骨盆腔炎症包括了子宮內膜炎、骨盆腔腹膜炎、輸卵管卵巢膿腫、輸卵管炎、輸卵管炎等，在定義上泛指女性的急性骨盆腔逆行性感染。在現今社會中不孕症夫婦的比例有逐年增加的趨勢，而骨盆腔炎症就是造成女性不孕症的原因之ㄧ。骨盆腔炎症的症狀與許多骨盆相關疾病相似，所以很難經由一般的實驗室檢查來診斷，因此針對骨盆腔炎症較具專一性、特異性的檢查在臨床診斷上就顯得很重要。而骨髓過氧化酶及一些前發炎因子如IL-1β、IL-6、IL-8及TNF-α等細胞激素與骨盆腔炎症的相關性並不清楚。因此，我們分別收集了骨盆腔炎症患者及健康婦女的血液檢體，以全自動血球分析儀、血清蛋白分析儀及ELISA的方法進行WBC、neutrophils、CRP、骨髓過氧化酶、IL-1β、IL-6、IL-8與TNF-α的檢測。實驗結果發現利用抗生素治療前的骨盆腔炎症患者其血漿中的WBC、neutrophils、CRP、骨髓過氧化酶、IL-1β、IL-6、IL-8及TNF-α的數值比治療後的數值皆有較高的表現。另外，我們再進一步比較骨盆腔炎症患者其治療前與健康婦女的血漿中的數值，結果發現除了IL-8沒有統計學上的差異之外，其他皆有較高的數值表現。而我們更進一步分析這些前發炎因子與WBC、neutrophils及CRP之間的相關性，結果發現IL-6與WBC、neutrophils、CRP的數值皆呈現相關性。因此我們發現患者血清中這些前發炎因子的表現能夠專一的顯示骨盆腔炎症發展進行的概括狀況。因此我們發現檢測血清中骨髓過氧化酶、IL-1β、IL-6、IL-8及TNF-α的濃度可以在臨床上診斷骨盆腔炎症時提供一個輔助的診斷工具。

Pelvic inflammatory disease (PID) is caused by micro-organisms which colonize in the endocervix and ascend to the endometrium and fallopian tubes and become manifestations such as endometritis, pelvic peritonitis, tubal abscess, and salpingitis in the fallopian tube. However, the role of myeloperoxidases and proinflammatory cytokines in PID is unclear. We therefore determine whether plasma myeloperoxidases and proinflammatory cytokines, interleukin 1beta (IL-1beta), IL-6, IL-8, and tumor necrosis factor-alpha (TNF-alpha) were useful plasma markers in PID patients. ELISA and PCR-RFLP were respectively used to measure the plasma levels and genetic polymorphism of myeloperoxidase. Furthermore, Multiplex bead array analysis was used to measure the plasma levels of proinflammatory cytokines in healthy controls as well as in PID patients before and after routine protocol treatments. We discussed the plasma level of myeloperoxidase was elevated in PID patients compared to that in normal controls and decreased significantly compared to that in the same patients after they received treatment. IL-1beta, IL-6, IL-8, and TNF-alpha were statistically elevated in PID patients before they received antibiotic treatment than after they did. However IL-8 was not significantly difference between healthy controls and PID patients. The relatively increased ratio of IL-6 was correlated with the count of WBC (r=0.448, P=0.003), neutrophil (r=0.472, P=0.002), and the level of CRP (r=0.412, P=0.008). We concluded that IL-1beta, IL-6, IL-8, and TNF-alpha may play important roles in the pathogenesis of PID. These biomarkers, particular IL-6, could be useful adjuncts for the clinical diagnosis of PID. Furthermore, elevated expression of myeloperoxidase may be involved in the pathogenesis of PID and could be useful for the diagnosis of PID.

Abstract in Chinese．．．．．．．．．．．．．．．． ．．2
Abstract in English ．．．．．．．．．．．．．．．．．．4
Abbreviation．．．．．．．．．．．．．．．．．．．．．．6
1.Introduction．．．．．．．．．．．．．． ．．．．．．7
2. Literature review．．．．．．．．．．．．．．．．．12
3. Material and Methods．．．．．．．．．．．．．．．．16
4. Results．．．．．．．．．．．．．．．．．．．．．．．22
5. Discussion ．．．．．．．．．．．．．．．．．．．．．28
6. References ．．．．．．．．．．．．．．．．．．．．．41
7. Tables ．．．．．．．．．．．．．．．．．．．．．．．55
8. Figures ．．．．．．．．．．．．．．．．．．．．．．．62
9. Appendix 1: Protocols of the study methods ．．．．．72
10. Appendix 2: Published papers．．．．．．．．．．．．76

References
[1]Dayan L. Pelvic inflammatory disease. Aust Fam Physician 2006;35:858-62.
[2]Quentin R, Lansac J. Pelvic inflammatory disease: medical treatment. Eur J Obstet Gynecol Reprod Biol 2000;92:189-92.
[3]Manavi K. A review on infection with Chlamydia trachomatis. Best Pract Res Clin Obstet Gynaecol 2006;20:941-51.
[4]Gray-Swain MR, Peipert JF. Pelvic inflammatory disease in adolescents. Curr Opin Obstet Gynecol 2006;18:503-10.
[5]Ross J. Pelvic inflammatory disease. BMJ 2001;322:658-9.
[6]de Kroon CD, de Jong LW. The practice guideline ''pelvic inflammatory disease'' (first revision) from the Dutch College of General Practitioners; a response from the perspective of gynaecology. Ned Tijdschr Geneeskd 2007;151:732-4.
[7]Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006;55:1-94.
[8]Angerman NS, Evans MI, Moravec WD, Schumacher GF, Hajj SN. C-reactive protein in the evaluation of antibiotic therapy for pelvic infection. J Reprod Med 1980;25:63-6.
[9]Hadgu A, Westrom L, Brooks CA, Reynolds GH, Thompson SE. Predicting acute pelvic inflammatory disease: a multivariate analysis. Am J Obstet Gynecol 1986;155:954-60.
[10]Peipert JF, Boardman L, Hogan JW, Sung J, Mayer KH. Laboratory evaluation of acute upper genital tract infection. Obstet Gynecol 1996;87:730-6.
[11]Nauseef WM. How human neutrophils kill and degrade microbes: an integrated view. Immunol Rev 2007;219:88-102.
[12]Roos D, Winterbourn CC. Immunology. Lethal weapons. Science 2002;296:669-71.
[13]Eiserich JP, Hristova M, Cross CE, Jones AD, Freeman BA, Halliwell B, van der Vliet A. Formation of nitric oxide-derived inflammatory oxidants by myeloperoxidase in neutrophils. Nature 1998;391:393-7.
[14]Valerius NH, Stendahl O, Hartwig JH, Stossel TP. Distribution of actin-binding protein and myosin in polymorphonuclear leukocytes during locomotion and phagocytosis. Cell 1981;24:195-202.
[15]Kalinski T, Jentsch-Ullrich K, Fill S, Konig B, Costa SD, Roessner A. Lethal candida sepsis associated with myeloperoxidase deficiency and pre-eclampsia. Apmis 2007;115:875-80.
[16]Lau D, Baldus S. Myeloperoxidase and its contributory role in inflammatory vascular disease. Pharmacol Ther 2006;111:16-26.
[17]Salvarani C, Casali B, Farnetti E, Pipitone N, Nicoli D, Macchioni PL, Cimino L, Bajocchi GL, Catanoso MG, Pattacini L, Ghinoi A, Restuccia G, Boiardi L. -463 G/A myeloperoxidase promoter polymorphism in giant cell arteritis. Ann Rheum Dis 2008;67:485-8.
[18]Pope SK, Kritchevsky SB, Ambrosone C, Yaffe K, Tylavsky F, Simonsick EM, Rosano C, Stewart S, Harris T. Myeloperoxidase polymorphism and cognitive decline in older adults in the Health, Aging, and Body Composition Study. Am J Epidemiol 2006;163:1084-90.
[19]Reynolds WF, Stegeman CA, Tervaert JW. -463 G/A myeloperoxidase promoter polymorphism is associated with clinical manifestations and the course of disease in MPO-ANCA-associated vasculitis. Clin Immunol 2002;103:154-60.
[20]Zappia M, Manna I, Serra P, Cittadella R, Andreoli V, La Russa A, Annesi F, Spadafora P, Romeo N, Nicoletti G, Messina D, Gambardella A, Quattrone A. Increased risk for Alzheimer disease with the interaction of MPO and A2M polymorphisms. Arch Neurol 2004;61:341-4.
[21]Crawford FC, Freeman MJ, Schinka JA, Morris MD, Abdullah LI, Richards D, Sevush S, Duara R, Mullan MJ. ssociation between Alzheimer''s disease and a functional polymorphism in the Myeloperoxidase gene. Exp Neurol 2001;167:456-9.
[22]Zakrzewska-Pniewska B, Styczynska M, Podlecka A, Podlecka A, Samocka R, Peplonska B, Barcikowska M, Kwiecinski H. Association of apolipoprotein E and myeloperoxidase genotypes to clinical course of familial and sporadic multiple sclerosis. Mult Scler 2004;10:266-71.
[23]Nagra RM, Becher B, Tourtellotte WW, Antel JP, Gold D, Paladino T, Smith RA, Nelson JR, Reynolds WF. Immunohistochemical and genetic evidence of myeloperoxidase involvement in multiple sclerosis. J Neuroimmunol 1997;78:97-107.
[24]Piedrafita FJ, Molander RB, Vansant G, Orlova EA, Pfahl M, Reynolds WF. An Alu element in the myeloperoxidase promoter contains a composite SP1-thyroid hormone-retinoic acid response element. J Biol Chem 1996;271:14412-20.
[25]Azevedo MS, Yuan L, Pouly S, Gonzales AM, Jeong KI, Nguyen TV, Saif LT. Cytokine responses in gnotobiotic pigs after infection with virulent or attenuated human rotavirus. J Virol 2006;80:372-82.
[26]Lanzke N, Kleinwachter R, Kerschischnik S, Sargsyan L, Groneberg DA, Kamradt T, Liesenfeld O, Krenn V, Sander M, Spies C. Differential effects of ethanol on IFN-gamma- and TNF-alpha-producing splenic T lymphocytes in a murine model of gram-negative pneumonia. Addict Biol 2007;12:59-68.
[27]Wen LL, Chiu CT, Huang YN, Chang CF, Wang JY. Rapid glia expression and release of proinflammatory cytokines in experimental Klebsiella pneumoniae meningoencephalitis. Exp Neurol 2007;205:270-8.
[28]Lahouassa H, Moussay E, Rainard P, Riollet C. Differential cytokine and chemokine responses of bovine mammary epithelial cells to Staphylococcus aureus and Escherichia coli. Cytokine 2007;38:12-21.
[29]Puliti M, Bistoni F, Orefici G, Tissi L. Exacerbation of group B streptococcal sepsis and arthritis in diabetic mice. Microbes Infect 2006;8:2376-83.
[30]Mikamo H, Johri AK, Paoletti LC, Madoff LC, Onderdonk AB. Adherence to, invasion by, and cytokine production in response to serotype VIII group B Streptococci. Infect Immun 2004;72:4716-22.
[31]Shuster DE, Kehrli ME Jr, Stevens MG. Cytokine production during endotoxin-induced mastitis in lactating dairy cows. Am J Vet Res 1993;54:80-5.
[32]Moyer CF, Sajuthi D, Tulli H, Williams JK. Synthesis of IL-1 alpha and IL-1 beta by arterial cells in atherosclerosis. Am J Pathol 1991;138:951-60.
[33]Lane A, Graham L, Cook M, Chantry D, Green F, Nigon F, Humphries SE. Cytokine production by cholesterol-loaded human peripheral monocyte-macrophages: the effect on fibrinogen mRNA levels in a hepatoma cell-line (HepG2). Biochim Biophys Acta 1991;1097:161-5.
[34]Rayment NB, Moss E, Faulkner L, Brickell PM, Davies MJ, Woolf N, Katz DR. Synthesis of TNF alpha and TGF beta mRNA in the different micro-environments within atheromatous plaques. Cardiovasc Res 1996;32:1123-30.
[35]Wang N, Tabas I, Winchester R, Ravalli S, Rabbani LE, Tall A. Interleukin 8 is induced by cholesterol loading of macrophages and expressed by macrophage foam cells in human atheroma. J Biol Chem 1996;271:8837-42.
[36]Aida Y, Maeno M, Suzuki N, Namba A, Motohashi M, Matsumoto M, Makimura M, Matsumura H. The effect of IL-1beta on the expression of inflammatory cytokines and their receptors in human chondrocytes. Life Sci 2006;79:764-71.
[37]Gerszten RE, Garcia-Zepeda EA, Lim YC, Yoshida M, Ding HA, Gimbrone MA Jr, Luster AD, Luscinskas FW, Rosenzweig A. MCP-1 and IL-8 trigger firm adhesion of monocytes to vascular endothelium under flow conditions. Nature 1999;398:718-23.
[38]Kritchevsky SB, Cesari M, Pahor M. Inflammatory markers and cardiovascular health in older adults. Cardiovasc Res 2005;66:265-75.
[39]Blake GJ, Ridker PM. Inflammatory bio-markers and cardiovascular risk prediction. J Intern Med 2002;252:283-94.
[40]Moss ML, Jin SL, Milla ME, Bickett DM, Burkhart W, Carter HL, Chen WJ, Clay WC, Didsbury JR, Hassler D, Hoffman CR, Kost TA, Lambert MH, Leesnitzer MA, McCauley P, McGeehan G, Mitchell J, Moyer M, Pahel G, Rocque W, Overton LK, Schoenen F, Seaton T, Su JL, Becherer JD. Cloning of a disintegrin metalloproteinase that processes precursor tumour-necrosis factor-alpha. Nature 1997;385:733-6.
[41]Medvedev AE, Espevik T, Ranges G, Sundan A. Distinct roles of the two tumor necrosis factor (TNF) receptors in modulating TNF and lymphotoxin alpha effects. J Biol Chem 1996;271: 9778-4.
[42]Kalb A, Bluethmann H, Moore MW, Lesslauer W. Tumor necrosis factor receptors (Tnfr) in mouse fibroblasts deficient in Tnfr1 or Tnfr2 are signaling competent and activate the mitogen-activated protein kinase pathway with differential kinetics. J Biol Chem 1996;271: 28097-104.
[43]Dinarello CA. Interleukin-1. Cytokine Growth Factor Rev 1997;8: 253-65.
[44]Thornberry NA, Bull HG, Calaycay JR, Chapman KT, Howard AD, Kostura MJ, Miller DK, Molineaux SM, Weidner JR, Aunins J. A novel heterodimeric cysteine protease is required for interleukin-1 beta processing in monocytes. Nature 1992;356:768-74.
[45]Cerretti DP, Kozlosky CJ, Mosley B, Nelson N, Van Ness K, Greenstreet TA, March CJ, Kronheim SR, Druck T, Cannizzaro LA. Molecular cloning of the interleukin-1 beta converting enzyme. Science 1992;256:97-100.
[46]Roebuck KA. Regulation of interleukin-8 gene expression. J Interferon Cytokine Res 1999;19:429-38.
[47]Richter HE, Holley RL, Andrews WW, Owen J, Miller KB. The association of interleukin 6 with clinical and laboratory parameters of acute pelvic inflammatory disease. Am J Obstet Gynecol 1999;181:940-4.
[48]Koyama N, Matsuura K, Okamura H. Cytokines in the peritoneal fluid of patients with endometriosis. Int J Gynaecol Obstet 1993;43:45-50.
[49]den Hartog JE, Ouburg S, Land JA, Lyons JM, Ito JI, Peña AS, Morré SA. Do host genetic traits in the bacterial sensing system play a role in the development of Chlamydia trachomatis-associated tubal pathology in subfertile women? BMC Infect Dis 2006;6:122.
[50]Vigano P, Infantino M, Lattuada D, Lauletta R, Ponti E, Somigliana E, Vignali M, DiBlasio AM. Intercellular adhesion molecule-1 (ICAM-1) gene polymorphisms in endometriosis. Mol Hum Reprod 2003;9:47-52.
[51]Centers for Disease Control, Taiwan 2007.
[52]Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006;55:1-94.
[53]Angerman NS, Evans MI, Moravec WD, Schumacher GF, Hajj SN. C-reactive protein in the evaluation of antibiotic therapy for pelvic infection. J Reprod Med 1980;25:63-6.
[54]Hadgu A, Westrom L, Brooks CA, Reynolds GH, Thompson SE. Predicting acute pelvic inflammatory disease: a multivariate analysis. Am J Obstet Gynecol 1986;155:954-60.
[55]Bevan CD, Johal BJ, Mumtaz G, Ridgway GL, Siddle NC. Clinical, laparoscopic and microbiological findings in acute salpingitis: report on a United Kingdom cohort. Br J Obstet Gynaecol 1995;102:407-14.
[56]Kelley J. Cytokines of the lung. Am Rev Respir Dis 1990;141:765-88.
[57]Bagavant H, Adams S, Terranova P, Chang A, Kraemer FW, Lou Y, Kasai K, Luo AM, Tung KS. Autoimmune ovarian inflammation triggered by proinflammatory (Th1) T cells is compatible with normal ovarian function in mice. Biol Reprod 1999;61:635-42.
[58]Romani L, Mencacci A, Cenci E, Spaccapelo R, Toniatti C, Puccetti P, Bistoni F, Poli V. Impaired neutrophil response and CD4+ T helper cell 1 development in interleukin 6-deficient mice infected with Candida albicans. J Exp Med 1996;183:1345-55.
[59]Lee J, Zhao X. Recombinant human interleukin-8, but not human interleukin-1beta, induces bovine neutrophil migration in an in vitro co-culture system. Cell Biol Int 2000;24:889-95.
[60]Shuster DE, Lee EK, Kehrli ME, Jr. Bacterial growth, inflammatory cytokine production, and neutrophil recruitment during coliform mastitis in cows within ten days after calving, compared with cows at midlactation. Am J Vet Res 1996;57:1569-75.
[61]Le JM, Vilcek J. Interleukin 6: a multifunctional cytokine regulating immune reactions and the acute phase protein response. Lab Invest 1989;61:588-602.
[62]Ridker PM, Cushman M, Stampfer MJ, Tracy RP, Hennekens CH. Inflammation, aspirin, and the risk of cardiovascular disease in apparently healthy men. N Engl J Med 1997;336:973-9.
[63]Wong LY, Leung RY, Ong KL, Cheung BM. Plasma levels of fibrinogen and C-reactive protein are related to interleukin-6 gene -572C>G polymorphism in subjects with and without hypertension. J Hum Hypertens 2007;21:875-82.
[64]Andrews WW, Hauth JC, Cliver SP, Conner MG, Goldenberg RL, Goepfert AR. Association of asymptomatic bacterial vaginosis with endometrial microbial colonization and plasma cell endometritis in nonpregnant women. Am J Obstet Gynecol 2006;195:1611-6.
[65]Ness RB, Kip KE, Hillier SL, Soper DE, Stamm CA, Sweet RL, Rice P, Richter HE. A cluster analysis of bacterial vaginosis-associated microflora and pelvic inflammatory disease. Am J Epidemiol 2005;162:585-90.
[66]Corbeil LB, Shively JN, Duncan JR, Schurig GG, Winter AJ. Bovine venereal vibriosis. Ultrastructure of endometrial inflammatory lesions. Lab Invest 1975;33:187-92.
[67]Tsai HT, Wang PH, Tee YT, Lin LY, Hsieh YS, Yang SF. Imbalanced serum concentration between cathepsin B and cystatin C in patients with pelvic inflammatory disease. Fertil Steril 2008 Mar 1. [Epub ahead of print].
[68]Klebanoff SJ. Myeloperoxidase. Proc Assoc Am Physicians 1999;111:383-9.
[69]Weiss SJ, Peppin G, Ortiz X, Ragsdale C, Test ST. Oxidative autoactivation of latent collagenase by human neutrophils. Science 1985;227:747-9.
[70]Buffon A, Biasucci LM, Liuzzo G, D''Onofrio G, Crea F, Maseri A. Widespread coronary inflammation in unstable angina. N Engl J Med 2002;347:5-12.
[71]Peipert JF, Boardman L, Hogan JW, Sung J, Mayer KH. Laboratory evaluation of acute upper genital tract infection. Obstet Gynecol 1996;87:730-6.
[72]Reynolds WF, Rhees J, Maciejewski D, Paladino T, Sieburg H, Maki RA, Masliah E. Myeloperoxidase polymorphism is associated with gender specific risk for Alzheimer''s disease. Exp Neurol 1999;155:31-41.
[73]Lundmark F, Salter H, Hillert J. An association study of two functional promotor polymorphisms in the myeloperoxidase (MPO) gene in multiple sclerosis. Mult Scler 2007;13:697-700.
[74]Manna I, Valentino P, La Russa A, Condino F, Nisticò R, Liguori M, Clodomiro A, Andreoli V, Pirritano D, Cittadella R, Quattrone A. Genetic variation in the myeloperoxidase gene and cognitive impairment in multiple sclerosis. J Negat Results Biomed 2006;5:3.
[75]Corder EH, Saunders AM, Strittmatter WJ, Schmechel DE, Gaskell PC, Small GW, Roses AD, Haines JL, Pericak-Vance MA. Gene dose of apolipoprotein E type 4 allele and the risk of Alzheimer''s disease in late onset families. Science 1993;261:921-3.