Anti-ovarian and anti-lymphocyte antibodies in patients with chronic vaginal candidiasis

Prevalence of nonviral reproductive tract infections/sexually transmitted infections in female patients with cervicovaginal discharge: Excerpts from a regional reference center in North India

Background

To study the prevalence of common nonviral reproductive tract infections/sexually transmitted infections (RTI/STI) prevailing among females who presented to our regional STI reference center and to ascertain the association of various symptoms with different RTI/STIs.

Materials and Methods

A retrospective analysis of female patients presenting to our STI Regional center located in the Department of Medical Microbiology in PGIMER, Chandigarh, was done between April 2018 and December 2019 for patients presenting with cervico-vaginal discharge. Two to three swabs were collected from each patient. The first swab was subjected to wet mount, gram stain, Potassium hydroxide (KOH) test, and culture on blood agar, the colonies obtained were identified by matrix-assisted laser desorption time of flight mass spectrometer (MALDI TOF-MS). Second swab was used for DNA extraction and detection of Neisseria gonorrhoeae (NG), Trichomonas vaginalis (TV), and Chlamydia trachomatis (CT) by polymerase chain reaction. The third swab, when available, was inoculated onto pleuropneumonia-like organisms (PPLO) broth.

Results

One thousand and thirteenth of 1472 (69%) female patients were symptomatic and the most common presenting symptoms were vaginal discharge (707/1013 [69.8%]), infertility (266/1013 [26.2%]), genital itching (60/1013 [5.9%]), lower abdomen pain (47/1013 [4.6%]) and burning micturition (16/1013 [1.6%]). The most prevalent RTI/STI was bacterial vaginosis (BV) 18.2% (269/1472), followed by vulvovaginal candidiasis (VVC) 6.8% (100/1472) and trichomoniasis (TV) 1.9% (28/1472). Five cases each of Mycoplasma genitalium and Ureaplasma urealyticum, three of NG and one of CT were also identified. Coinfections were seen in 40 (2.7%) cases. The most common causative agent responsible for VVC in our study was Candida albicans (65%).

Conclusion

RTI/STIs were common among women and 69% were symptomatic. BV was the most common STI present in 18.2%, followed by VVC (6.8%) and trichomoniasis (1.9%).

HSP90 antibodies: a detrimental factor responsible for ovarian dysfunction

PROBLEM

Earlier studies from our group have established that about 47% cases of autoimmune ovarian failure are due to presence of autoantibodies to Heat Shock Protein 90 (HSP90). However, there are no reports correlating pathological effects of HSP90 autoantibodies leading to ovarian failure.

METHOD OF STUDY

Antibodies to HSP90 in female mouse model were generated by active immunization with an immunodominant peptide of HSP90, followed by detailed analysis of several reproductive parameters.

RESULT

Estrous cyclicity remains unchanged; however, there was a significant drop in the fertility index due to an increase in pre- and post-implantation loss, associated with an increased incidence of degenerated eggs and embryos. The ovaries showed an increase in the number of empty and degenerated follicles and extensive granulosa cell deaths, which was reflected by the decrease in the levels of Nobox and Gja1 gene expression.

CONCLUSION

This study underlines a critical role played by HSP90 in ovarian folliculogenesis and highlights the implications of the presence of anti-HSP90 antibodies in infertile women.

Effectiveness of nystatin in polysymptomatic patients. A randomized, double-blind trial with nystatin versus placebo in general practice

BACKGROUND

Antifungal therapy has been claimed to be effective in polysymptomatic patients with diffuse symptoms from multiple body systems and even well defined diseases, traditionally not related to fungi. Hypersensitivity to fungus proteins and mycotoxins has been proposed as the cause.

METHODS

We conducted a 4-week randomized, double-blind, placebo-controlled study in 116 individuals selected by a 7-item questionnaire to determine whether the antifungal agent nystatin given orally was superior to placebo. At the onset of the study, the patients were free to select either their regular diet or a sugar- and yeast-free diet, which resulted in four different subgroups: nystatin + diet (ND); placebo + diet (PD); nystatin (N); and placebo (P).

RESULTS

Nystatin was significantly better than placebo in reduction of the overall symptom score (P < 0.003). In six of the 45 individually recorded symptoms, the improvement was significant (P < 0.01). All three active treatment groups reduced their overall symptom scores significantly (P < 0.0001), while the placebo regimen had no effect (P = 0.83). The benefit of diet was significant within both the nystatin (ND > N) and the placebo groups (PD > P).

CONCLUSIONS

Nystatin is superior to placebo in reducing localized and systemic symptoms in individuals with presumed fungus hypersensitivity as selected by a 7-item questionnaire. This superiority is probably enhanced even further by a sugar- and yeast-free diet.

Cross-reactivity between Candida albicans and human ovarian carcinoma as revealed by monoclonal antibodies PA10F and C6

Summary Antibodies against Candida albicans antigenic determinants have been reported to cross-react with human tumour cells. We have found that two monoclonal antibodies, C6 and PA1OF, developed at our laboratory against C. albicans antigenic determinants, cross-react with human ovarian cancer on Western blots and immunohistochemistry. We have subsequently used one of them, PA10OF, to test by means of immunohistochemistry a series of 37 human ovarian carcinomas. Out of 37 tumours, 25 (67.6%) expressed the antigen recognized by PA1OF. The reactivity, however, was concentrated on the subgroup of particularly aggressive, invasive carcinomas in advanced stages of the disease (19 out of 24 positive), whereas the antigen was expressed significantly less (P=0.0007) in the subgroup of much less aggressive stage I tumours of low malignant potential, also called borderline carcinomas (2 out of 13 positive). This cross-reactivity between C. albicans and ovarian carcinoma seems to be attributable to a common antigenic determinant related to tumour aggressiveness.

Premature ovarian failure and ovarian autoimmunity

Premature ovarian failure (POF) is defined as a syndrome characterized by menopause before the age of 40 yr. The patients suffer from anovulation and hypoestrogenism. Approximately 1% of women will experience menopause before the age of 40 yr. POF is a heterogeneous disorder with a multicausal pathogenesis involving chromosomal, genetic, enzymatic, infectious, and iatrogenic causes. There remains, however, a group of POF patients without a known etiology, the so-called "idiopathic" form. An autoimmune etiology is hypothesized for the POF cases with a concomitant Addison's disease and/or oöphoritis. It is concluded in this review that POF in association with adrenal autoimmunity and/or Addison's disease (2-10% of the idiopathic POF patients) is indeed an autoimmune disease. The following evidence warrants this view: 1) The presence of autoantibodies to steroid-producing cells in these patients; 2) The characterization of shared autoantigens between adrenal and ovarian steroid-producing cells; 3) The histological picture of the ovaries of such cases (lymphoplasmacellular infiltrate around steroid-producing cells); 4) The existence of various autoimmune animal models for this syndrome, which underlines the autoimmune nature of the disease. There is some circumstantial evidence for an autoimmune pathogenesis in idiopathic POF patients in the absence of adrenal autoimmunity or Addison's disease. Arguments in support of this are: 1) The presence of cellular immune abnormalities in this POF patient group reminiscent of endocrine autoimmune diseases such as IDDM, Graves' disease, and Addison's disease; 2) The more than normal association with IDDM and myasthenia gravis. Data on the presence of various ovarian autoantibodies and anti-receptor antibodies in these patients are, however, inconclusive and need further evaluation. A strong argument against an autoimmune pathogenesis of POF in these patients is the nearly absent histological confirmation (the presence of an oöphoritis) in these cases (< 3%). However, in animal models using ZP immunization, similar follicular depletion and fibrosis (as in the POF women) can be detected. Accepting the concept that POF is a heterogenous disorder in which some of the idiopathic forms are based on an abnormal self-recognition by the immune system will lead to new approaches in the treatment of infertility of these patients. There are already a few reports on a successful ovulation-inducing treatment of selected POF patients (those with other autoimmune phenomena) with immunomodulating therapies, such as high dosages of corticosteroids (288-292).

Production and function of cytokines in natural and acquired immunity to Candida albicans infection

Host resistance against infections caused by the yeast Candida albicans is mediated predominantly by polymorphonuclear leukocytes and macrophages. Antigens of Candida stimulate lymphocyte proliferation and cytokine synthesis, and in both humans and mice, these cytokines enhance the candidacidal functions of the phagocytic cells. In systemic candidiasis in mice, cytokine production has been found to be a function of the CD4+ T helper (Th) cells. The Th1 subset of these cells, characterized by the production of gamma interferon and interleukin-2, is associated with macrophage activation and enhanced resistance against reinfection, whereas the Th2 subset, which produces interleukins-4, -6, and -10, is linked to the development of chronic disease. However, other models have generated divergent data. Mucosal infection generally elicits Th1-type cytokine responses and protection from systemic challenge, and identification of cytokine mRNA present in infected tissues of mice that develop mild or severe lesions does not show pure Th1- or Th2-type responses. Furthermore, antigens of C. albicans, mannan in particular, can induce suppressor cells that modulate both specific and nonspecific cellular and humoral immune responses, and there is an emerging body of evidence that molecular mimicry may affect the efficiency of anti-Candida responses within defined genetic contexts.

Detection of antibodies to ovarian antigens in women with premature ovarian failure

Premature ovarian failure is a common condition of uncertain aetiology in most cases, although autoimmunity is thought to play a role in a proportion of cases. The frequency of ovarian antibodies, which may be markers for an autoimmune aetiology in this condition, remains unclear. To define this further, we have examined the sera of 45 women with premature ovarian failure (five with iatrogenic ovarian failure, nine with an associated autoimmune disease, and 27 with idiopathic ovarian failure), as well as four women with infertility due to Turner's syndrome and 41 pre- and post-menopausal controls. Using two human ovarian antigen preparations, 24% and 60% of the ovarian failure patients reacted in an ELISA (P < 0.05 and P < 0.001 compared with controls), but frequent cross-reactivity was found with fallopian tube antigens. The apparent aetiology of ovarian failure did not correlate with the presence of ovarian antibodies. Using bovine ovary as an antigen, there was a significant overall increase in binding by the ovarian failure patients, but this was almost identical to binding in an ELISA with bovine fallopian tube. In contrast to a previous report, there was no significant increase of binding to soluble or Triton-extracted membrane fractions of bovine corpora lutea containing the LH/hCG receptor by the patients with ovarian failure. These results suggest that ovarian antibodies are common in premature ovarian failure, but their specificity and pathogenic role are questionable.

Somatization disorder and the chronic candidiasis syndrome: a possible overlap

The close similarity between the complex of symptoms found in the recently described Chronic Candidiasis Syndrome and the Somatization Disorder is pointed out. Some evidence in support of the validity of the Chronic Candidiasis Syndrome is presented including some studies from the past and more recent medical literature regarding symptoms, physiological effects, and immunological findings accompanying Candida infections. Logical possibilities for the relationship of each disorder with the other is discussed. It is concluded that there is a possible overlap of the two disorders and that some patients currently diagnosed with Somatization Disorder may respond to the treatment for Chronic Candidiasis.

Vaginal infections in adult women

Often trivialized by the medical profession, vaginitis in adult women is not only extremely common but is the source of considerable distress and often results in marked suffering. Epidemiologic studies described in this article indicate the high prevalence of vaginitis and the large number of causes. Although the majority of infections in women are due to bacterial vaginosis, VVC, and trichomoniasis, it is clear that many other causes exist, and we have yet to discover the etiology of many clinical syndromes. Considerable progress has been made in understanding the pathogenesis of the three common vaginitides. Although excellent progress has been made by the pharmaceutical industry in providing new drugs for vaginitis, any further progress will require a better understanding of etiology and pathogenesis. Vaginitis causes major symptoms and is more than a nuisance problem. Clinicians owe it to their patients to attempt to make an accurate diagnosis and not to rely on empiric therapy.

What's new in the mechanisms of host resistance to Candida albicans infection?

Despite extensive investigation, the mechanisms of host resistance against C. albicans infection remain poorly understood. Granulocytes and macrophages are the major effector cell types; however, their intrinsic candidacidal activity is rather limited, and its full expression requires augmentation by components of the T cell-initiated lymphokine cascade. Consequently, susceptibility to recurrent mucocutaneous infections may be associated with aberrant T cell function. In contrast, protection from systemic infection appears to be mediated by candida-specific antibodies.

Murine candidiasis: susceptibility is associated with the induction of T cell-mediated, strain-specific autoreactivity

Inbred mice can be classified as susceptible or resistant to systemic infection with the yeast Candida albicans by histopathological evaluation of tissue lesions. Candida-specific memory T cell responses generated by resistant BALB/c mice are vigorous and sustained, whereas those displayed by susceptible CBA/H mice are weak. When spleen cells from immune mice were activated by culture with candida antigens in vitro, and injected into syngeneic and allogeneic recipients in the absence of further antigenic stimulation, cells from CBA/H mice induced a specific inflammatory response only in CBA/H recipients. In contrast, cells from immune BALB/c mice showed no specific activity. The effector cells were identified as T cells of the cytotoxic/suppressor subclass (CD4-, CD8+); and analysis in various F1 hybrid mice showed that reactivity was expressed only in animals carrying CBA/H genes. The data thus indicate that susceptibility to C. albicans infection is associated with the induction of a T cell subpopulation that has the potential to react specifically against unmodified self antigens expressed by the susceptible strain.

Chronic recurrent vaginal candidosis: easy to treat, difficult to cure. Results of intermittent treatment with a new oral antifungant

Research into the pathogenesis and treatment of chronic recurrent candidosis vaginalis did not come up with a clear answer of curing this phenomenon. In this investigation, data are presented of a therapy with a new antifungal agent, itraconazole. After a therapeutic treatment course, 17 patients received a prophylaxis for CRCV over 6 months. The treatment schedule for prophylaxis consisted of 4 capsules of 50 mg itraconazole on day 5 and 6 of the menstrual cycle. Eleven remained symptom-free in this period. Although there is no explanation for recurrence in most cases of CRCV, intermittent treatment schedules can be used to treat but not to cure these patients. Data of this investigation and data mentioned in the literature prove the necessity to discriminate between a sympatomtic and a mycological cure.

Murine candidiasis: cell-mediated immune responses correlate directly with susceptibility and resistance to infection

Cell-mediated immune responses were evaluated after immunization in two inbred mouse strains, CBA/H and BALB/c, that are respectively susceptible and resistant to infection with the yeast Candida albicans. Local immune responses, as measured by leucocytic infiltration into the draining lymph node, were similar; however, both delayed-type hypersensitivity responses and candida-specific lymphocyte proliferation in vitro were significantly stronger in the resistant strain. The response was controlled by genes mapping outside the major histocompatibility complex. A possible explanation for the down regulation of the immune response in CBA/H mice is discussed.

Antibodies to microbial, leukocyte and organ antigens

Hemagglutinating antibodies to Mycoplasma hominis were present in 30 of 83 infertile, 15 of 40 pregnant and 5 of 20 post-partum females and 20 of 82 infertile males in contrast to only 2 of 21 fertile females and 5 of 25 fertile males. Their presence correlated with sperm antibody detection by TAT in Lab. 4, the immunobead-binding assay of Lab. 1 and the SIT of Lab. 11, but not with other sperm antibody assays. Immunofluorescent antibodies to Chlamydia trachomatis, on the other hand, did not correlate with the incidence of sperm antibodies. Among 305 serum samples tested, 12 were positive for testicular antibodies, 8 had antibodies to kidney, 7 to ovary and 15 to endometrium. A majority of serum samples positive for antibodies to testis and ovary, but not endometrium, reacted against sperm in different assays. Eight of 135 samples tested had antibodies to human leukocyte antigenic HLA-Aw19 (Aw19, A28, A29, A30 and A32) and/or B35 (B35, B5 and B15) complexes. Six of these samples were also positive for sperm antibodies by one or more antibody assays. Cross-reactive antigens may be present in sperm, M. hominis, testis, ovary and leukocytes.

Cytotoxic antibodies to lymphocytes: relationship to sperm immunity

Sperm and T lymphocytes share antigens, and sera from infertile subjects with sperm immunity have agglutinating antibodies to T lymphocytes. In the present study, cytotoxic antibody titers to sperm (C-Sp) and lymphocytes (C-Ly) were measured in sera, seminal plasma, cervical mucus and vaginal secretions of 52 infertile couples. The samples were divided into C-Sp negative and C-Sp positive groups. C-Ly titers against control T lymphocytes were significantly elevated in C-Sp positive sera of 35 males (P less than 0.005) and 27 females (P less than 0.05) as compared with C-Sp negative sera. C-Ly titers against autologous or partner T lymphocytes were similarly elevated in the sera of both groups. Titers of C-Ly in C-Sp positive secretions (seminal plasma, cervical mucus and vaginal secretions) against autologous and partner, as well as control, T lymphocytes were significantly elevated. In addition, elevated titers of C-Ly to autologous, partner and control B lymphocytes were observed in sera, cervical mucus and vaginal secretions from females with sperm immunity. The infertile males, however, did not have significant B lymphocyte immunity. Immunofluorescence assays revealed a significantly higher incidence of sperm and T lymphocyte antibodies (primarily IgG) in the C-Sp positive than in the C-Sp negative group. Titration of 100 sera from infertile subjects (50 couples) against a panel of lymphocytes of known HLA specificities failed to reveal a pattern of activity against HLA antigens of the A, B and C loci. Absorption of immune sera with sperm or lymphocytes reduced C-Sp and C-Ly titers significantly (P less than 0.001). These results suggest that infertile subjects with sperm immunity produce antibodies to cross-reactive antigens present on sperm and T lymphocytes.

Fetal cytotoxic antibodies to maternal T-lymphocytes: a possible mechanisms for maternal tolerance of the fetal allograft

The absolute numbers of B lymphocytes and of total and "active" T lymphocytes in peripheral venous blood (Mv) from 15 females at the time of normal term deliveries were found to be significantly less (p less than 0.001) than in the fetal umbilical vein (Uv) or artery (Ua) or in the peripheral blood of 75 normal nonpregnant controls (Cv), suggesting that maternal cellular immunity at term is lowered. In 19 umbilical artery samples, titers of lymphocytotoxic antibodies (Cyt), expressed as the mean log of reciprocal titer values, were significantly higher (p less than 0.01 in each case)( than in matched maternal samples, against the following cell types: Maternal T cells (7.1 in Ua vs 1.21 in Mv sera); maternal B cells (3.23 vs 1.58); T cells (4.41 vs 1.38) but not B cells from other females at delivery; autologous T cells (2.9 vs 1.0); autologous B cells (1.88 vs 0.69); T (5.39 vs 0.81) and B (2.80 vs 1.25) cells from the paired Uv; T (3.78 vs 0.62) and B (2.64 vs 0.77) cells from the Uv of other newborn infants; and T (4.19 vs 2.0) but not B cells from controls (Cv). The highest Cyt titers in the umbilical artery samples were against maternal T lymphocytes. Immunofluorescence studies indicated that the Cyt antibodies were primarily IgG. Absorption of 13 other Ua sera with maternal T cells eliminated with Cyt activity against both Mv and Cv T cells; absorption with Cv T cells eliminated the reaction against Cv T while reducing cyt titres to Mv T lymphocytes. We conclude that the fetus produces lymphocytotoxic antibody specifically directed against maternal T lymphocytes, in addition to antibody against T lymphocytes of other adults.