What is lymphogranuloma venereum?
Lymphogranuloma venereum (LGV) is a sexually transmitted infection (STI) caused by specific strains (serovars L1, L2, and L3) of the bacteria Chlamydia trachomatis.
The more common non-LGV, C. trachomatis infection, commonly known as chlamydia, is largely restricted to the initial local mucosal site of infection, whereas LGV infection invades the lymphatic tissue.
How common is lymphogranuloma venereum?
Traditionally, classical LGV affects heterosexuals in endemic areas (South and West Africa, India, Southeast Asia, and the Caribbean). However, there have been outbreaks of LGV infections amongst men who have sex with men (MSM) in Europe, the United Kingdom, and the United States. It is still uncommon in New Zealand. However, following international outbreaks of infection amongst MSM, there has been a recent increase in local cases.
Who is at risk of lymphogranuloma venereum?
Sexually active people may be at risk of getting LGV. LGV is passed from person to person through direct contact with lesions, ulcers, or another area where the bacteria are located.
Transmission of C. trachomatis occurs during sexual penetration (vaginal, oral, or anal), may also occur via skin-to-skin contact and the sharing of equipment for rectal douching.
What are the signs and symptoms of lymphogranuloma venereum?
Once infected, the incubation period is on average 10–14 days before any signs or symptoms become apparent but it can be anywhere from 3 days to 6 weeks.
The three stages of LGV infection are summarised below.
In the primary infection, small painless genital papules, pustules, or shallow ulcers appear on the skin. These initial lesions are transient, meaning they heal quickly and disappear. They often go unnoticed or get mistaken for genital herpes.
Infected individuals tend not to seek medical help at this stage.
The onset of secondary infection occurs 2–6 weeks after the primary infection.
Painful and swollen lymph glands develop in the groin area. These occur on one side (two-thirds of cases) or both sides of the groin. Buboes (inflammatory swelling of the glands around the groin) can rupture and drain pus. The 'groove sign' (guttering along blood vessels) occurs in 15–20% of cases. Most male patients present with symptoms during this stage. Women may present with less specific symptoms, often pelvic and back pain.
Recipients of anal intercourse (usually MSM) tend to present with:
- Anal/rectal pain
- Tenesmus (feeling of needing to evacuate bowel despite an empty rectum)
These symptoms can be mistaken for ulcerative colitis.
Other symptoms include malaise, fever, chills, joint, and muscular pains, and vomiting.
Late-stage lymphogranuloma venereum
Deep-seated prolonged untreated infections may lead to significant complications, including:
- Lymphatic obstruction
- Severe genital oedema
- Rectal strictures (narrowing)
- Frozen pelvis
- Genital deformation.
What is the treatment and management of lymphogranuloma venereum?
Laboratory tests for lymphogranuloma venereum
In a patient (particularly MSM) showing anorectal signs or symptoms similar to LGV, a chlamydia nucleic acid amplification test should be taken from the affected site. If this test returns positive, a further test should be taken to find LGV-specific DNA. Ideally, also seek locally available expertise (a microbiologist, sexual health physician, or infectious disease specialist) about appropriate specimen collection and management.
A full sexual health screen taking into consideration the window periods for other sexually transmitted infections, is also needed. In particular, MSM need to be screened for syphilis, hepatitis C, and HIV because of the increased risk of multiple infections.
LGV is treated with antibiotics to cure the infection and prevent ongoing tissue damage. Treatment with doxycycline or erythromycin for at least 3 weeks is required. Azithromycin has also been used for ease of compliance. Resistance to doxycycline is very rare, at which point moxifloxacin is the next drug of choice. If necessary, buboes may be drained with a needle. Surgical management may also be required (eg, to repair fistulas and strictures as a result of late LGV).
For an individual presenting with rectal signs and symptoms (usually MSM), empiric antimicrobial therapy should cover other possible causes of proctitis (inflammation of the rectal lining), such as herpes simplex virus and gonorrhoea. Input from a sexual health specialist is recommended. Sexual contacts need to be notified, clinically assessed, and treated.
Follow-up with medical professionals should continue until all signs and symptoms have resolved. An individual infected with LGV should not resume any sexual activity until the infection is cured.
Can lymphogranuloma venereum be prevented?
As with other sexually transmitted infections, the risk of acquiring LGV is reduced by safe-sex practices including limiting the number of sexual partners, avoiding sexual contact with individuals from high-risk populations, and using condoms.
If you think you are infected, stop all sexual contacts and see your usual doctor or a specialist clinician at a sexual health clinic immediately.