Author:
JoelKravitz
Description
- Sexually transmitted disease
- Primary stage (not always seen):
- 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
- Now endemic among men who have sex with men (MSM) in industrialized countries
- Also known as:
- Struma
- Tropical bubo
- Nicolas-Favre-Durand disease
Etiology
Chlamydia trachomatis serotypes L1, L2, and L3
Signs and Symptoms
History
- Primary genital lesions:
- Incubation: 3-30 d after sexual exposure to C. trachomatis
- Painless genital chancre lasts 2-3 d (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
Diagnostic Tests & Interpretation
Lab
- Stand ard Chlamydia DNA probes do not test for lymphogranuloma venereum (LGV) strain
- False-positive VDRL in 20%
- Serologic testing and culture are the stand ard
- 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
Prehospital
No prehospital 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
Second Line
- Erythromycin: 500 mg PO q.i.d for 3 wk
- Azithromycin: 1,000 mg PO weekly for 3 wk
Pregnancy Prophylaxis |
| Erythromycin is the recommended regimen in pregnancy and during lactation |
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
- Follow up for HIV and Hep C testing
- Sexual contacts within 60 days should be tested and treated with antichlamydial therapy
- Azithromycin 1-g single dose
- Doxycycline 100 mg b.i.d for 7 d
ICD9
099.1 Lymphogranuloma venereum
ICD10
A55 Chlamydial lymphogranuloma (venereum)
SNOMED