Lymphogranuloma Venereum

Introduction

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. It may manifest as severe proctitis if acquired via anal sex.
It is a chronic disease caused by Chlamydia trachomatis (serotypes L1, L2, L3), an obligate intracellular microorganism.
It is most common in Asia, Africa, and South America. In Europe and North America, it is most prevalent among homosexuals, immigrants from endemic areas and people returning from endemic areas, such as soldiers, seamen, and vacationers.

Clinical features

A chronic granulomatous, locally. destructive disease that is characterized by:

  • progressive, indolent, serpiginous ulceration of the groins, pubes, genitals and anus
  • It may be classified into primary, secondary, and late stages

Primary stage

  • After an incubation period of 7 – 15 days, a papule or small non-indurated painless ulcer appears-
  • It usually goes unnoticed
  • Extra-genital lesions (rectal, oral) have also been described
  • Women probably act as asymptomatic carriers
  • Patients are very rarely seen at the primary stage

Secondary stage

  • About 3 – 6 weeks post-contact, a uni-or bilateral massive inguinal lymphadenopathy (bubo) appears
  • The glands elongate along the Poupart’s ligament to become sausage shaped
  • Buboes progress to involve the glands above and below the ligament, so that the depression formed by the ligament which
    separates these two groups of glands gives the “sign of the groove”
  • Pain in the gland is usual, and as the glands are matted together, the overlying skin develops an erythematous or violaceous hue
  • The glands eventually become fluctuant, break down and discharge
  • Inguinal lymphadenopathy occurs in only 20-30% of women with LGV
  • There is primary involvement of the rectum, vagina, cervix, or posterior urethra, which drain to the deep iliac or perirectal nodes.
    • This may produce symptoms of lower abdominal or back pain

Systemic symptoms usually present with:

  • Fever
  • Malaise
  • Arthritis
  • Loss of weight

Skin manifestations

  •  Erythema nodosum,
  • papulo-pustular lesions and
  • photodermatosis)

Raised ESR

Late stage

  • Spontaneous remission is common, though some patients enter the late stage
  • This is characterized by disfiguring and destructive sequelae
  • Impairment of the lymphatic drainage from fibrotic scarring leads to distant oedema and gross elephantiasis of the genitalia
    • There could be associated anorectal and vaginal strictures

Complications

  • Systemic spread of C. trachomatis in the secondary stage resulting in arthritis, pneumonia, hepatitis or rarely perihepatitis
  • Other rare systemic complications include pulmonary infection, cardiac involvement, aseptic meningitis, and ocular inflammatory disease
  • The late stage may be complicated by the genito-anorectal syndrome.
    • Reported more in homosexual men, and women who engage in receptive anal intercourse
  • Patients may also complain of fever, pain, and tenesmus.
  • Obstructed labour from elephantiasis of the vulva

Differential diagnoses

  • Buboes:
  • Chancroid
  • Infections of the lower limbs
  • Hodgkins disease and other lymphomas
  • Plague
  • Tularemia
  • Late stage: Tuberculosis
  • Deep mycosis of the genitalia
  • Squamous cell or basal cell carcinoma

Investigations

  • Culture and cell typing of the isolate from an aspirate of involved lymph node
  • Serological tests e.g. CFT and MIF; PCR

Treatment objectives

  • Eliminate the organism in the patient and sexual partner(s)
  • Prevent re-infection
  • Prevent complications
  • Counsel and screen for possible co-infection with HIV so that appropriate management can be instituted

Drug treatment

Recommended regimen:

  • Doxycycline 100 mg orally every 12 hours for 14 days

Or:

  • Erythromycin 500 mg orally every 6 hours for 14 days

Alternative regimen:

  • Tetracycline 500 mg orally every 6 hours for 14 days

Adjuvant measures

  • Aspirate fluctuant lymph nodes through healthy skin
  • Incision and drainage or excision of nodes may delay healing and is not recommended
  • Some patients with advanced disease may require treatment for longer than 14 days, and
    sequelae such as strictures and/or fistulae may require surgery

Notable adverse drug reactions, caution and contraindications

See Chlamydia

Prevention

  • Counselling, Compliance, Condom use and Contact treatment