- Email: [email protected]
Pregnancy complicated by severe Chlamydia psittaci infection acquired from a goat flock: a case report
European Journal of Obstetrics & Gynecoiogv and Reproductive
91
Biology, 31 (1990) 91-94
Els&icr EUROBS 00976
Pregnancy complicated by severe Chlamydia psittaci infection acquired from a goat flock: a case report P. Villemonteix
‘, G. Agius 2, B. Ducroz ‘, J. Rouffineau M. Castets ’ and G. Maguin’
3, V. Plocoste
i,
’ Service de Gynkologie-ObstPtrique, 2 Laboratoire de Microbiologic B, and ’ Service de R&animation Chirurgicale, Centre Hospitalier La MiMtrie, Poitiers, France Accepted for publication 8 November 1989 Pregnancy; Infection; Goat flock; C. psittaci
Case report
A 26-year-old farmer’s wife, in the 32nd week of her second pregnancy, presented with a temperature of 38.5’C, cough and headache. She had been treated at home with amoxicillin for 2 days, without benefit. She was admitted to the hospital on 4 May 1988, presenting with a premature labour and a quick delivery (1 hour) of a stillborn boy, weighing 1800 g, dead per partum. Six hours after admission, her temperature rose to 39.5” C and she developed acute adult respiratory distress syndrome. The chest radiogram showed bilateral and basal pulmonary oedema. Blood pressure was 60 mmHg. The oxygen pressure was 5.4 kPa, and the pulmonary capillary wedge pressure was 1.2 kPa at the intensive care unit (ICU). Continuous positive airways pressure without intubation was initiated. The blood creatinine value was 406 pmol/l, haemoglobin level 6.0 g/dl, haematocrit value 20%, bilirubin level 78.7 pmol/l, and the platelet count was 20.0 - 109/1. Fibrin degradation products at 80 mg/l (normal range less than 10 mg/l) and anti-platelet antibodies with a titer of 9720 in specific total immunoglobulins (IgT) were present. Acute pneumonitis, and renal, respiratory and circulatory failures associated with an haemolytic anaemia, and a disseminated intravascular coagulation with purpura were diagnosed. She responded well to intravenous amoxicillin, clavulanic acid, gentamicin and spiramycin. On 10 May 1988, the pulmonary, renal, hepatic and haematological functions returned to normal, and the patient was discharged from the ICU. A follow-up of 6 months was uneventful. Bacteriological cultures from blood, urine, stools, cervix, placental and fetal tissues were negative. No virus or Chlamydia isolations were performed. A compleCorrespondence: P. Villemonteix, Chef de Clinique, Service de Gyn&zologie, Obsdtrique Tour&), CHR La Mil&rie, B.P. 577,86021 Poitiers Cedex, France. 0028-2243/90/$03.50
8 1990 Elsevier Science Publishers B.V. (Biomedical Division)
(Pr. H. de
92 TABLE I Chlamydia psittaci ovine strains Dates
05-05-88 19-05-88
and Chlamydia
trachomatis
titers by CFT and IFA using antigens
CFT C. psittacci
IFA C. psittacci
avian
ovine
avian
20 160
40 160
from avian and
IFA C. trachomatis ovine
IgT
IgM
IgT
IgM
32 2048
C6 24
16 2048
(6 24
IgT
IgM
32 2048
<6 12
ment fixation test (CFT), routinely used, was negative with antigens from the following organisms: Myxovirus injluenza A and B, Myxovirus parainfluenza, respiratory syncytial virus, adenovirus, Herpes simplex virus, coxsackie viruses type Bl to 6, cytomegalovirus, Coxiella burneti and Mycoplasma pneumoniae. An immunofluorescence assay (IFA) for detecting specific IgT against Legionella pneumophila was negative. A CFT and an IFA for Chlumydia psittaci were carried out using both avian and ovine abortion strains as antigens. Serologic findings showed a significant increase in IgT, with specific IgM, indicating an active chlamydial infection (Table I). In addition, alI these serologic investigations performed on sera from here husband were completely negative.
Fig. 1. Electronic microscopy
slide = X 36 500 syncytiotrophoblastic
cell inclusions
= sizes 300 to 500 nm.
93
No histologic abnormality was found in the fetal tissues, except for the presence of haemorrhagic foci in the liver. The placental tissues showed an acute placentitis, with few trophoblastic basophil inclusions. An IFA using an antibody anti-Chlumydia in tissue sections showed elementary body-like formations located in syncytiotrophoblast. Electronic microscopy examination showed inclusions, sizing 300 to 500 run, surrounded by a rigid wall (Fig. 1). Further inquiries revealed that 1 month before the onset of her symptoms the patient had helped goats drop their kids on the farm. Spontaneous abortions and death of one third of the goat flock occurred. There was no other cattle on the farm, and the flock was not vaccinated. A C. psittacci infection was serologically diagnosed within the flock. Discussion Chlamydiae are obligate intracellular bacteria, including one genus Chlamydia and two species C. trachomatis and C. psittacci (Moulder 1984). C. trachomatis infects only humans whereas C. psittacci is a common pathogen in many avian and mammalian species [4]. In humans, C. psittacci infections almost always result from exposure to infected avian species. However, rare infections due to mammalian strains of C. psittucci, are usually symptomless or symptoms similar to a mild lower respiratory illness may occur [l]. In addition, scarce and severe cases of ovine C. psittucci infections have been described during pregnancy [2,5-7,9]. Fetal death occuring in ante [5-71, per [9] or post [7] partum remains a frequent outcome. Moreover, a favourable evolution for the foetus has only been reported in one case after a Caesarean section [2]. Toxic products from the chlamydial metabolism and tissue damage would explain placental insufficiency followed by fetal death [3]. Clinical presentation in pregnant women always showed a prodromal influenzalike illness for 2-4 days. Afterwards, maternal prognosis was closely linked with the control of multiple organ failure. Cardiac failure may be fatal [2], whereas renal failure was usually resolving itself within 5-7 days [7]. The frequent presence of disseminated intravascular coagulation, requiring heparinotherapy and platelet transfusions before any surgery, might result from the release of thromboplastic products and/or chlamydial endotoxin into maternal circulation [3]. It should be noted that in our observation intensive care was needed in order to control the respiratory distress syndrome. Only serological investigations were performed because the diagnosis of a chlamydial infection was not initially considered. The Chlumydia serology clearly showed an active infection but failed to distinguish the antibody response to avian or ovine strains of C. psittucci. The envelope antigens from various animal strains, used for serological determinations [8], show many epitopes which induce large cross-reactivities [4]. However, the occupational history of the patient and the C. psittucci infection occuring in the goat flock strongly suggest that the infection has been acquired from this animal source. Histopathological examination may strengthen a chlamydial involvement, especially when immunostaining techniques and electronic microscopy were used [lo]. Our case seems to be the first acquired from goat flock. It should be noted that previous reports have mentioned a
94
transmission from sheep [2,5,6,9]. Recently, a double infection with C. psittucci and C. burneti has been reported during pregnancy [6]. Finally, pregnant women, especially during the third trimester, are more liable to C. psittacci infection. Direct examination and isolation of Chlamydia should be attempted from placental and fetal tissues in cases of febrile abortion. Thus, the removal from potential sources of zoonotic infections should always be recommended to pregnant women, particularly those living in the farming communities. Acknowledgements The authors thank Dr. Franqois Eb from the laboratory of Bacteriology, Hospital Centre, Amiens, for performing the serology of Chlamydiu psittuci using antigens from avian and ovine strains, and Dr. Pierre Levillain from the laboratory of Pathology, Hospital Centre, Poitiers, for performing the histopathological, and electronic microscopy examination. References 1 Baker CC, Cooper B. (1983) A case of good management. J. Infect 1983;6:71-73. 2 Beer RJS, Bradford WP, Hart RJC. Pregnancy complicated by psittacosis acquired from sheep. Br Med J 1982;284:1156-1157. 3 Buxton D. Potential danger to pregnant women of Chlumydia psittuci from sheep. Vet Ret 1986;118:510-511. 4 Eb F, Orfila J, Milan A, G&al MF. In&% 6pidCmiologique du typage par immunofluorescence de Chlumydiu psittacci. Ann Inst Pasteur/Microbial 1986;137B;77-93. 5 Johnson FWA, Ma&son BA, Williams H, Laing AG, Jandrial V, Davidson-Lamb R, Halliday GJ, Hobson D, Wong SY, Hadley KM, Moffat MAJ, Postlethwaite R. Abortion due to infection with Chlumydiu psirtucci in a sheep farmer’s wife. Br Med J 1985;290:592-594. 6 M&kern D, White R, Paul ID, Caul EO, Roome APCH, Westmoreland, D. Concomitant zoonotic infections with ovine Chkzmydiu and ‘Q’ fever in pregnancy: clinical features, diagnosis, management and public health implications. Br J Obstet Gynaecol 1988;95:294-298. 7 M&inlay AW, White N, Buxton D, Inghs JIM, Johnson FWA, Burtz JB, BrettIe RP. Severe Chlumydiu psittucci sepsis in pregnancy. Q J Med 1985;57:689-696. 8 Moulder JW. Looking at Chlamydiae without looking at their hosts. Am Sot Microbial News 1984;50:353-362. 9 Roberts W, Grist NR, Giroud P. Human abortion associated with infection by ovine abortion agent. 1967;Br. Med J 4~37. 10 Wong SY, Gray ES, Buxton D, Fiiayson J, Johnson FWA. Acute placentitis and spontaneous abortion caused by CMamydia psittuci of sheep origin: a histological and ultrastructural study. J Clin Path01 1985;38:707-711.
91
Biology, 31 (1990) 91-94
Els&icr EUROBS 00976
Pregnancy complicated by severe Chlamydia psittaci infection acquired from a goat flock: a case report P. Villemonteix
‘, G. Agius 2, B. Ducroz ‘, J. Rouffineau M. Castets ’ and G. Maguin’
3, V. Plocoste
i,
’ Service de Gynkologie-ObstPtrique, 2 Laboratoire de Microbiologic B, and ’ Service de R&animation Chirurgicale, Centre Hospitalier La MiMtrie, Poitiers, France Accepted for publication 8 November 1989 Pregnancy; Infection; Goat flock; C. psittaci
Case report
A 26-year-old farmer’s wife, in the 32nd week of her second pregnancy, presented with a temperature of 38.5’C, cough and headache. She had been treated at home with amoxicillin for 2 days, without benefit. She was admitted to the hospital on 4 May 1988, presenting with a premature labour and a quick delivery (1 hour) of a stillborn boy, weighing 1800 g, dead per partum. Six hours after admission, her temperature rose to 39.5” C and she developed acute adult respiratory distress syndrome. The chest radiogram showed bilateral and basal pulmonary oedema. Blood pressure was 60 mmHg. The oxygen pressure was 5.4 kPa, and the pulmonary capillary wedge pressure was 1.2 kPa at the intensive care unit (ICU). Continuous positive airways pressure without intubation was initiated. The blood creatinine value was 406 pmol/l, haemoglobin level 6.0 g/dl, haematocrit value 20%, bilirubin level 78.7 pmol/l, and the platelet count was 20.0 - 109/1. Fibrin degradation products at 80 mg/l (normal range less than 10 mg/l) and anti-platelet antibodies with a titer of 9720 in specific total immunoglobulins (IgT) were present. Acute pneumonitis, and renal, respiratory and circulatory failures associated with an haemolytic anaemia, and a disseminated intravascular coagulation with purpura were diagnosed. She responded well to intravenous amoxicillin, clavulanic acid, gentamicin and spiramycin. On 10 May 1988, the pulmonary, renal, hepatic and haematological functions returned to normal, and the patient was discharged from the ICU. A follow-up of 6 months was uneventful. Bacteriological cultures from blood, urine, stools, cervix, placental and fetal tissues were negative. No virus or Chlamydia isolations were performed. A compleCorrespondence: P. Villemonteix, Chef de Clinique, Service de Gyn&zologie, Obsdtrique Tour&), CHR La Mil&rie, B.P. 577,86021 Poitiers Cedex, France. 0028-2243/90/$03.50
8 1990 Elsevier Science Publishers B.V. (Biomedical Division)
(Pr. H. de
92 TABLE I Chlamydia psittaci ovine strains Dates
05-05-88 19-05-88
and Chlamydia
trachomatis
titers by CFT and IFA using antigens
CFT C. psittacci
IFA C. psittacci
avian
ovine
avian
20 160
40 160
from avian and
IFA C. trachomatis ovine
IgT
IgM
IgT
IgM
32 2048
C6 24
16 2048
(6 24
IgT
IgM
32 2048
<6 12
ment fixation test (CFT), routinely used, was negative with antigens from the following organisms: Myxovirus injluenza A and B, Myxovirus parainfluenza, respiratory syncytial virus, adenovirus, Herpes simplex virus, coxsackie viruses type Bl to 6, cytomegalovirus, Coxiella burneti and Mycoplasma pneumoniae. An immunofluorescence assay (IFA) for detecting specific IgT against Legionella pneumophila was negative. A CFT and an IFA for Chlumydia psittaci were carried out using both avian and ovine abortion strains as antigens. Serologic findings showed a significant increase in IgT, with specific IgM, indicating an active chlamydial infection (Table I). In addition, alI these serologic investigations performed on sera from here husband were completely negative.
Fig. 1. Electronic microscopy
slide = X 36 500 syncytiotrophoblastic
cell inclusions
= sizes 300 to 500 nm.
93
No histologic abnormality was found in the fetal tissues, except for the presence of haemorrhagic foci in the liver. The placental tissues showed an acute placentitis, with few trophoblastic basophil inclusions. An IFA using an antibody anti-Chlumydia in tissue sections showed elementary body-like formations located in syncytiotrophoblast. Electronic microscopy examination showed inclusions, sizing 300 to 500 run, surrounded by a rigid wall (Fig. 1). Further inquiries revealed that 1 month before the onset of her symptoms the patient had helped goats drop their kids on the farm. Spontaneous abortions and death of one third of the goat flock occurred. There was no other cattle on the farm, and the flock was not vaccinated. A C. psittacci infection was serologically diagnosed within the flock. Discussion Chlamydiae are obligate intracellular bacteria, including one genus Chlamydia and two species C. trachomatis and C. psittacci (Moulder 1984). C. trachomatis infects only humans whereas C. psittacci is a common pathogen in many avian and mammalian species [4]. In humans, C. psittacci infections almost always result from exposure to infected avian species. However, rare infections due to mammalian strains of C. psittucci, are usually symptomless or symptoms similar to a mild lower respiratory illness may occur [l]. In addition, scarce and severe cases of ovine C. psittucci infections have been described during pregnancy [2,5-7,9]. Fetal death occuring in ante [5-71, per [9] or post [7] partum remains a frequent outcome. Moreover, a favourable evolution for the foetus has only been reported in one case after a Caesarean section [2]. Toxic products from the chlamydial metabolism and tissue damage would explain placental insufficiency followed by fetal death [3]. Clinical presentation in pregnant women always showed a prodromal influenzalike illness for 2-4 days. Afterwards, maternal prognosis was closely linked with the control of multiple organ failure. Cardiac failure may be fatal [2], whereas renal failure was usually resolving itself within 5-7 days [7]. The frequent presence of disseminated intravascular coagulation, requiring heparinotherapy and platelet transfusions before any surgery, might result from the release of thromboplastic products and/or chlamydial endotoxin into maternal circulation [3]. It should be noted that in our observation intensive care was needed in order to control the respiratory distress syndrome. Only serological investigations were performed because the diagnosis of a chlamydial infection was not initially considered. The Chlumydia serology clearly showed an active infection but failed to distinguish the antibody response to avian or ovine strains of C. psittucci. The envelope antigens from various animal strains, used for serological determinations [8], show many epitopes which induce large cross-reactivities [4]. However, the occupational history of the patient and the C. psittucci infection occuring in the goat flock strongly suggest that the infection has been acquired from this animal source. Histopathological examination may strengthen a chlamydial involvement, especially when immunostaining techniques and electronic microscopy were used [lo]. Our case seems to be the first acquired from goat flock. It should be noted that previous reports have mentioned a
94
transmission from sheep [2,5,6,9]. Recently, a double infection with C. psittucci and C. burneti has been reported during pregnancy [6]. Finally, pregnant women, especially during the third trimester, are more liable to C. psittacci infection. Direct examination and isolation of Chlamydia should be attempted from placental and fetal tissues in cases of febrile abortion. Thus, the removal from potential sources of zoonotic infections should always be recommended to pregnant women, particularly those living in the farming communities. Acknowledgements The authors thank Dr. Franqois Eb from the laboratory of Bacteriology, Hospital Centre, Amiens, for performing the serology of Chlamydiu psittuci using antigens from avian and ovine strains, and Dr. Pierre Levillain from the laboratory of Pathology, Hospital Centre, Poitiers, for performing the histopathological, and electronic microscopy examination. References 1 Baker CC, Cooper B. (1983) A case of good management. J. Infect 1983;6:71-73. 2 Beer RJS, Bradford WP, Hart RJC. Pregnancy complicated by psittacosis acquired from sheep. Br Med J 1982;284:1156-1157. 3 Buxton D. Potential danger to pregnant women of Chlumydia psittuci from sheep. Vet Ret 1986;118:510-511. 4 Eb F, Orfila J, Milan A, G&al MF. In&% 6pidCmiologique du typage par immunofluorescence de Chlumydiu psittacci. Ann Inst Pasteur/Microbial 1986;137B;77-93. 5 Johnson FWA, Ma&son BA, Williams H, Laing AG, Jandrial V, Davidson-Lamb R, Halliday GJ, Hobson D, Wong SY, Hadley KM, Moffat MAJ, Postlethwaite R. Abortion due to infection with Chlumydiu psirtucci in a sheep farmer’s wife. Br Med J 1985;290:592-594. 6 M&kern D, White R, Paul ID, Caul EO, Roome APCH, Westmoreland, D. Concomitant zoonotic infections with ovine Chkzmydiu and ‘Q’ fever in pregnancy: clinical features, diagnosis, management and public health implications. Br J Obstet Gynaecol 1988;95:294-298. 7 M&inlay AW, White N, Buxton D, Inghs JIM, Johnson FWA, Burtz JB, BrettIe RP. Severe Chlumydiu psittucci sepsis in pregnancy. Q J Med 1985;57:689-696. 8 Moulder JW. Looking at Chlamydiae without looking at their hosts. Am Sot Microbial News 1984;50:353-362. 9 Roberts W, Grist NR, Giroud P. Human abortion associated with infection by ovine abortion agent. 1967;Br. Med J 4~37. 10 Wong SY, Gray ES, Buxton D, Fiiayson J, Johnson FWA. Acute placentitis and spontaneous abortion caused by CMamydia psittuci of sheep origin: a histological and ultrastructural study. J Clin Path01 1985;38:707-711.