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Lymphogranuloma Venereum, Emergency Medicine

Basics

Description

- 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

- Secondary stage: - Systemic symptoms: - Fever and malaise - Myalgias

- Proctitis: - Rectal bleeding - Tenesmus - Constipation

- 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

- Genital strictures - Perineal and perianal fistulae - Elephantiasis of the ipsilateral leg

  • Sexually transmitted disease
  • Primary stage:Painless papule, pustule, or ulcer
  • Secondary stage:Spread to regional lymph nodesFluctuant 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:StrumaTropical buboNicolas " “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. trachomatisPainless genital chancre lasts 2 " “3 days (rarely, a papule or vesicle)Often transient and not noticedMay present as proctitis
  • Secondary stage:Systemic symptoms:Fever and malaiseMyalgiasLymphadenopathy; usually inguinal:May ulcerate and drain pusProctitis:Rectal bleedingTenesmusConstipation
  • Tertiary stage:Symptoms mimic inflammatory bowel disease or proctocolitisElephantiasisStrictures

Physical Exam

  • Primary stage:Painless papule, pustule, or ulcerUsually anogenital region
  • Secondary stage:Tender inguinal adenopathy:Occurs 1 " “3 wk after initial inoculationAdenopathy is unilateral in 2/3 of casesBuboes (large inguinal lymph nodes) form in inguinal and femoral chainsGroove 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 proctocolitisPerirectal lymphatic inflammation causes fistulae and strictures
  • Tertiary disease (invasive if untreated):Chronic proctocolitis:Abdominal painRectal bleedingGenital stricturesPerineal and perianal fistulaeElephantiasis 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)