Trichomoniasis is a significant sexually transmitted disease (STD) in the spectrum of public health and primary care because of its association with agents such as human immunodeficiency virus and Neisseria gonorrhoeae. However, its true significance may be underestimated due to diagnostic modalities that exhibit poor sensitivity. A total of 1,086 genital specimens from two urban emergency departments, a suburban urgent-care facility, and a metropolitan outpatient physician group were subjected to transcription-mediated amplification-based Trichomonas vaginalis analyte-specific-reagent (ASR) testing (Gen-Probe, Inc.). The rate of positive molecular ASR results (14.5%) doubled that of direct saline preparation (7.0%; P < 0.0002). Analogous increases were observed at one emergency department and within the outpatient physician group (P < 0.0002). No significant increase in the rate of positive molecular ASR results was observed from the facilities that encountered a lower frequency of black/African American patients. While positive T. vaginalis findings via direct saline preparation did not have a significant association with concomitant Chlamydia trachomatis or N. gonorrhoeae infection overall, a positive T. vaginalis ASR result was a better predictor of concomitant C. trachomatis or N. gonorrhoeae infection (odds ratios of 2.34 and 4.46, respectively; P < 0.0001). The increased rate of positive T. vaginalis ASR results was observed in both point-of-care (P ‫؍‬ 0.02 versus direct saline preparation) and laboratory (P ‫؍‬ 0.003) testing. Highly sensitive T. vaginalis molecular ASR not only transcends issues of specimen integrity and microscopic acumen but also has an increased ability to predict the likelihood of additional STDs in defined populations.In spite of the discovery of Trichomonas vaginalis nearly 175 years ago and documentation of its inhabitation of the female urogenital tract and the male urinary tract in the late 1800s, pathogenicity was not ascribed to this agent until the European literature of the 20th century (19). Reports have since shown the significance of antecedent T. vaginalis infection, especially in human immunodeficiency virus coinfection (22, 37), acquisition (21), and transmission (17, 23); in pregnancy-related complications (10, 43); and in associations with pelvic inflammatory disease (16) and Neisseria gonorrhoeae infection (16,24). T. vaginalis is currently thought to be responsible for approximately 50% of all curable infections worldwide (5); worldwide estimates of annual trichomoniasis incidence have reached 180 million cases (42).While the aforementioned data may be of tremendous significance, trichomoniasis prevalence rates, both worldwide and in the United States, are thought to be grossly underestimated. Schwebke and Burgess (32) hypothesize that the variable sensitivity of T. vaginalis diagnostic testing contributes partially to these artificially low statistics. Direct examination of genital saline collections continues to serve as a common basis for laboratory detection...

A total of 7,899 specimens submitted for live clinical Trichomonas vaginalis analyte-specific reagent (ASR) screening from 2008 to 2010 were audited on the basis of patient gender, specimen source, molecular Neisseria gonorrhoeae and Chlamydia trachomatis results, and relative light unit (RLU) data yielded by T. vaginalis ASR. Only 1.4% of the screening was ordered by emergency department clinicians. The screening volume in 2010 was 126% higher than that in 2008. The proportions of annual female and male screening remained consistent throughout the 3-year interval (ϳ92 and 8%, respectively). Although 71.8 and 9.5% of screening was performed on endocervical and vaginal specimens, respectively, over the 3-year period, no significant difference was noted in the T. vaginalis detection rates (8.9 and 8.6%, P ‫؍‬ 0.85). Increased T. vaginalis detection was derived from female urine specimens (12.6%) compared to female genital swabs (P ‫؍‬ 0.0004). The proportion of female urine screening increased during the 3-year interval (P < 0.0002). T. vaginalis detection rate in males was 6.6%, with no difference between urethral and urine T. vaginalis detection (P ‫؍‬ 0.53). The mean RLU value for 714 positive specimens was 3,971,441; analogous values for each female specimen source and combined male source testing showed no variance (P > 0.29). Combined-gender T. vaginalis detection rate (9.1%) was significantly greater than those of C. trachomatis (5.9%) and N. gonorrhoeae (1.5%; P < 0.0002). Equivocal results presented at a rate of 0.4%. T. vaginalis ASR is an increasingly utilized assay that yields higher detection rates than other sexually transmitted infection etiologies in this community subacute care setting.

Transcription-mediated amplification (TMA) enhances detection of Neisseria gonorrhoeae and Chlamydia trachomatis from rectal and pharyngeal sources. The utility of TMA for detection of Trichomonas vaginalis has recently been described. We report on the performance of TMA for detection of sexually transmitted infection (STI) agents from extraurogenital sources, with a focus on T. vaginalis. Within a 21-month interval, 1,314 consecutive male patient encounters at an STI clinic resulted in collection of 2,408 specimens for C. trachomatis, N. gonorrhoeae, and T. vaginalis TMA screening. A total of 471 encounters were managed with a single specimen collection (94.9% urine), with 12.7% positive for at least one STI agent. This detection percentage increased to 14.4% with collection of specimens from two sources and to 20.3% with collection from three sources (P ‫؍‬ 0.03 versus single-source sampling). A total of 44.4% of encounters were managed by collection of urine and pharyngeal specimens and 19.1% by the addition of a third (rectal) collection. While procurement of urine and rectal specimens resulted in greater detection of C. trachomatis (6.1% and 11.3% rates, respectively) than of other STI agents, 858 pharyngeal specimens yielded a 2.9% T. vaginalis detection rate compared with 2.1% for N. gonorrhoeae and 1.6% for C. trachomatis. All T. vaginalis pharyngeal detections were confirmed by TMA-based alternative target testing. A total of 38.1% of T. vaginalis-positive pharyngeal specimens were derived from symptomatic patient encounters. A total of 85.7% of males with T. vaginalis-positive pharyngeal collections indicated strictly heterosexual preference. Additional specimen source sampling is necessary to make STI screening comprehensive. Incorporation of extraurogenital sources into assessment for T. vaginalis detection may identify additional symptomatic and asymptomatic male STI carriers.

A 38-year-old native of Mexico presented with a protracted history of gastrointestinal distress and headache. The patient denied any cough but noted fever, chills, poor appetite, and an approximately 20-pound weight loss over the past 3 months. The persistent headaches and exhaustion rendered the patient unable to work. The patient's past medical history was noncontributory. The patient had lived in the United States for the past 8 years, spending the first 6 to 7 years working at a packing company and the remainder at a cleaning company prior to his illness. The patient did admit contact with a commercial sex worker on at least one occasion more than 5 years ago. The patient denies tobacco, illicit drug, and alcohol use.The results of the physical examination were significant, in part, for hemorrhagic lesions suggestive of herpes simplex virus on the upper and lower lips. Computed tomography (CT) imaging of the abdomen and pelvis revealed findings consistent with fecal impaction. No acute intracranial bleeding was noted on the brain CT scan. However, an observed ethmoid sinusitis prompted a magnetic resonance imaging (MRI) series. Extensive increased signal intensity in the periventricular and deep white matter was observed, suggestive of a primary demyelinating disorder or AIDS-related encephalopathy.The laboratory data included a C-reactive-protein level of 18 mg/liter (reference range, 0 to 8 mg/liter) and a peripheral leukocyte count of 9,800/l (reference range, 4,000 to 10,000/l) with a left shift (94% segmented neutrophils). Electrolyte and albumin deficiencies were noted, but the total protein level was elevated at 9.1 g/dl (reference range, 6.2 to 8.0 g/dl). Fecal studies recovered no bacterial or parasitic pathogens. A lumbar puncture obtained cerebrospinal fluid (CSF) with a total protein level of 84 mg/dl (reference range, 12 to 60 mg/dl), a nucleated-cell count of 22/mm 3 (reference range, 0 to 5/mm 3 ) with 94% lymphocytes, and a glucose level of 4 mg/dl (reference range, 40 to 70 mg/dl). A Gram stain of cytospun material was performed at a satellite laboratory (Fig. 1). Erik Munson

T he S-shaped Gram-negative bacilli were catalase positive and exhibited darting motility. Off-label performances of a Campylobacter jejuni/C. coli PCR assay (Prodesse ProGastro SSCS; Hologic, San Diego, CA) (1) on a suspension of isolated growth and on a 1:3 dilution of primary pleural fluid yielded organism-specific fluorescent output (cycle threshold values of 24.8 and 40.5, respectively). Subsequent manipulations of the isolate demonstrated optimal growth under microaerophilic conditions (85% N 2 , 5% O 2 , 10% CO 2) at 42°C. Growth was favored on CDC anaerobic blood agar (see Fig. 1B in the photo quiz) versus routine blood agar (see Fig. 1A in the photo quiz) when the isolate was incubated in that environment for 24 h. The isolate was definitively identified as Campylobacter jejuni via DNA sequence analysis of the 16S rRNA gene. Although the isolate was initially recovered via 37°C anaerobic incubation, subsequent subcultures of the isolate failed to grow under anaerobic conditions and did not exhibit luxurious growth in a 37°C microaerophilic environment. Kassem et al. (2) reported that differential expression of genetic respiratory determinants enables C. jejuni to survive in a variety of thermal or oxygen concentration niches. The differential expression also affects host-pathogen interaction. Such data may explain both the recovery of the primary isolate on CDC anaerobic blood agar at 37°C and its inability to reproduce on that medium ex vivo. The gastrointestinal tract was thought to be the antecedent source for the pleuritic isolate of C. jejuni, as a fecal specimen collected on hospital day 4 was positive for Campylobacter jejuni/C. coli by the same PCR assay (cycle threshold, 35.0). Campylobacter bacteremia is a rare disease, with susceptible hosts being those with liver disease, hypogammaglobulinemia, HIV infection, or other immune deficiency (3). Early literature reported C. jejuni bacteremias to be less common than those of C. fetus etiology (4). Blaser et al. (5) reported C. jejuni to be serum sensitive (complement-dependent antibody-mediated killing), with Campylobacter fetus bacteremias being largely serum resistant. A recent Spanish case series (6) reporting incidences of 66% for C. jejuni and 19% for C. fetus over a 23-year period may convey a paradigm shift, possibly reflective of advances in the capability of treating immunocompromised patients. Although inoculated blood culture vials failed to yield any indication of growth on Bactec FX following 5 days of incubation, the diffuse B-cell lymphoma hypothetically provided a portal of entry into the bloodstream to facilitate extraintestinal C. jejuni disease. A definitive role for C. jejuni in respiratory disease is not well characterized, largely because attempts to isolate the organism from those sites are rare. An Australian case series (7) identified nine HIV-positive patients with C. jejuni bacteremia. Seven of these nine patients were diagnosed with both pneumonia and diarrhea. Klebsiella pneumoniae was isolated from respiratory secretio...