Synopses

Chlamydiae as Pathogens:
New Species and New Issues
Rosanna W. Peeling* and Robert C. Brunham†
*
Laboratory Centre for Disease Control Health,
Winnipeg, Manitoba, Canada
†
Department of Medical Microbiology,
University of Manitoba, Winnipeg, Canada

The recognition of genital chlamydial infection as an important public health

problem was made first by the recognition of its role in acute clinical syndromes, as
well as in serious reproductive and ocular complications, and secondly by our
awareness of its prevalence when diagnostic tests became widely accessible. The
recent availability of effective single dose oral antimicrobial therapy and sensitive
molecular amplification tests that allow the use of noninvasive specimens for
diagnosis and screening is expected to have a major impact in reducing the
prevalence of disease in the next decade. Clinical manifestations associated with
Chlamydia pneumoniae infection continue to emerge beyond respiratory illness. In
particular, its association with atherosclerosis deserves further investigation.
Chlamydia pecorum, a pathogen of ruminants, was recently recognized as a new
species. The continued application of molecular techniques will likely elucidate an
expanding role for chlamydiae in human and animal diseases, delineate the
phylogenetic relationships among chlamydial species and within the eubacteria
domain, and provide tools for detection and control of chlamydial infections.

Chlamydiae are obligate intracellular cases of active trachoma worldwide (seven

bacteria that grow in eukaryotic cells and million include blindness from conjunctival
cause a wide spectrum of human disease scarring and eyelid deformities [2]). In the
(Table). Species were grouped according to last two decades, genital chlamydial infection
their biologic and biochemical properties and has been identified as a major public health
a greater than 95% homology in their 16s problem because of the recognition that
ribosomal RNA sequences (1). Molecular chlamydial infection is associated with
analyses led to the reclassification of some disease syndromes such as nongonococcal
Chlamydia psittaci strains as Chlamydia urethritis, mucopurulent cervicitis, pelvic
pneumoniae, a human pathogen, and Chla- in flammat or y disease (PID ) , ec topic
mydia pecorum, a pathogen of ruminants. pregnancy, and tubal infertility. The World
Given the diverse host range of C. psittaci Health Organization estimated 89 million
strains, more reclassification within this new cases of genital chlamydial infections
species may be likely. worldwide in 1995 (3). In the United States,
The oldest reported disease associated each year an estimated four million new
with C. trachomatis infection is trachoma, a cases occur and 50,000 women become
sequela of ocular infection. This disease was infertile as a result of infection (4).
described in China and in the Ebers papyrus C. psittaci infection, acquired through
in Egypt thousands of years ago and r e sp ir at or y dr op le t tr an sm is si on o f
continues to be a major cause of preventable chlamydiae from infected birds, has been
blindness, with an estimated 500 million considered for many years an occupational
hazard for employees of pet shops and
Address for correspondence: Rosanna W. Peeling, LCDC
Chlamydia Laboratory, Health Sciences Centre MS 673C, 820
poultry processing plants (5). Sources of
Sherbrook St., Winnipeg, Manitoba, Canada R3A 1R9; fax: human C. psittaci infection other than
204-787-4699; e-mail: [email protected]. infected birds have been identified and may

Vol. 2, No. 4—October-December 1996 307 Emerging Infectious Diseases

 Synopses

Table. Spectrum of human diseases caused by Chlamydiae

Species Acute Diseases Sequelae/Chronic Diseases
C. trachomatis

Serovars A-C conjunctivitis trachoma

Serovars D-K urethritis proctitis, epididymo-orchitis, Reiter’s Syndrome
cervicitis pelvic inflammatory disease, ectopic pregnancy, tubal
infertility, Fitz-Hugh Curtis Syndrome
ophthalmia neonatorum
neonatal pneumonia
LGV serovars lymphogranuloma venereum

C. pneumoniae pharyngitis ?cardiovascular disease

sinusitis ?asthma
bronchitis
community-acquired pneumonia

C. psittaci
parrot atypical pneumonia
canaries hepatic and renal
pigeons dysfunction
turkeys endocarditis
ducks
chickens
cats conjunctivitis
ewes abortion

be more common than currently recognized. to attach to glycosaminoglycan (GAG)

Detection of C. psittaci in household cats and receptors on eukaryotic cell surfaces (9).
breeding catteries illustrates the expanding GAG appears to form a trimolecular complex
number of chlamydial diseases in animals with the host cell since (EB) infectivity is
that are transmissible to humans (6,7). inhibited by the addition of heparan or
C. pneumoniae is a human pathogen heparan sulfate to culture, and pretreatment
recognized as an important cause of of EBs with heparan sulfate lyase abolishes
respiratory illness (8). Approximately 40% to EB infectivity. The mechanism of endocytic
60% of adult populations around the world uptake remains unclear. Once inside the
have antibodies to C. pneumoniae, which host cell, chlamydiae reside in a membrane-
suggests that the infection is extraordinarily bound vacuole that can evade phagolysosomal
prevalent, and reinfection is common. fusion. The endosome is transported to the
Current interest centers on the emerging distal region of the Golgi apparatus and
role of C. pneumoniae infection in the incorporates host-derived sphingolipids into
pathogenesis of atherosclerosis and asthma. the inclusion membrane (10,11). Thus it
appears that chlamydiae are able to
Biology of Chlamydiae: An Update intercept host vesicular traffic bound for the
Chlamydiae have a unique biphasic life plasma membrane to sequester lipids and
cycle with dimorphic forms that are function- possibly other host substances synthesized
ally and morphologically distinct. An extra- in the Golgi. Subversion of host vesicular
cellular form, the elementary body (EB), is traffic may represent a dual advantage for
infectious but metabolically inactive. Once chlamydiae in obtaining materials from the
endocytosed, the EB differentiates into a host for its metabolism as well as in
larger pleomorphic form called the reticulate modifying the inclusion membrane to evade
body (RB), which replicates by binary fission. lysosomal fusion and immune detection.
The precise mechanism by which EBs attach Chlamydiae are considered energy para-
and gain entry into the host cell is unknown. sites because they lack the enzymes of the
Recent work suggests that chlamydiae electron transport chain and thus require
employ a molecular mimic of heparan sulfate adenosine triphosphate (ATP) and nutrient

Emerging Infectious Diseases 308 Vol. 2, No. 4—October-December 1996

 Synopses

resources from the host to fuel their counseling clinics have been effective. In
metabolism and replication. Chlamydiae are asymptomatic men, who are less likely to
incapable of de novo nucleotide biosynthesis access care, asymptomatic infection is not
and are dependent on host nucleotide pools adequately addressed by current public
(12). In spite of the successful selection of health programs.
various metabolic mutants of C. trachomatis, In contrast to genital chlamydial infec-
progress in elucidating the host-parasite tion, trachoma is a household disease that
metabolic relationship has been hampered has disappeared in many parts of the world
by multiple salvage metabolic pathways in because of improved living conditions and
the host and the lack of a genetic shuttle hygiene. In trachoma-endemic areas, severe
system for chlamydiae. disease leading to scarring and blindness
may be the result of frequent reinfection or
C. trachomatis persistent infection in those whose immune
system does not mount an adequate response
Epidemiology to clear the infection. For both ocular and
Genital infections due to C. trachomatis genital chlamydial infections, recent ad-
are the most common sexually transmitted vances in diagnostic and screening technol-
diseases in many industrialized countries (3). ogy and single dose antimicrobial therapy
Each year, an estimated four million new will likely have a significant impact on the
cases occur in the United States and three efficacy of disease control programs and the
million in Europe. These infections present opportunity for eventual disease eradication.
unique problems for public health control
programs because 50 % to 70% of infections Laboratory Diagnosis
in women (and perhaps men) are clinically Since curative antibiotic therapy for
silent. Unrecognized and untreated, the chlamydial infections is readily available
bacteria may remain infectious in the host and inexpensive, early diagnosis is an
for months and be readily transmitted to sex essential component of public health pro-
partners. Furthermore, most reported infec- grams to control these infections. The goals
tions occur in the 15- to 24-year-old age of early identification are to interrupt the
group. Young women with cervical chlamy- chain of transmission in the community and
dial infections are at risk for pelvic to prevent long-term sequelae. Isolation of
inflammatory disease, which can lead to the organism in cell culture had been the
long-term reproductive sequelae such as traditional method for laboratory diagnosis
chronic pelvic pain, ectopic pregnancy, and and has remained the method of choice for
tubal infertility. Babies born to infected medicolegal specimens because of its speci-
mothers are also at risk for conjunctivitis ficity. However, culture requires expensive
and pneumonia. The annual direct and equipment, technical expertise, and strin-
indirect costs of genital chlamydial infec- gent transport conditions to preserve speci-
tions in the United States are estimated at men viability; it also has a turnaround time
$2.4 billion (4). of 2 to 3 days. Hence, in many settings,
Control programs emphasizing early culture has been replaced by antigen-
diagnosis, targeted screening, partner notifi- detection methods, such as enzyme immu-
cation, and effective treatment have led to a noassays (EIA) and direct fluorescence
slow decline in the incidence of genital assays (DFA), which have less demanding
chlamydial infection in countries where transport requirements and can provide
these programs have been implemented (13). results on the same day. EIAs are suitable
The true rate of decline may be higher than for public health laboratories serving large
the reported rate because of increased geographic areas because specimens are
sensitivity of laboratory testing and more stable in transport under ambient conditions
widespread screening. In women, screening and are inexpensive because they allow
of chlamydial infection at the time of specimens to be processed in batches by
Papanicolaou tests, prenatal visits, or automated equipment. Assays are typically
attendance at family planning or pregnancy based on the capture of the chlamydial

Vol. 2, No. 4—October-December 1996 309 Emerging Infectious Diseases

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lipopolysaccharide (LPS) using monoclonal cervical swab EIA, and 37% for urine EIA
or polyclonal antibodies linked to a solid- (21). For men in the same study, the
phase support. Early problems with low sensitivity of urine LCR was 96% compared
specificity because of cross-reactivity be- with 68% for urine EIA, and 38% for urethral
tween the chlamydial LPS and that of other swab culture. In a multicenter study of 2,132
gram-negative bacteria have been largely women, cervical swab LCR showed a
overcome by confirmation with DFA or a sensitivity of 87% to 98% compared with a
blocking antibody assay. With a lower sensitivity of 52% to 92% for culture (22). In
detection limit of 10,000 elementary bodies, LCR studies, a true positive was defined as
EIA lacks sensitivity as a screening assay, culture positive or LCR positive confirmed
especially for asymptomatic men (14,15). with DFA or another LCR assay with a
Nucleic acid-based hybridization probe tests different DNA target. Thus it appears that
offer higher specificity but no substantial molecular amplification techniques for the
improvement on sensitivity (15). Nucleic detection of C. trachomatis in urine speci-
acid amplification tests based on polymerase mens from both men and women are a
chain reaction (PCR), ligase chain reaction substantial improvement over conventional
(LCR), and transcription-mediated amplifi- diagnostic and screening methods and will
cation technology are now commercially provide an important tool for decreasing the
available. The precision of nucleic acid reservoir of infection, especially in asymp-
hybridization and the rapid amplification of tomatic men.
a single gene target facilitated the design of In the diagnostic laboratory, molecular
diagnostic tests with specificities in excess of techniques present different problems for
99% and lower detection limits of 1-10 EBs. specimen handling and interpretation of
In addition, these tests offer all the results than cell culture or antigen detection
advantages of nonculture tests in terms of (15). Inherent in the increased sensitivity of
ambient specimen transport, batching, auto- these molecular techniques is the potential
mation, and rapid processing time of 4 hours. for false-positive results due to cross
Duplex testing for the simultaneous detec- contamination between specimens, and run-
tion of chlamydial and gonococcal DNA from to-run contamination from equipment, re-
a single specimen is also commercially agents, and supplies. These problems can be
available in some countries. overcome by observing stringent rules for
A major advantage of the increased specimen preparation (e.g., dedicated equip-
sensitivity of these molecular amplification ment) and separating specimen processing
tests is that noninvasive specimens, such as and reagent preparation areas to prevent
urine, can be used for testing. The ease of contamination. Enzymatic or photochemical
collection and the lack of sampling bias of sterilization can be used to eliminate run-to-
urine specimens make screening feasible in run contamination. False-negative results
settings outside physicians’ offices. PCR may be due to substances in specimens
assays on urethral or cervical swabs for the inhibitory to enzymes used for amplification.
laboratory diagnosis of genital chlamydial Known inhibitors include phosphate ions,
infection in symptomatic men and women heparin, heme, crystals in the urine
show sensitivities of 89% to 100% and specimens, and detergents used in specimen
specificities of 99% to 100% compared with processing. Internal controls are now com-
the traditional culture or PCR test, con- mercially available to detect false negatives.
firmed by a second PCR reaction targeting a Although molecular tests are more
different gene (16-18). For urine specimens, expensive than EIA, cost-effectiveness stud-
PCR assays show sensitivities of 87% to ies should take into consideration the
100% for men and 92% for women and benefits of averting the enormous costs of
specificities of 96% to 100% for men and 95% long-term reproductive sequelae in women
for women (18-20). In a study of 447 women with undetected infections, adverse preg-
with a prevalence of infection of 6%, the nancy outcomes, and HIV infection. Targeted
sensitivity of urine LCR was 96% compared screening of women to detect cervical
with 56% for cervical swab culture, 78% for chlamydial infection decreases the incidence

Emerging Infectious Diseases 310 Vol. 2, No. 4—October-December 1996

 Synopses

of symptomatic PID (23). Patients with ance and the additional cost of contact
genital gonococcal or chlamydial infections tracing can make single dose azithromycin
are also at increased risk for human more cost-effective than doxycycline (34).
immunodeficiency virus (HIV) (24). Al-
though the risk for HIV may be lower in Pathogenesis
patients with chlamydial infection than in Interesting findings in three areas of C.
those with genital ulcer disease, the higher trachomatis pathogenesis further delineate
prevalence of chlamydial infection in some the complex bacteria-host relationship in
populations means that the population disease and may have implications for
attributable risk for HIV may be substan- vaccine design. These new observations
tially higher for chlamydia. Shortening the include the extensive but unexpected poly-
duration of infectiousness by early diagnosis morphism of the major outer membrane
and treatment could have a major impact on protein (MOMP), the evidence for genetic
risk reduction for HIV infection. A recent susceptibility to disease, and the association
study showed that strengthening sexually of antibody response to the 60 kDa heat
transmitted disease control through educa- shock protein (CHSP60) with the develop-
tion, access to diagnosis, and treatment ment of adverse sequelae following ocular
reduced the incidence of HIV by 42% in study and genital infections.
communities in Tanzania over 2 years (25).
Polymorphism of MOMP
Treatment The ecologic success of a pathogen is
Azithromycin prescribed as a single oral determined in part by its ability to evade
1-g dose is equivalent to the traditional 7- host defenses. With C. trachomatis, MOMP
day regimen of doxycycline for treating is a major target for protective host immune
ocular and uncomplicated genital chlamydial responses, such as neutralizing antibodies
infections (26-28). Compared with conven- and possibly, protective T-cell responses
tional therapy, azithromycin has excellent (35,36). The basis for MOMP antigenic
pharmacokinetic characteristics, such as variation is allelic polymorphism at the omp-
increased bioavailability; lower incidence of 1 locus, and immune selection appears to be
gastrointestinal tract side effects; and occurring in host populations frequently
increased concentration in mucus, macroph- exposed to C. trachomatis (37). Each variant
ages, and tissues with a half life of 5 to 7 days apparently only infects hosts lacking serovar-
(29). These characteristics allow for single specific immunity to that variant, and the
dosing, which alleviates the problem of ecologic success of chlamydiae may be due to
patient noncompliance with multiday regi- their ability, under immune selection pres-
mens. With single-dose therapy, the poten- sure, to generate successive allelic variants
tial for reinfection due to earlier resumption (36). DNA sequence analyses of isolates from
of sexual activity is a concern. At present, different populations show that most MOMP
there are limited data on the use of single- variants are results of single amino acid
dose therapy in adolescents, during preg- substitutions (37-39). Recombination of
nancy, and for syndromes such as PID, sequences from MOMP during mixed infec-
cervicitis, and nongonococcal urethritis (30- tions may also have occurred. Recombinant
33). Studies are needed to determine if these variants with mosaic sequences of MOMP
regimens achieve clinical and microbiologic from different strains were especially fre-
cure while preserving fertility and prevent- quent in persons with high rates of infection.
ing further tissue damage to the upper MOMP variants were also more frequently
genital tract. found in women with PID than in those with
Although the higher cost of azithromycin lower genital tract infections, which sug-
may be prohibitive for its use in resource- gests a relationship between sequence
limited settings, selective use in persons at variation in MOMP and more invasive
high risk or in those with a history of disease (39). Clearly, the extensive polymor-
noncompliance may prove cost-effective. The phism of MOMP, the tempo for variation, and
cost of retreatment as a result of noncompli- the mechanism of immune selection have

Vol. 2, No. 4—October-December 1996 311 Emerging Infectious Diseases

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important implications for vaccine design response. In a study of trachoma in the

(35). Gambia, HLA DRB1*0701 was positively
correlated with CHSP60 response, while
Genetic Susceptibility to Disease DRB1*0301 and DQB1*0501 were negatively
HLA B27 has been associated with associated (48). However, these alleles were
Reiter’s syndrome following genital chlamy- not associated with trachoma and may
dial infection (40). Only a subset of infected reflect linkage disequilibrium between HLA
persons appear to have long-term complica- class II alleles and polymorphic markers for
tions after acute or repeated chlamydial other immune response genes.
infections. In a study of 306 persons from At present, it remains unclear whether
trachoma-endemic communities in the antibody to CHSP60 is causally involved in
Gambia, the HLA class I antigen HLA-A28 chlamydial immunopathogenesis or is merely
was significantly more common in case- a marker of persistent chlamydial infection
patients than in age-, sex-, and location- (35). Both may be true. In cells persistently
matched controls (41). In particular, the infected with C. trachomatis, the expression
A*6802 allele was overrepresented among of CHSP60 is normal, while other antigens,
case-patients. It may be that immunopathol- such as MOMP, are downregulated, thus
ogy is associated with HLA-A*6802 re- providing continued antigenic stimulation
stricted cytotoxic T-lymphocyte responses. for the CHSP60 antibody response observed
The frequency of HLA class II alleles was in persons with long-term sequelae (49). T-
similar among cases and controls suggesting cell responses to chlamydial antigens,
that, if class II restricted T-cell responses including CHSP60, were more depressed in
are important in immunopathology, they persons with trachoma than in those who
were not targeted at single epitopes. No recovered from infection without sequelae
individual HLA type was associated with (50). Persons with trachoma or reproductive
protection from scarring, which suggests sequelae have high levels of serum antibody
that multiple or complex T-cell responses response to C. trachomatis. In guinea pigs
may be involved in protective immunity. and in gene knock-out mice, both B- and T-
Susceptibility to chlamydial PID in a study cell responses have been important in
of sex workers in Nairobi, Kenya, has been immunity and resolution of infection (51,52).
associated with a HLA class I allele, HLA A- Therefore, persons with long-term sequelae
31 (42). Studies are needed to determine may have predominantly Th 2 responses,
whether susceptibility to silent PID, ectopic characterized by high levels of B-cell
pregnancy, and progression to tubal factor response and inadequate T-cell responses
infertility are associated with HLA class I that may not clear the infection thus leading
restricted immune responses. to chronic inflammation. Immunopathology
may also be the result of a hit-and-run
Role of CHSP60 in Immunopathology mechanism in which immune response to
Antibody response to a 57 kDa chlamy- CHSP60 breaks self-tolerance to the human
dial protein was initially observed more HSP60 and leads to an autoimmune reaction
frequently in women with tubal infertility that results in tissue damage (35).
than in controls (43). This protein was
subsequently identified as a heat shock C. psittaci
protein of the GroEL family of stress
proteins. The association between antibody Epidemiology
response to CHSP60 and PID, ectopic Human infections with C. psittaci are
pregnancy, tubal infertility, and trachoma caused by occupational exposure to infected
(44-48) has been documented. The risk birds or household handling of nasal
factors associated with CHSP60 antibody discharge or fecal material from pet birds.
response are similar to those for chlamydial Birds can be healthy carriers of C. psittaci.
PID and include older age and chronic or Increased shedding and susceptibility to
repeated infections. There appears to be disease occur under conditions of stress such
genetic restriction for the CHSP60 antibody

Emerging Infectious Diseases 312 Vol. 2, No. 4—October-December 1996

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as shipping, crowding, starvation, or egg because culture is technically demanding

laying. Person-to-person transmission is and represents an important biohazard. The
rare but has been observed in outbreaks. In complement fixation assay is genus specific.
the C. psittaci pandemic of 1929-30, infected Its interpretations should depend on clinical
birds from Argentina were shipped to symptoms and patien t history . Th e
different parts of the world causing out- microimmunofluorescence (MIF) assay can
breaks of infection worldwide with death detect species-specific IgM or IgG antibod-
rates of up to 40% (5). Since then C. psittaci ies. Antigen detection methods, such as EIA,
has been isolated from more than 130 species have been used, but they are based on the
of birds. Thus, all avian species, including capture of the genus-specific LPS. PCR
wild birds, should be regarded as potential assays are not yet commercially available
sources of zoonosis. but can offer lower detection limits of 10 EBs
Reports of outbreaks of psittacosis in or less (57,58). Molecular techniques not only
duck and turkey processing plants show provide more sensitive and rapid diagnosis
that, in spite of availability of medicated than serology, but they also provide the
feed, diagnostic testing, and screening of opportunity for fingerprinting strains. This
poultry, C. psittaci infections continue to be is particularly useful in outbreak investiga-
a public health concern (53,54). High rates of tions and for the confirmation of zoonotic
chlamydial infection in household cats and transmission from infected birds or animals.
asymptomatic carriage of C. psittaci in cats The recommended treatment for C.
from breeding catteries raise the possibility psittaci infection is 250 mg of tetracycline 4
that human C. psittaci infection from pets times daily for 21 days. Although the death
other than birds may be underdiagnosed rate is low, prolonged hospitalization may be
(6,7,55,56). Studies of animal and cellular required. Protracted recovery and high
tropism of various strains within the species incidence of relapse have also been noted.
may give important clues to the pathogenesis
of C. psittaci infections. C. pneumoniae
Clinical Manifestations Epidemiology
Human infection caused by exposure to C. pneumoniae is a common cause of
infected birds or poultry is manifested as a acute respiratory tract infections and ac-
flulike illness characterized by fever, chills, counts for 6% to 10% of community-acquired
headache, and less frequently, cough, pneumonia (8). Infection is usually mild or
myalgias, rash, arthralgia and joint swell- asymptomatic but can be severe, especially
ing, and atypical pneumonia in more severe in the elderly, probably as a result of
cases. The incubation period is 6 to 19 days. underlying illness, impaired mucociliary
Infections transmitted from ruminants are clearance, and immune senescence. Unlike
rare, but placentitis, disseminated intravas- C. psittaci, C. pneumoniae is spread by
cular coagulation, and spontaneous abortion person-to-person transmission by respira-
in women exposed to infected sheep during tory droplet and has an incubation period of
lambing have been reported (56). Zoonoses 7 to 21 days. Outbreaks of infection have
associated with exposure to ruminants are been reported in families, schools, military
characterized by multiorgan involvement barracks, and nursing homes. Coinfection
often resulting in hepatic and renal dysfunc- with viruses (e.g., influenza and respiratory
tion and endocarditis. Human conjunctivitis, syncytial virus) and with bacteria has been
glomerulonephritis, and endocarditis caused reported frequently. Seroepidemiologic stud-
by C. psittaci from infected cats and pigeons ies show that most primary infections occur
have been reported (55). during school age and the early teenage
years; among adults seroprevalence is 40% to
Diagnosis and Treatment 70%. Reinfections are common, and serum
Serodiagnosis has been the method of antibodies do not appear to be protective.
choice for human C. psittaci infections

Vol. 2, No. 4—October-December 1996 313 Emerging Infectious Diseases

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Laboratory Diagnosis compared with the 3 weeks or more that it

Accurate and rapid laboratory diagnostic takes by MIF to demonstrate seroconversion.
methods leading to improved patient care, Because reinfections are common and LPS-
appropriate use of antimicrobial therapy, based serologic tests are not useful in
and better understanding of the epidemiol- reinfection, the MIF assay remains the most
ogy of this emerging pathogen (59,60) are useful and specific tool for the serodiagnosis
needed. Culture is highly specific but is of r espiratory in fection s due to C.
technically demanding often requiring mul- pneumoniae.
tiple passages over a period of weeks to show
a positive result. C. pneumoniae has been Treatment
isolated from the nasopharynx of healthy The newer macrolides, clarithromycin
persons, but the rate of asymptomatic and azithromycin, with longer tissue half-
carriage in a normal population is unknown life and concentration in mucus and
(61). macrophages and improved bioavailability
Antigen detection tests, such as EIA and can potentially provide shorter and better-
DFA, and molecular detection methods, such tolerated regimens for the treatment of
as PCR assays, provide a rapid diagnosis respiratory infections due to C. pneumoniae
without stringent transport requirements. than doxycycline or erythromycin, which
Monoclonal antibodies specific for C. have to be given for 2 to 3 weeks to avoid
pneumoniae are now commercially available relapse. They may also be preferred for
for DFA and for culture confirmation (62). empiric therapy as they provide broader
PCR assays have lower detection limits of 10 coverage than erythromycin against etiologic
to 100 EBs (57,58,63-65). The protocol agents in community-acquired pneumonia.
developed by Tong and Sillis amplifies a The optimal duration of treatment for
target sequence conserved between C. respiratory infections due to C. pneumoniae
pneumoniae and C. psittaci and hence can needs to be determined since studies with
detect DNA from either pathogen in a single documented microbiologic cure are limited,
assay (57). A nested PCR procedure is used to and recurrence of infection is common (67).
differentiate between the C. pneumoniae
and C. psittaci amplicons. The protocol of Association with Atherosclerosis
Rasmussen et al. amplifies a genus-specific The association of C. pneumoniae infec-
target, followed by species differentiation tion with coronary heart disease and acute
using restriction enzyme digestion (58). The myocardial infarction was first made on the
development of multiplex PCR assays basis of elevated IgG and IgA antibodies and
containing primers specific for a panel of LPS containing immune complexes in 50% to
respiratory pathogens will be useful. 60% in patients with coronary heart disease
The MIF assay is the standard method or acute myocardial infarction compared
used for chlamydia serology today. Ekman with 7% to 12% in the controls. This study
compared the performance of the comple- did not take into account risk factors for
ment fixation (CF), LPS-based EIA, and MIF heart disease such as smoking, hyperten-
tests for the serodiagnosis of C. pneumoniae sion, or serum lipid levels. Subsequently,
and C. psittaci infections in an elderly several cross-sectional studies involving 46
population and found that the CF test has a to 461 study participants have shown that a
sensitivity of 10% compared with 88% and similar association of IgG antibodies against
72% for MIF and EIA, respectively (66). IgM C. pneumoniae with coronary artery disease
antibodies were only detected in 11% of the and carotid disease with adjusted odds ratios
cases. IgM antibodies are rarely produced in of 1.6 to 2.6 after controlling for known risk
reinfections with C. pneumoniae. CF tests factors (68-72). Electron microscopy, PCR,
may be useful in early initial infections as and immunochemic al evidence of C.
LPS antibodies are produced early in pneumoniae in coronary arterial fatty
infection. Serodiagnosis may be made by streaks and atheromatous plaques have also
demonstrating a fourfold rise in CF or EIA been described (72,73).
titer in paired sera taken a week apart,

Emerging Infectious Diseases 314 Vol. 2, No. 4—October-December 1996

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Two more recent studies reported equivo- turn promote atherosclerosis. Tissue injury
cal findings. In one, C. pneumoniae was through C. pneumoniae-specific circulating
detected in 79% of 90 coronary atherectomy immune complexes in patients with chronic
specimens from symptomatic patients by heart disease may be an alternate mecha-
direct immunofluorescence and was con- nism or compounding atherogenesis. The
firmed by electron microscopy. Only 4% of 24 idea that an infectious agent is involved in
control nonatherosclerotic coronary speci- the atherogenic process is not new, but the
mens were positive for C. pneumoniae (74). role of C. pneumoniae in this process needs to
The 24 control samples included 12 from be defined.
heart transplant patients whose arteries
were damaged, but not by atherosclerosis. Association with Asthma
The absence of C. pneumoniae in these tissue The prevalence of asthma, an important
samples argues against its role as a chronic respiratory disorder, has been
passenger recruited to the site of injury in steadily increasing. Viral and Mycoplasma
macrophages. In the other study, C. pneumoniae infections have been implicated
pneumoniae was not detected in 58 coronary in exacerbating the disease. The first
atheroma specimens by culture, PCR, or observations on the association of C.
electron microscopy (75). The seroprevalence pneumoniae infection with the exacerbation
of C. pneumoniae in 65 case-patients was not of asthma were made in 1986 when wheezing
different from that in 28 asymptomatic was associated with acute bronchitis due to
controls. In fact, IgG titers were higher in C. pneumoniae infection (8,77). Subsequent
controls than in case-patients. Nonetheless, studies showed that exacerbation of asthma
data suggest that the association of C. due to C. pneumoniae infection may occur in
pneumoniae with atherosclerosis is consis- 1% to 11% of respiratory infections in adults
tent and biologically plausible. Whether C. as well as children. The mechanism underly-
pneumoniae is causally involved or is a ing the association is unclear. Preliminary
bystander trapped in the atherogenic process results in animal models suggest that C.
is unclear. pneumoniae can produce persistent infection
The sustained IgA and IgG antibody and cause pulmonary inflammation, and
levels against C. pneumoniae in persons with production of chlamydia-specific IgE anti-
atherosclerosis suggest that chronic infec- bodies in children with reactive airway
tion may be frequent after infection. The site disease has been demonstrated (78). A
of colonization for a chronic C. pneumoniae possible scenario for this association is an
infection may be in the alveolar macrophages antigen-specific allergic reaction with the
of the lung. Thus the initial event in release of pulmonary inflammatory media-
atherogenesis may be the formation of the tors and recruitment of inflammatory cells to
fatty streak. Fatty streaks consist of lipid- the airways, causing airway epithelial
laden macrophages derived from blood damage. Activated T lymphocytes and
monocytes and T lymphocytes attracted to cytokines appear to play a critical role as
the arterial subintima. Conversion of the mediators of persistent inflammation in
fatty streak to atheroma depends on many asthma. IL-4 is essential for B lymphocytes
factors, e.g., the proliferation and differen- class switching from IgG to IgE. In vitro
tiation of smooth muscle cells and fibro- human IgE synthesis is reciprocally regu-
blasts. Chronic infection with C. pneumoniae lated by IL-4 and interferon-gamma. Thus
may result from organisms harbored in cytokines from a Th 2 response to infection
macrophages trapped in the arterial wall. would facilitate and promote IgE production.
Growth of C. pneumoniae in endothelial, Immunotherapy or glucocorticoid therapy
smooth muscle cells, and macrophages from targeting CD4 + T cells may decrease the
peripheral blood monocytes has been re- proinflammatory role of these cells and
ported (76). Injured blood vessels initiate alleviate symptoms of asthma. The role of
events that promote thrombosis and platelet persistent infection in the pathogenesis of
adhesion at the site of injury. These events in asthma merits further study because, unlike

Vol. 2, No. 4—October-December 1996 315 Emerging Infectious Diseases

 Synopses

viral infections, C. pneumoniae infections Dr. Peeling is a research scientist and chief of
can be eradicated through appropriate the Division of Chlamydial and Mycoplasma
antimicrobial therapy. Diseases at the Laboratory Centre for Disease
Control, Health Canada. She is interested in the
diagnosis and pathogenesis of chlamydial infec-
tions with particular emphasis on the develop-
ment, risk assessment, and possible prevention of
The hallmark of chlamydial infection is adverse ocular and reproductive sequelae in
that most persons infected have mild to no human chlamydial infections.
apparent clinical disease and some have Dr. Brunham is professor and head of the
severe disease. Asymptomatic infection not Department of Medical Microbiology at the
only creates a problem in detecting cases for University of Manitoba. He has a long standing
disease control programs but also contrib- interest in the immunology of chlamydial
utes to the development of long-term adverse infections, and his current research focus is on
vaccine development.
sequelae, such as scarring trachoma from
ocular C. trachomatis infection, pelvic
inflammatory disease, ectopic pregnancy, References
1. Weisburg WG, Hatch TT, Woese CR. Eubacterial
and tubal factor infertility from genital C.
origin of chlamydiae. J Bacteriol 1986;167:570-4.
trachomatis infection. The recent availabil- 2. Dawson CR, Jones BR, Tarizzo ML. Guide to
ity of effective single dose oral antimicrobial trachoma control in programmes for the prevention of
therapy and sensitive molecular amplifica- blindness. Geneva: World Health Organization, 1981.
tion tests that allow the use of noninvasive 3. Sexually Transmitted Diseases. World Health
specimens for diagnosis and screening is Organization Press Release WHO/64, 25 August
1995.
expected to have a major impact in reducing 4. Washington A, Johnson RE, Sanders L Jr. Chlamydia
the prevalence of disease in the next decade. trachomatis infection in the United States: what are
New information from cell biology as well as they costing us? JAMA 1987;257:2070-2.
data from observing the interaction of 5. Schachter J, Dawson CR. Psittacosis. Human
chlamydiae with the host in terms of Chlamydial Infections. Littleton, MA: PSG Publishing
metabolic requirements and immune evasion Co., 1978.
6. Nasisse MP, Guy JS, Stevens JB, English RV,
strategies offer clues about the pathogenesis Davidson MG. Clinical and laboratory findings in
of chlamydia infections and may eventually chronic conjunctivitis in cats: 91 cases (1983-1991). J
lead to an effective vaccine. Sporadic Am Vet Med Assoc 1993;203:834-7.
outbreaks of psittacosis continue to be 7. Pointon AM, Nicholls JM, Neville S, Allanson M,
reported despite the use of medicated feed Coles C, Lawrence D. Chlamydia infection among
breeding catteries in south Australia. Australian
and the screening of poultry. Recent reports
Veterinary Practitioner 1991;21:58-63.
of C. psittaci in cats from breeding catteries 8. Grayston JT. Infections caused by Chlamydia
illustrate the potential of zoonotic diseases pneumoniae strain TWAR. Clin Infect Dis 1992;15:757-
transmissible to humans from pets other 63.
than birds. Two new species of chlamydiae, 9. Stephens RS. Molecular mimicry and Chlamydia
C. pneumoniae and C. pecorum, were desig- trachomatis infection of eucaryotic cells. Trends
Microbiol 1994;2:99-101.
nated in 1989 and 1992, respectively. 10. Hackstadt T, Scidmore MA, Rocky DD. Lipid
Clinical manifestations associated with C. metabolism in Chlamydia trachomatis-infected cells:
pneumoniae infection continue to emerge. directed trafficking of Golgi-derived sphingolipids to
Possible links to chronic conditions, such as the chlamydial inclusion. Proc Natl Acad Sci U S A
atherosclerosis and asthma remain to be 1995;92:4877-81.
elucidated. With the recent discovery of the 11. Hackstadt T, Rocky DD, Heinzen RA, Sidmore MA.
Chlamydia trachomatis interrupts an exocytic
involvement of infectious agents in other pathway to acquire endogenously synthesized
chronic conditions, it seems reasonable to sphingomyelin in transit from the Golgi apparatus to
apply molecular tools for chlamydial detec- the plasma membrane. EMBO J 1996;15:964-77.
tion to identify their potential involvement 12. McClarty G. Chlamydiae and the biochemistry of
in other etiologically undefined chronic intracellular parasitism. Trends Microbiol 1994;2:157-
64.
inflammatory conditions such as inflamma-
tory bowel disease and rheumatoid arthritis.

Emerging Infectious Diseases 316 Vol. 2, No. 4—October-December 1996

 Synopses

13. Peeling RW. Chlamydia trachomatis and Neisseria 26. Martin DH, Mroczkowski TF, Dalu ZA, McCarty J,
gonorrhoeae: Pathogens in retreat? Current Opinion Jones RB, Hopkins SJ, et al. A controlled trial of a
in Infectious Diseases 1995;8:26-34. single dose of azithromycin for the treatment of
14. Lin JSL, Jones WE, Yan L, Wirthwein KA, Flaherty chlamydial urethritis and cervicitis. N Engl J Med
EE, Haivanis RM, et al. Underdiagnosis of 1992;327:921-5.
Chlamydia trachomatis infection: diagnostic 27. Bailey RL, Arullendran P, Whittle HC, Mabey DCW.
limitations in patients with low-level infection. Sex Randomised controlled trial of single-dose
Transm Dis 1992;19:259-65. azithromycin in the treatment of trachoma. Lancet
15. Peeling RW, Brunham RC. Molecular techniques for 1993;342:453-6.
the laboratory identification of Chlamydia 28. Ossewaarde JM, Plantema FHF, Rieffe M, Nawrocki
trachomatis. Journal of the International Federation RP, de Vries A, van Loon AM. Efficacy of single-dose
of Clinical Chemistry 1994;6:78-82. azithromycin versus doxycycline in the treatment of
16. Bauwens JE, Clark AM, Stamm WE. Diagnosis of cervical infections caused by Chlamydia trachomatis.
Chlamydia trachomatis endocervical infections by a Eur J Clin Microbiol Infect Dis 1992;11:693-7.
commercial polymerase chain reaction assay. J Clin 29. Worm A-M, Osterlind A. Azithromycin levels in
Microbiol 1993;31:3023-7. cervical mucus and plasma after a single 1.0 g oral
17. de Barbeyrac B, Pellet I. Dutilh B, Bebear C, Dumon dose for chlamydia cervicitis. Genitourin Med
B, Geniaux M, et al. Evaluation of the Ampicor 1995;71:244-6.
Chlamydia trachomatis test versus culture in genital 30. Hammerschlag MR, Golden NH, Oh MK, Gelling M,
samples in various prevalence populations. Sturdevant M, Pernell PR, et al. Single dose of
Genitorurin Med 1994;70:162-6. azithromycin for the treatment of genital chlamydial
18. Wisenfeld HC, Uhrin M, Dixon BW, Sweet RL. infections in adolescents. J Pediatr 1993;122:961-5.
Diagnosis of male Chlamydia trachomatis urethritis 31. Bush MR, Rosa C. Azithromycin and erythromycin in
by polymerase chain reaction. Sex Transm Dis the treatment of cervical chlamydial infection during
1994;21:268-71. pregnancy. Obstet Gynecol 1994;84:61-3.
19. Jaschek G, Gaydos CA, Welsh L, Quinn TC. Direct 32. Lauharanta J, Saarinen K, Mustonen M-T, Happonen
detection of Chlamydia trachomatis in urine H-P. Single-dose oral azithromycin versus seven-day
specimens from symptomatic and asymptomatic men doxycycline in the treatment of non-gonococcal
by using a rapid polymerase chain reaction assay. J urethritis in males. J Antimicrob Chemother
Clin Microbiol 1993;31:1209-12. 1993;31:177-83.
20. Toye B, Peeling RW, Jessamine P, Claman P, 33. Lister PJ, Balechandran T, Ridgway GL, Robinson
Gemmill I. Diagnosis of Chlamydia trachomatis JA. Comparison of azithromycin and doxycycline in
infections in asymptomatic men and women by PCR the treatment of non-gonococcal urethritis in men. J
assay. J Clin Microbiol 1996;34:1396-400. Antimicrob Chemother 1993;31:185-92.
21. Chernesky MA, Jang D, Lee H, Hu H, Sellors J, 34. Magid D, Douglas JM, Schwartz JS. Doxycycline
Tomazic-Allen SJ, et al. Diagnosis of Chlamydia compared with azithromycin for treating women with
trachomatis infections in men and women by testing genital Chlamydia trachomatis infections: an
first-void urine by ligase chain reaction. J Clin incremental cost-effectiveness analysis. Ann Intern
Microbiol 1994;32:2682-5. Med 1996;124:389-99.
22. Schachter J, Stamm WE, Quinn TC, Andrews WW, 35. Brunham RC, Peeling RW. Chlamydia trachomatis
Burczak JD, Lee H. Ligase chain reaction to detect antigens: role in immunity and pathogenesis. Infect
Chlamydia trachomatis infection of the cervix. J Clin Agents Dis 1994;3:218-33.
Microbiol 1994;32:2540-3. 36. Brunham RC, Plummer F, Stephens RS. Bacterial
23. Scholes D, Stergachis A, Heidrich FE, Andrilla HA, antigenic variation, host immune response and
Holmes KK, Stamm WE. Selective screening for patho ge n-host co -evolution. Infect Immun
chlamydia reduces the incidence of pelvic inflammatory 1993;61:2273-6.
disease: results from a randomised intervention trial. 37. Brunham R, Yang C, Maclean I, Kimani J, Maitha G,
J Infect Dis 1996 (in press). Plummer F. Chlamydia trachomatis from individuals
24. Cameron DW, Simonsen JN, D’Costa LJ, Ronald AR, in a sexually transmitted disease core group exhibit
Maitha GM, Gakinya MN, et al. Female to male frequence sequence variation in the major outer
transmission of human immunodeficiency virus type membrane protein (omp1) gene. J Clin Invest
1: risk factors for seroconversion in men. Lancet 1994;94:458-63.
1989;ii:403-7. 38. Hayes LJ, Bailey RL, Mabey DCW, Clarke IN, Pickett
25. Grosskurth H, Mosha F, Todd J, Mwijarubi E, Klokke MA, Watt PJ, et al. Genotyping of Chlamydia
A, Senkoro K, et al. Impact of improved treatment of trachomatis from a trachoma endemic village in the
sexually transmitted diseases on HIV infection in Gambia by a nested polymerase chain reaction:
rural Tanzania: randomised controlled trial. Lancet identification of strain variants. J Infect Dis
1995:346:530-6.

Vol. 2, No. 4—October-December 1996 317 Emerging Infectious Diseases

 Synopses

1992;166:1173-7. 53. Hinton DG, Shipley A, Galvim JW, Harkin JT,

39. Dean D, Schachter J, Dawson CR, Stephens RS. Brunton RA. Chlamydiosis in workers at a duck farm
Comparison of the major outer membrane protein and processing plant. Aust Vet J 1993;70:174-6.
variant sequence regions of B/Ba isolates: a molecular 54. Hedberg K, White KE, Forfang JC, Korlath JA,
epidemiologic approach to Chlamydia trachomatis Friendshuh, Hedberg CW, et al. An outbreak of
infections. J Infect Dis 1992;166:383-92. psittacosis in Minnesota turkey industry workers:
40. Schachter J, Dawson CR. Reiter’s Syndrome. Human implications for modes of transmission and control.
Chlamydial Infections. Littleton, MA: PSG Publishing Am J Epidemiol 1989;130:569-77.
Co., 1978. 55. Hadley KM, Carrington D, Frew CE, Gibson AAM,
41. Conway DJ, Holland MJ, Campbell AE, Bailey RL, Hislop WS. Ovine chlamydiosis in an abattoir worker.
Krausa P, Peeling RW, et al. HLA class I and class II J Infect Dis 1992;25:105-9.
polymorphism and trachomatous scarring in a 56. Regan RJ, Dathan JRE, Treharne JD. Infective
chlamydia trachomatis-endemic population. J Infect endocarditis with glomerulonephritis associated with
Dis 1996;174:643-6. cat chlamydia (C. psittaci) infection. British Heart
42. Kimani J, Maclean IW, Bwayo JJ, MacDonald K, Journal 1979;42:349-52.
Oyugi J, Maitha GM, et al. Risk factors for Chlamydia 57. Tong CYW, Sillis M. Detection of Chlamydia
trachomatis pelvic inflammatory disease among sex pneumoniae and Chlamydia psittaci in sputum
workers in Nairobi, Kenya. J Infect Dis 1996;173:1437- samples by PCR. J Clin Pathol 1993;46:313-7.
44. 58. Rasmussen SJ, Douglas FP, Timms P. PCR detection
43. Brunham RC, Maclean IW, Binns B, Peeling RW. and differentiation of Chlamydia pneumoniae,
Chlamydia trachomatis: its role in tubal infertility. J Chlamydia psittaci and Chlamydia trachomatis. Mol
Infect Dis 1985;152:1275-82. Cell Probes 1992;6:389-94.
44. Wagar EA, Schachter J, Bavoil P, Stephens RS. 59. Saikku P. Diagnosis of acute and chronic Chlamydia
Differential human serologic response to two 60,000 pneumoniae infections. In: Orfila J, et al., editors.
molecular weight Chlamydia trachomatis antigens. J Chlamydial Infections. Bologna: Societa Editrice
Infect Dis 1990;162:922-7. Esculapio, 1994.
45. Brunham RC, Peeling R, Maclean I, Kosseim ML, 60. Peeling RW. Laboratory diagnosis of Chlamydia
Paraskevas M. Chlamydia trachomatis-associated pneumoniae infections. Canadian Journal of Infectious
ectopic prgnancy:serologic and histologic correlates. J Diseases 1995;6:198-203.
Infect Dis 1992;165:1076-81. 61. Gnarpe J, Gnarpe H, Sundelof B. Endemic prevalence
46. Toye B, Laferriere C, Claman P, Jessamine P, Peeling of Chlamydia pneumoniae in subjectively healthy
R. Association between antibody to the chlamydial persons. Scand J Infect Dis 1991;23:387-8.
heat shock protein and tubal infertility. J Infect Dis 62. Montalban GS, Roblin PM, Hammerschlag MR.
1993;168:1236-40. Performance of three commercially available
47. Arno JN, Yuan Y, Cleary RE, Morrison RP. Serologic monoclonal reagents for confirmation of Chlamydia
responses of infertile women to the 60-kd chlamydial pneumoniae in cell culture. J Clin Microbiol
heat shock protein. Fertil Steril 1995;64:730-5. 1994;32:1406-7.
48. Peeling RW, Bailey RL, Conway D, Holland MJ, 63. Campbell LA, Melgosa MP, Hamilton DJ, Kuo C-C,
Dillon E, Mabey DCW. Antibody response to the Grayston JT. Detection of Chlamydia pneumoniae by
chlamydial heat shock protein 60 is associated with polymerase chain reaction. J Clin Microbiol
scarring trachoma. 96th American Society for 1992;30:434-9.
Microbiology meeting, New Orleans, May 1996. 64. Gaydos CA, Roblin PM, Hammerschlag MR, Hyman
Abstract #2871. CL, Eiden JJ, Schacter J, et al. Diagnostic utility of
49. Beatty WL, Byrne GI, Morrison RP. Morphologic and PCR-Enzyme Immunoassay, culture, and serology for
antigenic characterization of interferon gamma the detection of Chlamydia pneumoniae in
mediated persistent Chlamydia trachomatis infection symptomatic and asymptomatic patients. J Clin
in vitro. Proc Natl Acad Sci U S A 1993;90:3998-4002. Microbiol 1994;32:903-5.
50. Holland MJ, Bailey RL, Hayes LJ, Whittle HC, Mabey 65. Black CM, Fields PI, Messmer TO, Berdal BP.
DCW. Conjunctival scarring in trachoma is associated Detection of Chlamydia pneumoniae in clinical
with depressed cell-mediated immune responses to specimens by polymerase chain reaction using nested
chlamydial antigens. J Infect Dis 1993;168:1528-31. primers. Eur J Clin Microbiol Infect Dis 1994;13:752-
51. Morrison RP, Feilzer K, Tumas DB. Gene knock-out 6.
mice establish a primary role for major 66. Ekman MR, Leinonen M, Syrjala H, Linnanmaki E,
histocompatibility complex class II-restricted Kujala P, Saikku P. Evaluation of serological methods
responses in Chlamydia trachomatis genital tract in the diagnosis of Chlamydia pneumoniae during an
infection. Infect Immun 1995;63:4661-8. epidemic in Finland. Eur J Clin Microbiol Infect Dis
52. Igietseme JU, Magee DM, Williams DM, Rank RG. 1993;12:756-60.
Role for CD8+ T cells in antichlamydial immunity
defined by chlamydia-specific T-lymhocyte clones.
Infect Immun 1994;62:5195-7.

Emerging Infectious Diseases 318 Vol. 2, No. 4—October-December 1996

 Synopses

67. Roblin P, Montalban G, Hammerschlag MR. 73. Kuo CC, Shor A, Campbell L, Fukushi H, Patton D,
Susceptibilities to clarithromycin and erythromycin Grayston JT. Demonstration of Chlamydia
of isolates of Chlamydia pneumoniae from children pneumoniae in Atherosclerotic Lesions of Coronary
with pneumonia. Antimicrob Agents Chemother Arteries. J Infect Dis 1993;167:841-9.
1994;38:1588-9. 74. Muhlestein JB, Hammond E, Carlquist JF, Radicke
68. Grayston JT, Thom DH, Kuo C-C, Campbell LA, E, Thomson MJ, Karagounis LA, et al. Increased
Wang S-P. Chlamydia pneumoniae (TWAR) and incidence of Chlamydia species within the coronoary
atherosclerosis. In: Orfila J, Byrne G, Chernesky MA, arteries of patients with symptomatic atherosclerotic
et al, editors. Chlamydial Infections. Bologna: Societa versus other forms of cardiovascular disease. J Am
Editrice Esculapio, 1994. Coll Cardiol 1996;27:1555-61.
69. Saikku P, Leinonen M, Tenkanen L, Linnanmaki E, 75. Weiss SM, Roblin PM, Gaydos C, Cummings P, Patton
Ekman M-R, Manninen V, et al. Chronic Chlamydia D, Schulhoff N, et al. Failure to detect Chlamydia
pneumoniae Infection as a Risk Factor for Coronary pneumoniae in coronary atheromas of patients
Heart Disease in the Helsinki Heart Study. Ann undergoing atherectomy. J Infect Dis 1996;173:957-
Intern Med 1992;116:273-8. 62.
70. Thom D, Grayston JT, Siscovick D, Wang S-P, Weiss 76. Godzik K, O’Brien E, Wang S-K, Kuo CC. In Vitro
N, Daling J. Association of Prior Infection With Susceptibility of Human Vascular Wall Cells to
Chlamydia pneumoniae and Angiographically Infection with Chlamydia pneumoniae. J Clin
Demonstrated Coronary Artery Disease. JAMA Microbiol 1995;33:2411-4.
1992;268:68-72. 77. Hahn DL, Dodge RW, Golubjatnikov R. Association of
71. Melnick S, Shahar E, Folsom A, Grayston JT, Sorlie P, Chlamydia pneumoniae (TWAR) infection with
Wang S-P, et al. Past Infection by Chlamydia wheezing, asthmatic bronchitis and adult-onset
pneumoniae Strain TWAR and Asymptomatic asthma. JAMA 1991,266:225-30.
Carotid Atherosclerosis. Am J Med 1993;95:499-504. 78. Emre U, Sokolovskaya N, Roblin PM, Schachter J,
72. Shor A, Kuo CC, Patton D. Detection of Chlamydia Hammerschlag M. Detection of anti-Chlamydia
pneumoniae in coronary arterial fatty streaks and pneumoniae IgE in children with reactive airway
atheromatous plaques. S Afr Med J 1992;82:158-61. disease. J Infect Dis 1995;148:727-32.

Vol. 2, No. 4—October-December 1996 319 Emerging Infectious Diseases