Escherichia coli 12 4 0 Streptococcussp. 10 2 4 Group Dstreptococcus 8 4 Group Bstreptococcus 7 2 Staphylococcussp. 6 3 4 Enterobactersp. 3 0 0 Anaerobes Bacteroidessp. 20 14 7 Peptostreptococcussp. 3 2 Fusobacteriurnsp. 0 0

associatedwith lethal toxicityby inoculating germ-free micewith

mycoplasma

isolated from humans. Moller etal.7 were able to demonstrate severe in-flammation in theuterinetubes of grivetmonkeys inoculated with

mycoplasma.

These studiessuggest a definite role of

mycoplasma

in infection of the

genitaltract inanimals.

The roleofmycoplasmaas agenital-tract

patho-gen in humans is still controversial. Equally un-clearisthe precise role ofmycoplasmaas acauseof

histologically proven chronic endometritis. Horne

et al. first reported subclinical endometrial

in-flammationin 63% of patientswithpositive

myco-plasma cultures. They reported the characteristic

focal accumulation ofsubacute inflammatory cells beneath thesurface epithelium, aroundaspiral ar-teriole, orbeside aglandinthese patients. Bercov-icietal.3_did

notfindthespecific

changes

described by Horneetal. in 5 endometrialbiopsiespositive for mycoplasma.

Gump

and

colleagues

2

were not abletodemonstrateanysignsofinflammationin 10 endometrial biopsies that were positive for

myco-plasma. Paavonenetal.8_did

notfinda significant association between

plasma-cell

endometritis and the presence ofmycoplasmastrains.

In the present study, 7 patients in the initial

screening group were positive for mycoplasma strains but only had evidence ofchronic

endo-metritis. Overall, therewere40 sampleswith

pos-itivemycoplasma cultures and 23 sampleswith no growth. Thedifference intheincidenceofchronic endometritisbetween these 2 groupswas not statis-tically significant.

To

determine whether

myco-plasma

hadanysynergistic effectwith other

patho-gens in causing endometritis, we compared the group of patientswithmycoplasmaand other

patho-gens with the group of patients with only other

pathogens. The incidence ofchronic endometritis was not significantly different between these 2

groups.

Onecould argue thatwe should haveexamined

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study-CHRONIC ENDOMETRITISAND MYCOPLASMA CULTURES CHATWANI ET AL ingwas chronic endometritis and not acute pelvic

infection, we felt that grouping all similar out-comes together,

regardless

of when the samples

wereobtained, wasthemostappropriate method of examiningourdata.

The results of thepresent

study

demonstrate that the presence ofmycoplasmaintheuterinecavityis notassociatedwithanincreased incidenceofchronic endometritis. Furthermore, the presence of

myco-plasma and other pathogens in the uterine cavity doesnotincreasethe histologicevidence ofchronic

endometritis. These findings may be due to the

limitedpathogenicityof

mycoplasma

or the

inabil-ity of these organismsto colonizethe uterine cavi-tiesofsomepatients.

REFERENCES

1. Horne I--IW, HertigAT, KundsinRB, Kosasa TS:

Sub-clinical endometrial inflammation and T-Mycoplasma: A possiblecauseof human reproductivefailure. Int

_J

Fertil

18:226-231, 1973.

2. GumpDW, Gibson M, Ashikaga T:Lack ofassociation

between genital mycoplasmas and infertility. N Engl

_J

Med 310:937-941, 1984.

3. Bercovici B, Haas H, Sacks T, Laufer A: Isolation of mycoplasmasfrom the genitaltractofwomenwith repro-ductive failure, sterilityor vaginitis. Isr

_J

Med Sci 14:

347-352, 1978.

4. HirthRS,NielsenRW,PlastridgeWN:Bovine salpingo-oophritis produced with semen containing mycoplasma.

PatholVet3:616-632, 1966.

5. RubenZ, LeinDH,TourtellotteME:Bovine

mycoplas-mosisand reproductivefailure:Anoverviewof

experimen-tal andnaturalcasestudiesandfuture outlook. Presentedat

the 1stInternationalSymposium of Veterinary Diagnosti-cians, Mexico,January1977.

6. GabridgeMG:Roleofgramnegative sepsisinlethal

toxic-ity induced by mycoplasma.

_J

Infect Dis 130:529-533, 1974.

7. MoilerBR,FreundtEA, MardhP: Experimental pelvic inflammatory disease provoked byChlamydiatrachomatis

and Mycoplasmahominis ingrivetmonkeys. Am

_J

Obstet Gynecol 152:280-286, 1985.

8. PaavonenJ,KiviatN,BrunhamRC,StevensCE, Kuo C, Stamm WE, etal.: Prevalenceand manifestationsof

en-dometritis among women with cervicitis. Am

_J

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