Lymphogranuloma venereum



Lymphogranuloma venereum


Frederick A. Pereira


Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports


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Classic lymphogranuloma venereum (LGV) is an uncommon sexually transmitted infection (STI) occurring in the tropics. It is characterized by three stages of disease: (1) transient genital ulceration; (2) painful, suppurative inguinal lymphadenopathy; and (3) fibrosis, lymphatic obstruction, and genital elephantiasis. A new LGV syndrome has emerged in the industrialized world among men who have sex with men (MSM). The clinical picture consists of proctitis with associated tenesmus, mucopurulent discharge, abdominal pain, and perianal ulceration. Ulceration can mimic herpes simplex and chancroid. Endoscopy shows mucosal ulcers and erosions indistinguishable from inflammatory bowel disease. Lymphadenopathy is not a prominent feature of the proctitis syndrome. Asymptomatic infection occurs in all forms of LGV. LGV is a systemic disease of lymphoid tissue caused by serovars L1, L2 and L3 of Chlamydia trachomatis (CT), and it is associated with extragenital manifestations such as erythema nodosum, myalgia, reactive arthritis, fever, fatigue and weight loss.



Management strategy


Treatment should be started on the basis of clinical suspicion, epidemiologic information, and exclusion of other diagnoses causing similar clinical findings. Treatment should not be delayed pending positive laboratory confirmation. Chlamydiae are obligate intracellular bacteria that must be grown in cell culture. Culture is technically difficult, and false negatives are common. Nucleic acid amplification tests (NAATs) are now considered the method of choice to detect CT. The standard, commonly used NAATs do not differentiate between LGV and non-LGV serovars. If CT is detected, the specimen should then be sent to a reference laboratory for specific genotyping. A single complement fixation test in titer greater than 1 : 64, or a fourfold rise in titer over a few weeks is suggestive of LGV.


The treatment of choice for all forms of LGV is doxycycline 100 mg twice daily for 3 weeks. HIV positive patients should be closely monitored for treatment failure and relapse. Fluoroquinolones, tetracyclines and sulfonamides are contraindicated in pregnant and lactating women. These women should be treated with erythromycin 500 mg four times daily for 3 weeks. Children with LGV should be treated with erythromycin. Azithromycin 1 g once a week for 3 weeks has been used successfully as an alternative to erythromycin. Fluoroquinolones, particularly moxifloxacin, have antichlamydial activity, but there are only anecdotal reports of its use in LGV. Sulfonamides are associated with treatment failure and are not considered first line. Fluctuant buboes should be drained by needle aspiration through the superior pole. After treatment, patients should have a test of microbiological cure using a NAAT; testing should be deferred 4 weeks as the residual nucleic acid of non-viable organisms can produce false positive results.


All patients with LGV should be tested for other STIs and blood-borne diseases, particularly HIV and hepatitis B and C. The anogenital area should be examined for condyloma acuminata and epithelial neoplasia. Hepatitis B immunization should be offered to non-immune patients. Intensive and repeated safe-sex counseling is necessary because most patients continue to engage in high-risk behaviors. The incubation period of LGV is approximately 3 weeks. However, if an ulcer goes unnoticed or symptoms ignored, diagnosis can be delayed and the actual period of infectivity may be considerably longer. Therefore, anyone having sexual contact with an LGV patient within 60 days should be given a full course of treatment.


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Aug 7, 2016 | Posted by in Dermatology | Comments Off on Lymphogranuloma venereum

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