II. Etiology
- Sexually Transmitted Infection
- Caused by Chlamydia trachomatis subtypes L1, L2, L3 in the United States
III. Epidemiology
- Previously rare in the United States
- Recent outbreaks in U.S.
- More common in HIV patients and homosexual men
IV. Symptoms
-
General
- Fever and chills
- Headache or meningismus
- Anorexia
- Arthralgias and Myalgias
-
Proctocolitis if rectal exposure
- Mucus or bloody discharge from anus
- Anal Pain
- Constipation
- Tenesmus
V. Signs
- Transient Genital Lesion (Genital Ulcer)
- Appears 3 days to 3 weeks after exposure
- Starts as nontender Papule
- Develops small painless Vesicle or non-indurated Genital Ulcer at site within 3 to 30 days
- Rectal lesion or Proctocolitis
- Women and homosexual men
- Rectal ulcer
- Bloody rectal discharge
- Inguinal Syndrome (Painful inguinal adenopathy)
- Occurs 2-6 weeks after exposure
- Unilateral in 66% of cases
- Painful, tender inguinal or femoral Lymphadenopathy (Bubo)
- Inguinal Lymphadenopathy: Groove sign
- Large circular Lymph Nodes (buboes) above and below inguinal ligament
- May also involve rectal Lymph Nodes
- Inguinal Lymphadenopathy: Groove sign
- May progress to matted nodes and fistulas
VI. Complications
- Perirectal Abscess
- Perianal Fistula or Stricture
- Secondary Bacterial Infection
- Lymphatic obstruction with secondary genital elephantiasis
VII. Diagnosis: Options (choose one)
-
Chlamydia trachomatis serotype L1, L2, L3 culture positive
- Bubo aspirate
- Rectal lesion culture
- Immunofluorescence showing Leukocytes with inclusion bodies
- Inguinal Lymph Node aspirate
- Microimmunofluorescence positive
- Lymphogranuloma venereum strain of Chlamydia trachomatis
VIII. Labs
- STD testing
- Chamydia PCR
- Gonorrhea PCR
- HIV Test (all patients with LGV)
- Syphilis Testing such as RPR (in all patients with LGV)
- Other labs are not required, but may be abnormal if tested for other reason
- Complete Blood Count
- Erythrocyte Sedimentation Rate elevated
- Liver Function Tests abnormalities
IX. Diagnosis
- Diagnosis is clinical
- Chamydia Trachomatis PCR
- Positive in Lymphogranuloma venereum
- Aspiration of bubo can be sent to lab (but not needed if presentation is classic)
- Safe to aspirate, but do NOT lance buboes
- Do NOT biopsy lesions due to risk of sinus tract formations
X. Differential Diagnosis
XI. Management
- Precautions
- Avoid incising or lancing buboes (needle aspiration is safe and some experts recommend)
- Treat for 3 weeks due to Lymphogranuloma venereum invasive and more difficult to treat nature
- Preganancy or Lactation
- Erythromycin Base 500 mg orally four times daily for 21 days
- Active infection
- Doxycycline 100 mg orally twice daily for 21 days (preferred)
- Erythromycin Base 500 mg orally four times daily for 21 days
- Azithromycin 1 gram once weekly for 3 weeks
- Treat asymptomatic sexual contacts from last 60 days
- Doxycycline 100 mg PO bid for 7 days OR
- Azithromycin 1 gram PO x1 dose
XII. Complications
-
Proctocolitis
- Fistulas and strictures may occur with delayed treatment