LYMPHOGRANULOMA VENEREUM (LGV)

Male

Female

LGV (Lymphogranuloma venereum) is a sexually transmitted disease (STD) caused by three strains of the bacterium Chlamydia trachomatis. The visual signs include genital papule(s) (e.g., raised surface or bumps) and or ulcers, and swelling of the lymph glands in the genital area. LGV may also produce rectal ulcers, bleeding, pain, and discharge, especially among those who practice receptive anal intercourse. Genital lesions caused by LGV can be mistaken for other ulcerative STDs such as syphilis, genital herpes, and chancroid. Complications of untreated LGV may include enlargement and ulcerations of the external genitalia and lymphatic obstruction, which may lead to elephantiasis of the genitalia.

Pathophysiology Lymphogranuloma venereum (LGV) is caused by C trachomatis, an obligate intracellular pathogen (ie, the bacterium lives within human cells), and strains L1, L2, and L3 have been associated with infection. LGV is primarily a disease of lymphatic tissue. Because Chlamydia species cannot traverse the intact epithelial barrier, access to lymphatic vessels is gained through microtrauma in the skin or mucous membranes. The pathogen then enters the draining lymph nodes, causing lymphangitis or lymphadenitis. The causal pathologic process involves thrombolymphangitis and perilymphangitis and the consequent spread of the inflammatory reaction from the affected lymph nodes to surrounding tissues. Causative agent Chlamydia trachomatis, an obligate intracellular human pathogen, is one of three bacterial species in the genus Chlamydia. C. trachomatis is a Gram-negative bacteria, therefore its cell wall components retain the counter-stain safranin and appear pink under a light microscope. Identified in 1907, C. trachomatis was the first chlamydial agent discovered in humans. C. trachomatis includes three human biovars: trachoma (serovars A, B, Ba or C), urethritis (serovars D-K), and lymphogranuloma venereum (LGV, serovars L1, 2 and 3). Many, but not all, C. trachomatis strains have an extrachromosomal plasmid. Chlamydia species are readily identified and distinguished from other chlamydial species using DNA-based tests. Most strains of C. trachomatis are recognized by monoclonal antibodies (mAbs) to epitopes in the VS4 region of MOMP. However, these mAbs may also cross-react with two other Chlamydia species, C. suis and C. muridarum. Incubation period The incubation period for LGV (the time interval between sexual contact and the appearance of symptoms) varies on average from 10 to 14 days. At times the incubation period may be as long as up to 6 weeks after sexual contact with an infected partner. Management of LGV Exposure Recommendation: Clinicians should encourage partners of patients with LGV whose exposure occurred within 60 days prior to symptom onset to be examined and treated with a full 21-day course of doxycycline. Partners of patients with LGV who had sexual contact with the patient within 60 days prior to symptom onset should be examined and treated. No data on which to base the optimal contact interval have been published; some clinicians may treat partners whose exposure occurred up to 6 months prior to the patients symptom onset.

The appropriate length of LGV treatment in asymptomatic, sexual contacts remains under investigation. In New York State, in accordance with the treatment guidelines for contacts of other sexually transmitted diseases, a full 21-day course of doxycycline is recommended. The Centers for Disease Control and Prevention and the British Association for Sexual Health and HIV recommend that sex partners who had contact within 30 days of the patients symptoms should be evaluated and treated with regimens for uncomplicated chlamydia infection (azithromycin 1g PO in a single dose, or doxycycline 100 mg PO bid for 7 days).1,2 Recommended Regimen Doxycycline 100 mg orally twice a day for 21 days Alternative Regimen Erythromycin base 500 mg orally four times a day for 21 days Some STD specialists believe that azithromycin 1.0 g orally once weekly for 3 weeks is probably effective, although clinical data are lacking. Management of Sex Partners Persons who have had sexual contact with a patient who has LGV within the 60 days before onset of the patients symptoms should be examined, tested for urethral or cervical chlamydial infection, and treated with a standard chlamydia regimen (azithromycin 1 gm orally x 1 or doxycycline 100 mg orally twice a day for 7 days). The optimum contact interval is unknown; some specialists use longer contact intervals. Nursing Management Azithromycin All sexual contacts should be tested and treated, whenever possible Expedited partner therapy (EPT) Patient and partner education