Lymphogranuloma Venereum

LGV is primarily an infection of the lymphatics and lymph nodes caused by Chlamydia trachomatis serotypes L1, L2, and L3. LGV is a rare disease that is more frequently seen in men than in women. Transmission is by sexual contact, primarily with asymptomatic female carriers.

The incubation period is 3 to 30 days after inoculation. Constitutional symptoms may be present, and the anorectal syndrome is more common in females and homosexual males, consisting of pruritus, pain, and tenesmus. LGV presents on the genitalia as a painless papule, shallow ulcer, herpetiform lesion, or urethritis. This lesion heals in approximately one week. The second stage begins within two to six weeks after the initial lesion and is referred to as the inguinal stage. During this stage, inguinal lymph nodes swell and form painful, firm nodes that enlarge. Bacteria travel through the regional lymphatics producing unilateral lymphangitis, referred to as buboes. These nodes may rupture or form hard masses. A classic sign of LGV is the "groove sign of Greenblatt,'' formed by Poupart's ligament crossing over enlarged femoral lymph nodes. Inguinal and femoral lymphadenopathy is seen in approximately 20% of infected females and is often unilateral (25). The rectum, cervix, and vagina are more commonly affected in females. These areas drain into

Table 7 Lymphogranuloma Venereum

Clinical

Differential

Diagnosis

Symptoms appearance

diagnosis

Therapy

Lymphogranulo

Painful, enlarged Chronic lym-

Initial stage:

Recommended

ma venereum

lymph nodes phangitis,

syphilis,

treatment:

esthiomene,

chancroid,

doxycycline.

buboes

genital herpes

Alternative

Inguinal stage:

treatment:

syphilis,

erythromycin,

chancroid,

lymph node

genital herpes,

drainage or

incarcerated

aspiration may

inguinal

be indicated

hernia,

inguinal

lymphadeno-

pathy

Anorectal stage:

Crohn's

disease,

trauma,

malignancy

Elephantiasis:

tuberculosis,

filariasis,

fungal,

parasites,

granuloma

inguinale

the iliac or perirectal nodes and may present as lower back or abdominal pain. Involvement of the iliac lymph nodes can result in pelvic adhesions. Complications include rectal strictures, stenosis, perianal abscesses, fistulas, proctocolitis, and perianal outgrowths of lymphatic tissue. If untreated, the disease can progress to genital elephantiasis, chronic lymphatic obstruction, worsening strictures and fistulas, or a "frozen" pelvis.

Other diseases to be considered in the differential diagnosis include, in those patients who recognize the early, subtle erosion or ulcer, HSV, chancre, or chancroid. Later disease can be confused with any cause of lymphadenopathy, an incarcerated inguinal hernia, or malignancy. The diagnosis is made by complement fixation, immunofluorescence, or isolation of the organism from aspiration of an infected bubo or rectal swab when proctocolitis is present.

The treatment is doxycycline 100 mg b.i.d. or erythromycin 500 mg q.i.d. for 21 days (8) (Table 7).

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