Published on 18/03/2015 by admin
Filed under Dermatology
Last modified 22/04/2025
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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
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.
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.
Chlamydial serology
Culture
Nucleic acid amplification tests
Jebbari H, Alexander S, Ward H, Evans B, Solomou M, Thornton A, et al. Sex Transm Infect 2007; 83: 324–6.
A review of 492 cases of LGV proctitis syndrome showed that 99% occurred in men. Fourteen percent had concomitant hepatitis C, 5% syphilis, and 74% HIV disease.
Van der Bij AK, Spaargaren J, Morré SA, Fennema HS, Mindel A, Coutinho RA, et al. Clin Infect Dis 2006; 42: 186–94.
LGV testing is recommended for MSM with anorectal CT. Successful treatment of LGV (serovars L1–L3) proctitis requires a 3-week course of doxycycline, whereas for CT proctitis caused by serovars D–K a 1-week course is given. If routine LGV serovar typing is not available, the authors advise empiric administration of the full LGV regimen for MSM with anorectal chlamydial proctitis.
Singhrao T, Higham E, French P. Sex Transm Infect 2011; 87: 123–4.
The authors report two MSM who presented with painful, persistent anal ulceration without proctitis. NAAT testing of material taken from the ulcers revealed LGV-associated serovars of CT. LGV, along with herpes simplex, chancroid and syphilis, must be included in the differential diagnosis of anal ulcers.
Herring A, Richens J. Sex Transm Infect 2006; 82(iv): 23–5.
The laboratory diagnosis of LGV consists of detection of CT-specific DNA followed by genotyping to identify serovars L1, L2, or L3. The first step is the detection of CT using a NAAT. Any NAAT positive for CT from MSM should then be sent to a reference laboratory for genotyping. Culture is the most specific diagnostic method, but few laboratories have facilities to culture chlamydiae. Complement fixation studies may be useful for diagnosis. High or rising titers in a symptomatic patient is suggestive of LGV.
Rönn MM, Ward H. BMC Infect Dis 2011; 11: 70.
In 13 studies the prevalence of HIV among LGV occurring in MSM ranged from 67% to 100%. HIV+ MSM are disproportionately affected by LGV.
Pendle S, Gowers A. Sex Transm Dis 2012; 39: 79–80.
Reactive arthritis is usually associated with serovars D through K of CT, but it can also occur with LGV-associated serovars. Reactive arthritis can be a manifestation of asymptomatic LGV. Screening for LGV should be done in MSM who present with acute arthropathy.
van den Bos RR, van der Meijden WI. Int J STD AIDS 2007; 18: 715–16.
Following treatment of LGV proctitis, 17 of 26 patients (65%) were subsequently treated for another STI within 3 years. Health education and counseling efforts must be intensified because patients continue to engage in high-risk sexual activities.
Soni S, Srirajaskanthan R, Lucas SB, Alexander S, Wong T, White JA. Aliment Pharmacol Ther 2010; 32: 59–65.
Rectal biopsies from patients with LGV proctitis showed mucosal ulcers, cryptitis, crypt abscesses, and granulomas. These findings closely resemble those of inflammatory bowel disease. Gastroenterologists must remain alert to the diagnosis of LGV.
Centers for Disease Control and Prevention. MMWR Recomm Rep 2006; 55(RR-11): 1–94.
Tetracycline antibiotics, including doxycycline, and minocycline appear to be effective for LGV. Because of convenient dosing and minimal toxicity, doxycycline is the recommended treatment.
McLean CA, Stoner BP, Workowski KA. Clin Infect Dis 2007; 44(S): 147–52.
Doxycycline 100 mg twice daily for 3 weeks is recommended as first-line treatment for LGV. Azithromycin 1.0 g orally once weekly for 3 weeks appears to be effective against LGV. Erythromycin base 500 mg four times a day orally is the preferred treatment for pregnant women with LGV. Sulfonamides may not sterilize lesions and treatment failure can ensue.
Méchaï F, de Barbayrac B, Aoun O, Mérens A, Umbert P, Rapp C. Sex Transm Infect 2010; 86: 278–9.
The authors report a patient with LGV proctitis who failed a full 3-week course of doxycyline. The patient achieved rapid clinical cure with a 10-day course of moxifloxacin 400 mg daily.
Hill SC, Hodson L, Smith A. Int J STD AIDS 2010; 21: 772–6.
Fifty-five patients were treated with doxycycline, and seven patients were treated with azithromycin 1 g per week for 3 weeks. All patients treated with azithromycin achieved clinical cure, and microbiological cure was proven in six. Half the treated patients returned for follow-up within 3 months; a notable proportion tested positive for newly acquired STIs. Patients continue to engage in high-risk behaviors after treatment, and safe-sex counseling efforts need to be intensified.
Becker LE. Int J Dermatol 1976; 15: 26–33.
Incision and drainage of buboes is not recommended. Fluctuant buboes should be aspirated superiorly through normal skin with a large-bore needle to prevent sinus formation.
Sulfonamides
Sulfonamides are less effective than other antibiotic options and are a last resort in those sensitive to more effective options.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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Doxycycline 100 mg orally twice daily for 21 days
Erythromycin base 500 mg orally four times daily for 21 days
Azithromycin 1.0 g orally once weekly for 3 weeks
Aspiration of buboes
Moxifloxicin 400 mg daily for 10 days
