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

[Outline]

• DESCRIPTION
• ETIOLOGY

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

[Outline]

• SIGNS AND SYMPTOMS
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

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

Pregnancy Considerations

Erythromycin is the recommended regimen in pregnancy and during lactation

[Outline]

• PRE-HOSPITAL
• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

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

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS

• 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

ICD9

099.1 Lymphogranuloma venereum

ICD10

A55 Chlamydial lymphogranuloma (venereum)

[Outline]

• ICD9
• ICD10

• 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.

Joel Kravitz