5/17/2017 Trachoma:Background,Pathophysiology,Epidemiology

Trachoma
Updated:Aug23,2016
Author:SoheilaRostami,MD,FAACCChiefEditor:HamptonRoy,Sr,MDmore...

OVERVIEW

Background
Trachomaistheworldsleadingcauseofpreventableblindnessofinfectiousorigin.This
diseaseisachronickeratoconjunctivitiscausedbytheobligateintracellularbacterium
Chlamydiatrachomatis.[1]

Ctrachomatiscanbespreadbyeitherdirectcontactwithaninfectedperson'seyesornose
orindirectcontact,suchasthroughcontactwithclothingorfliesthathavecomeintocontact
withaninfectedperson'seyesornose.Poorsanitation,crowdedlivingconditions,and
insufficientcleanwaterandtoiletscanalsoincreasethespreadoftrachoma.Disease
transmissionoccursprimarilybetweenchildrenandthewomenwhocareforthem.Some
havecharacterizedthistransmissioncyclebydescribingtrachomaasadiseaseofthe
crche(daynursery).Fliesthattransmittrachomapreferentiallylaytheireggsonhuman
feceslyingexposedonsoil.

Repeatedepisodesofreinfectionwithinthefamilycausechronicfollicularorintense
conjunctivalinflammation(activetrachoma),whichleadstotarsalconjunctivalscarring.The
scarringdistortstheuppertarsalplateand,insomeindividuals,leadstoentropionand
trichiasis(cicatricialtrachoma).Theendresultincludescornealabrasionscornealscarring
andopacificationand,ultimately,blindness.

Preventionoftrachomarelatedblindnessrequiresanumberofinterventions.TheWorld
HealthOrganization(WHO)andtheirpartnersendorsethesurgery,antibiotics,facial
cleanliness,andenvironmentalimprovement(SAFE)strategyfortrachomacontrol.[2]The
interventionsarediscussedingreaterdetailinTreatment.

Pathophysiology
TrachomaiscausedbyserovarsA,B,Ba,andCofCtrachomatis.Differentserovars
predominateindifferentfamiliesandindifferentcommunities.

Chlamydiaearegramnegative,obligateintracellularbacteria.ThespeciesCtrachomatis
causestrachomaandalsogenitalinfections(serovarsDK)andlymphogranuloma
venereum(serovarsL1L3).SerovarsDKoccasionallycauseasubacutefollicular
conjunctivitisthatmaybeclinicallyindistinguishablefromtrachoma,includingfollicular
conjunctivitiswithpannus,butrarelyconjunctivalscarring.However,thesegenitalserovars
donottypicallyenterstabletransmissioncycleswithincommunities.Therefore,theyarenot
involvedinthegenesisoftrachomablindness.Regardlessoftheserovar(whichis
determinedbypolymorphismsinasurfaceexposedprotein),isolatesofCtrachomatis
obtainedfromtheeyehavemutationsthatinactivatethegenescodingfortryptophan

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5/17/2017 Trachoma:Background,Pathophysiology,Epidemiology

synthase,whereasgenitalisolateshaveafunctionalenzyme.[3]

Infectioncausesinflammation,thatis,apredominantlylymphocyticandmonocyticinfiltrate
withplasmacellsandmacrophagesinfollicles.Thefolliclesaretypicalgerminalcenterswith
islandsofintenseBcellproliferationsurroundedbyseasofTcells.Recurrentconjunctival
reinfectioncausestheprolongedinflammationthatleadstoconjunctivalscarring.Scarringis
associatedwithatrophyoftheconjunctivalepithelium,lossofgobletcells,andreplacement
ofthenormal,loose,vascularsubepithelialstromawiththickcompactbandsoftypeIVand
typeVcollagen.

Theclinicalchangesareadelayedtypehypersensitivityreactiontothechlamydialantigens
(thoughttobeHSP60).Thisinducesanimmuneresponsewithgerminalcenters(seenas
follicles)andintenseinflammatoryinfiltrateandtheformationofpapillae.Overtime,this
intenseinflammationleadstoscarformation,which,inturn,causescontractionandbuckling
ofthetarsalplateoftheupperlid,producingentropionandtrichiasis.

Epidemiology
Frequency
UnitedStates

TrachomawasonceendemicinNorthAmericaandEurope,butitdisappearedinthese
locationsduringthe20thcenturyaslivingstandardsinthoselocationsimproved.

International

TrachomaisendemicinpartsofAfrica,Asia,theMiddleEast,LatinAmerica,thePacific
Islands,andaboriginalcommunitiesinAustralia.[4,5,6,7,8]Worldwide,anestimated229
millionpeoplein53countriesliveintrachomaendemicareas.Inhyperendemicareas,most
membersofnearlyallfamiliesmayhaveactivedisease.Whentheoverallcommunity
prevalencedecreasestoaround20%,activediseaseisclearlyseentoclusterinfamilies.In
1of5families,mostchildrenhaveactivetrachoma(asopposedto1in5childreninmost
families).Thisclusteringbecomesmoreapparentincommunitiesastheprevalence
decreases.

Mortality/Morbidity

Blindnessfromanycauseisassociatedwithincreasedriskofmortalityinendemic
communities.Approximately1.2millionpeopleareblindbecauseoftrachoma.

Race
Adiseaseofpovertyandpoorhygiene,trachomahasnoracialpreponderance.

Trachomapersistsinareaswithpoorpersonalandcommunityhygiene,forexample,
communitieswithinadequateaccesstowaterandsanitationinhot,dry,dustyclimates.

Trachomatypicallyaffectsthemostmarginalized,deprivedmembersofacommunity.

Sex

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5/17/2017 Trachoma:Background,Pathophysiology,Epidemiology

Activediseasemostcommonlyoccursinpreschoolchildrenofbothsexesandtheir(usually
female)careproviders.

Trichiasisandblindnessmaybe24timesmorecommoninwomenthanmen.

Age
Activediseasemostcommonlyoccursinpreschoolchildren,withthehighestprevalencein
childrenaged35years.

Cicatricialdiseaseismostcommoninmiddleagedadults.Theagegroupinwhichcicatricial
diseasebeginstoappeardependsontheintensityoftransmissioninthecommunity.In
areasofextremelyhighendemicity,rarecasesoftrichiasisoccurinchildrenyoungerthan10
years.

Becauseofrepeatinfection,agingmaybeaccompaniedbysequentialworseningofdisease.
Youngchildrenhavefolliculartrachomawithintenseconjunctivalinflammationyoungadults,
especiallymothers,havetrachomatousscarringandmiddleagedpatientsorgrandparents
havetrichiasisandcornealopacity.However,thesesignsarenotmutuallyexclusive.
Individualsmayhaveepisodesoffolliculartrachomawithintenseconjunctivalinflammation
evenaftercicatricialcomplicationsdeveloptherefore,follicles,scarring,andtrichiasismay
allbepresentinthesamepatient.

ClinicalPresentation

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