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Lymphogranuloma venereum: Pathogen, Diagnosis and Treatment

Definition

Lymphogranuloma venereum is a sexually transmitted disease due to infection with chlamydia trachomatis (serovar L1-L3), leading to genital ulcers and inguinal lymphadenopathy. Synonyms: Lymphogranuloma inguinale, Lymphopathia venerea, Nicolas-Durand-Favre disease.

Epidemiology of Lymphogranuloma Venereum

LGV causes 2–10% of genital ulcerative disease in Southeast Asia and Africa. It has been endemic among European men who have sex with men (MSM) since 2003, with rising figures (2400 confirmed cases in 2018).

Etiology of Lymphogranuloma venereum

Pathogen

The pathogen of lymphogranuloma venereum is Chlamydia trachomatis, a gram-negative obligate intracellular bacteria. Serotypes L1, L2, and L3 cause lymphogranuloma venereum.

Morphology of Chlamydia trachomatis:

Elementary bodies are the extracellular form of Chlamydia trachomatis with a diameter of 0.3 μm. After endocytosis in the host cell, inclusion bodies are formed by the corresponding intracellular multiplication, in which numerous new elementary bodies mature. A few days after infection, the elementary bodies are released by lysis of the host cell.

Signs and Symptoms

The incubation period is 1–4 weeks. Initially, an ulcerative lesion develops at the site of infection (genital or anorectal), followed by locoregional spread with lymphadenopathy and fistulas. If left untreated, an irreversible fibrosis stage follows with lymphoedema and stenosis.

Proctitis:

Proctitis is the most common initial manifestation in Europe, with anorectal pain and bloody secretions.

Genital ulcers:

A genital papule or pustule develops and leads to a singular ulcer (2–10 mm). The genital ulcer heals spontaneously, often before the manifestation of lymphadenopathy.

Lymphadenopathy:

Tender and painful groin lumps are typical symptoms of lymphogranuloma venereum. At the time of presentation, the genital ulcer may have already healed. Lymphnodes may become purulent and cause inguinal ulcerations (Bubo). Further symptoms are fever and chills. In the case of anorectal infection, lymphadenopathy develops in the pelvic lymph nodes.

Diagnosis

First, a non-specific Chlamydia DNA test (NAAT) is carried out from a rectal swab, lymph node aspirate or genital ulcer. If positive, special NAAT/PCR tests should confirm the genovar L1–L3. If this is unavailable, a high IgA anti-MOMP titer (AK against chlamydia) indicates LGV.

Further laboratory tests:

Test for syphilis, gonorrhea, hepatitis (B and C) and HIV.

Partner study:

Accurate history and examination of any sexual partners are necessary.

Differential Diagnosis

Please refer to section differential diagnosis of genital ulcers.

Therapy of Lymphogranuloma Venereum

• First choice: Doxycycline 100 mg p.o. 1-0-1 for 21 days.
• Alternatives: Erythromycin 500 mg p.o. 1-1-1-1 for 21 days or azithromycin 1 g per week for three weeks.
• Treatment of sexual partners.

References

Center for Disease Control and Prevention: “Sexually Transmitted Infections (STI) Treatment Guidelines,” 2021. [Online]. Available: https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf

Center for Disease Control and Prevention: Lymphogranuloma Venereum (LGV) https://www.cdc.gov/std/treatment-guidelines/lgv.htm

IUSTI, “European guideline on the management of lymphogranuloma venereum.,” 2019. [Online]. Available: https://iusti.org/wp-content/uploads/2019/12/IUSTILGVguideline2019.pdf.

Mabey und Peeling 2002 MABEY, D. ; PEELING, R. W.: Lymphogranuloma venereum.
In: Sex Transm Infect
78 (2002), Nr. 2, S. 90–2

  Deutsche Version: Diagnose und Therapie des Lymphogranuloma venereum