The Journal of Emergency Medicine
Volume 40, Issue 1 , Pages 69-70, January 2011

Association of Trichomonas Infection with Gonorrhea or Chlamydia

Department of Emergency Medicine, State University of New York-Downstate, Brooklyn, New York

published online 01 February 2010.

Article Outline

 

To the Editor:

I read with great interest the recent article by Wegner et al. regarding the association of infection with Trichomonas vaginalis with concurrent infection with either Neisseria gonorrhea or Chlamydia trachomatis (1). Sexually transmitted diseases pose a diagnostic dilemma for the Emergency Physician. The laboratory turnaround time often precludes the definitive diagnosis during the same patient visit. Thus, one may be left with either a return visit or treatment based on the best evidence available.

The incidence of Trichomonas infection previously has been estimated to be 7.4 million cases per year in the United States (2). The true burden of disease is impossible to determine as its detection relies on poorly sensitive tests, and positive tests are not required to be reported.

Wegner's study was well designed, with the intention of reducing the amount of empiric treatment delivered, considering the inherent potential for harm that these treatments hold. A limitation of their study that was not emphasized was the test they used to determine infection with Trichomonas. The wet mount, although used for many years for the diagnosis of trichomonad infection, is a poorly sensitive and highly user-dependent test. The sensitivity of wet mount is reported to be between 50% and 70% (3, 4). The Methods section of the Wegner article states that the samples for wet mount were received by the laboratory for testing (1). There is no discussion as to the delay between collection of the specimen and the performance of the wet mount. It has been previously demonstrated that wet mount slides should be read immediately after procurement to avoid significant decreases in sensitivity. In this study, slides known to be positive for trichomonads were read at 10-min intervals. By 30 min, 35% were negative and by 2 h, 78% were negative (5). Wegner's retrospective analysis did not control for the physician's method of collection of the specimen. The use of the cervical vaginal lavage technique has been shown to increase the sensitivity of the wet mount. In this technique, a 5-mL aliquot of normal saline is used to bathe the cervix two to three times before drawing the fluid up from the posterior vaginal fornyx (6).

Culture has long been considered the gold standard for diagnosis of Trichomonas (7). Modified Diamond's medium is the preferred substrate for inoculation (8). There are a number of commercially available tests, which may improve detection rates. The InPouch TV Culture System (Biomed, White City, OR) is a combined wet mount and culture kit. The OSOM Trichomonas Rapid Test (Genzyme Diagnostics, Cambridge, MA) is a dipstick test similar to standard pregnancy tests that uses murine monoclonal antibodies. The sensitivity of this rapid test has been shown to be 83% (9).

This study relied on a poor choice of test to diagnose Trichomonas infection and therefore failed to prove any lack of association between Trichomonas infection and either Chlamydia or gonorrhea. I would encourage clinicians to refrain from relying on this conclusion and to continue to treat patients based on known prevalence rates of disease, clinical presentation, and clinician's gestalt.

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References 

  1. Wegner S, Yen MJ, Witting M. Evidence against the “booty pack”: Trichomonas not associated with gonorrhea or Chlamydia. J Emerg Med. 2009;37:124–126
  2. Weinstock H, Berman S, Cates W. Sexually transmitted disease among American youth: incidence and prevalence estimates, 2000. Perspect Sex Reprod Health. 2004;36:6–10
  3. Krieger JN, Tam MR, Stevens CE, et al. Diagnosis of trichomoniasis. JAMA. 1988;259:1223–1227
  4. Radonjic IV, Dzamic AM, Mitrovic SM, Arsic Arsenijevic VS, Popadic DM, Kranjcic Zec IF. Diagnosis of Trichomonas vaginalis infection: the sensitivities and specificities of microscopy, culture and PCR assay. Eur J Obstet Gynencol Reprod Biol. 2006;126:116–120
  5. Kingston MA, Bansal D, Carlin EM. ‘Shelf life’ of Trichomonas vaginalis. Int J STD AIDS. 2003;14:28–29
  6. Kissinger PJ, Dumestre J, Clark RA. Vaginal swabs versus lavage for detection of Trichomonas vaginalis and bacterial vaginosis among HIV-positive women. Sex Transm Dis. 2005;32:227–230
  7. Swygard H, Seña AC, Hobbs MM, Cohen MS. Trichomoniasis: clinical manifestations, diagnosis and management. Sex Transm Inf. 2004;80:91–95
  8. Gelbart SM, Thomason JL, Osypowski PJ, Kellett AV, James JA, Broekhuizen FF. Growth of Trichomonas vaginalis in commercial culture media. J Clin Microbiol. 1990;28:962–964
  9. Huppert JS, Batteiger BE, Braslins P. Use of an immunochromatographic assay for rapid detection of Trichomonas vaginalis in vaginal specimens. J Clin Microbiol. 2005;43:684–687

PII: S0736-4679(09)00926-3

doi:10.1016/j.jemermed.2009.08.067

Refers to article:

  • Evidence Against the “Booty Pack”: Trichomonas Not Associated with Gonorrhea or Chlamydia , 19 November 2007

    Stephen Wegner, M. Jim Yen, Michael Witting
    The Journal of Emergency Medicine August 2009 (Vol. 37, Issue 2, Pages 124-126)

The Journal of Emergency Medicine
Volume 40, Issue 1 , Pages 69-70, January 2011

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