Sexually Transmitted Infections: Lymphogranuloma Venereum

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Chapter 53 Sexually Transmitted Infections: Lymphogranuloma Venereum

INTRODUCTION

Description: Lymphogranuloma venereum (LVG) is a potentially destructive infection caused by one of a number of serotypes (L-1, L-2, L-3) of Chlamydia trachomatis. Although uncommon in the United States, this infection causes significant morbidity.
Prevalence: Uncommon (600 cases per year in the United States).
Predominant Age: Younger reproductive.
Genetics: LVG is 20 times more common in men than in women.

ETIOLOGY AND PATHOGENESIS

Causes: LGV is caused by several serotypes of Chlamydia trachomatis.
Risk Factors: Sexual trauma and exposure to the infective agent.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Painless vesicle that heals quickly leaving no scar, generally located on posterior aspect of vulva or vestibule
• Proctitis, tenesmus, or bloody rectal discharge in anorectal infections (anal intercourse)
• Progressive adenopathy with bubo formation (groove sign—the “groove sign” is not specific to LGV; it may also be seen in other inflammatory processes such as acne inversa)
• Severe fibrosis and scarring (elephantiasis, “esthiomene”; rectal stenosis may occur)

DIAGNOSTIC APPROACH

Differential Diagnosis

• Granuloma inguinale
• Chancroid
• Herpes simplex
• Syphilis
• Cancer (vulvar or colon)

Associated Conditions: Other sexually transmitted infections, human immunodeficiency virus (HIV), dyspareunia, rectal stricture or stenosis.

Workup and Evaluation

Laboratory: Complement fixation test (a titer of greater than 1 : 64 is highly suspicious for LGV). Approximately 20% of patients with LGV will have false-positive Venereal Disease Research Laboratory (VDRL) test results.
Imaging: No imaging indicated.
Special Tests: None indicated. (Biopsy of the lesions is not diagnostic because of the nonspecific damage present. Enlarged lymph nodes should not be biopsied or opened: chronic sinuses will result.)
Diagnostic Procedures: Complement fixation testing—80% of patients have a titer of 1 : 16 or greater. Genital and lymph node specimens (i.e., lesion swab or bubo aspirate) may be tested for C. trachomatis by culture, direct immunofluorescence, or nucleic acid detection.

Pathologic Findings

None (nonspecific inflammatory changes).

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation, culture or Gram stain, topical cleansing and care.
Specific Measures: Antibiotic therapy. Treatment should be started even before results of confirmatory tests are received.
Diet: No specific dietary changes indicated.
Activity: No restriction. (Sexual continence required until infection is resolved.)
Patient Education: American College of Obstetricians and Gynecologists Patient Education Pamphlet AP009 (How to Prevent Sexually Transmitted Diseases). Patients should be advised to have all sexual partners seen for diagnosis and treatment.

Drug(s) of Choice

Doxycycline 100 PO twice a day for 3 weeks or tetracycline, 500 mg PO four times a day, for 3 weeks.
Contraindications: Erythromycin estolate and tetracyclines are contraindicated in pregnancy and should not be used.
Precautions: Doxycycline is contraindicated in pregnant women.
Interactions: See individual agents.

Alternative Drugs

Erythromycin (500 mg PO four times a day for 3 weeks) or sulfadiazine (2 g PO loading dose, 1 g PO four times a day for 14 to 21 days) may be substituted. Azithromycin (1.0 g PO once weekly for 3 weeks) has been suggested but clinical data are lacking.

FOLLOW-UP

Patient Monitoring: Follow-up evaluation for cure with culture or other tests should be carried out, as should screening for other sexually transmitted diseases. (As with all sexually transmitted diseases, all sexual partners within the preceding 30 days should be screened and treated for probable infections as well.)
Prevention/Avoidance: Use of barrier contraception (condoms, diaphragm), limitation or elimination of risky behavior (sexual promiscuity).
Possible Complications: In one third of patients, abscess formation, rupture, and fistula formation occur. Chronic progressive lymphangitis with chronic edema and sclerosing fibrosis may occur, causing extensive destruction of the vulva. Rectal stenosis also may occur and may be life threatening.

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Expected Outcome: If detected early, successful treatment with minimal sequelae may be expected. Long-term scarring and disfigurement are common.

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy, although the possibility of vertical transmission of other associated conditions (such as human immunodeficiency virus infection) should be considered. Doxycycline use is contraindicated in pregnant women.
ICD-9-CM Codes: 099.1.

REFERENCES

Level I

Martin DH, Mroczkowski TF, Dalu ZA, et al. A controlled trial of a single dose of azithromycin for the treatment of chlamydial urethritis and cervicitis. The Azithromycin for Chlamydial Infections Study Group. N Engl J Med. 1992;327:921.

Level II

Daling JR, Weiss NS, Hislop, et al. Sexual practices, sexually transmitted diseases, and the incidence of anal cancer. N Engl J Med. 1987;317:973.

Golden N, Hammerschlag M, Neuhoff S, Gleyzer A. Prevalence of Chlamydia trachomatis cervical infection in female adolescents. Am J Dis Child. 1984;138:562.

McLelland BA, Anderson PC. Lymphogranuloma venereum. Outbreak in a university community. JAMA. 1976;235:56.

Osewe PL, Peterman TA, Ransom RL, et al. Trends in the acquisition of sexually transmitted diseases among HIV-positive patients at STD clinics, Miami 1988–1992. Sex Transm Dis. 1996;23:230.

Pearlman MD, McNeeley SG. A review of the microbiology, immunology and clinical implications of Chlamydia trachomatis infections. Obstet Gynecol Surv. 1992;47:448.

Level III

Abrams AJ. Lymphogranuloma venereum. JAMA. 1968;205:199.

Anonymous. Treatment for Neisseria gonorrhoeae and Chlamydia trachomatis.. N Engl J Med. 1984;311:124-126.

Anonymous. Screening and treatment of chlamydial infections. N Engl J Med. 1989;321:1046.

Ballard RC, Ye H, Matta A, et al. Treatment of chancroid with azithromycin. Int J STD AIDS. 1996;7:9.

Bell TA, Grayston JT. Centers for Disease Control guidelines for prevention and control of Chlamydia trachomatis infections. Summary and commentary. Ann Intern Med. 1986;104:524.

Campbell WF, Dodson MG. Clindamycin therapy for Chlamydia trachomatis in women. Am J Obstet Gynecol. 1990;162:343.

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR. 2006;55:21.

Eckert LO, Lentz GM. Infections of the lower genital tract. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:582.

Goens JL, Schwartz RA, De Wolf K. Mucocutaneous manifestations of chancroid, lymphogranuloma venereum and granuloma inguinale. Am Fam Physician. 1994;49:415. 423.

Pruessner HT, Hansel NK, Griffiths M. Diagnosis and treatment of chlamydial infections. Am Fam Physician. 1986;34:81.

Sevinsky LD, Lambierto A, Casco R, Woscoff A. Lymphogranuloma venereum: tertiary stage. Int J Dermatol. 1997;36:47.

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