Lymphogranuloma Venereum (LGV)
Lymphogranuloma venereum (LGV) is a disease caused by 3 unique strains of Chlamydia trachomatis and characterized by a small, often asymptomatic skin lesion, followed by regional lymphadenopathy in the groin or pelvis. Alternatively, if acquired by anal sex, it may manifest as severe proctitis. Without treatment, LGV may cause obstruction of lymph flow and chronic swelling of genital tissues. Diagnosis is by clinical signs, but laboratory confirmation with serologic or immunofluorescent testing is usually possible. Treatment is 21 days of a tetracycline or erythromycin.
LGV is caused by serotypes L1, L2, and L3 of the bacteria Chlamydia trachomatis. These serotypes differ from the chlamydial serotypes that cause trachoma, inclusion conjunctivitis, urethritis, and cervicitis because they can invade and reproduce in regional lymph nodes.
LGV occurs sporadically in the US but is endemic in parts of Africa, India, Southeast Asia, South America, and the Caribbean. It is diagnosed much more often in men than women.
The 1st stage begins after an incubation period of about 3 days with a small skin lesion at the site of entry. It may cause the overlying skin to break down (ulcerate) but heals so quickly that it may pass unnoticed.
The 2nd stage usually begins in men after about 2 to 4 wk, with the inguinal lymph nodes on one or both sides enlarging and forming large, tender, sometimes fluctuant masses (buboes). The buboes stick to deeper tissues and cause the overlying skin to become inflamed, sometimes with fever and malaise. In women, backache or pelvic pain is common; the initial lesions may be on the cervix or upper vagina, resulting in enlargement and inflammation of deeper perirectal and pelvic lymph nodes. Multiple draining sinus tracts may develop and discharge pus or blood.
In the 3rd stage, lesions heal with scarring, but sinus tracts can persist or recur. Persistent inflammation due to untreated infection obstructs the lymphatic vessels, causing swelling and skin sores.
People who engage in receptive anal sex may have severe proctitis or proctocolitis with bloody purulent rectal discharge during the 1st stage. In the chronic stages, colitis simulating Crohn disease may cause tenesmus and strictures in the rectum or pain due to inflamed pelvic lymph nodes. Proctoscopy may detect diffuse inflammation, polyps, and masses or mucopurulent exudate—findings that resemble inflammatory bowel disease.
LGV is suspected in patients who have genital ulcers, swollen inguinal lymph nodes, or proctitis and who live in, have visited, or have sexual contact with people from areas where infection is common. LGV is also suspected in patients with buboes, which may be mistaken for abscesses caused by other bacteria.
Diagnosis has usually been made by detecting antibodies to chlamydial endotoxin (complement fixation titers > 1:64 or microimmunofluorescence titers > 1:256) or by genotyping using a PCR-based NAAT. Antibody levels are usually elevated at presentation or shortly thereafter and remain elevated. Direct tests for chlamydial antigens with immunoassays (eg, enzyme-linked immunosorbent assay [ELISA]) or with immunofluorescence using monoclonal antibodies to stain pus or NAATs may be available through reference laboratories (eg, Centers for Disease Control and Prevention in the US).
All sex partners should be evaluated.
After apparently successful treatment, patients should be followed for 6 mo.
Doxycycline 100 mg po bid, erythromycin 500 mg po qid, or tetracycline 500 mg po qid, each for 21 days, are effective for early disease. Azithromycin 1 g po once/wk for 1 to 3 wk is probably effective, but neither it nor clarithromycin has been adequately evaluated.
Swelling of damaged tissues in later stages may not resolve despite elimination of the bacteria. Buboes may be drained by needle or surgically if necessary for symptomatic relief, but most patients respond quickly to antibiotics. Buboes and sinus tracts may require surgery, but rectal strictures can usually be dilated.
Current sex partners, if infected, are treated.