Chlamydia hepatitis

Congenital chlamydial hepatitis is a disease that occurs when the fetus is infected with chlamydia antenatally from a mother with chlamydia infection.

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Prevalence

Chlamydia infection is one of the most widespread infections worldwide, including in Russia. In the population of childbearing age, urogenital chlamydia is detected with high frequency. In pregnant women, the detection rate of chlamydia infection ranges from 10 to 70%.

In newborns, chlamydial infection is recorded in 5-38% of cases.

What causes chlamydial hepatitis?

The genus Chlamydie included 3 species of pathogens: C. psiitaci, C. pneumoniae and C. trachomatis. The latter, sexually transmitted, causes diseases of the genitourinary tract, gastrointestinal tract, respiratory tract, eyes, etc. Chlamydia occupy an intermediate position between bacteria and viruses, they are obligate intracellular energy parasites. C. trachomatis penetrates the host cell by pinocytosis, uses the ATP produced by it for its growth and reproduction and is protected from destruction by the phagosomal membrane. When entering the human body, chlamydia can simultaneously exist in various stages of development, including persistent forms. When infected during pregnancy, a woman develops mucopurulent discharge from the cervical canal, colpitis, dysuric phenomena, and a large number of leukocytes are detected in the cervical secretion and urine. The risk of developing an infectious process in the fetus and newborn depends on the time of infection or exacerbation of chlamydia in the pregnant woman. The most dangerous in terms of infection of the fetus is the development of chlamydial infection in the mother in the third trimester of pregnancy.

Chlamydial infection in a pregnant woman leads to chronic placental insufficiency, which has an adverse effect on the growth and development of the fetus. In women infected with chlamylia, pregnancy in most cases still ends in term delivery, but even at full term, intrauterine infection with damage to various organs and systems is often diagnosed in newborns.

The ascending route (through the cervix and membranes of the fetal egg) is typical for intrauterine infection with chlamydia. The pathogen gets on the mucous membranes of the urethra, upper respiratory tract, is swallowed with infected amniotic fluid, causing damage to the gastrointestinal tract.

Intrauterine chlamydial infection is characterized by depression of T-cell immunity with a deficiency of T-helpers, dysfunction of mononuclear phagocytes and moderate increase in the activity of natural killers. Intrauterine infection with chlamydia causes damage to many organs and systems, including the liver, while infection of the liver with chlamydia is noted with a very high frequency - up to 16.7%.

Morphology

When the liver is damaged as a result of intrauterine infection with chlamydia, a picture of hepatitis occurs.

Macroscopically: the liver is enlarged, of a dense consistency, brown-yellow color. The bile ducts are passable. Histological examination reveals discomplexation of the liver beams, foci of liver cell necrosis with lymphoid-leukocyte infiltration in the periportal zone, foci of extramedullary hematopoiesis; protein dystrophy of parenchymatous cells, intracellular cholestasis, and in places, regeneration of hepatocytes.

Symptoms of Chlamydial Hepatitis

Children with intrauterine chlamydial infection are often born prematurely, with an Apgar score of < 6-7 points, with signs of morphofunctional immaturity. If the disease is in the initial stage at the time of birth, the infection manifests itself in the first 3 days, if in the middle, the child has clinical manifestations of chlamydia at birth.

Children have general intoxication symptoms. At the same time, lesions of organs and systems are varied. Intrauterine pneumonia, respiratory distress syndrome, conjunctivitis, gastroenteropathy, generalized forms of this infection are typical.

Hepatitis and biliary tract damage are rare in intrauterine chlamydia.

The children's condition is assessed as moderately severe, sometimes severe. They are lethargic and restless. Children eat poorly and regurgitate.

Jaundice appears from the first day after birth, it can increase over several days. Almost all have hepatosplenic syndrome. The liver protrudes from the hypochondrium by 3-5 cm, moderate density, with a smooth surface. In half of the cases, children have conjunctivitis; often an increase in several groups of lymph nodes.

In a biochemical blood test in patients with cholestasis, a 1.5-2-fold increase in bilirubin levels with a predominance of the conjugated fraction, a mild (2-3-fold) increase in the activity of liver cell enzymes - ALT, AST, LDH, and GGT are usually detected.

Congenital chlamydial hepatitis may manifest acutely with cholestasis syndrome. Against the background of general infectious intoxication, moderate or severe jaundice develops, hemorrhagic syndrome may appear in the form of petechial rash, hemorrhages at injection sites. All children have an enlarged liver, often the spleen protrudes from the hypochondrium by 1-2 cm.

A biochemical blood test shows a 5-10-fold increase in the total bilirubin level, with the conjugated fraction not always predominating (a simultaneous significant content of free bilirubin in the blood serum indicates a deficiency in the bilirubin conjugation system). The activity of hepatocellular enzymes usually slightly exceeds the norm, but a 2-fold increase in the activity of alkaline phosphatase and GGT is observed.

Ultrasound reveals an increase in the size of the liver, increased echogenicity of the parenchyma, and often thickening of the gallbladder walls.

Variants of the course of chlamydial hepatitis

Congenital chlamydial hepatitis is generally acute with gradual (2-3 months) normalization of blood biochemical parameters. The liver enlargement persists much longer, up to the 12th month. With cholestasis syndrome, the resolution of jaundice is delayed, it can persist up to the 5th month.

There are descriptions of cases of wave-like chlamydial hepatitis, with exacerbations of the course, when after the initial manifestation of clinical and biochemical symptoms of the disease, normalization of indicators occurs after 2-3 months, and then after several months, a pronounced hepatitis syndrome occurs again, lasting 1-2 months, and only the appointment of etiotropic therapy leads to the resolution of the disease. Chronic course of chlamydial hepatitis is not observed.

Diagnosis of chlamydial hepatitis

Chlamydial infection is diagnosed based on the detection of the pathogen Chlamydia trachomatis from the eyes and urethra, but more often by increasing titers of specific antibodies of the class, antibodies to chlamydia of the IgM class are not always detected. Using PCR, chlamydial DNA can be identified in biological substrates, including blood serum.

Differential diagnostics are carried out with congenital hepatitis of other etiology. At present, by detecting specific markers, it is almost always possible to establish the etiology of congenital hepatitis, given that the picture of the disease with different pathogens can be very similar. In case of chlamydial antenatal infection, the obstetric and gynecological history of the mother and the indication of the presence of clinical and laboratory signs of this infection in her are important.

It should be noted that neonates often have an antenatal infection caused by two or sometimes more pathogens. For example, in 23% of cases, intrauterine mixed infection was detected in the form of a combination of cytomegalovirus and chlamydial. This fact should be taken into account when diagnosing congenital hepatitis and planning therapy.

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Treatment of chlamydial hepatitis

Chlamydial infection is successfully treated with macrolide antibiotics. If the chlamydial nature of congenital hepatitis is established, children are prescribed erythromycin or azithromycin (sumamed). Erythromycin is used in a daily dose of 40-50 mg per 1 kg of body weight for 7 days, azithromycin (sumamed) - on the 1st day at a dose of 10 mg / kg, and in the following 4 days - at a dose of 5 mg / kg. In case of severe intoxication, infusion detoxifying therapy is carried out. The appointment of hepatoprotectors, for example, phosphogliv, is indicated. Conjunctivitis and urethritis of the same etiology are often detected in children with congenital chlamydial hepatitis. In this regard, along with antibacterial therapy, sanitation of local inflammatory processes is carried out.

Prevention of chlamydial hepatitis

Prevention of antenatal chlamydial infection consists of identifying and treating chlamydia in pregnant women.