Acta Prediatr Scand 68: 765-767, 1979 CASE REPORT PNEUMONIA ASSOCIATED WITH CHLAMYDIA TRACHOMATIS INFECTION IN AN INFANT ANfTA HALLBERG, PER-ANDERS MARDH , KENNETH PERSSON and TORVALD RIPA From the Department oj'Paediatrics, University oj'Lllnd, Malmo General Hospital, Malmo , the Department oj'Medical Microbiology , University oj'Lund, Lund, and the Department oj'Virology , University oj' Lund, Malmo General Hospital , Sweden
ABSTRACT, Hallberg, A" MlIrdh, P.-A., Persson, K., and Ripa, T. (Departments of Paediatrics and Virology, Malmo General Hospital, and Department of Medical Mictobiology, University Hospital, Lund, Sweden). Pneumonia associated with Chklmydia trachomatis infection in an infant. Acta Paediatr Scand, 68: 765, 1979.-Chlamydia trachoma/is was isolated from the epipharynx of a lO-week-old baby girl taken ill with pneumonia but without signs of conjunctivitis. The infant developed specific antibodies to the organism. The course of the pneumonia was protracted, with cough and tachypnea. The baby, who was afebrile, improved on antibiotic therapy but pulmonary infiltrates persisted for several months. To our knowledge, this is the first case of pneumonia in an infant associated with C. trachomatis infection reported elsewhere than North America. KEY WORDS: Infant, Chlamydia trachoma/is, pneumonia
During recent years it has become evident that Chlamydia trachoma tis is a common cause of sexually transmitted diseases (15) , and complications thereof, such as acute epididymitis (5) and salpingitis (II). C. trachomatis may be transmitted from the mother to her baby resulting in conjunctivitis (12) and pneumonia (3). The first case of pneumonitis associated with C . trachomatis infection was first described in 1975 by Schachter and colleagues (14). Since then a number of reports have appeared (2, 3, 7, 8, 9, 10, 15), aU from North America, describing chlamydiaassociated pneumonitis in newborns. In the present communication a case of pneumonia, strongly suspected to be caused by C. tra chomatis, is described in a Swedish infant.
CASE HISTORY A 10-week-old girl was admitted to the Department of Paediatrics, Malmo General Hospital , because of wheezing and cough persisting for 2 weeks. She was in good condition and afebrile . A diagnosis of obstructive bronchitis was recorded . Two weeks later she was brought
back with symptoms of tachypnea , cough and wheezing, but was still afebrile. A pUlmonary radiograph revealed diffuse interstitial and patchy alveolar infiltrates. She was given ampicillin (50 mg/kg/day) for 6 days and the symptoms regressed. C. trachomatis was isolated from the epipharynx, by means of an isolation technique described elsewhere (13) . Tests for Bordetella per/llssis and cytomegalovirus proved negative. No antibodies to cytomegaloviru s, respiratory syncytial virus, or to Mycoplasma pneumoniae were found . By the time the result of the culture for chlamydia was available, she had improved and another pulmonary radiograph showed only a few remaining infiltrates . Nevertheless, erythromycin (60 mg/kg/day) was given for 2 weeks . One week later the infant again had diffuse and widespread lung infiltrates, and erythromycin was given for a further 2 weeks. One week after the conclusion of this treatment, the patient began to cough again and the lung infiltrates had progressed. Trimethoprim/sulphamethoxazole (trimethoprim 8 mg/kg/day and sulphamethoxazole 40 mg/kg/day) was then given for 2 weeks, after which her symptoms and the infiltrates disappeared . Five days after she had completed the treatment course, the infant once again started to cough ; she had tachypnea and was wheezing. She was then admitted to the Department of Paed iatrics. C. tra choma tis could no longer be isolated form the epipharynx , nor from rec tum , vagina or the conjunctivae. There was no eosinophilia, and the serum levels of IgG and JgM were within the normal range (Table I) . The first serum sample from the infant was obtained at the age of 5 '/2months. TgG (but not IgM) antibodies to C. trachomaActa Paediatr Scand 68
A. Hallb erg et al.
Table I . Resllits o/some labora tory tests NT = not te sted Age(weeks) Parameter stud ied
S - Lellkocyte~ ( X
6.0 25 NT NT NT 4890 37 .2
9.0 18 NT NT NT 5620 NT
7.8 13 187 7 0.8 6470 36.8
109 /1) ESR (mm) S-Eosinophi ls ( X 10"/1) P-lgG (g/l) P-JgM (g/ I) Weight (g) Rectal temp . (0e)
tis at a titre of I : 5 12 were demon strated. u ing a microimmunofluorescence tes t (17) . Trime thoprim/sll iphamet ho xazo le was given for a further 4 weeks . The treatme nt re sulted in th e di sappearance of the sy mptoms but diffuse pulmonary infiltrates still persisted. At delivery. the mother had IgG-a ntibodies aga inst C. trachoma tis at a titre of I : 16- 1 : 32. Six month s later the titre was I : 256 (igG) . At the time when the gi rl was admitted to the Paed iatric Depart ment . C. tracl/amotis co uld not be i olated from the cervix/ure thra of the mother. However. 3 month s later. the orga nis m was recovered from both these s ites. C. tra chomatis cou ld not be isolated from the single urethral s pecimen obtained from the father .
DISCUSSION Infants may after birth be colonized with C . trachomatis in the eyes and/or epipharynx as well as in the rectum and genital tract (3 , 14, IS). Some colonized infants may develop conjunctivitis and/or pneumonia. Recently , Schachter et a t. ( 16) estimated that 14 out of I 000 newborns in San Francisco develop conjunctivitis due to an infection with C. trachomatis. The corresponding figure for pneumonia is 8. Harrison and co-workers (10) found C. trachomatis in th e naso pharynx and/or a specific antibody response to the organism in 9 out of 30 infants with signs of pneumonitis and in one of the 28 matched control s. Bee m & Saxon (3) reported that in 18 infants with C. trachomatis-as ociated pneumonia, only ha lf had conj unc tivitis. They a lso found that 10 of II infants with conjunc tivitis, but without lower respiratory tract illness, had a positive culture for C . trachomatis from the nasophary nx (3). C. trachoma tis was isolated from the epiActll I'll edilltr SWlld 68
pharynx of our patient, whereas cultures from both eyes proved negative. Two months after the isolation of C. tra chomatis from the epipharynx the child still had signs of pneumonia. She then had IgG antibodies to C. trachomatis at a titre of 1 : 512. There is no reason to believe that the antibodies demonstrated in the infant originated from the mother, as the level in the child was much higher than had been detected in the mother prior to birth. The high level of IgG antibodies in the child was found at the age of 5 1/2 months when maternal antibodies would be virtually gone. The failure to detect JgM antibodies probably reflects the late timing of specimen collection. Conclusive evidence of C. tra choma tis as being the cause of pneumonitis in newborn infants is the isolation of the organism from open-lung biopsies of children with pneumonitis who have developed high titres of specific antibodie to the organism (2, 8). In our case the organism was not isolated directly from the pulmonary lesions but circumstantial evidence strongly points to C. tra choma tis as being the cause of the pneumonia. The clinical course was consistent with that of some of the earlier reported cases of C. trachomatis-associated pneumonia in infants (3,9, 10, 14, 15) . C. tra chomatis has been recovered in several series of pregnant women in frequencie s up to 12% (I, 6, IS). It has been estimated ( I , 6, IS) that the risk of a child developing a clinical infectoin with C. tra choma tis is at least 50 % , if borne by a woman infected with the organism in the lower genital tract. The first set of cultures for C . trachoma tis from the mother in the case described were negative which , however, might be due to the fac t th at the speci men s had been stored frozen prior to stud y. Harri son et a t. (10) , found that eos inophilia and/o r e levated se rum levels of IgG and IgM occur in so me newborn s with pneumonitis caused by C. trachomatis. No erum specimen s were available from our patient until she reached the age of 5 1/2 month s. However, on thi s occasion the infant had no eosinophilia
Chlamydia trachoma/is pneumonia and normal serum level of IgG and IgM (Table I). The protracted course of the disease in our patient corresponds to some earlier described cases (2, 3). It may be wondered whether the child was re-infected by her mother, who received no treatment until late in the course of her baby's illness . Beem & Saxon (4) administered sulphisoxazole (150 mg/kg/day) to some infants with pneumonia and C. trachomatis infection, while erythromycin ethyl succinate (40 mg/kg/ day) was given to others. Four days after treatment with either of these antibiotics, chlamydiae could no longer be recovered from the epipharynx of the patients, but not until 3 weeks later did pulmonary radiographs appear normal. In other cases of C. trachomatis associated pneumonia (9) recovery after 3 months without the institution of antibiotic treatment has been described. However, as some infants may be seriously ill, systemic therapy with erythromycin or sulphonamides has been recommended (4, 15). The infant described here was given erythromycin for two 2-week periods and trimethoprim/sulphamethoxazole for a further 2 and 4 weeks, respectively. During treatment she improved, but the symptoms reappeared and the pulmonary infiltrates progressed shortly after treatment was discontinued. This indicate that antibiotic treatment of infants with pneumonia caused by C. trachomatis should be administered over a comparatively long period of time.
ACKNOWLEDGEMENT This study was supported by grant 16X-4509 by the Swedish Medical Re earch Council.
REFERENCES 1. Alexander, E. R., Chandler, 1. W ., Pheiffer, T. A., Wang , S.-P., English, M. & Holmes, K. K .: Prospective study of perinatal Chlamydia trachomatis infection . In D. Hobson & K . K. Holmes (eds.): Nongonococcal urethritis and related infections. American Society for MicrobiOlogy , Washington D.C. 1977, p . 148. 2. Arth, C., Von Schmidt, B ., Grossman, M. & Schachter, 1. : Chlamydial pneumonitis. J Pediatr, 93: 447, 1978.
3. Beem, M. O . & Saxon, E. M.: Respiratory tract colonization and a distinctive pneumonia yndrome in infant infected with Chlamydia trachomatis . N Engl J Med , 296: 306, 1977. 4. Beem, M. O . & Saxon, E. M. : Uncertainties in the treatment of Chlamydia infections in infants . N Engl J Med , 296: 1124, 1977. 5. Berger, R. E., Alexander, E. R., Monda, G. D., Ansell, J., McCormick, G. & Holmes , K . K. : Chlamydia trachomatis as a cause of acute " idiopathic" epididymitis. N Engl J Med, 298: 301,1978. 6. Chandler, J . W., Alexander, E. R ., Pheiffer, T. A., Wang , S.-P., Holmes, K . K. & Engli h, M .: Ophthalmia neonatorum associated with maternal chlamydial infections . Trans Am Acad Ophthalmol OlOlaryngol. 83: 302, 1977. 7. Embil, J. A. , Ozere, R. L. & MacDonald , S . W .: Chlamydia trachoma tis and pneumonia in infants : report of two cases. Canad Med Assoc J, 119: 1199, 1978. 8. Frommell , G . T ., Bruhn, F. W . & Schwartzman, 1. D. : 1 olation of Chlamydia trachomatis from infant lung tissue. N Engl J Med . 296: 1150, 1977. 9. Hammer chlag, M. R.: Chlamydial pneumonia in infants. N Engl J Med . 298: 1083, 1978. 10. Harrison , H . R. , English, M . G., Lee, C. K . & Alexander, E. R.: Chlamydia trachomllTis infant pneumonitis . N Engl J Med. 298: 702, 1978. II. Mftrdh , P.-A., Ripa. K. T ., Svensson, L. & Westrom . L. : Chlamydia trachoma tis infection of the fallopian tubes in patients with acute alpingitis. N Engl J Med. 296: 1377, 1977. 12. Rees. E ., Tait, A .. Hobson, D. & Johnson , F. W. A. : Chlamydia in relation to cervical infection and pelvic inflammatory disease. In D. Hobson & K . K . Holmes (ed .): Nongonococcal urethritis and related infections . American Society for Microbiology, Washington, D.C . 1977, p. 67 . 13 . Richmond, S. J .: Isolation of chlamydia ubgroup A (Chlamydia tra chomatis) in irradiated McCoy cell .
Medical Laboratory Te chnology. 31:7,1974. 14. Schachter, J ., Lum, L. , Gooding, C. A. & 0 tIer, B .: Pneumoniti following inclusion blennorrhea. J Pediatr. 87: 779, 1975. 15. Schachter, J.: Chlamydia infections. N Engl J Med. 298: 428,490 and 540, 1978. 16. Schachter, J ., Grossman, M., Holt , J ., Sweet. R. & Mills , J.: Prospective study on chlamydial infection in the newborn . 18th Interscience Conference on Antimicrobial Agents and Chemotherapy. Atlanta. Ga. 1978. Abstract No. 477 . 17 . Treharne , 1. D .. Darougar, S. & Jone , B. R. : Modification of the micro-immunofluorescence test to provide a routine serodiagnostic te s t for chlamydial infection. J Clin Pathol . 30: 510, 1977. Submitted Jan . 16, 1979 Accepted March 5, 1979 (A. H .) Department of Paediatrics Malmo General Hospital 21401 Malmo Sweden Anll PlIedi"'r SClIlltl6Ii