939.

e2 Lymphogranuloma Venereum ALG

• Unilateral inguinal adenopathy in 70% of • A clinical algorithm for evaluation of genital

BASIC INFORMATION
DEFINITION
Lymphogranuloma venereum (LGV) is a sexu-
ally transmitted, systemic disease caused by
Chlamydia trachomatis, serovars L1, L2, or L3.
SYNONYMS
Tropical bubo
Poradenitis inguinalis
LGV
ICD-10CM CODE
A55 Chlamydial lymphogranuloma
(venereum)
EPIDEMIOLOGY &
DEMOGRAPHICS
INCIDENCE (IN U.S.): Rare; <300 cases/yr
PREVALENCE:
• Endemic in Africa, India, parts of Southeast
Asia, South America, and the Caribbean
• Increased number of cases among men who
have sex with men in Europe and the U.S.
PREDOMINANT SEX: Male:female ratio is 5:1.
PHYSICAL FINDINGS & CLINICAL
PRESENTATION
Primary stage:
• Primary lesion caused by multiplication of
organism at site of infection
• Papule, shallow ulcer
• Herpetiform lesion at site of inoculation (most
common)
• Incubation period of 3 to 21 days
• Most common site of lesion in women:
Posterior wall, fourchette, or vulva
• Spontaneous healing without scarring
Second stage:
• Inguinal syndrome: Characteristic inguinal
adenopathy (Fig. E1)
• Begins 1 to 4 wk after primary lesion
• Syndrome is the most frequent clinical sign of
the disease
cases
• Symptoms: Painful, extensive adenitis (bubo)
and suppuration may occur with numerous
sinus tracts
• “Groove sign” signaling femoral and inguinal
node involvement (20%); most often seen in
men
• Involvement of deep iliac and retroperitoneal
lymph nodes in women may present as a
pelvic mass
Third stage (anogenital syndrome):
• Subacute: Proctocolitis
• Late: Tissue destruction or scarring, sinuses,
abscesses, fistulas, strictures of perineum,
elephantiasis
ETIOLOGY
Chlamydia trachomatis is the causative agent.
There are three serotypes: L1, L2, and L3.
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
• Inguinal adenitis, suppurative adenitis, retro-
peritoneal adenitis, proctitis, schistosomiasis.
• Recall exposure in men who have sex with
men (MSM) or women can result in proc-
tocolitis from LGV mimicking inflammatory
bowel disease, and clinical findings may
include mucoid and/or hemorrhagic rectal
discharge, anal pain, constipation, fever, and/
or tenesmus.
• Section II describes the differential diagnosis
of genital sores.
WORKUP
• Diagnosis is based on clinical suspicion and
serology, epidemiologic information, and the
exclusion of other etiologies for proctocolitis,
inguinal lymphadenopathy, or genital or rec-
tal ulcers. Biopsy is contraindicated because
sinus tracts develop.
• Screening for other sexually transmitted
diseases.
ulcer disease is described in Section III,
“Evaluation of Patients with Genital Lesions
or Ulcers.”
LABORATORY TESTS
• Genital and lymph node specimens (i.e.,
lesion swab or bubo aspirate) can be tested
for C. trachomatis by culture or direct immu-
nofluorescence, using nucleic acid amplifica-
tion techniques, including real-time poly-
merase chain reaction (PCR).
• Additional molecular procedures (e.g., PCR-
based genotyping) can be used to differ-
entiate LGV from non-LGV C. trachomatis
in rectal specimen; however, they are not
widely available and results are not available
in a timeframe that would influence clinical
management.
• Complement fixation test:
1. Titer >1:64 in active infection, lower titers
may be nonspecific.
2. Convalescent titers no difference.
• Microimmunofluorescence titers >1:256
might support the diagnosis of LGV in the
appropriate clinical context.
• Cell culture of Chlamydia aspiration of fluctu-
ant node yields highest rates of recovery.
• Complete blood count: Mild leukocytosis with
lymphocytosis or monocytosis.
• Elevated sedimentation rate.
• Venereal Disease Research Laboratories
(VDRL) and HIV screening to rule out other
sexually transmitted diseases.
1. The co-infection rate of LGV and HIV is
approximately 84%.
2.  Proctocolitis associated with LGV may
increase the risk of contracting HIV when
engaging in anal intercourse.
IMAGING STUDIES
Computed tomography scan for suspected ret-
roperitoneal adenitis
TREATMENT
NONPHARMACOLOGIC THERAPY
• Avoid milk and milk products while taking
medication.
• Practice sexual abstinence.
• Treat sexual partners. Persons who have had
sexual contact with a patient who has LGV
within 60 days before onset of the patient’s
symptoms should be examined, tested for
urethral or cervical chlamydial infection, and
treated with a chlamydia regimen (azithro-
mycin 1 g orally single dose or doxycycline
100 mg orally twice a day for 7 days).

ACUTE GENERAL Rx
• Recommended regimen: Doxycycline 100 mg
PO bid ×21 days
• Alternative regimen: Erythromycin base 500
mg PO qid ×21 days
1. Use for pregnant women to avoid negative
FIG E1  Lymphogranuloma venereum. Bilateral inguinal buboes with separation of the matted left inguinal developmental effects of doxycycline
and femoral lymph nodes by the inguinal ligament, creating the pathognomonic sign of the “groove.” (From • Surgical:
Ryan ET: Hunter’s tropical medicine and emerging infectious diseases, ed 10, 2020, Elsevier.) 1. Aspirate fluctuant nodes

Descargado para Alfredo Quintero Corella (yutualfred19@gmail.com) en Panama United Nations Development Programme de ClinicalKey.es por Elsevier en mayo
18, 2022. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.
Lymphogranuloma Venereum ALG 939.e3

2. Incise and drain abscesses
• Combination of medical and surgical treat-
ment may be necessary
CHRONIC Rx
• Longer course of therapy will be needed
for chronic or relapsing cases, which may
be caused by reinfection and/or inadequate
treatment.
• A rectal stricture requires a colostomy.
• Surgery should be considered only after anti-
biotic treatment.
DISPOSITION
Good prognosis with early treatment, usually
resulting in complete resolution of symptoms.
REFERRAL
Surgical consultation if patient develops
obstruction, fistula, or rectal stricture. May
need referral to plastic surgeon if patient has
lymphatic obstruction.
PEARLS &
CONSIDERATIONS
COMMENTS
• The most common clinical manifestation of
LGV among heterosexuals is tender inguinal
and/or femoral lymphadenopathy that is typi-
cally unilateral.
• Rectal exposure in women or MSM can
result in proctocolitis mimicking inflamma-
tory bowel disease.
• Pregnant and lactating women should be
treated with erythromycin regimen.
• Congenital transmission does not occur, but
infection may be acquired through an infect-
ed birth canal.
• Persons with both LGV and HIV infection
should receive the same regimens as those
who are HIV negative. Prolonged therapy
may be required, and delay in resolution of
symptoms may occur.
• When diagnosed with LGV, patients should
also be screened for other STIs, especially
HIV, gonorrhea, and syphilis.
• Patient education materials may be obtained
through local and state health clinics.
RELATED CONTENT
Lymphogranuloma Venereum (Patient
Information)
AUTHORS: Kathryn G. Vollum, MD, and
Kelly McNamara, MD

SUGGESTED READINGS
CDC, MMWR 64(No.3), 2015. June 5.
Pathela P et al: Lymphogranuloma venereum: old pathogen, new story, Curr Infect
Dis Rep 9:143-150, 2007.

Descargado para Alfredo Quintero Corella (yutualfred19@gmail.com) en Panama United Nations Development Programme de ClinicalKey.es por Elsevier en mayo
18, 2022. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.