Lymphogranuloma venereum

Aka: Lymphogranuloma venereum, LGV

1. See Also
   1. Sexually Transmitted Disease
   2. Genital Ulcer
2. Etiology
   1. Sexually Transmitted Disease
   2. Caused by Chlamydia trachomatis subtypes L1, L2, L3 in the United States
3. Epidemiology
   1. Previously rare in the United States
   2. Recent outbreaks in U.S.
      1. More common in HIV patients and homosexual men
4. Symptoms
   1. General
      1. Fever and chills
      2. Headache or meningismus
      3. Anorexia
      4. Arthralgias and Myalgias
   2. Proctocolitis if rectal exposure
      1. Mucus or bloody discharge from anus
      2. Anal Pain
      3. Constipation
      4. Tenesmus
5. Signs
   1. Genital Lesion
      1. Appears 3 days to 3 weeks after exposure
      2. Starts as nontender Papule
      3. Develops small painless Vesicle or non-indurated Genital Ulcer at site within 3 to 30 days
   2. Rectal lesion or Proctitis
      1. Women and homosexual men
   3. Inguinal Syndrome
      1. Occurs 2-6 weeks after exposure
      2. Unilateral in 66% of cases
      3. Painful, tender inguinal or femoral Lymphadenopathy (Bubo)
         1. Inguinal Lymphadenopathy: Groove sign
            1. Large circular lymph nodes (buboes) above and below inguinal ligament
         2. May also involve rectal lymph nodes
      4. May progress to matted nodes and fistulas
6. Differential Diagnosis
   1. Inflammatory Bowel Disease
7. Complications
   1. Perirectal Abscess
   2. Perianal Fistula or Stricture
   3. Secondary Bacterial Infection
   4. Lymphatic obstruction with secondary genital elephantiasis
8. Diagnosis: Options (choose one)
   1. Chlamydia trachomatis serotype L1, L2, L3 culture positive
      1. Bubo aspirate
      2. Rectal lesion culture
   2. Immunofluorescence showing Leukocytes with inclusion bodies
      1. Inguinal lymph node aspirate
   3. Microimmunofluorescence positive
      1. Lymphogranuloma venereum strain of Chlamydia trachomatis
9. Labs
   1. Complete Blood Count
      1. Leukocytosis
   2. Erythrocyte Sedimentation Rate elevated
   3. Liver Function Tests abnormalities
10. Diagnosis
    1. Diagnosis is clinical
    2. Aspiration of bubo can be sent to lab (but not needed if presentation is classic)
       1. Safe to aspirate, but do NOT lance buboes
11. Differential Diagnosis
    1. See Genital Ulcer
12. Management
    1. Precautions
       1. Avoid incising or lancing buboes (needle aspiration is recommended)
    2. Preganancy or Lactation
       1. Erythromycin base 500 mg orally four times daily for 21 days
    3. Active infection
       1. Doxycycline 100 mg orally twice daily for 21 days (preferred)
       2. Erythromycin base 500 mg orally four times daily for 21 days
       3. Azithromycin 1 gram once weekly for 3 weeks
    4. Treat asymptomatic sexual contacts from last month
       1. Doxycycline 100 mg PO bid for 7 days or
       2. Azithromycin 1 gram PO x1 dose
13. References
    1. (2004) MMWR Morb Mortal Wkly Rep 53(42): 985-8 [PubMed]
    2. Workowski (2006) MMWR Recomm Rep 55:1-94 [PubMed]