Journal of Andrological Sciences 2009;16:130-132
Chlamydia trachomatis attacks young male
T. Cai, S. Mazzoli*, D. Bani**, T. Sacchi Bani**, R. Bartoletti Department of Urology, University of Florence, Italy; * STDs Centre, Santa Maria Annunziata Hospital, Florence, Italy; ** Department of Anatomy, Histology & Forensic Medicine, University of Florence, Italy Summary
Chlamydia trachomatis infection, even if has a potential role in chronic
prostatitis pathogenesis, has a controversial impact on male fertility. The role of Chlamydia trachomatis infections of the upper male genital tract as probable aetiological factors for male infertility has been fully argued, without any convincing demonstration of a clear correlation. In this case report, an electron transmission microscopic evaluation of spermatozoa obtained from a patients with chronic prostatitis due to Chlamydia trachomatis infection has been showed. In this case, we stress the role of Chlamydia trachomatis Key words
infection in young males, highlighting the role of Chlamydia trachomatis in Chlamydia trachomatis • Spermatozoa • spermatozoa damaging and fertility decreasing.
Chlamydia trachomatis (C. trachomatis) is the most prevalent bacterial
cause of sexual y transmitted infections1. Moreover, World Health Or-
ganization estimates that more than 92 mil ion of C. trachomatis infec-
tions occurred worldwide in the last years 1. This high diffusion is prob-
ably due also to the fact that approximately 75% of C. trachomatis infec-
tions in women and up to 50% of those in men are asymptomatic and
this is why, due to the low reported incidence rates of genital chlamydial
infections in the population 2. Recent reports have established that C.
trachomatis causes symptomatic infection in the lower male genital
tract and that should have a potential role in chronic prostatitis patho-
genesis 3. Furthermore, we recently showed a clear correlation between
poor semen quality and C. trachomatis infections in young male patients
affected by chronic prostatitis due to C. trachomatis infection4. Even if
the pathophysiology of C. trachomatis infection damage on human fertil-
ity is also unclear for the moment, few hypotheses have been, recently,
purposed 5-6. Some Authors state that C. trachomatis could directly
damage male sperm5 while others suggested a probable immuno-medi-
ated damage. In fact, the presence of anti-chlamydial immunoglobulin
(Ig) A in semen from males with a previous contact with C. trachomatis
is associated with elevated levels of T lymphocytes, that have been also
correlated with the presence of antisperm antibodies 6. In our previous
study, we have found a statistical y significant differences between pa-
tients affected by C. trachomatis infection and those with uropathogens
Corresponding author: Tommaso Cai, Department of Urology, University of Florence, via dell’Antella 58, 50011 Florence, Italy – Tel. +39 0552496347 – Fax +39 0552496452 – E-mail: Chlamydia trachomatis attacks young male spermatozoon infections in terms of sperm concentration, percent- Figure 1. C. trachomatis elementary body (arrow) attached to age of motile sperm and that of normal morphological the thin cytoplasmic layer of a spermatozoon (diameter 0.1 µm). forms, highlithing the probable direct damage of C. Electron microscopy photo. Original magnification x 7,500.
trachomatis against spermatozoa 4. In addition, we have found a strong correlation between positivity to Heat Shock Protein 60, 70 and sperm concentra-tion and normal morphological forms, highlighting the immuno-mediated damage too 4. Recently, the use of electron microscopy in the study of male affected by C. trachomatis infections has been improved, due to the extreme smal size of this microrganisms. We present, here, a case of a 30-year-old patient affected by chronic prostatitis, positive to C. trachomatis infec-tion markers, in which an electron transmission micro-scopic evaluation has been performed.
Figure 2. C. trachomatis forms free in the seminal fluid, elemen- Case report
tary bodies and reticulary body. Electron microscopy photo. Origi- A 30-year-old patient affected by clinical y demon- strated chronic prostatitis underwent Meares-Stamey test, performed according to European Association of Urology (EAU) guidelines by using a 4-glass test 7. Al genital samples were col ected, in accordance with indications described in our previous report 8. Al biological samples was analysed for the detection of Chlamydia trachomatis (CT), urogenital Mycoplas-mata, Neisseria gonorrhoeae, Human Papil oma virus, Herpes virus 1 and 2 by PCR (Polymerase Chain Re-action) and aerobic, anaerobic and microaerophylic common bacteria and yeasts by culture 8. The patient showed positivity both for CT plasmidic DNA and mucosal IgA in total ejaculate, while was negative for al the other tests. In order to perform the electron microscopy analysis, sperm sample has been fixed in Karnovsky’s reagent, rinsed overnight in 0.1 mol/L underwent microbiological analyses that confirmed cacodylate buffer (pH 7.2), postfixed in 1% buffered the absence of C. trachomatis infection. OsO , dehydrated, and embedded in Epon-Araldite (Fluka, Milan, Italy). Ultrathin sections were cut with Discussion
an LKB ultramicrotome (Vienna, Austria) and stained Chlamydia trachomatis, an obligate intracel ular para- with uranyl acetate and lead citrate. Observations site, has a biphasic life cycle characterized by an EB were made with a TEM CM 10 (Philips, Eindhoven, with infective capacity and a reticular body RB that the Netherlands), at magnifications of x 7,500, by a is able to replicate within eukaryotic cel s 9. In details, dedicated evaluator. The Figure 1 shows a C. tracho- the organism has a unique developmental cycle in matis elementary body (EB) (arrow) attached to the which it exists in two alternating forms: an extracel-thin cytoplasmic layer of a spermatozoon (diameter lular, metabolical y inactive, infectious form, EB and 0.1 µm), while the Figure 2 shows Chlamydia forms an intracel ular, metabolical y active, reproducing form, free in the seminal fluid from the same patient, es- RB. This developmental cycle is necessary because C. pecial y reticulary bodies (RB) and EB, that should trachomatis need to utilize the intracel ular machinery of be the infecting form of C. trachomatis. The patients a host cel in order to reproduce 10. An obvious conse-underwent standard antibiotic therapy for C. tracho- quence of this developmental cycle is that, at the site of matis infections, in accordance with EAU guidelines infection, the reproductive tract wil periodical y contain (doxycycline 2 times daily 100 mg oral y for 21 days) 7. significant numbers of highly infectious EB, and these At the fol ow-up visit, the patient showed improve- may be encountered by any gametes that are present ment in symptoms relief and quality of life and, then, in the reproductive tract at that time 10. Hosseinzadeh and co-workers have, recently, demonstrated that EB legos-Avila G, Diaz-Gutierrez O, et al. Update on the impact of Chlamydia trachomatis infection on male can have a direct and negative effect on sperm physi- fertility. Andrologia 2004;36:1-23.
ology and this was seen primarily via a reduction in 3 Ochsendorf FR. Sexually transmitted infections: impact sperm motility, which was reflected in a corresponding on male fertility. Andrologia 2008;40:72-5.
increase in sperm death 11. The same group, have also 4 Mazzoli S, Cai T, Addonisio P, Bechi A, Mondaini N, demonstrated that Ct-induced death of human sperm Bartoletti R. Chlamydia trachomatis infection is related is primarily caused by lipopolysaccharide (LPS) 10, to poor semen quality in young prostatitis patients. Eur Urol 2009 May 27 [Epub ahead of print].
by means of a caspase-mediated apoptosis 12. LPS 5 Eley A, Pacey AA, Galdiero M, Galdiero M, Galdiero is, then, a heat-stable complex and unique glycoli- F. Can Chlamydia trachomatis directly damage your pid that is present in al Gram-negative bacteria. It is sperm? Lancet Infect Dis 2005;5:53-7.
the immunodominant antigen of most Gram-negative 6 Munoz G, Posnett DN, Witkin SS. Enrichment of gam- bacteria and is considered to be intimately associated ma delta T lymphocytes in human semen: relation be- with the virulence of the pathogen 13. C. trachomatis tween gamma delta T cell concentration and antisperm antibody status. J Reprod Immunol 1992;22:47-57.
LPS is known to be particularly spermicidal 10 and is 7 Naber KG, Bergman B, Bishop MC, Bjerklund-Johansen composed of a simple structure containing lipid A and TE, Botto H, Lobel B, et al.; Urinary Tract Infection (UTI) Kdo 14. In particular, C. trachomatis LPS interacts with Working Group of the Health Care Office (HCO) of the CD14 on the sperm surface (and, possibly, Tol -like European Association of Urology (EAU). EAU guidelines receptors if present), leading to increased production of for the management of urinary and male genital tract infections. Urinary Tract Infection (UTI)Working Group of reactive oxygen species, resulting in caspase-mediated the Health Care Office (HCO) of the European Associa- apoptosis 5. Excessive generation of reactive oxygen tion of Urology (EAU). Eur Urol 2001;40:576-88.
species is related to an increase in sperm defects both 8 Mazzoli S, Cai T, Rupealta V, Gavazzi A, Castricchi in vitro and in infertile men 15. Several studies showed Pagliai R, Mondaini N, et al. Interleukin 8 and anti-chla- that in vivo model, C. trachomatis were phagocytized mydia trachomatis mucosal IgA as urogenital immuno- logic markers in patients with C. trachomatis prostatic and kil ed by polimorphonucler leukocytes and macro- infection. Eur Urol 2007;51:1385-93.
phages 16. However, C. trachomatis can resists in poli- 9 Satta A, Stivala A, Garozzo A, Morello A, Perdichizzi morphonucler leukocytes and macrophages inclusion A, Vicari E, et al. Experimental Chlamydia trachomatis as intact form, promoting the establishment of latent or infection causes apoptosis in human sperm. Hum Re- chronic infections states and circumvents bactericidal 10 Hosseinzadeh S, Pacey AA, Eley A. Chlamydia tra- immune mechanisms and selective drug therapy 16. chomatis-induced death of human spermatozoa is This characteristic may act as a factor for dissemination caused primarily by lipopolysaccharide. J Med Micro- of C. trachomatis infections to the female partners. The ability to cause persistent infection is, then, one of the 11 Hosseinzadeh S, Brewis IA, Eley A, Pacey AA. Coincu- major characteristics of C. trachomatis in its appropriate bation of human spermatozoa with Chlamydia tracho- matis serovar E causes premature sperm death. Hum hosts. C. trachomatis has also been demonstrated to enter a persistent state after treatment with cytokines 12 Eley A, Hosseinzadeh S, Hakimi H, Geary I, Pacey AA. such as interferon-gamma (Interferon-gamma), treat- Apoptosis of ejaculated human sperm is induced by ment with antibiotics, or restriction of certain nutrients, co-incubation with Chlamydia trachomatis lipopolysac- or to enter this state spontaneously under certain cul- charide. Hum Reprod 2005;20:2601-7.
ture conditions 17. While the organism is in the persistent Hakimi H, Geary I, Pacey A, Eley A. Spermicidal activity of bacterial lipopolysaccharide is only partly due to lipid state, metabolic activity is reduced, and the organism is often refractory to antibiotic treatment 17. In conclusion, 14 Rund S, Lindner B, Brade H, Holst O. Structural analy- the present case report underlines the role of C. tracho- sis of the lipopolysaccharide from Chlamydia tracho- matis infection in young males and highlights the dam- matis serotype L2. J Biol Chem 1999;274:16819-824.
age to spermatozoa by C. trachomatis. The role of C. 15 Aitken RJ, Buckingham DW, Brindle J, Gomez E, Baker trachomatis infection in male fertility decreasing should HW, Irvine DS. Analysis of sperm movement in relation to the oxidative stress created by leukocytes in washed now be clearer, due to the many published studies and sperm preparations and seminal plasma. Hum Reprod 16 Hammerschlag MR. The intracellular life of chlamydiae. References
Semin Pediatr Infect Dis 2002;13:239-48.
1 World Health Organization. Global prevalence and 17 Gallegos-Avila G, Ortega-Martínez M, Ramos-González incidence of selected curable sexually transmitted dis- B, Tijerina-Menchaca R, Ancer-Rodríguez J, Jaramillo- eases: overview and estimates. Geneva: World Health Rangel G. Ultrastructural findings in semen samples of infertile men infected with Chlamydia trachomatis and 2 Gonzales GF, Munoz G, Sanchez R, Henkel R, Gal- mycoplasmas. Fertil Steril 2009;91:915-9.


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