Lymphogranuloma venereum

Background

• Cased by L1, L2, L3 serovars of Chlamydia trachomatis
• Sexually transmitted
• Often co-infected with HIV
• More common in tropical and sub-tropical climates

Clinical Features

Painless genital ulcer from lymphogranuloma venereum

Inguinal femoral lymphadenopathy (bilateral) from lymphogranuloma venereum

• Incubation period 3-30 days
• Stage 1 (Primary): Self-limited painless genital papule/ulcer (lasts ~2-3 days)
  • Seen on coronal sulcus in men, posterior vaginal fourchette in women
  • Can also occur in rectum (hemorrhagic proctitis), urethra, vagina
• Stage 2 (Secondary): Painful inguinal and/or femoral lymphadenopathy (2-6 weeks after primary lesion)
  • Lymph nodes become necrotic → suppurative → formation of buboes
    • Fluctuant lymph nodes classically form a "groove sign" when adenopathy extends above and below the inguinal ligament
  • Systemic symptoms: fever, myalgia, malaise
    • Occasionally - arthritis, ocular, cardiac, pulmonary, aseptic meningitis, hepatitis
• Stage 3 (Tertiary): Proctocolitis, anorectal syndrome
  • Usually manifests in women or men who have sex with men
  • Rectal pain, discharge, bleeding
  • Can also → fistula, abscess, strictures, megacolon

Differential Diagnosis

Sexually transmitted diseases

• Chancroid
• Chlamydia trachomatis
• Granuloma inguinale
• Hepatitis B
• Herpes Simplex Virus-2
• HIV
• Human papillomavirus
• Lymphogranuloma venereum
• Neisseria gonorrhoeae
• Trichomonas
• Syphilis

Evaluation

• Nucleic Acid Amplification Tests (NAAT)
• Immunofluorescence
• Culture (needle aspiration of bubo)
• Serology
• Consider anoscopy
• Also consider testing for HIV and other possible coinfections

Management

• Doxycycline 100mg PO BID x 21 days (first choice) OR
• Erythromycin 500mg PO QID x 21 days OR
  • Preferred for pregnant and lactating females
• Azithromycin 1g PO weekly for 3 weeks OR
  • Alternative for pregnant women - poor evidence for this treatment currently
• Tetracycline, Minocycline, or Moxifloxacin (x21 days) are also acceptable alternatives to Doxycycline
• Treat sexual partner
  • Doxycycline 100mg PO BID x 7 days OR
  • Azithromycin 1gm PO x1

Disposition

• Discharge
• Instruct patient to abstain from sexual activities until completion of treatment

See Also

• STDs
• Chlamydia trachomatis