Lymphogranuloma venereum (LGV) diagnosis and treatment

Last updated: December 2017

Background

  • LGV is a serovar (L1, L2, L3) of Chlamydia trachomatis and can cause invasive disease
  • The incidence of LGV has increased in the developed world in the last 10 years predominantly in men who have sex with men. Ongoing outbreaks have occurred in European, North American and Australasian capital cities mostly amongst HIV positive MSM. A proportion of cases have also been identified in HIV positive men without rectal symptoms and HIV negative men with rectal symptoms. Presence of other STIs and hepatitis C has been associated with LGV diagnosis.

Two clinical syndromes are seen:

  • the ano-rectal syndrome presenting with usually symptomatic proctitis – most often seen in HIV positive MSM
  • the genito-inguinal syndrome presenting with an initial small genital ulcer followed by inguinal lymphadenopathy and, if untreated, bubo formation – more often seen in heterosexual transmission in developing countries.

Clinical features

Clinical features are divided into three stages primary, secondary and tertiary. 

Primary lesion

  • Includes a painless papule, pustule or ulcer on the skin of an exposed site usually in the ano-genital or oral area
  • Proctitis which may be haemorrhagic and include symptoms of rectal pain, anorectal bleeding, mucoid discharge, tenesmus, constipation and other lower GI symptoms
  • Pharyngeal infection causing pharyngitis or ulceration
  • Asymptomatic infection in rectal sites especially in HIV positive patients

Secondary lesions

  • Lymphangitis and perilymphangitis especially in the inguinal and femoral regions
  • Systemic symptoms of fever, arthritis, pneumonitis, reactive arthritis

Tertiary lesions

Persistence of infection may lead to chronic inflammation and destruction of involved tissue, with complications such as rectal stricture or perforation.

^ Back to top

Diagnosis

Presumptive

Clinical suspicion especially in HIV positive men who have sex with men presenting with symptomatic or asymptomatic proctitis, or HIV negative MSM presenting with symptomatic proctitis

Confirmed

Positive NAAT (nucleic acid amplification test, such as PCR) of lesion swab

  • Initial test for Chlamydia trachomatis
  • Followed by LGV serovar specific NAAT

^ Back to top

Management

Antibiotic treatment

  • Patients presenting with proctitis should be treated at presentation before the availability of results
  • initial treatment for proctitis depends on clinical presentation and preliminary results.

Doxycycline 100mg orally 12 hourly for 7 days (extending to 21 days if LGV)

+/-treatment for gonorrhoea, herpes, syphilis and LGV

  • If LGV is suspected, and return for follow up unlikely, a full 21-day Doxycycline course can be initiated

Standard therapy for LGV patients

Doxycycline 100 mg orally twice a day for 21 days (D).

Alternative therapy

Erythromycin 500mg every 6 hours for 21 days

or

Azithromycin 1 gram weekly for three doses

^ Back to top

Patient education

The following points should be discussed:

  • the importance of immediate testing and treatment of all sex partners
  • abstinence from sex until treatment completed
  • need for follow up clinical review in 1 week
  • need for test of cure 4 weeks after completion of treatment
  • patient education/provision of literature on LGV
  • that LGV is a notifiable disease
  • that screening for HIV, hepatitis C and other STIs is recommended.

^ Back to top

Partner notification

Patients need to be contact traced/referred for contact tracing. Trace back period is 3 months.

^ Back to top

Follow up

  • Evaluation of symptoms and signs until resolved
  • Check reaction to medication
  • Enquiry about sexual activity since treatment
  • Ensure contact tracing has occurred
  • Screen for other STIs (if not done already) and arrange follow up at 3 months for blood borne virus serology and syphilis testing.
  • Need for follow up testing for cure 4 weeks after completion of treatment
  • Advise condom use until serology at 3 months in case of concomitant undiagnosed HIV, syphilis or hepatitis

^ Back to top

Further information

For further information on diagnosis and management of lymphogranuloma venereum contact Adelaide Sexual Health Centre.

^ Back to top

Disclaimer

These guidelines are based on review of current literature, current recommendations of the United States Centres for Disease Control and Prevention, World Health Organization, the British Association for Sexual Health and HIV, Australian national and state guidelines, and expert opinion. Local antimicrobial sensitivities are reflected in these recommendations.

They are written primarily for use by Clinic 275 in the setting of a specialist Sexual Health Clinic, with on-site laboratory facilities. Some flexibility is required in applying them to other clinical settings.

^ Back to top