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Lymphogranuloma Venereum (LGV) | Questions & Answers | 2010 Treatment Guidelines

Question 1: Does lymphogranuloma venereum (LGV) always present as proctitis, or does it also sometimes present as a painful ulcerative lesion on the genitalia?

Answer: The 2010 STD Treatment Guidelines (page 26) provide an overview of clinical manifestations of LGV. In heterosexuals, LGV presents primarily as tender lymphadenopathy in the inguinal or femoral region, and is typically unilateral. While recent reports have focused on LGV proctitis, self-limited genital ulcer or papule sometimes occurs in the genital area at the site of inoculation. However, by the time patients seek care, these lesions have often disappeared. Proctitis or proctocolitis due to LGV may be the presenting symptom complex in men who have sex with men (MSM) or women with rectal exposure. This can cause mucoid or hemorrhagic rectal discharge, anal pain, tenesmus, and other symptoms. In these cases, inguinal or femoral lymphadenopathy and genital lesions may not be present at all.

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Question 2: Can we send a positive chlamydia rectal swab to the CDC to test for lymphogranuloma venereum (LGV) serovar?

Answer: The 2010 STD Treatment Guidelines do not indicate sending rectal swabs to CDC for LGV testing. Clinicians should consult with their state public health laboratories to see whether mechanisms exist to obtain laboratory confirmation of suspected LGV specimens. The Guidelines do state (page 26) that "in the absence of specific LGV diagnostic testing, patients with a clinical syndrome consistent with LGV, including proctocolitis or genital ulcer disease with lymphadenopathy, should be treated for LGV."

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Question 3: Rectal lymphogranuloma venereum (LGV) requires slightly different antimicrobial therapy than routine chlamydia infection. Now that we are testing rectal specimens with nucleic acid amplification tests (NAATs) and finding chlamydia infection, is it important that an attempt be made to identify LGV serovars or continue with routine genital chlamydia treatment?

Answer: The 2010 STD Treatment Guidelines do not specifically address this point: clinicians will need to distinguish between uncomplicated rectal chlamydial infection (which presumably will respond to standard antichlamydial treatment regimens) and more aggressive clinical presentations of chlamydial proctitis or proctocolitis, which requires a more prolonged treatment course. Clinical findings consistent with LGV proctitis/proctocolitis may include, "mucoid and/or hemorrhagic rectal discharge, anal pain, constipation, fever, and/or tenesmus" (2010 STD Treatment Guidelines, page 26). Patients with these findings should be treated empirically using LGV treatment regimens, since LGV serovar confirmation testing is not widely available.

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