Molecular Detection of Chlamydia

trachomatis and HPV Infections

in Cervical Samples With Normal
and Abnormal Cytopathological
Findings
Francisco Danilo Ferreira de Paula, M.Sc.,1 Ana Paula Fernandes, Ph.D.,1*
Bianca Bianco do Carmo, M.Sc.,1 Daniela Cristina Duarte Vieira, B.Sc.,2
Miriam Santos Dutra, B.Sc.,2 Caleb Guedes Miranda dos Santos, B.Sc.,1
Maria do Carmo M. Souza, B.Sc.,3 Tulio Cesar Alvim Andrade, M.D.,3
Annamaria Ravara Vago, Ph.D.,2 and Paula Avila Fernandes M.D., Ph.D.1

It has been suggested that Chlamydia trachomatis (CT) and

human papillomaviruses (HPV) co-infection could contribute to
development of intraepithelial lesions. In this study, HPV and CTDNA were investigated in 250 cervicovaginal samples of patients
from Minas Gerais, Brazil. The cytological analysis revealed that
70% of samples (175) were negative, 5.2% (13) presented atypical squamous or glandular cells of undetermined signicance
(ASCUS/AGUS), 12.4% (31) presented low-grade squamous intraepithelial lesion (LSIL), 10.8% (27) high-grade squamous intraepithelial lesion (HSIL), and 1.6% (4) invasive carcinoma. HPVDNA and HPV/CT co-infection was observed in 40% (100/250)
and in 5.2% (13/250) of samples, respectively. Among the positive
cytological samples, HPV-DNA was detected in 73.3% and CTDNA in 9.33% and in 13%, if only the HPV positive samples
were considered. The highest co-infection rate (15.4%) was
observed among ASCUS/AGUS samples. Although a signicant
association was found for HPV infection and the precursor
lesions of cervical cancer, it was not possible to establish a signicant association between these lesions and CT or HPV/CT coinfection. Diagn. Cytopathol. 2007;35:198202.
'

2007 Wiley-Liss, Inc.

1
Faculdade de Farmacia, Universidade Federal de Minas Gerais, Minas
Gerais, Brazil
2
Departamento de Morfologia, Instituto de Ciencias Biologicas, Universidade Federal de Minas Gerais, Minas Gerais, Brazil
3
Distrito Centro Sul da Prefeitura de Belo Horizonte, Minas Gerais,
Brazil
Contract grant sponsors: FAPEMIG and CNPq; Contract grant numbers:
CDS 206/04 and 48034/04-2
*Correspondence to: Ana Paula Fernandes, Ph.D., Faculdade de Farmacia, Universidade Federal de Minas Gerais, Av. Antonio Carlos, 6627CEP 31270 901, Belo Horizonte, Minas Gerais, Brazil.
E-mail: anav@uai.com.br
Received 17 May 2006; Accepted 9 November 2006
DOI 10.1002/dc.20629
Published online in Wiley InterScience (www.interscience.wiley.com).

198

Diagnostic Cytopathology, Vol 35, No 4

Key Words: human papillomaviruses (HPV); Chlamydia trachomatis; PCR; squamous intraepithelial lesions; cervical cancer

Cervical cancer is one of the most frequent diseases in

women and a considerable cause of morbidity and mortality. Mortality rates are estimated from 10/100,000 cases
per year in many industrialized countries to over 40/
100,000 cases a year in developing countries.1 The occurrence of 19,260 new cases of cervical cancer is estimated
in Brazil during the year of 2006.2
Cervical cancer is closely related to persistent infection by high-risk (16, 18, 45, 31, 33, 58, 52) human papillomaviruses (HPV).3,4 In a study performed with biopsy
samples obtained from patients of 22 countries, using polymerase chain reaction (PCR), HPV DNA was found in
99.7% of the cervical cancer cases, pointing out that HPV
is indeed the cause of this type of neoplasia.4,5
However, HPV infection may not be sufcient to
induce the development of cervical cancer and cigarette
smoking, multiparity, age of rst intercourse, immunosupression, and lifetime sexual partners are other risk factors that have been described. Other factors, that are still
controversial in literature, include use of oral contraceptive, certain nutritional deciencies, and Chlamydia trachomatis infection.1,3,5
A higher C. trachomatis DNA prevalence in HPV-positive samples when compared with HPV-negative samples
has been shown in several studies.610 It has been argued
that C. trachomatis seropositive patients have a two-fold
higher risk of developing squamous cancer than C. trachomatis seronegative patients.11 It has been also reported
that both C. trachomatis and HPV infections are related
'

2007 WILEY-LISS, INC.

Diagnostic Cytopathology DOI 10.1002/dc

C. TRACHOMATIS AND HPV INFECTIONS IN CERVICAL SAMPLES

to the increase of Ki67 expression, a tracer for cell proliferation, in cervical epithelium. Moreover, C. trachomatis
infection increases HPV 16 protein expression in lowgrade squamous lesions, suggesting that the infection
could modify the virus activity.12 Regarding the serotype,
there is evidence of association of serotype G to the development of squamous cervical cell carcinoma.13 On the
other hand, positive serology for C. trachomatis would
not be associated with a higher risk of developing other
types of cervical tumors such as adenocarcinoma and adenosquamous carcinoma.
Despite these studies, literature data are still conicting.
Evidences of a negative correlation between C. trachomatis infection and the development of squamous intraepithelial and invasive cervical lesions have been also
obtained.1416
In the present study, we investigated the correlation
between the co-infection by these pathogens and the cytopathological changes in women attending three public health
services of Belo Horizonte, Minas Gerais state, Brazil.

Material and Methods

Population Evaluated
The two hundred and fty patients of this study attended
three public health services as they presented clinical, colposcopic, and cytopathological indications of uterine cervical pathologies. Cervical samples were collected to perform cytopathological analysis and molecular PCR tests
to detect HPV and C. trachomatis infections, according to
procedures described below. This study was approved by
the Institutional Ethics Committee of the Universidade
Federal de Minas Gerais, in accordance with the precepts
established by the Helsinki Declaration. All participants
have given their informed consent for the study.

Sample Collection
Cervical samples (n 250) were collected using liquidbased cytology technique according to the manufacturers
recommendations (DNA-Citoliq System, DIGENE, Brazil).
All the smears were xed in 95% ethylic alcohol and,
afterwards, stained by Papanicolaou method.

Cytopathological Analysis
The smears were analyzed randomly without previous
knowledge of the results of the molecular analyses. The
diagnostics were classied according to Bethesda System.17
In the comparative analysis of the cytopathological
results, a result was considered negative when it presented
a normal or inammatory pattern. Smears diagnosed with
atypical squamous or glandular cells of undetermined signicance (ASCUS and/or AGUS), low-grade squamous
intraepithelial lesion (LSIL), high-grade squamous
intraepithelial lesion (HSIL), and invasive carcinoma
were considered positive.

Molecular Analysis
Molecular tests were carried out in all the collected samples. DNA extraction was conducted as described.18 The
PC03 and PC04 oligonucleotides, which amplify a 110 pb
fragment from the human b-globin gene,19 were used to
verify the integrity and quality of the DNA extracted. The
MY09 and MY11 generic oligonucleotides, which are
complementary to the L1 region of the genome of most
HPV subtypes,20 were used. Samples that presented negative results for HPV using MY09 and MY11 were retested with GP5/GP6 primers. These oligonucleotides
amplify a 110 pb fragment in L1 region.21 To identify
C. trachomatis infection, KL5/KL6 oligonucleotides, complementary to the cryptic plasmid of the C. trachomatis22
were used. DNA positive samples previously tested by
hybrid capture method were utilized as positive control of
the reaction. PCR negative controls were performed for
each set of reactions. PCR products were analyzed by
silver stained 6% polyacrilamide gel electrophoresis.23

Statistical Analysis
To compare the differences between the analyzed parameters, the Pearson chi-square test was performed and,
when needed, the Fisher Test. A degree of signicance
a 0.05 was considered for all tests. The statistical programs utilized were SPSS 10.0 and Statxact 3.0.

Results
Most of the patients (87.2%) analyzed in this study presented ages ranging from 20 to 59 years. In 70% of the
cases (175 patients), the results of the cytopathological
analysis were negatives. Thirteen patients (5.2%) presented ASCUS/AGUS diagnosis, 31 (12.4%) presented
LSIL, 27 (10.8%) HSIL, and 4 (1.6%) invasive epidermoid carcinoma.
By using PCR technique, HPV DNA was detected in
40% (100/250) of the cases. Table I presents data related
to the cytological ndings and to the HPV DNA detection
in the cervical samples. Considering only the positive
cytological samples, HPV infection was detected in
73.3% (55/75) of the cases. There was a signicant association between the cytopathological diagnosis and the
presence of HPV. HPV detection rate increased according
to the lesions severity. In fact, HPV infection was
detected in all carcinoma cases (P
0.01).
As for C. trachomatis infection, 9.2% (23/250) of the
samples were positive. Considering only the positive cytopathological results (Table II), the C. trachomatis detection rate by PCR was 9.33% (7/75) and no association
was observed between the cytopathological diagnosis and
the infection caused by this pathogen (P 0.892).
Among the 100 HPV-positive samples, 13 were also
positive for C. trachomatis, whereas in the HPV-negative
Diagnostic Cytopathology, Vol 35, No 4

199

Diagnostic Cytopathology DOI 10.1002/dc

DE PAULA ET AL.
Table I. Correlation Between Cytopathological Results and HPV DNA
Detection
HPV/DNA positive
Variables

Grade

Cytology Negative
ASCUS
LSIL
HSIL
Carcinoma

Table II. Correlation Between Cytopathological Results and

C. trachomatis DNA Detection

HPV/DNA negative

(%)

(%)

45
9
22
20
4

25.7
69.2
71.0
74.1
100

130
4
9
7
0

74.3
30.8
29.0
25.9

CT/DNA positive
P-value

Variables

0.000*

Cytology Negative
ASCUS
LSIL
HSIL
Carcinoma

Grade

CT/DNA negative

(%)

(%)

P-value

16
2
3
2
0

9.1
15.4
9.7
7.4
0

159
11
28
25
4

90.9
84.6
90.3
92.6
100

0.892*

*Pearson chi-square test.

*Pearson chi-square test.

samples, the presence of C. trachomatis DNA was determined in 6.7% (10/150) of the cases (P 0.09).
The HPV/C. trachomatis co-infection rate was of 5.2%
(13/250) and of 13%, if only the HPV-positive samples
were considered. In both situations, no association was
detected between co-infection and the cytopathological diagnosis (P 0.429). The highest co-infection rate
(15.4%) was observed in the samples diagnosed as ASCUS/
AGUS (Table III); no epidermoid carcinoma samples showed association between the two pathogens.

Table III. Correlation Between Cytopathological Results and HPV and

C. trachomatis Co-infection

Discussion
The identication of factors that could act in association
to the HPV infection in the progression of a LSIL to a
HSIL or to invasive carcinoma is relevant to the understanding of the development of cancer in patients infected
by HPV. Thus, it is essential to use specic and sensitive
methods to possibly detect the association between C. trachomatis and HPV and its relation with squamous intraepithelial and invasive lesions in the uterine cervix.
Amongst the patients presenting negative cytological
results, 25.7% were positive for DNA-HPV. This data is
similar to those previously found in Brazilian asymptomatic women (prevalence varying from 15 to 27%) seen at
cervical cancer screening centers.24,25 Among those
patients with positive cytological results, 73.3% were also
positive for the presence of DNA-HPV. DNA-HPV was
detected in all cases of invasive carcinoma and in 71%
and 74% of the LSIL and HSIL samples, respectively.
These data are similar to those previously observed.2630
In Brazil, the presence of HPV DNA in samples of
patients presenting squamous intraepithelial and invasive
lesions has ranged from 55.2% to 91%, depending on the
detection method and the material used.3136
Studies performed in Brazil employing molecular methods for detection of C. trachomatis infection have showed
a frequency variation of 0.6% to 20.7%.3740 In the present study, the presence of C. trachomatis DNA was
detected in 9.2% of the samples. No association was
found between the severity of the squamous lesions and
the presence of C. trachomatis. In addition, the detection
rate of C. trachomatis DNA in samples presenting squamous intraepithelial lesions was similar to that detected in
200

Diagnostic Cytopathology, Vol 35, No 4

HPV/CT positive
Variables

Grade

Cytology Negative
ASCUS
LSIL
HSIL
Carcinoma

HPV/CT negative

(%)

(%)

P-value

7
2
2
2
0

4.0
15.4
6.50
7.40
0

168
11
29
25
4

96.0
84.6
93.5
92.6
100

0.429*

*Pearson chi-square test.

the patients with negative cytopathological diagnosis

(9%). These ndings suggest that, in contrast to HPV, C.
trachomatis seems not to be involved in the development
of these lesions as reported in other studies.14,41,42 It is
noteworthy that detection rates of C. trachomatis DNA in
patients presenting cervical squamous intraepithelial
lesion vary largely (9.2% to 43%), even in those studies
that used a similar methodology.6,8,14 In this study, C. trachomatis DNA was not detected in epidermoid carcinoma
samples. Nevertheless, it should be highlighted that only
four epidermoid carcinoma samples were analyzed herein.
A recent study detected that, among the risk factors
investigated, the most signicant one to persistent HPV
infection was a previous C. trachomatis infection.43 The
studies based on the serologic detection C. trachomatis
infection partly corroborate these ndings. A higher risk
to develop epidermoid invasive cancer in patients with
positive serology for C. trachomatis was detected, even
after adjustments for HPV infection, as reported by Franceschi in his review.4 On the other hand, studies in which
C. trachomatis infection was ascertained by means of
molecular techniques, the results are still conicting.7,9,10,14,41,42
Our ndings showed that C. trachomatis DNA frequency
was higher in HPV-positive samples than in HPV-negative
samples (13% versus 6.7%), but this result was not statistically signicant. Molano et al.41 and Lehmann et al.7 veried the presence of C. trachomatis in 6.9% and 10.3% of
the HPV-positive patients, respectively. Silva et al.44 and
Cavaliere et al.45 have also reported higher detection
rates of C. trachomatis infection in HPV-positive patients.
However, in these later studies a very small number (14
and 7, respectively) of HPV-positive patients were ana-

Diagnostic Cytopathology DOI 10.1002/dc

C. TRACHOMATIS AND HPV INFECTIONS IN CERVICAL SAMPLES

lyzed, which were selected from a special population segment. A higher C. trachomatis DNA frequency in HPVpositive patients may indicate, however, only a high-risk
sexual behavior, since both pathogens are sexually transmitted. De Lima Soares et al.25 veried that 43.3% of the
HPV infection diagnosed cases occurred simultaneously
with other sexually transmitted diseases. Moreover, the
establishment of an inammatory process by one of the
two pathogens could favor the subsequent development of
a co-infection.10,12 In the present study the highest detection rate for co-infection was observed in the samples diagnosed as ASCUS/AGUS (15.4%). These cases could be a
consequence of the inammatory process induced by C.
trachomatis and only the follow-up of these patients would
allow us to test this hypothesis.
Among the 13 co-infected samples, 7 were negative in
the cytopathological analysis, 2 were diagnosed as
ASCUS, 2 as LSIL, and 2 as HSIL. Additional investigation is required regarding the correlation of co-infection,
HPV typing and the progression of the squamous cervical
lesions. A signicant correlation among C. trachomatis
co-infection and multiple infection by different HPV
types41 or by high-risk HPVs6 has also been reported.
Up to the moment, the results herein presented are the
rst published in Brazil referring to HPV and C. trachomatis co-infection determined by PCR in cervical samples. However, considering the data on frequency of C.
trachomatis and HPV infection observed in the present
study, its experimental design and the signicant association between HPV and the presence of cervical lesions, it
was not possible to establish an association between the
C. trachomatis infection or the co-infection by those
pathogens and the development of lesions that are precursors of uterine cervical cancer. So, further studies are
required, especially considering the most recent evidence
of the decreasing of the caveolin-1 (tumor supressor gene)
expression and increasing of c-myc oncogene expression
in cervical samples dissected from the transformation
zone of patients diagnosed by PCR as C. trachomatispositive and HPV-negative.46

7.

8.

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13.

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18.

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