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Lymphogranuloma venereum
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Lymphogranuloma venereum (LGV) is an uncommon sexually transmitted infection occurring mainly in the tropics. It is caused by one of the three serovars (L1, L2, L3) of the intracellular bacterium Chlamydia trachomatis . The incubation period is 1–4 weeks, after which three subsequent stages can follow: a primary stage with transient genital ulceration, a secondary stage with painful, suppurative inguinal lymphadenopathy, and a tertiary fibrotic stage complicated with lymphatic obstruction and genital elephantiasis.
LGV can be associated with extragenital manifestations such as erythema nodosum, myalgia, reactive arthritis, fever, malaise, and weight loss.
In recent years, developed countries have experienced a shift in LGV epidemiological patterns and clinical presentation. Since 2003, LGV has emerged in Europe and North America as a leading cause of proctitis and proctocolitis in men who have sex with men (MSM). Endemic acquired cases of LGV in heterosexuals are extremely rare in Europe and there is no evidence of transmission of LGV within the European heterosexual population. Among MSM, about 25% of the anorectal LGV infections are asymptomatic. Today in developed countries LGV is predominantly associated with rectal infection and the classical findings of inguinal lymphadenopathy are increasingly uncommon. The diagnosis is confirmed by the detection of serovar L of C. trachomatis from the site of infection (ulcer base exudate, rectal mucosa, or bubo aspirates). The diagnostic method of choice is detecting C. trachomatis nucleic acid using nucleic acid amplification tests (NAATs) and confirmation by real-time polymerase chain reaction assays for LGV-specific DNA.
Management Strategy
Treatment should not be delayed pending laboratory confirmation, so that progression to chronic phase is prevented. Prolonged courses of antibiotics (at least 3 weeks) are required.
The treatment of choice is doxycycline 100 mg twice daily for 3 weeks. Fluoroquinolones and tetracyclines 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. Moxifloxacin (400 mg once daily for 3 weeks), minocyclin (300 mg loading dose, followed by 200 mg twice daily for 3 weeks), and rifampicin (600 mg once daily for 3 weeks) are mentioned as escape treatments in the current European guidelines.
If alternative treatment regimens are used, a test of cure must be performed 4–6 weeks after end of treatment.
HIV-positive patients are treated with the same regimens; however, these patients may require prolonged treatment and they must be closely monitored for treatment failure and relapse.
Fluctuant buboes may require aspiration through healthy adjacent skin; surgical incision is usually contraindicated due to risk of complications such as sinus formation.
All patients with LGV should also be tested for other sexually transmitted infections (STIs; at a minimum syphilis and gonorrhea) including HIV, hepatitis B, and hepatitis C before starting therapy.
Intensive and repeated safe-sex counseling is necessary because most patients continue to engage in high-risk behaviors. Sex partners within the last 3 months should be offered testing for LGV from all exposed sites and empirical treatment with doxycycline.
2019 European guideline on the management of lymphogranuloma venereum
De Vries HJ, De Barbeyrac B, De Vrieze NH, et al. J Eur Acad Dermatol Venereol 2019; 33(10): 1821–8.
Assessment of alternative diagnostic methods (e.g., Chlamydia serology) can be found in this review. However, they are generally considered to be unreliable.
Lymphogranuloma venereum 2015: clinical presentation, diagnosis, and treatment
Stoner BP, Cohen SE. Clin Infect Dis 2015; 61(Suppl 8): S865–73.
Proctitis and proctocolitis are now the most common clinical manifestations of LGV. The classic inguinal presentation with buboes is becoming increasingly uncommon.
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