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Lymphogranuloma Venereum and Sexually Transmitted Proctitis
Lymphogranuloma venereum (LGV) and sexually transmitted proctitis are relatively uncommon in the general population, occurring more often in male homosexuals and promiscuous heterosexuals. Certain infections are typically seen when proctitis is identified in a patient with a history of promiscuous sexual activity ( Table 106.1 ). LGV is rare but leads to a pathologic condition that can be confused with other granulomatous diseases ( Fig. 106.1 ). Because of social reasons, there has been a great variation in the incidence of LGV. While incidences decreased for a while, it has now recurred (see “Additional Resources”).
TABLE 106.1
Common Organisms Causing Sexually Transmitted Proctitis a
Hamlyn E, Taylor C. Sexually transmitted proctitis. Postgraduate Medical Journal. 2006;82(973):733-736.
| Organism | Common Symptoms and Signs | Investigations | Recommended First Line Treatment |
|---|---|---|---|
| Gonorrhoea | Commonly asymptomatic. Pruritus ani, constipation, mucopurulent anal discharge with or without bleeding, rectal pain, and tenesmus. | Culture (gold standard) NAAT (not validated, always confirm with culture) | Cefixime 400 mg stat or ceftriaxone 250 IM or spectinomycin 2 g IM |
| Chlamydia (non-LGV serovars) | Commonly asymptomatic. Pruritus ani, mucoid discharge, perianal pain. | NAAT (not validated) | Azithromycin 1 g stat or doxycycline 100 mg bd for 1 week |
| LGV | Systemic symptoms (fever and malaise). Purulent, often bloodstained anal discharge. Severe pain, tenesmus, constipation. Symptoms and signs may be mistaken for those of inflammatory bowel disease. | NAAT as for chlamydia—refer to reference lab if positive for typing | Doxycycline 100 mg bd for 3 weeks |
| Syphilis | Primary syphilis—anorectal chancres commonly asymptomatic, may be associated with pain or discomfort, itching, bleeding, discharge, and tenesmus. Secondary syphilis—snail track ulcers and mucous patches. Perianal condylomata lata. Generalized rash, fever, and lymphadenopathy may be present. | Dark ground microcopy if ulcer present. Serological tests: RPR/VDRL > 70% sensitive in primary syphilis, 100% sensitive in secondary syphilis EIA/TPPA/TPHA > 70% sensitive in primary syphilis, 100% in secondary syphilis. Stay positive after treatment and in latent infection |
Procaine penicillin IM 750 mg daily for 10 days or benzathine penicillin 2.4 g IM stat or doxycycline 100 mg bd for 14 days. Advice should be sought if the patient is HIV infected as treatment regimens may vary. |
| Herpes simplex virus | Vesicular lesions, severe pain, difficulty in passing a bowel motion, tenesmus, discharge, viraemic symptoms such as fever and lymphadenopathy. | Viral culture or PCR | Acyclovir 200 mg 5 × daily for 5 days |
bd, Twice daily; EIA, enzyme immunoassay; HSV, herpes simplex virus; IM, intramuscular; LGV, lymphogranuloma venereum; NAAT, nucleic acid amplification testing; PCR, polymerase chain reaction; RPR, rapid plasma reagin test; STI, sexually transmitted infections; TPPA, Treponema pallidum particle agglutination; TPHA, Treponema pallidum haemagglutination assay; VDRL, Venereal Disease Research Laboratories.
a It should be noted that more than one infection may be present.
Lymphogranuloma Venereum.
Lymphogranuloma Venereum
The organism that causes LGV is Chlamydia trachomatis. Worldwide, C. trachomatis accounts for approximately 50 million new infections of LGV each year. It is the leading bacterial cause of sexually transmitted disease (STD) in the United States. C. trachomatis is divided into three biovars based partly on host susceptibility and DNA homology. The trichoma biovar and the LGV biovar cause human infections, whereas the third biovar does not. The trichoma biovar multiplies in columnar epithelial cells, and the LGV strains also are capable of multiplying in macrophages. The biovars have been subdivided into 15 serovars, which appear to cause specific infections. Anorectal LGV infections occur in homosexual men and heterosexual women engaging in anal intercourse. Infection also may be spread by infected vaginal secretions in women or through lymphatic spread from genital infection.
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