Basics
Description
- Sexually transmitted disease
- Primary stage:
- Painless papule, pustule, or ulcer
- Secondary stage:
- Spread to regional lymph nodes
- Fluctuant inguinal lymphadenopathy (buboes)
- Lymphadenopathy may be unilateral or bilateral
- Responsive to antibacterial therapy
- Tertiary stage:
- If untreated, significant tissue damage and destruction may result
- Endemic in Southeast Asia, Latin America, parts of Africa, and the Caribbean
- Increasing incidence among men who have sex with men
- Also known as:
- Struma
- Tropical bubo
- Nicolas " “Favre " “Durand disease
Etiology
Chlamydia trachomatis serotypes L1, L2, and L3 ‚
Diagnosis
Signs and Symptoms
History
- Primary genital lesions:
- Incubation: 3 " “30 days after sexual exposure to C. trachomatis
- Painless genital chancre lasts 2 " “3 days (rarely, a papule or vesicle)
- Often transient and not noticed
- May present as proctitis
- Secondary stage:
- Systemic symptoms:
- Fever and malaise
- Myalgias
- Lymphadenopathy; usually inguinal:
- May ulcerate and drain pus
- Proctitis:
- Rectal bleeding
- Tenesmus
- Constipation
- Tertiary stage:
- Symptoms mimic inflammatory bowel disease or proctocolitis
- Elephantiasis
- Strictures
Physical Exam
- Primary stage:
- Painless papule, pustule, or ulcer
- Usually anogenital region
- Secondary stage:
- Tender inguinal adenopathy:
- Occurs 1 " “3 wk after initial inoculation
- Adenopathy is unilateral in 2/3 of cases
- Buboes (large inguinal lymph nodes) form in inguinal and femoral chains
- Groove sign: Scarred or coalescent buboes above and below inguinal ligament give a linear depression parallel to the inguinal ligament (seen in 30%)
- Anal-receptive patients may develop hemorrhagic proctocolitis
- Perirectal lymphatic inflammation causes fistulae and strictures
- Tertiary disease (invasive if untreated):
- Chronic proctocolitis:
- Abdominal pain
- Rectal bleeding
- Genital strictures
- Perineal and perianal fistulae
- Elephantiasis of the ipsilateral leg
Diagnosis Tests & Interpretation
Lab
- Standard Chlamydia DNA probes do not test for lymphogranuloma venereum (LGV) strain
- False-positive VDRL in 20%
- Serologic testing and culture are the standard
- Complement fixation titers >1:64 are consistent with LGV infection
Diagnostic Procedures/Surgery
Bubo aspiration " ”specific but expensive and impractical ‚
Differential Diagnosis
- Genital herpes (ulcers usually not seen in LGV)
- Syphilis " ”nodes nontender, longer incubation
- Chancroid " ”multiple ulcers, no systemic symptoms
- Granuloma inguinale " ”lesions painless and bleed easily
Treatment
Pre-Hospital
No pre-hospital issues ‚
Initial Stabilization/Therapy
No field or ED stabilization required ‚
Ed Treatment/Procedures
If large, buboes may need to be aspirated or drained to avoid or minimize scarring ‚
Medication
First Line
Doxycycline: 100 mg PO BID for 3 wk ‚
Second Line
- Azithromycin: 1,000 mg PO weekly for 3 wk
- Erythromycin: 500 mg PO QID for 3 wk
Erythromycin is the recommended regimen in pregnancy and during lactation ‚
Follow-Up
Disposition
Admission Criteria
Hospitalization is rarely needed (i.e., severe systemic symptoms) ‚
Discharge Criteria
Immunocompetent patient without systemic involvement ‚
Issues for Referral
- Outpatient follow-up is required to confirm diagnosis and cure
- Rectal infection may require retreatment
Follow-Up Recommendations
- Ensure that sexual partners are tested and treated
- Sexual contacts within 60 days should be tested and treated with antichlamydial therapy
Pearls and Pitfalls
- Diagnosis is based on clinical suspicion, epidemiologic patterns, and exclusion of other etiologies
- Consider this diagnosis in men who have sex with men
- Treat to avoid tertiary disease which is not responsive to antibiotic therapy alone
- Treatment course is at least 3 wk of antibiotics
Additional Reading
- Centers for Disease Control and Prevention: 2002 guidelines for treatment of sexually transmitted diseases. Available at: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf#page=28.
- McLean ‚ CA, Stoner ‚ BP, Workowski ‚ KA. Treatment of lymphogranuloma venereum. Clin Infect Dis. 2007;44:S147 " “S152.
- White ‚ JA. Manifestations and management of lymphogranuloma venereum. Curr Opin Infect Dis. 2009;22:57 " “66.
- White ‚ J, Ison ‚ C. Lymphogranuloma venereum: What does the clinician need to know? Clin Med. 2008;8:327 " “330.
Codes
ICD9
099.1 Lymphogranuloma venereum ‚
ICD10
A55 Chlamydial lymphogranuloma (venereum) ‚
SNOMED
- 186946009 Lymphogranuloma venereum (disorder)