Lymphogranuloma Venereum (LGV)

Lymphogranuloma venereum (LGV) is a sexually transmitted infection (STI) caused by unique serovars of Chlamydia trachomatis (L1, L2, L3) that are unlike those that typically cause urethritis, cervicitis, and proctitis (A-K). It occurs only sporadically in North America but is endemic in many parts of the developing world. A recent outbreak of LGV proctocolitis has been reported among men who have sex with men (MSM) in North America and Europe. Many of these individuals were coinfected with HIV.

HIV alters the natural history and response to therapy of many STIs; however, its impact on LGV remains unclear. No current evidence exists to support a difference in acquisition, natural history, or response to therapy of LGV in the setting of HIV coinfection.

Recommendation:

Clinicians should include LGV as part of the differential diagnosis of genital ulcer disease, inguinal lymphadenopathy, or proctocolitis, especially in men who have sex with men.

LGV progresses over several clinical stages. The incubation period is between 3 days and 1 month after exposure. Infection is initially characterized by a small and often innocuous non-tender papule, vesicle, or ulcer, which is often overlooked by the patient. This lesion occurs at the place of contact with an infected partner and thus may involve almost any aspect of the genital or rectal tissue. Lesions in the urethra or cervix can provoke symptoms of urethritis or cervicitis. Over time, these primary lesions resolve without therapy.

The hallmark of LGV is unilateral or bilateral tender lymphadenopathy that dramatically evolves 2 to 6 weeks after the primary lesion. Lymphadenopathy may or may not be associated with signs of lymphangitis. The involved lymph nodes increase rapidly in size, and pain and erythema are common. If adjacent to one another, several involved lymph nodes may coalesce. The central areas of such lymph nodes can then undergo necrosis. Fluctuant and suppurative lymph nodes then develop, causing the classic ‘bubo’ of LGV. The bubo may then rupture and drain purulent material, which is associated with relief from symptoms. The ‘groove sign’ characteristic of LGV is seen if both the inguinal and the femoral nodes are involved. Resolving buboes can result in significant scarring. In women, lymphatic drainage patterns result in potential involvement of deep pelvic lymph nodes with attendant pelvic, abdominal, and lower back pain.

In both men and women, infection occurring as a result of anal intercourse can cause proctocolitis. Symptoms include fever, pain, tenesmus, and bloody rectal discharge. Colonic mucosal ulcerations develop and may be replaced by progressively enlarging areas of granulation tissue, which, in time, lead to fistulas and strictures. For these reasons, LGV has been occasionally misdiagnosed as Crohn’s disease. Of note, non-LGV serovars also occasionally cause a less aggressive form of proctocolitis. Invasive LGV is characterized by constitutional symptoms such as fever, chills, and malaise. Superinfection with other bacterial species may also complicate the presentation.