Correspondence

More on Chlamydia Pneumonia and Meningoencephalitis

N Engl J Med 1995; 332:62-63January 5, 1995

Article

To the Editor:

Socan and colleagues (Aug. 11 issue)1 described an 18-year-old man with pneumonia and meningoencephalitis thought to be due to Chlamydia pneumoniae. Their diagnosis was based on serologic findings (high IgG and IgM antibody titers to C. pneumoniae by microimmunofluorescence assay at presentation, with declining titers thereafter), positive direct-immunofluorescence tests of the cerebrospinal fluid and throat washings, and the exclusion of many other likely agents.

Our experience is that the microimmunofluorescence test for C. pneumoniae antibody lacks both sensitivity and specificity for infection when it is compared with culture and the polymerase chain reaction.2,3 This is especially true when single measurements are used, rather than the most stringent criterion of a fourfold rise in the IgG titer. In a previously reported case of meningoradiculitis4 cited by Socan et al., the diagnosis of C. pneumoniae infection was based on serologic evidence alone.

To our knowledge, direct immunofluorescence testing has never been properly evaluated as a method of detecting chlamydial elementary bodies in cerebrospinal fluid. This method is of questionable value for the detection of C. pneumoniae in respiratory tract specimens. Our laboratory has identified C. pneumoniae by culture in such specimens from 15 to 20 percent of patients presenting with community-acquired bronchitis and pneumonia.5 Our culture results correlate well with those obtained by the polymerase chain reaction.3 Yet our evaluation of direct immunofluorescence testing with the monoclonal antibody (Cellabs, Australia) used by Socan and colleagues resulted in a sensitivity and a specificity of less than 30 percent as compared with culture. Our evaluation of another C. pneumoniae–specific monoclonal antibody (Washington Research Foundation, Seattle) yielded similar findings (unpublished data).

Was the sputum evaluated microscopically and by culture for other respiratory pathogens? Was enteroviral infection considered and excluded as a potential cause of meningoencephalitis? We believe the evidence of C. pneumoniae infection in this patient is uncertain at best.

Steven M. Weiss, M.D.
Patricia M. Roblin, M.S.
Margaret R. Hammerschlag, M.D.
SUNY Health Science Center at Brooklyn, Brooklyn, NY 11203-2098

5 References

1. 1

   Socan M, Beovic B, Kese D. Chlamydia pneumonia and meningoencephalitis. N Engl J Med 1994;331:406-406
   Full Text | Web of Science | Medline

2. 2

   Kern DG, Neill MA, Schachter J. A seroepidemiologic study of Chlamydia pneumoniae in Rhode Island: evidence of serologic cross-reactivity. Chest 1993;104:208-213
   CrossRef | Web of Science | Medline

3. 3

   Gaydos CA, Roblin PM, Hammerschlag MR, et al. Diagnostic utility of PCR-enzyme immunoassay, culture, and serology for detection of Chlamydia pneumoniae in symptomatic and asymptomatic patients. J Clin Microbiol 1994;32:903-905
   Web of Science | Medline

4. 4

   Michel D, Antoine JC, Pozzetto B, Gaudin OG, Lucht F. Lumbosacral meningoradiculitis associated with Chlamydia pneumoniae infection. J Neurol Neurosurg Psychiatry 1992;55:511-511
   CrossRef | Web of Science | Medline

5. 5

   Chirgwin K, Roblin PM, Gelling M, Hammerschlag MR, Schachter J. Infection with Chlamydia pneumoniae in Brooklyn. J Infect Dis 1991;163:757-761
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: There is disagreement about the value of microimmunofluorescence testing for specific IgM and IgG antibodies in the diagnosis of C. pneumoniae infection.1 The specificity and sensitivity of the test remain to be clarified. Serum samples from 100 blood donors tested for IgM antibodies by this assay at our institution were negative (unpublished data). Although in microbiologic analysis the isolation of the pathogen is usually considered the best evidence, in the case of organisms that are difficult to grow culture may not be the only method with which other tests should be compared.2 Nevertheless, we agree with Weiss et al. that isolation of C. pneumoniae from the cerebrospinal fluid would provide the best evidence that this bacterium caused the acute meningoencephalitis in our patient.

Previous reports of central nervous system manifestations caused by C. pneumoniae are few, and the diagnosis has been based on serologic tests alone.3,4 We acknowledge that the direct immunofluorescence assay using monoclonal antibodies to detect C. pneumoniae antigens in the cerebrospinal fluid remains to be tested for specificity and sensitivity.

The cultures of sputum and blood from our patient remained sterile. Enteroviral infection was not excluded as a potential cause of meningoencephalitis by either culture or serologic testing.

We hope that our case report will stimulate further studies of the relation between C. pneumoniae and central nervous system disease.

Maja Socan, M.D.
Bojana Beovic, M.D.
University Medical Center

Darja Kese
Institute of Microbiology, 61000 Ljubljana, Slovenia

4 References

1. 1

   Saikku P. The epidemiology and significance of Chlamydia pneumoniae. J Infect 1992;25:Suppl 1:27-34
   CrossRef | Web of Science | Medline

2. 2

   Tong CY, Sillis M. Detection of Chlamydia pneumoniae and Chlamydia psittaci in sputum samples by PCR. J Clin Pathol 1993;46:313-317
   CrossRef | Web of Science | Medline

3. 3

   Fryden A, Kihlstrom E, Maller R, Persson K, Romanus V, Ansehn S. A clinical and epidemiological study of “ornithosis“ caused by chlamydia psittaci and chlamydia pneumoniae (strain TWAR). Scand J Infect Dis 1989;21:681-691
   CrossRef | Web of Science | Medline

4. 4

   Sundelof B, Gnarpe H, Gnarpe J. An unusual manifestation of Chlamydia pneumoniae infection: meningitis, hepatitis, iritis and atypical erythema nodosum. Scand J Infect Dis 1993;25:259-261
   CrossRef | Web of Science | Medline

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