Lymphogranuloma venereum

Aka: Lymphogranuloma venereum, LGV, Lymphogranuloma venereum proctocolitis

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II. Pathophysiology

  1. Sexually Transmitted Infection
  2. Caused by Chlamydia Trachomatis subtypes L1, L2, L3 in the United States
    1. Differs from other Chlamydia Trachomatis genitourinary infections (serotypes D to K)

III. Epidemiology

  1. Previously rare in the United States
  2. Recent outbreaks in U.S.
    1. More common in HIV patients and homosexual men

IV. Symptoms

  1. General
    1. Fever and chills
    2. Headache or meningismus
    3. Anorexia
    4. Arthralgias and Myalgias
  2. Proctocolitis if rectal exposure
    1. Mucus or bloody discharge from anus
    2. Anal Pain
    3. Constipation
    4. Tenesmus

V. Signs

  1. Transient Genital Lesion (Genital Ulcer)
    1. Appears 3 days to 3 weeks after exposure
    2. Starts as nontender Papule
    3. Develops small painless Vesicle or non-indurated Genital Ulcer at site within 3 to 30 days
  2. Rectal lesion or Proctocolitis
    1. Women and homosexual men
    2. Rectal ulcer
    3. Bloody rectal discharge
  3. Inguinal Syndrome (Painful inguinal adenopathy)
    1. Occurs 2-6 weeks after exposure
    2. Unilateral in 66% of cases
    3. Painful, tender inguinal or femoral Lymphadenopathy (Bubo)
      1. Inguinal Lymphadenopathy: Groove sign
        1. Large circular Lymph Nodes (buboes) above and below inguinal ligament
      2. May also involve rectal Lymph Nodes
    4. May progress to matted nodes and fistulas

VI. Complications

  1. Perirectal Abscess
  2. Perianal Fistula or Stricture
  3. Secondary Bacterial Infection
  4. Lymphatic obstruction with secondary genital Elephantiasis

VII. Diagnosis: Options (choose one)

  1. Chlamydia Trachomatis serotype L1, L2, L3 culture positive
    1. Bubo aspirate
    2. Rectal lesion culture
  2. Immunofluorescence showing Leukocytes with inclusion bodies
    1. Inguinal Lymph Node aspirate
  3. Microimmunofluorescence positive
    1. Lymphogranuloma venereum strain of Chlamydia Trachomatis

VIII. Labs

  1. STD testing
    1. Chamydia PCR
    2. Gonorrhea PCR
    3. HIV Test (all patients with LGV)
    4. Syphilis Testing such as RPR (in all patients with LGV)
  2. Other labs are not required, but may be abnormal if tested for other reason
    1. Complete Blood Count
      1. Leukocytosis
    2. Erythrocyte Sedimentation Rate elevated
    3. Liver Function Tests abnormalities

IX. Diagnosis

  1. Diagnosis is clinical
  2. Chamydia Trachomatis PCR
    1. Positive in Lymphogranuloma venereum
  3. Aspiration of bubo can be sent to lab (but not needed if presentation is classic)
    1. Safe to aspirate, but do NOT lance buboes
    2. Do NOT biopsy lesions due to risk of sinus tract formations

X. Differential Diagnosis

  1. See Genital Ulcer
  2. See Inguinal Lymphadenopathy
  3. Proctocolitis
    1. Inflammatory Bowel Disease

XI. Management

  1. Precautions
    1. Avoid incising or lancing buboes (needle aspiration is safe and some experts recommend)
    2. Treat for 3 weeks due to Lymphogranuloma venereum invasive and more difficult to treat nature
  2. Preganancy or Lactation
    1. Erythromycin Base 500 mg orally four times daily for 21 days
  3. Active infection
    1. Doxycycline 100 mg orally twice daily for 21 days (preferred)
    2. Erythromycin Base 500 mg orally four times daily for 21 days
    3. Azithromycin 1 gram once weekly for 3 weeks
  4. Treat asymptomatic sexual contacts from last 60 days
    1. Doxycycline 100 mg PO bid for 7 days OR
    2. Azithromycin 1 gram PO x1 dose

XII. Complications

  1. Proctocolitis
    1. Fistulas and strictures may occur with delayed treatment

XIII. References

  1. (2004) MMWR Morb Mortal Wkly Rep 53(42): 985-8 [PubMed]
  2. Workowski (2006) MMWR Recomm Rep 55:1-94 [PubMed]
  3. Yonke (2022) Am Fam Physician 105(4): 388-96 [PubMed]

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