Mycoplasmal pelvic inflammatory diseases.
Infections of the pelvic organs are often grouped together under the term "pelvic inflammatory diseases (P.I.D.)," which have multifactorial etiologies, In women of 25-35 age group, it is most often caused by microbial agents that are transmitted during sexual intercourse. Genital mycoplasmas, especially M. hominis, account for 10-15% of PID cases. This paper describes the incidence of mycoplasma in PID lesions. An ultra structure of M.hominis is also described.
A total of 222 patients in the age group of 18-45 years, attending the gynaecology department of a municipal hospital with complaints of lower genital tract infection (L.G.T.I.) were investigated from each patients, 2 cervical swabs were collected and immediately processed by (a) wet film, method for T. vaginalis,(b)Grams and Giemsa stains for N. gonorrhoea and inclusion bodies respectively, and (c)by culture studies on different media such as (i) Thyer-Martin, blood agar and Columbia agar with human blood for G. vaginalis. (ii)Sabouraud sagar. MacConkey's agar medium, PPLO broth and agar supplemented with argmine at pH = 7 for M. hominis and PPLO borth and agar supplemented with urea at pH between 6 and 6.4 for U urealyticum.
Laparoscopic samples from 11 patients of the PID group were obtained by aspiration of fluid through the masses or through the Douglas' pouch and were processed similarly; Transport media were used wherever necessary. None of the patients had received any treatment before sampling. Identification of various microorganisms was done by standard procedures as described by Cruiskshank. M. hominis and U. urealyticum were confirmed by growth inhibition on agar. Antibody studies and Chlamydial cultures were not done.
For electron microscopic studies, colonies of M. hominis were fixed in 3% glutaraldehyde for 3-4 hours at 4°C and processed further.
Out of 222 female patients with LGT1, 25 suffered with pelvic inflammatory disease (PID).
Out of these 25 cases of PID, 5 patients gave history of termination of pregnancy. In another 4 cases, IUCD was introduced immediately after termination of pregnancy where as in 3 cases, PID occurred soon after laparoscopic sterilization coupled with MTP.
In remaining 13 cases no surgical interference was done prior to onset of infection. These cases had history of chronic LGTI which might have given rise to ascending infection leading to PID.
Out of 25 cases of PID, in 11 cases laparoscopic study was done. Samples for microbiological studies were obtained by aspiration of fluid from masses or Douglas pouch. In 7 cases out of 11 evidence of pelvic infection in the form of masses, pyosalphingx or inflammation of tubes was detected, where as in other 4 cases the tubes and ovaries appeared healthy.
M. homonis was isolated in 5 cases out of 25 giving 20% isolation rate from cervical samples where as in 12% of cases (3 cases) M. hominis was isolated from the fallopian tube by laparoscopic sampling. In patients with LGTI M. hominis was isolated in 14 cases giving 6.3% isolation rate.
In 2 cases (8%) of PID, U. urealyticum was isolated. In both the cases, cervical as well as laparoscopic samples gave positive results. In patients with LGTI the isolation rate of U. urealyticum was 27.1%.
In one case (SP) where M. hominis was isolated by laparoscopic sample, the strain was confirmed by electron microscopy.
Electron microscopy revealed typical appearance* of M. hominis cell showing a limiting membrane, ribosomes and vacuoles [Fig. 1].
In the present study, M. hominis was isolated in 20% and 12% from cervical and laparoscopic samples respectively of patients suffering from PID. Mardh and Westrom have reported isolation of M. hominis from the cervix in 31 (62 percent), and 4 (8 per cent) patients had this microorganism isolated in pure culture from the fallopian tubes. Eschenbach et al have recovered M. hominis more frequently from endocervical culture in women with pelvic inflammatory disease than in women without upper genital tract disease.
In 2 cases of PID, U. urealyticum was isolated from the laparoscopic samples while in 10 patients the cervical cultures were positive for U. urealyticum. Mardh and Westrom6 have isolated T-mycoplasma from the fallopian tubes in 2 out of 50 cases of salpingitis. According to these authors, the recovery of T-strains from the fallopian tubes in salpingitis suggests that T-strain mycoplasma might be associated with inflammatory conditions of the adenexa.
While discussing on the causation of pelvic inflammatory disease, Keith et al have postulated the role of trichomonad and sperm as vectors carrying the microorganisms from the lower genital tract to the fallopian tubes. Fowlkes et al have demonstrated an association of U. urealyticum (T-mycoplasma) and sperm and this association might be the cause of serious infection in upper genital tract of women.
In conclusion, it can be said that genital mycoplasmas are important etiologic agents in 12-20% of PID cases.
We wish to thank Dr. E. A. Freundr, FAO/WHO collaborating centre for Animal Mycoplasmas, Aarhus, Denmark for interpretation of electron microphotographs.