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Net Letter
ARTICLE IN PRESS
doi:
10.25259/IJDVL_217_2021

Mycoplasma genitalium: A descriptive study of 196 cases

Department of Dermatology, Hospital Clínic de Barcelona, Barcelona, Spain
Department of Infectious Diseases, Hospital Clínic de Barcelona, Barcelona, Spain
Department of Microbiology, Hospital Clínic de Barcelona, Barcelona, Spain
Corresponding Author: Dr. Francesc Alamon-Reig, Department of Dermatology, Hospital Clínic de Barcelona, C/ Villarroel, Barcelona, Spain. alamon@clinic.cat
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Alamon-Reig F, Riera-Monroig J, González-Cordón A, Bosch J, Alsina M, Fuertes I. Mycoplasma genitalium: A descriptive study of 196 cases. Indian J Dermatol, Venereol Leprol doi: 10.25259/IJDVL_217_2021

Sir,

Mycoplasma genitalium is an emerging sexually transmitted infection and the second most common cause of non-gonococcal urethritis, after Chlamydia trachomatis.1,2 It is also a potential risk-factor for cervicitis, obstetric complications and a cofactor for HIV transmission. The high prevalence of asymptomatic Mycoplasma genitalium infections and its ability to develop antimicrobial resistance have led to public health concerns.1,2

The latest guidelines recommend testing for Mycoplasma genitalium infection in patients with non-gonococcal urethritis or with features suggestive of pelvic inflammatory disease. Although routine screening based on risk factors is currently not recommended, it may be performed in some high-risk patients.3

We aimed to describe the demographic characteristics and clinical features of patients diagnosed with Mycoplasma genitalium to guide future selective screening strategies for this infection.

This is a retrospective, observational, single-center study including patients diagnosed with Mycoplasma genitalium by Multiplex Real-time Polymerase Chain Reaction Allplex© STI Essential Assay Q (Seegene) between September 2018 and December 2019, in a tertiary hospital in Barcelona. Clinico-demographic characteristics such as age, gender, nationality, sexual orientation, drug use, sexual risk behaviours, site of infection, presence of symptoms, coinfection with other sexually transmitted infection, HIV-related information and treatment undertaken were recorded for every patient.

Patients with previously detected Mycoplasma genitalium in the same location within last 3 months were excluded, attributing such cases to persistent infection.

Among the 196 patients included for analysis, 187 (95.4%) were male with a mean age of 36.6 ± 8.3 years, 106 (54.1%) were non-Spanish and 166 (84.7%) were men who had sex with men. Most patients [157 (80.1%)] reported a sexually transmitted infection and 94 (48%) disclosed chemsex use [Table 1].

Table 1:: Demographic characteristics of patients with Mycoplasma genitalium infection
Characteristic Frequency, no (%)
(n = 196)
Age, mean (SD) [range], y 36.6 (8.3) [19-63]
Gender
 Male 187 (95.4)
 Female 7 (3.6)
 Transgender female 2 (1.0)
Nationality
 Spanish 90 (45.9)
 Other (non-Spanish) 106 (54.1)
Sexual orientation
 MSM 166 (84.7)
 Heterosexual 19 (9.7)
  MSW 12 (6.1)
  Women 7 (3.6)
 TSM 2 (1.0)
 Not available 9 (4.6)
History of previous STI
 Yes 157 (80.1)
 No 13 (6.6)
 Not available 26 (13.3)
Chemsex user
 Yes 94 (48)
 No 46 (23.5)
 Not available 56 (28.5)

MSM: Men who have sex with men, MSW: Men who have sex with women, TSM: Transgender female who have sex with men, STI: Sexually transmitted infection

Clinical features and therapeutic management are presented in Table 2. Urethra was the commonest location in both homosexual [77 (46.4%)] and heterosexual [10 (83.3%)] men. Most infections were asymptomatic [119 (60.7%)], while (53, 56.4%) of the urethral infections were symptomatic. Among the heterosexual individuals, 11 (55%) presented with symptoms, compared to 54 (33.1%) men who had sex with men.

Table 2:: Clinical features and therapeutic management in patients with Mycoplasma genitalium infection
Characteristic Frequency, no (%)
(n = 196)
Location
 Urethra 95 (48.5)
 Rectum 73 (37.2)
 Pharynx 21 (10.7)
 Cervix 7 (3.6)
Symptoms
 Present 73 (37.3)
 Absent 119 (60.7)
 Not available 4 (2.0)
Coinfection (syphilis)
 Present 25 (12.8)
 Absent 152 (77.6)
 Not available 19 (9.6)
Coinfection (Other STI)
 Same location as MG 27 (13.8)
 Location
  Urethra 18 (44.0)
  Rectum 13 (26.0)
  Pharynx 15 (30.0)
 Coinfecting microorganism
  C. trachomatis 14 (28.0)
  N. gonorrhoeae 29 (58.0)
  Other 7 (14.0)
HIV Infection
 Present 143 (73.0)
 Absent 52 (26.5)
 Not available 1 (0.5)
HIV viral load
 Detectable (>50 cp/mL) 21 (14.7)
 Undetectable (<50 cp/mL) 122 (85.3)
Treatment
 Yes 149 (76.0)
  Azithromycin (5-day regimen) 58 (29.6)
  Azithromycin (1g single-dose) 23 (11.7)
  Moxifloxacin 10 (5.1)
  Ceftriaxone + Azithromycin (1g single-dose) 32 (16.3)
  Doxycycline 7 (3.6)
  Other 19 (9.7)
 No 39 (20.0)
 Not available 8 (4.0)

STI: Sexually transmitted infection, MG: Mycoplasma genitalium, C. trachomatis: Chlamydia trachomatis, N. gonorrhoeae: Neisseria gonorrhoeae, HIV: Human immunodeficiency virus, CD4: CD4+ T cells

Regarding coinfection, 27 (13.8%) patients presented at least one other concomitant sexually transmitted infection in the same location where Mycoplasma genitalium was identified. Urethra was the commonest site of coinfection, accounting for 18 (44%) cases. Patients with coinfection reported symptoms in 18 (66.9%) cases, versus 55 (33.3%) of the non-coinfected. Neisseria gonorrhoeae was the most frequent co-infecting agent in 29 (58%) patients, followed by Chlamydia trachomatis [14 (28%)]. Overall, 143 (73%) patients had concomitant HIV infection. Most patients received treatment 149 (76%), commonest being azithromycin in a 5-day regimen in 58 (29.6%) cases [Table 2].

Urethral samples demonstrated maximum yield of Mycoplasma genitalium in 95 (48.5%) cases, possibly attributable to the previously described higher rates of symptomatic infection in this location. However, rectal or pharyngeal infections maybe underestimated.4 Remarkably, men who had sex with men demonstrated more Mycoplasma genitalium infections in the rectum [73 (41.0%)] and pharynx [21 (12.7%)], which may explain the higher rates of asymptomatic infection in this group 108 (66.7%). Current guidelines do not recommend treatment of asymptomatic infection in these two sites.

Coinfection with Neisseria gonorrhoeae or Chlamydia trachomatis in the same location was noted in 13.8% (n = 27) of all individuals, which is similar to that found by Read et al. in a series of men who had sex with men (17%).5 Neisseria gonorrhoeae, which is the commonest bacterial sexually transmitted infection in our region, accounted for (58%, 29) of coinfections. Our data suggest that coinfection influences patient symptoms.

Some of our patients were being periodically tested in a high-risk sexually transmitted infection follow-up program, which could have led to overestimated rates of co-infection with HIV or other sexually transmitted infections along with the use of chemsex in our sample. Chemsex is a growing high-risk sexual practice involving intentional sex under the influence of recreational drugs, mostly among homosexual men, practised by almost half of the population studied. Macrolide resistance could not be assessed in our population, which should be evaluated in further studies to better determine the utility of macrolides in such patients.

Most patients in this study were people living with HIV and men having sex with men. More than half of the infections were asymptomatic. Urethral location and coinfection, particularly with Neisseria gonorrhoeae, influenced clinical presentation. The heterosexual group presented with symptoms more frequently than men having sex with men. Further evidence is required to design screening programs and to assess variables that are associated with symptomatic Mycoplasma genitalium infections.

Declaration of patient consent

Patient’s consent is not required as patient’s identity is not disclosed or compromised.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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