Mycoplasma genitalium infection

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Mycoplasma genitalium
File:Mycoplasma genitalium.gif
Scientific classification
Kingdom: Bacteria
Division: Firmicutes
Class: Mollicutes
Order: Mycoplasmatales
Family: Mycoplasmataceae
Genus: Mycoplasma
Species: M. genitalium
Binomial name
Mycoplasma genitalium
Tully et al., 1983

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]

Overview

Mycoplasma genitalium infection is caused by the bacteria Mycoplasma genitalium. It was first isolated from 2 men with urethritis in the early 1980s, but was not recognized as a sexually transmitted disease until the early 1990s, following the development of polymerase chain reaction (PCR). Co-infection of Mycoplasma genitalium with other STDs is not uncommon. However, an isolated infection with Mycoplasma genitalium must be differentiated from other STDs, which may have a similar presentation. Mycoplasma genitalium infection is more common than Neisseria gonorrhea, but less common than Chlamydia trachomatis. However, it is not recognized as a common STD, largely because the infection is mostly asymptomatic. Symptoms are related to the complications it may cause, such as PID and cervicitis in women, and urethritis and epididymitis in men. Prompt antibiotic treatment is needed to prevent complications. Mycoplasma genitalium infection is prevented by promoting safe sexual practice, as well as the use of condoms.

Historical Perspective

Classification

Mycoplasma genitalium infection can be divided based on the clinical presentation into:[2][6][7][8][9][10]

  • Asymptomatic Mycoplasma genitalium infection
  • Symptomatic Mycoplasma genitalium infection: symptoms are related to PID or cervicitis in women and urethritis or epididymitis in men

Pathophysiology

Pathogenesis

Mode of Transmission

  • Mycoplasma genitalium is recognized as a sexually transmitted disease (STD) with the mode of transmission being through direct genital-to-genital contact and subsequent inoculation of infected secretions. Transmission of Mycoplasma genitalium has also been implicated in penile-anal intercourse.[2]
  • Mycoplasma genitalium is less likely to be transmitted via oro-genital contact, as carriage in the oropharynx is low.[2]
  • Whether or not Mycoplasma genitalium is vertically transmitted from mother to newborn is yet to be studied. However, the bacterium has been isolated from the respiratory tract of newborns.[2]

Incubation Period

The incubation period of Mycoplasma genitalium is unknown yet.[11]

Infectious Dose

The infectious dose of Mycoplasma genitalium is unknown yet.[11]

Factors facilitating the pathogenesis of Mycoplasma genitalium

The following virulence factors have been implicated in the pathogenesis of Mycoplasma genitalium:[1][2][12]

  • Adhesion molecules: Mycoplasma genitalium has the ability to attach to different types of cells, including red blood cells, respiratory cells, fallopian tube cells, as well as sperm cells. It is believed that the attachment to sperm cells facilitates the spread of Mycoplasma genitalium to the female genital tract. MgPa, a major adhesion in attachment protein complex, facilitates not only adhesion to epithelial cells, but also the motility of Mycoplasma genitalium.
  • Intracellular localization: Mycoplasma genitalium is a facultative intracellular organism and this allows for its survival both inside and outside of cells.
  • Antigenic variation: Mycoplasma genitalium is able to generate surface lipoprotein with high frequency, which helps it evade the human immune system.
  • Toxins: Mycoplasma genitalium has a calcium-dependent membrane associated nuclease known as MG-186. MG-186 is capable of degrading host cell nucleic acid, hence providing a source of nucleotides for the growth and pathogenesis of Mycoplasma genitalium.
  • Enzymes: Glyceraldehyde 3-phosphate dehydrogenase (GADPH) acts as a ligand to the receptors mucin and fibronectin, found on vaginal and cervical epithelium.
  • Immunological response: Mycoplasma genitalium possesses an immunogenic protein, MG-309, which secretes pro-inflammatory cytokines, such as IL-6 and IL-8. MG-309 exerts its effect via attaching to a toll-like receptor, hence activating nuclear factor kappa B (NF-kB)

Genetics

There are no identified genetic factors associated with Mycoplasma genitalium infection.

Associated Conditions

Mycoplasma genitalium infection is associated with co-infection with other sexually transmitted diseases, such as:[13]

Gross Pathology

Gross pathology of Mycoplasma genitalium infection is related to the disease processes it may result: cervicitis, PID, urethritis, or epididymitis.

Microscopic Pathology

Microscopic pathology of Mycoplasma genitalium infection is related to the disease processes it may result: cervicitis, PID, urethritis, or epididymitis.

Causes

The cause of Mycoplasma genitalium infection is Mycoplasma genitalium.

Differentiating Mycoplasma genitalium Infection from Other Diseases

Mycoplasma genitalium infection must be distinguished from other sexually transmitted diseases, which may have a similar presentation. These include:

Epidemiology and Demographics

  • The incidence and prevalence of Mycoplasma genitalium is not well established, because more than half of the women who tested positive were asymptomatic.[2]
  • In the United States, the prevalence of Mycoplasma genitalium was estimated as follows:[13]
    • The prevalence of Mycoplasma genitalium in all females aged 14-70 years old is 16.3%.
    • The prevalence of Mycoplasma genitalium in all males aged 18-78 years old is 17.2%.
    • Infection in both males and females was more prevalent in those younger than 30 years of age.
    • The overall prevalence of Mycoplasma genitalium infection is 1%, which makes it more prevalent than Neisseria gonorrhea (0.4%), but less common than Chlamydia trachomatis (4.2%).[14]
  • Between the years 2002-2011, the prevalence of Mycoplasma genitalium worldwide ranged between 4%-42%.[12]

Risk Factors

There several risk factors that have been identified with Mycoplasma genitalium infection. These risk factors include:[2][4][15]

  • High risk sexual behavior, defined as having >3 new sexual partners in the past year
  • Being engaged in sexual contact with persons with STDs, particularly Mycoplasma genitalium
  • Non-white race
  • Young age (<20 years old)
  • Smoking
  • Having less than high school education
  • Having an annual income of less than $10,000
  • Risk factors specific to females includes:

Screening

There are no recommendations for screening for Mycoplasma genitalium.[16]

Natural history, Complications and Prognosis

Natural History

If left untreated, Mycoplasma genitalium infection can lead to persistent cervicitis, PID, or urethritis.[3]

Complications

The following complications may be the result of Mycoplasma genitalium infection:[2][5][6][7][8][17][18][19][20][21]

Prognosis

The prognosis of Mycoplasma genitalium infection is generally excellent. Cure rates are almost 100% with the correct and prompt antibiotic treatment.[3]

History and Symptoms

The presenting symptoms of Mycoplasma genitalium are related to the disease processes it may cause. Presenting symptoms can be divided based on gender:

Physical Examination

Physical examination findings in Mycoplasma genitalium are related to the disease processes it may cause. These findings can be divided based on the several disease pathologies in males and females.

Laboratory Findings

  • Culture of Mycoplasma genitalium is not commonly used, as culture takes about 6 months to grow and is not widely available.[2]
  • Nucleic acid amplification test (NAAT) via polymerase chain reaction (PCR) or transcription-mediated amplification (TMA) is the preferred method for isolating Mycoplasma genitalium. Samples can be obtained from urine, urethral, vaginal or cervical swabs. However, first void urine sample is considered the best method for isolating the organism in both females and males.[2][3][22][26][27][28]

Imaging Findings

X Ray

There is no role for x ray in Mycoplasma genitalium infection.

CT

CT scan may be used if Mycoplasma genitalium infection has been complicated by pelvic inflammatory disease (PID). These include thickened and fluid-filled tubes with or without free pelvic fluid.

MRI

MRI may be used if Mycoplasma genitalium infection has been complicated by pelvic inflammatory disease (PID).

Other Diagnostic Studies

There are no other diagnostic studies for Mycoplasma genitalium infection.

Medical Therapy

Mycoplasma genitalium is intracellular and hence, eradication of the organism is sometimes challenging. The antibiotic drug of choice and dosing depends on susceptibility of the Mycoplasma genitalium strain, as well as the clinical presentation of the infection, as follows:[2][3][5]

  • Doxycycline has poor efficacy for Mycoplasma genitalium.
  • For uncomplicated Mycoplasma genitalium infection susceptible to macrolides, azithromycin given as a single 1g dose or 500mg on day 1 followed by 250mg on days 2-5 may be used. Another macrolide that may be used is josamycin 500mg, given 3 times daily for 10 days.
  • For uncomplicated macrolide resistant Mycoplasma genitalium infection, moxifloxacin 400mg once daily is given for 7-10 days.
  • Pristinamycin 1g 4 times daily is given for 7-10 days when both azithromycin and moxifloxacin fail.
  • For complicated Mycoplasma genitalium infection, moxifloxacin 400mg once daily is used for 14 days.

Surgery

Surgical intervention is not recommended for the management of Mycoplasma genitalium infection.

Primary Prevention

Since Mycoplasma genitalium infection is a sexually transmitted disease, prevention must target safe sexual practices. These include:[29][30]

  • Practicing safe sex with one partner and avoiding multiple sexual partners
  • Using condoms and/or other barrier methods

Secondary Prevention

Secondary prevention in Mycoplasma genitalium infection consists of the following measures:[2]

  • Prompt treatment with antibiotics to prevent complications of the infection
  • Partner notification and evaluation: if partner does not attend evaluation for infection, then he/she can be offered the same treatment as the patient
  • Screening for other sexually transmitted diseases

References

  1. 1.0 1.1 Taylor-Robinson D, Jensen JS (2011). "Mycoplasma genitalium: from Chrysalis to multicolored butterfly". Clin. Microbiol. Rev. 24 (3): 498–514. doi:10.1128/CMR.00006-11. PMC 3131060. PMID 21734246.
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 Jensen JS, Cusini M, Gomberg M, Moi H (2016). "Background review for the 2016 European guideline on Mycoplasma genitalium infections". J Eur Acad Dermatol Venereol. doi:10.1111/jdv.13850. PMID 27605499.
  3. 3.0 3.1 3.2 3.3 3.4 "Sexually Transmitted Diseases: Summary of 2015 CDC Treatment Guidelines". J Miss State Med Assoc. 56 (12): 372–5. 2015. PMID 26975162.
  4. 4.0 4.1 4.2 Manhart LE, Critchlow CW, Holmes KK, Dutro SM, Eschenbach DA, Stevens CE, Totten PA (2003). "Mucopurulent cervicitis and Mycoplasma genitalium". J. Infect. Dis. 187 (4): 650–7. doi:10.1086/367992. PMID 12599082.
  5. 5.0 5.1 5.2 5.3 Ross JD, Jensen JS (2006). "Mycoplasma genitalium as a sexually transmitted infection: implications for screening, testing, and treatment". Sex Transm Infect. 82 (4): 269–71. doi:10.1136/sti.2005.017368. PMC 2564705. PMID 16877571.
  6. 6.0 6.1 6.2 6.3 Falk L, Fredlund H, Jensen JS (2004). "Symptomatic urethritis is more prevalent in men infected with Mycoplasma genitalium than with Chlamydia trachomatis". Sex Transm Infect. 80 (4): 289–93. doi:10.1136/sti.2003.006817. PMC 1744873. PMID 15295128.
  7. 7.0 7.1 7.2 7.3 Jensen JS, Orsum R, Dohn B, Uldum S, Worm AM, Lind K (1993). "Mycoplasma genitalium: a cause of male urethritis?". Genitourin Med. 69 (4): 265–9. PMC 1195084. PMID 7721285.
  8. 8.0 8.1 8.2 8.3 Anagrius C, Loré B, Jensen JS (2005). "Mycoplasma genitalium: prevalence, clinical significance, and transmission". Sex Transm Infect. 81 (6): 458–62. doi:10.1136/sti.2004.012062. PMC 1745067. PMID 16326846.
  9. 9.0 9.1 9.2 Tosh AK, Van Der Pol B, Fortenberry JD, Williams JA, Katz BP, Batteiger BE, Orr DP (2007). "Mycoplasma genitalium among adolescent women and their partners". J Adolesc Health. 40 (5): 412–7. doi:10.1016/j.jadohealth.2006.12.005. PMC 1899169. PMID 17448398.
  10. 10.0 10.1 10.2 Korte JE, Baseman JB, Cagle MP, Herrera C, Piper JM, Holden AE, Perdue ST, Champion JD, Shain RN (2006). "Cervicitis and genitourinary symptoms in women culture positive for Mycoplasma genitalium". Am. J. Reprod. Immunol. 55 (4): 265–75. doi:10.1111/j.1600-0897.2005.00359.x. PMID 16533338.
  11. 11.0 11.1 Public Health Agency of Canada http://www.phac-aspc.gc.ca/lab-bio/res/psds-ftss/mycoplasma-genitalium-eng.php Accessed on Oct 6, 2016.
  12. 12.0 12.1 Sethi S, Singh G, Samanta P, Sharma M (2012). "Mycoplasma genitalium: an emerging sexually transmitted pathogen". Indian J. Med. Res. 136 (6): 942–55. PMC 3612323. PMID 23391789.
  13. 13.0 13.1 Getman D, Jiang A, O'Donnell M, Cohen S (2016). "Mycoplasma genitalium Prevalence, Coinfection, and Macrolide Antibiotic Resistance Frequency in a Multicenter Clinical Study Cohort in the United States". J. Clin. Microbiol. 54 (9): 2278–83. doi:10.1128/JCM.01053-16. PMC 5005488. PMID 27307460.
  14. Manhart LE, Holmes KK, Hughes JP, Houston LS, Totten PA (2007). "Mycoplasma genitalium among young adults in the United States: an emerging sexually transmitted infection". Am J Public Health. 97 (6): 1118–25. doi:10.2105/AJPH.2005.074062. PMC 1874220. PMID 17463380.
  15. Hancock EB, Manhart LE, Nelson SJ, Kerani R, Wroblewski JK, Totten PA (2010). "Comprehensive assessment of sociodemographic and behavioral risk factors for Mycoplasma genitalium infection in women". Sex Transm Dis. 37 (12): 777–83. doi:10.1097/OLQ.0b013e3181e8087e. PMC 4628821. PMID 20679963.
  16. United States Preventive Services Task Force https://www.uspreventiveservicestaskforce.org/BrowseRec/Search?s=mycoplasma+genitalium Accessed on Oct. 6, 2016.
  17. 17.0 17.1 Wetmore CM, Manhart LE, Lowens MS, Golden MR, Whittington WL, Xet-Mull AM, Astete SG, McFarland NL, McDougal SJ, Totten PA (2011). "Demographic, behavioral, and clinical characteristics of men with nongonococcal urethritis differ by etiology: a case-comparison study". Sex Transm Dis. 38 (3): 180–6. doi:10.1097/OLQ.0b013e3182040de9. PMC 4024216. PMID 21285914.
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  19. 19.0 19.1 Falk L, Fredlund H, Jensen JS (2005). "Signs and symptoms of urethritis and cervicitis among women with or without Mycoplasma genitalium or Chlamydia trachomatis infection". Sex Transm Infect. 81 (1): 73–8. doi:10.1136/sti.2004.010439. PMC 1763725. PMID 15681728.
  20. 20.0 20.1 Gaydos C, Maldeis NE, Hardick A, Hardick J, Quinn TC (2009). "Mycoplasma genitalium as a contributor to the multiple etiologies of cervicitis in women attending sexually transmitted disease clinics". Sex Transm Dis. 36 (10): 598–606. doi:10.1097/OLQ.0b013e3181b01948. PMC 2924808. PMID 19704398.
  21. Short VL, Totten PA, Ness RB, Astete SG, Kelsey SF, Haggerty CL (2009). "Clinical presentation of Mycoplasma genitalium Infection versus Neisseria gonorrhoeae infection among women with pelvic inflammatory disease". Clin. Infect. Dis. 48 (1): 41–7. doi:10.1086/594123. PMC 2652068. PMID 19025498.
  22. 22.0 22.1 Moi H, Reinton N, Moghaddam A (2009). "Mycoplasma genitalium in women with lower genital tract inflammation". Sex Transm Infect. 85 (1): 10–4. doi:10.1136/sti.2008.032748. PMID 18842689.
  23. Wiesenfeld HC, Sweet RL, Ness RB, Krohn MA, Amortegui AJ, Hillier SL (2005). "Comparison of acute and subclinical pelvic inflammatory disease". Sex Transm Dis. 32 (7): 400–5. PMID 15976596.
  24. Peipert JF, Ness RB, Blume J, Soper DE, Holley R, Randall H, Sweet RL, Sondheimer SJ, Hendrix SL, Amortegui A, Trucco G, Bass DC (2001). "Clinical predictors of endometritis in women with symptoms and signs of pelvic inflammatory disease". Am. J. Obstet. Gynecol. 184 (5): 856–63, discussion 863–4. doi:10.1067/mob.2001.113847. PMID 11303192.
  25. Horner PJ, Taylor-Robinson D (2011). "Association of Mycoplasma genitalium with balanoposthitis in men with non-gonococcal urethritis". Sex Transm Infect. 87 (1): 38–40. doi:10.1136/sti.2010.044487. PMID 20852310.
  26. Workowski KA, Bolan GA (2015). "Sexually transmitted diseases treatment guidelines, 2015". MMWR Recomm Rep. 64 (RR-03): 1–137. PMID 26042815.
  27. Huppert JS, Mortensen JE, Reed JL, Kahn JA, Rich KD, Hobbs MM (2008). "Mycoplasma genitalium detected by transcription-mediated amplification is associated with Chlamydia trachomatis in adolescent women". Sex Transm Dis. 35 (3): 250–4. doi:10.1097/OLQ.0b013e31815abac6. PMC 3807598. PMID 18490867.
  28. Högdahl M, Kihlström E (2007). "Leucocyte esterase testing of first-voided urine and urethral and cervical smears to identify Mycoplasma genitalium-infected men and women". Int J STD AIDS. 18 (12): 835–8. doi:10.1258/095646207782716983. PMID 18073017.
  29. LeFevre ML. USPSTF: behavioral counseling interventions to prevent sexually transmitted infections. Ann Intern Med 2014;161:894–901.
  30. Warner L, Stone KM, Macaluso M, et al. Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiologic studies. Sex Transm Dis 2006;33:36–51.

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