Lymphogranuloma venereum overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Nate Michalak, B.A.
Overview
Lymphogranuloma venereum (LGV), also known as lymphopathia venerea, tropical bubo, climatic bubo, strumous bubo, poradenitis inguinales, Durand-Nicolas-Favre disease, lymphogranuloma inguinale and neekerisankkeri in Finland, is a sexually transmitted disease caused by the invasive serovars L1, L2, or L3 of Chlamydia trachomatis.
Historical Perspective
LGV was first described by Wallace in 1833 and again by Durand, Nicolas, and Favre in 1913.
Pathophysiology
Lymphogranuloma venereum (LGV) is caused by serovars L1, L2, or L3 of the bacterium Chlamydia trachomatis. C. trachomatis is an obligate intracellular pathogen transmitted through vaginal, anal, or oral sexual contact. C. trachomatis alternates between two forms: the infectious elementary body (EB) and noninfectious, replicating reticulate body (RB). EBs enter through skin abrasions or microabrasion, or by crossing mucous membranes. EBs produce major out membrane protein (MOMP), which binds to heparan sulfate receptors on epithelial cells and are then phagocytized forming chlamydial inclusions. EBs begin to differentiate into RBs that start replicating. Endocytosis and bacterial replication cause host cell destruction leading to the formation of a papule at the site of inoculation. EBs and RBs then travel through lymphatics to regional lymph nodes, primarily to inguinal lymph nodes. C. trachomatis continues to replicate within monocytes causing lymphadenopathy and eventually the formation of buboes. Associated conditions include coinfection with other sexually transmitted diseases.
Causes
Chlamydia trachomatis is a Gram-negative, obligate intracellular pathogen causing Lymphogranuloma venereum.
Classification
Lymphogranuloma venereum (LGV) may be classified into three stages: primary LGV characterized by a self-limited papule, secondary LGV characterized by painful lymphadenopathy, and tertiary LGV (genitoanorectal syndrome) characterized by proctocolitis.
Epidemiology and Demographics
In the United States, Europe, Australia and most of Asia and South America LGV is generally considered to be a rare disease. However, a recent outbreak in the Netherlands among gay men has led to an increase of LGV in Europe and the United States. A majority of these patients are HIV co-infected. Since the 2004 Dutch outbreak 341 cases have been reported in the UK and 80 cases in the US, but infectious-disease experts fear the actual number is substantially larger because this form of chlamydia is difficult to diagnose and many physicians are not aware of its existence.
Soon after the initial Dutch report national and international health authorities launched warning initiatives and multiple LGV cases where identified in several more European countries (Belgium, France, the UK, Germany, Sweden, Italy and Switzerland) and the US and Canada. All cases reported in Amsterdam and France and a considerable part of LGV infections in the UK and Germany are caused by a newly discovered Chlamydia variant L2b, a.k.a the Amsterdam variant. The L2b variant could be traced back and was isolated from anal swabs of men who have sex with men who visited the STI city clinic of San Francisco in 1981. This finding suggests that the recent LGV outbreak among MSM in industrialised countries is a slowly evolving epidemic. As of end 2005, new LGV cases are continued to be reported in the Netherlands and other European countries at rates approaching one or two cases per week in each country.
Risk Factors
LGV is more common in men than women. The main risk factor is having multiple sexual partners.
Diagnosis
Laboratory Findings
Because of limitations in a commercially available test, diagnosis is primarily based on clinical findings. Direct identification of the bacteria from a lesion or site of the infection may be possible through testing for chlamydia but, this would not indicate if the chlamydia infection is LGV. However, the usual chlamydia tests that are available have not been FDA approved for testing rectal specimens. In a patient with rectal signs or symptoms suspicious for LGV, a health care provider can collect a specimen and send the sample to his/her state health department for referral to CDC, which is working with state and local health departments to test specimens and validate diagnostic methods for LGV.
Treatment
Medical Therapy
There is no vaccine against the bacteria. LGV can be treated with three weeks of antibiotics. CDC STD Treatment Guidelines recommend the use of doxycyline, twice a day for 21 days. An alternative treatment is erythromycin base or azithromycin. The health care provider will determine which is best.
Surgery
Patients with rectal strictures as a complication of LGV may need surgery to prevent bowel obstruction and bowel infarction.
Primary Prevention
The surest way to avoid transmission of sexually transmitted diseases is to abstain from sexual contact, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is asymptomatic and uninfected.
Male latex condoms, when used consistently and correctly, may reduce the risk of LGV transmission. Genital ulcer diseases can occur in male or female genital areas that may or may not be covered (protected by the condom).
Having had LGV and completing treatment does not prevent re-infection. Effective treatment is available and it is important that persons suspected of having LGV be treated as if they have it. Persons who are treated for LGV treatment should abstain from sexual contact until the infection is cleared.