Lymphogranuloma venereum

Background

• Infection caused by Chlamydia trachomatis serovars L1, L2 and L3
• Transmitted sexually through vaginal, anal, or oral contact

Epidemiology

• Uncommon in Canada but more common in parts of Africa, Asia, South America, and the Caribbean
• Occasional outbreaks among men who have sex with men

Clinical Manifestations

Primary LGV

• Incubation period 3 to 30 days
• Starts with small painless papule at site of inoculation that may ulcerate
• Only noticed in 50% of patients

Secondary LGV

• Latency of 2 to 6 weeks from primary lesion
• Presents with systemic symptoms, including fevers and chills, malaise, myalgias, and arthralgias
• May have abscess with or without draining sinuses
• Occasionally involves arthritis, pneumonitis, hepatitis, and rarely involves carditis, aseptic meningitis, or ocular inflammation

Secondary LGV with lymphadenopathy

• Most commonly involves painful inguinal or femoral lymphadenopathy, called "buboes"
• The "groove sign", where nodes are seen above and below the inguinal ligament, is highly specific for LGV

Secondary LGV with anorectal symptoms

• Presents with acute hemorrhagic proctitis
• May also cause constipation

Tertiary LGV

• Also called chronic LGV, and occurs in 10 to 20% of untreated patients
• Characterized by chronic inflammation that causes:
  • Lymphadtic obstruction leading to genital elephantiasis
  • Genital and rectal strictures and fistulae
• Can cause esthiomene, extensive destruction of genitalia

Investigations

• Anoscopy/sigmoidoscopy/proctoscopy
  • Similar appearance to ulcerative colitis
• Bubo aspiration
  • Usually contains small amount of milky fluid
  • Aspirate through healthy skin

Diagnosis

• Typically done by diagnosing Chlamydia trachomatis and then confirming the serotype with the reference laboratory
• Sample should be taken from swab of lesion (if primary), or bubo aspirate, swab of rectum, vagina, oropharynx, or urethra, or urine (if secondary or tertiary)
• Chlamydia testing with culture or NAAT
• Confirmatory testing with DNA sequencing or RFLP at a reference laboratory

Management

• Do not treat with excision or incision and drainage
• Antibiotics
  • First-line: doxycycline 100 mg PO bid for 21 days
  • Alternative: erythromycin 500 mg PO qid for 21 days
  • Alternative: azithromycin 1 g PO weekly for 3 weeks
• Perform a test-of-cure at 3 to 4 weeks following completion of treatment
• Also treat any sexual partners within the last 60 days
  • Azithromycin 1 g PO once or doxycycline 100 mg PO bid for 7 days
• Also rule out other concurrent sexually-transmitted infections, including chancroid and donovanosis

Prevention

• Consistent use of condoms or other barrier methods, including for oral sex
• Avoid mucosal trauma if possible