Spontaneous Resolution of Extragenital Chlamydial and Gonococcal Infections Prior to Therapy

To the Editor: Most studies of the natural history of Chlamydia trachomatis infections have focused on infection of the genital tract, and not on infection at extragenital sites (i.e., the oropharynx and rectum). Studies on the natural history of gonococcal infections at any mucosal site are sparse.1 We have read with interest the studies published in Sexually Transmitted Diseases on the natural history of genital chlamydia revealing that chlamydia resolution before therapy is common (roughly 20%–30% in the interval between initial testing and returning for therapy).2–4 Knowledge of the natural history of chlamydial and gonococcal infections could have implications in screening recommendations. We were interested in studying the natural history of extragenital chlamydial and gonococcal infections. We retrospectively evaluated data collected between July 2003 and January 2006 as part of a study to validate the performance of nucleic acid amplification tests (NAATs) for diagnosis of chlamydia and gonorrhea at oropharyngeal and rectal sites. There were 812 participants from 4 clinical sites (1 STD clinic and 3 HIV clinics) in the cities of Birmingham and Chicago. At enrollment, participants were tested for chlamydia and gonorrhea at these extragenital sites by culture and 3 NAATs, and infection at a specific extragenital site was defined as a positive culture or 2 or more positive NAATs at that site. Subjects with extragenital chlamydia or gonorrhea who were not treated at enrollment (because they lacked clinical syndromes warranting treatment or were not a contact) were asked to return for treatment and had repeat testing performed at the corresponding extragenital site. Of 40 (5%) patients identified as having an extragenital chlamydial or gonococcal infection, 17 were excluded from our analyses because they received antibiotics at enrollment. In the remaining 23 subjects (19 [83%] men and 4 [17%] women; 11 [48%] HIV-positive), there were a total of 13 extragenital chlamydial infections (11 rectal and 2 oropharyngeal) and 17 extragenital gonococcal infections (6 rectal and 11 oropharyngeal) (Table 1). Three of 11 patients (27%) with oropharyngeal gonorrhea had spontaneous resolution whereas one of two patients (50%) with oropharyngeal chlamydia did likewise. Two of 11 (18%) with rectal chlamydial infections resolved spontaneously but none of the patients with rectal gonorrhea had spontaneous resolution.TABLE 1: Baseline Extragenital Infections Stratified by Site, Diagnostic Test Positivity, and Proportion Resolved on Repeat Testing at the Time of TreatmentThe median interval between enrollment and treatment visits was 11 days (range, 4–31 days). There were no associations of extragenital infections with demographical or clinical factors in this small sample size. No subjects had symptoms or signs of extragenital infection at the time of returning for therapy. These preliminary data demonstrate that as seen for genital chlamydia, spontaneous resolution of extragenital chlamydia or gonorrhea before therapy also occurs and is not uncommon for oropharyngeal infections. A better understanding of the natural history of these extragenital infections could be an important component in determining the timing of treatment and necessity for rescreening. With our study's limited sample size and retrospective study design, a prospective study with a larger sample size is warranted to confirm our study findings and further refine our understanding of the natural history of extragenital chlamydial and gonococcal infections. We thank Dr. Edward W. Hook, III for his contributions to the research. Senu K. Apewokin, MD William M. Geisler, MD, MPH Department of Medicine Division of Infectious Diseases University of Alabama at Birmingham Birmingham, Alabama Laura H. Bachmann, MD, MPH Infectious Diseases Section Department of Medicine WG Hefner Medical Center Salisbury, NC Wake Forest University Health Sciences Winston-Salem, NC