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Lymphogranuloma Venereum Among Men Who Have Sex with Men



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Am Fam Physician. 2005 Mar 15;71(6):1222-1225.

The Centers for Disease Control and Prevention has released a report on lymphogranuloma venereum (LGV). The report is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5342a2.htm.

LGV is a systemic, sexually transmitted disease (STD) caused by a variety of the bacterium Chlamydia trachomatis that rarely occurs in the United States and other industrialized countries; the prevalence of LGV is greatest in Africa, Southeast Asia, Central and South America, and Caribbean countries. However, in the Netherlands, which typically has fewer than five cases a year, as of September 2004 a total of 92 cases of LGV had been confirmed during the preceding 17 months among men who have sex with men (MSM). An alert was sent to the Early Warning and Reporting System of the European Union and to the European Surveillance of Sexually Transmitted Infections Network.

In April 2004, a report was made to the CDC, and state and local health departments were alerted. Of the 92 cases confirmed in the Netherlands, 30 occurred during 2003 and 62 during 2004. Some of these patients reported having multiple sex partners in cities in Europe and the United States. Limited information has been reported regarding LGV occurrence outside the Netherlands. However, physicians should be vigilant for LGV, especially among MSM exposed to persons from Europe, and be prepared to diagnose the disease and provide appropriate treatment to patients and their exposed sex partners (see accompanying box).

Recent reports from Belgium, France, and Sweden confirm that LGV is occurring elsewhere in Europe. In July 2004, the CDC identified an L2 LGV strain on a rectal swab specimen from a patient in the United States who had signs and symptoms similar to those of the patients in the Netherlands. In this case, no known exposure to European MSM was reported; U.S. contacts of the patient were evaluated and treated.

Etiology, Clinical Manifestations, Diagnosis, and Treatment of Lymphogranuloma Venereum

Etiology

Lymphogranuloma venereum (LGV) is caused by Chlamydia trachomatis serovars L1 to L3. (C. trachomatis serovars B and D-K are responsible for the syndromes of non-gonococcal urethritis and cervicitis.)

Clinical manifestations

The primary lesion produced by LGV is a small, non-painful genital papule, which can ulcerate at the site of inoculation after an incubation period of three to 30 days. This lesion can remain undetected within the urethra, vaginal vault, or rectum.

Common clinical manifestations include (1) tender, unilateral, or bilateral inguinal and/or femoral adenopathy, which can become fluctuant; and (2) hemorrhagic proctitis or proctocolitis, which is associated with receptive anal intercourse. The clinical and histologic presentation of LGV proctocolitis can be similar to the initial manifestations of inflammatory bowel disease.

Diagnosis

Diagnosis is based primarily on clinical findings; routine laboratory confirmation might not be possible.

Serologic tests for C.trachomatis (i.e., microimmunofluorescence or complement fixation) can support diagnosis.

Direct identification of C. trachomatis from a lesion (i.e., bubo) or site of the infection (e.g., rectum) can be made by using culture or by using nonculture nucleic acid testing; however, neither method is specific for LGV, and use of rectal swabs for nucleic acid testing is not cleared by the U.S. Food and Drug Administration.

Treatment

[corrected] The recommended treatment is administration of 100 mg of doxycycline, twice daily for 21 days. Alternative treatment is 500 mg of erythromycin base orally, four times a day for 21 days. Some subspecialists believe 1 g of azithromycin, administered orally once weekly for three weeks, is effective; however, clinical data are lacking.

Sex partners who had contact with the patient within 30 days of the patient’s onset of symptoms should be evaluated; in the absence of symptoms, they should be treated with either 1 g of azithromycin in a single dose, or 100 mg of doxycycline, twice a day for seven days.



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