Lymphogranuloma Venereum (LGV)

Lymphogranuloma venereum (LGV) is caused by C. trachomatis serovars L1, L2, or L3 (386,387). The most common clinical manifestation of LGV among heterosexuals is tender inguinal and/or femoral lymphadenopathy that is typically unilateral. A self-limited genital ulcer or papule sometimes occurs at the site of inoculation. However, by the time patients seek care, the lesions have often disappeared. Rectal exposure in women or MSM can result in proctocolitis mimicking inflammatory bowel disease, and clinical findings may include mucoid and/or hemorrhagic rectal discharge, anal pain, constipation, fever, and/or tenesmus (388,389). Outbreaks of LGV protocolitis have been reported among MSM (390-392). LGV can be an invasive, systemic infection, and if it is not treated early, LGV proctocolitis can lead to chronic colorectal fistulas and strictures; reactive arthropathy has also been reported. However, reports indicate that rectal LGV can be asymptomatic (393). Persons with genital and colorectal LGV lesions can also develop secondary bacterial infection or can be coinfected with other sexually and nonsexually transmitted pathogens.

Diagnostic Considerations

Diagnosis is based on clinical suspicion, epidemiologic information, and the exclusion of other etiologies for proctocolitis, inguinal lymphadenopathy, or genital or rectal ulcers. Genital lesions, rectal specimens, and lymph node specimens (i.e., lesion swab or bubo aspirate) can be tested for C. trachomatis by culture, direct immunofluorescence, or nucleic acid detection (394). NAATs for C. trachomatis perform well on rectal specimens, but are not FDA-cleared for this purpose. Many laboratories have performed the CLIA validation studies needed to provide results from rectal specimens for clinical management. MSM presenting with protocolitis should be tested for chlamydia; NAAT performed on rectal specimens is the preferred approach to testing.

Additional molecular procedures (e.g., PCR-based genotyping) can be used to differentiate LGV from non-LGV C. trachomatis in rectal specimens. However, they are not widely available, and results are not available in a timeframe that would influence clinical management.

Chlamydia serology (complement fixation titers >1:64 or microimmunofluorescence titers >1:256) might support the diagnosis of LGV in the appropriate clinical context. Comparative data between types of serologic tests are lacking, and the diagnostic utility of these older serologic methods has not been established. Serologic test interpretation for LGV is not standardized, tests have not been validated for clinical proctitis presentations, and C. trachomatis serovar-specific serologic tests are not widely available.

Treatment

At the time of the initial visit (before diagnostic tests for chlamydia are available), persons with a clinical syndrome consistent with LGV, including proctocolitis or genital ulcer disease with lymphadenopathy, should be presumptively treated for LGV. As required by state law, these cases should be reported to the health department.

Treatment cures infection and prevents ongoing tissue damage, although tissue reaction to the infection can result in scarring. Buboes might require aspiration through intact skin or incision and drainage to prevent the formation of inguinal/femoral ulcerations.

Recommended Regimen

  • Doxycycline 100 mg orally twice a day for 21 days

Alternative Regimen

  • Erythromycin base 500 mg orally four times a day for 21 days

Although clinical data are lacking, azithromycin 1 g orally once weekly for 3 weeks is probably effective based on its chlamydial antimicrobial activity. Fluoroquinolone-based treatments also might be effective, but the optimal duration of treatment has not been evaluated.

Other Management Considerations

Patients should be followed clinically until signs and symptoms have resolved. Persons who receive an LGV diagnosis should be tested for other STDs, especially HIV, gonorrhea, and syphilis. Those who test positive for another infection should be referred for or provided with appropriate care and treatment.

Follow-up

Patients should be followed clinically until signs and symptoms resolve.

Management of Sex Partners

Persons who have had sexual contact with a patient who has LGV within the 60 days before onset of the patient’s symptoms should be examined and tested for urethral, cervical, or rectal chlamydial infection depending on anatomic site of exposure. They should be presumptively treated with a chlamydia regimen (azithromycin 1 g orally single dose or doxycycline 100 mg orally twice a day for 7 days).

Special Considerations

Pregnancy

Pregnant and lactating women should be treated with erythromycin. Doxycycline should be avoided in the second and third trimester of pregnancy because of risk for discoloration of teeth and bones, but is compatible with breastfeeding (317). Azithromycin might prove useful for treatment of LGV in pregnancy, but no published data are available regarding an effective dose and duration of treatment.

HIV Infection

Persons with both LGV and HIV infection should receive the same regimens as those who are HIV negative. Prolonged therapy might be required, and delay in resolution of symptoms might occur.

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