Jan Jeremias

Interleukin 1 receptor antagonist gene polymorphism in women with vulvar vestibulitis.

OBJECTIVE Vulvar vestibulitis is a chronic inflammatory syndrome of unknown cause and pathogenesis. We examined the relation between vulvar vestibulitis and polymorphisms in the gene coding for the interleukin 1 receptor antagonist, a naturally occurring down-regulator of proinflammatory immune responses. STUDY DESIGN Cells from the lower genital tract of 68 women with vulvar vestibulitis, 343 women with no history of vulvodynia, and 40 women with human papillomavirus cervical infection were tested by polymerase chain reaction for the different alleles of the gene encoding for interleukin 1 receptor antagonist. The presence of human papillomavirus in the specimens was determined by polymerase chain reaction with the use of degenerate consensus primers to the conserved L1 gene. RESULTS Allele 2 of the gene encoding the interleukin 1 receptor antagonist was present in homozygous form in 52.9% of women with vulvar vestibulitis. In marked contrast only 8. 5% of the control women and 2.5% of women with human papillomavirus were homozygous for this allele (P </=.0001). Among the women with vulvar vestibulitis, 57.5% of those without human papillomavirus, as well as 52.2% of those with human papillomavirus, were homozygous for allele 2 of the gene encoding interleukin 1 receptor antagonist. CONCLUSION The unique distribution of interleukin 1 receptor antagonist alleles among women with vulvar vestibulitis suggests that polymorphism in this gene may be a factor influencing susceptibility to this syndrome, severity of symptoms, or both.

Unsuspected Chlamydia trachomatis infection and in vitro fertilization outcome.

OBJECTIVE Chlamydia trachomatis infections of the female genital tract, although a major cause of infertility, are often asymptomatic and undetected. Since many infertile women now seek in vitro fertilization, a procedure whereby fertilization and embryo implantation are precisely timed, we sought to determine the relation between an unsuspected C. trachomatis infection and the ability of embryos to implant and develop after their transfer to the uterus. STUDY DESIGN At the time of oocyte aspiration, endocervical samples were obtained from 216 women and assayed by enzyme-linked immunoassay for immunoglobulin A antibodies to C. trachomatis structural membrane components and to recombinant C. trachomatis heat shock protein. The presence of C. trachomatis in the cervices was assessed by the polymerase chain reaction. The outcome of each in vitro fertilization cycle was then ascertained. RESULTS Oocytes from 198 (91.7%) of the women were fertilized in vitro and subsequently transferred to the uterus. Term deliveries of healthy infants occurred after 68 (34.3%) of these transfers. Cervical immunoglobulin A antibodies to chlamydial heat shock protein were detected in 5 (7.3%) of the women with term births, and 1 (1.5%) also had immunoglobulin A antibody to chlamydial structural components; 3 (4.4%) were positive by the polymerase chain reaction for C. trachomatis. In contrast, among the 130 women whose embryo transfers did not result in an ongoing pregnancy, 36 (27.7%) had cervical antiheat shock protein immunoglobulin A (p = 0.0007) and 24 (18.5%) had antichlamydial structural component immunoglobulin A (p = 0.0002); 15 (11.5%) of these women had positive results of polymerase chain reaction for C. trachomatis. The majority of women with cervical antibodies to chlamydial structural antigens were also positive for antibody to heat shock protein. However, only 35% of the women with antibodies to heat shock protein were also positive for the other chlamydial antibodies. C. trachomatis was detected by polymerase chain reaction in 29.2% of women with anti-C. trachomatis antibodies and 7.8% of women with anti-heat shock protein antibodies. Women positive for antichlamydial immunoglobulin A were more likely to be undergoing a repeat in vitro fertilization cycle than were women who were antibody negative (p = 0.007). CONCLUSION Unsuspected C. trachomatis infection or reactivation of an immune response to the C. trachomatis heat shock protein may induce an inflammatory reaction in the uterus that impairs embryo implantation and/or facilitates immune rejection after uterine transfer of in vitro fertilized embryos.

Proliferative response to conserved epitopes of the Chlamydia trachomatis and human 60-kilodalton heat-shock proteins by lymphocytes from women with salpingitis.

OBJECTIVE Our objective was to determine whether an upper genital tract Chlamydia trachomatis infection sensitizes lymphocytes to heat-shock protein epitopes expressed in both the human and chlamydial 60 kd heat-shock protein. STUDY DESIGN Peripheral blood mononuclear cells were isolated from women with or without a prior documented salpingitis and tested for their ability to proliferate in response to the recombinant C. trachomatis heat-shock protein and to five synthetic peptides corresponding to conserved epitopes expressed in both the human and chlamydial heat-shock proteins. RESULTS Among 22 healthy women with no history of chlamydial infections or salpingitis and 10 women seen for complaints other than a C. trachomatis infection, none had positive lymphocyte responses to any of the peptides and only one responded to the chlamydial heat-shock protein. Among nine women with a single episode of salpingitis none responded to the chlamydial heat-shock protein and one exhibited a positive lymphocyte response to a single peptide. This woman was also positive for C. trachomatis in the cervix. In contrast, among the 10 women with two or more episodes of salpingitis four (40%) had proliferation in response to the chlamydial heat-shock protein and five (50%) had positive lymphocyte responses to one of the peptides; two of these women also had C. trachomatis detected in their cervices. CONCLUSION In women with a history of C. trachomatis upper genital tract infections, infection with C. trachomatis or other microorganisms can induce a lymphocyte proliferative response to the chlamydial 60 kd heat-shock protein and to epitopes present in the human heat-shock protein.

Vaginal eosinophils and IgE antibodies to Candida albicans in women with recurrent vaginitis

Eosinophils were identified in 31 of 121 (25.6%) vaginal smears obtained from women with recurrent vaginitis. The presence of eosinophils correlated (p less than 0.005) with the occurrence of IgE antibodies to Candida albicans in vaginal fluid. Localized allergic responses to C. albicans or other allergens may contribute to the pathogenesis of recurrent vaginitis in sensitized women.

Detection of Chlamydia trachomatis in semen by the polymerase chain reaction in male members of infertile couples

OBJECTIVE Our objective was to evaluate the presence of asymptomatic Chlamydia trachomatis infection by means of the polymerase chain reaction in male members of couples with previously undiagnosed infertility. STUDY DESIGN Twenty-eight infertile-couples who had negative cultures or negative results when tested by deoxyribonucleic acid probe for Chlamydia trachomatis in semen and cervical samples were studied. Semen samples were tested for Chlamydia trachomatis by means of the polymerase chain reaction. Sera from both partners were diluted 1:128 and tested for immunoglobulin M antibodies to Chlamydia. Sera and ejaculated sperm were evaluated for the presence of antisperm antibodies. Semen analyses were also performed. RESULTS Chlamydia trachomatis was identified in semen from 11 (39.3%) of the male partners. Its detection correlated with the presence in the ejaculate of motile sperm containing antisperm antibodies (p < 0.01). Either antisperm immunoglobulin G, immunoglobulin A, or both were located on sperm only from 5 (45.5%) of the 11 men whose results were positive when tested for Chlamydia trachomatis. Similarly, immunoglobulin G or immunoglobulin A antibodies to sperm were only detected in 5 (45.5%) of the spouses of men with Chlamydia in semen. Immunoglobulin M antibody to Chlamydia trachomatis was identified in only one of the men. However, antichlamydial immunoglobulin M antibodies were present in sera from 6 (54.5%) female partners of men with seminal Chlamydia trachomatis but in none of the other 17 women (p < 0.01). CONCLUSION Although undetected by culture of deoxyribonucleic acid probe of semen samples, Chlamydia trachomatis was nevertheless identified in semen of some symptom-free men by the polymerase chain reaction. This is probably a result of the increased sensitivity of the polymerase chain reaction to detect Chlamydia trachomatis. The increased prevalence of an autoimmune response to sperm in men with this organism in their semen suggests that a subclinical chlamydial infection may activate an immune response to sperm. A similar association between Chlamydia trachomatis in semen and circulating antisperm antibodies in female partners indicates that Chlamydia may also induce an immune response to sperm in women. Infertility in these couples may be the result of a direct inflammatory response in the cervix or endometrium to repeated Chlamydia exposure or of the ability of Chlamydia to evoke an immune response to spermatozoa.

Interferon-γ in the diagnosis and pathogenesis of pelvic inflammatory disease

Serologic markers were evaluated to determine if they could aid in the differential diagnosis of pelvic inflammatory disease in 48 consecutive women seeking evaluation for pelvic pain: On the basis of clinical and microbiologic parameters, 29 patients (60.4%) were diagnosed as having pelvic inflammatory disease. Neisseria gonorrhoeae only was isolated from the cervix of eight (27.6%) patients with pelvic inflammatory disease, five (17.2%) had only Chlamydia , and two (6.9%) had Neisseria and Chlamydia , whereas in 15 (48.3%) patients no pathogen was isolated. Interferon-γ was present in significantly more sera ( p Neisseria , seven (87.5%) had circulating interferon-γ; three (60%) of the women with only Chlamydia , one (50%) woman with Neisseria and Chlamydia , and eight (57.1 %) with no identified pathogens were also positive for interferon-γ. Sera from 11 of 28 patients with pelvic inflammatory disease (39%) but only one of 19 sera from women without pelvic inflammatory disease (5%) also inhibited the Candida -induced proliferation of control lymphocytes. This immunosuppressive activity was prevented by immunoprecipitation of interferon-γ by anti-interferon-,γ antibody but not by treatment with anti-interferon-α antibody. The persistence of interferon-γ in the sera of patients with pelvic inflammatory disease may aid in the differential diagnosis of this disease and increase our understanding of the pathogenesis of microbial-mediated tubal damage.

Immune Recognition of the 60kD Heat Shock Protein: Implications for Subsequent Fertility

The 60kD heat shock protein (hsp60) is a highly conserved protein and a dominant antigen of most pathogenic bacteria. In some women, chronic or repeated upper genital tract infections with Chlamydia trachomatis, and possibly with other microorganisms, induces immune sensitization to epitopes of hsp60 that are present in both the microbial and human hsp60. Once a woman becomes sensitized to these conserved epitpes, any subsequent induction of human or bacterial hsp60 expression will reactivate hsp60-sensitized lymphocytes and initiate a pro-inflammatory immune response. Hsp60 is expressed during the early stages of pregnancy, by both the embryo and the maternal decidua. We examined, therefore, whether women who were sensitized to hsp60 experienced less successful pregnancy outcomes compared to women who were not sensitized to this antigen. In women undergoing in vitro fertilization (IVF), the presence of cervical IgA antibodies reactive with the C. trachomatis hsp60 correlated with implantation failure after embryo transfer. Further analysis revealed that an immunodominant epitope for these IgA antibodies was an hsp60 epitope shared between C. trachomatis and man. In subsequent studies of women not undergoing IVF, cervical IgA antibodies to the human hsp60 were identified in 13 of 91 reproductive age women. This antibody was most prevalent in those women with a history of primary infertility (p = 0.003). In addition, cervical anti-hsp60 IgA correlated with the detection of the pro-inflammatory cytokines interferon-γ (p = 0.001) and tumor necrosis factor-α (p = 0.02) in the cervix. Conversely, women with proven fertility had the highest prevalence of the anti-inflammatory cytokine, interleukin 10, in their cervices (p = 0.001). In an analysis of serum samples in a third study, women with a history of two or more consecutive first trimester spontaneous abortions had a higher prevalence (p = 0.01) of IgG antibodies to the human hsp60 (36.8%) than did age matched fertile women (11.1%) or women with primary infertility (11.8%). Immune sensitization to epitopes expressed by the human hsp60 may reduce the probability of a successful pregnancy outcome due to reactivation of hsp60-reactive lymphocytes, induction of a pro-inflammatory cytokine response and interference with early embryo development and/or implantation.

Detection of Chlamydia trachomatis by the polymerase chain reaction in the cervices of women with acute salpingitis

OBJECTIVE Our objective was to determine whether an increased prevalence of Chlamydia trachomatis could be detected by the polymerase chain reaction as opposed to culture in the cervices of women with acute salpingitis. STUDY DESIGN Endocervical samples from 15 women with laparoscopy-verified acute salpingitis and 20 women seeking medical help for conditions other than pelvic pain were tested for Chlamydia trachomatis with the polymerase chain reaction. The oligonucleotide primer pairs used were specific for a 144 bp region of the major outer membrane protein that contained a single EcoRI endonuclease cleavage site. The detection of a 144 bp band that was cleaved by EcoRI to a 103 bp band denoted a Chlamydia trachomatis-positive sample. Cervical samples were cultured for Chlamydia trachomatis with the use of McCoy cells. The lymphocyte proliferative response to Chlamydia trachomatis elementary bodies was also determined. RESULTS Nine of the 15 women (60%) with salpingitis had positive results when tested with the polymerase chain reaction for cervical Chlamydia trachomatis. Only two of these women (13%), both of whom had positive results when tested with the polymerase chain reaction, had cultures that were positive for Chlamydia trachomatis (p < 0.02). Among the 20 other women, only two patients with cervicitis had positive cultures for Chlamydia. Those women plus two women with unexplained recurrent abortions had positive polymerase chain reaction test results for Chlamydia trachomatis. A lymphocyte proliferative response to Chlamydia trachomatis was detected in five of eight women with salpingitis, as well as three of the other four patients, all of whom had positive polymerase chain reaction test results; lymphocytes from the remaining women were unresponsive. Follow-up cervical samples were obtained 4 to 6 months after treatment from six of the patients with salpingitis who had positive polymerase chain reaction test results; at that time five had negative polymerase chain reaction test results for Chlamydia trachomatis. CONCLUSION The polymerase chain reaction appeared to be more sensitive and more rapid than culture in detecting Chlamydia trachomatis in the cervices of women with acute salpingitis. This assay may be of value for the early diagnosis of chlamydial infections.

Individual differences in tumour necrosis factor and interleukin-1 production induced by viable and heat-killed Candida albicans.

The in vitro production of tumour necrosis factor (TNF) and interleukin-1 (IL-1) by peripheral blood mononuclear cells from 27 healthy women in response to viable and heat-killed Candida albicans was measured. Production of both cytokines was proportional to the concentration of viable C. albicans and increased at a steady rate for at least 24 h. No relationship was observed between the levels of IL-1 and TNF produced by the mononuclear cells from any individual. Some women were high TNF producers and low IL-1 producers or vice versa. Higher levels of TNF were induced by heat-killed C. albicans than by viable organisms in 26 of the 27 subjects. In marked contrast, IL-1 was induced preferentially by viable C. albicans in 23 of the 27 women. Thus, TNF and IL-1 production induced by C. albicans appears to be non-coordinately regulated and may involve different Candida moieties.

Testing for high-risk human papillomavirus types will become a standard of clinical care

Testing for high-risk human papillomavirus types should become a standard of care for women in the United States because cervical cancer is an infectious disease. Current care is based on cytologic screening and a pathologic staging of cellular tissue changes. Before these cellular modifications, there is a demonstrable pattern of human papillomavirus infection. Human papillomavirus is the most frequently acquired sexually transmitted disease in women and is usually eliminated without treatment. Persistence of high-risk human papillomavirus types can lead to abnormal cervical cellular changes. When these cervical cellular changes occur, physician interventions hasten human papillomavirus elimination. Currently, adding human papillomavirus screening to the Papanicolaou smear identifies a population for closer follow-up studies. In the future a vaccine should be introduced to prevent infections, and medical treatments to hasten the elimination of high-risk human papillomavirus types should become part of standard medical practice.