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07-SEPTEMBER-2008 03:17:44 - Lymphogranuloma venereum Lymphogranuloma venereum Classification and external resources ICD-10 A55. ICD-9 099.1 DiseasesDB 29101 MedlinePlus 000634 eMedicine emerg/304 med/1356 derm/617 MeSH D008219 Lymphogranuloma venereum LGV, also known as lymphopathia venerea, tropical bubo, climatic bubo, strumous bubo, poradenitis inguinales, Durand-Nicolas-Favre disease and lymphogranuloma inguinale, is a sexually transmitted disease caused by the invasive serovars L1, L2, or L3 of Chlamydia trachomatis. LGV was first described by Wallace in 18331 and again by Durand, Nicolas, and Favre in 1913. 23 Contents 1 Overview 2 Signs and symptoms 2.1 Primary stage 2.2 Secondary stage 3 Prognosis 4 Long term complications 5 Diagnosis 6 Further recommendations 7 Treatment 8 References and external links Overview LGV is primarily an infection of lymphatics and lymph nodes. Chlamydia trachomatis is the bacteria responsible for LGV. It gains entrance through breaks in the skin, or it can cross the epithelial cell layer of mucous membranes. The organism travels from the site of inoculation down the lymphatic channels to multiply within mononuclear phagocytes of the lymph nodes it passes. In the United States, Europe, Australia and most of Asia and South America LGV is generally considered to be a rare disease. However, a recent outbreak in the Netherlands among gay men has led to an increase of LGV in Europe and the United States.45 A majority of these patients are HIV co-infected. Since the 2004 Dutch outbreak 341 cases have been reported in the UK and 80 cases in the US, but infectious-disease experts fear the actual number is substantially larger because this form of chlamydia is difficult to diagnose and many physicians are not aware of its existence. Soon after the initial Dutch report national and international health authorities launched warning initiatives and multiple LGV cases where identified in several more European countries Belgium, France, the UK, Germany, Sweden, Italy and Switzerland and the US and Canada. All cases reported in Amsterdam and France and a considerable part of LGV infections in the UK and Germany are caused by a newly discovered Chlamydia variant L2b, a.k.a the Amsterdam variant. The L2b variant could be traced back and was isolated from anal swabs of MSM who visited the STI city clinic of San Francisco in 1981. This finding suggests that the recent LGV outbreak among MSM in industrialised countries is a slowly evolving epidemic. As of end 2005, new LGV cases are continued to be reported in the Netherlands and other European countries at rates approaching one or two cases per week in each country. Signs and symptoms The clinical manifestation of LGV depends on the site of entry of the infectious organism the sex contact site and the stage of disease progression. Inoculation at the mucous lining of external sex organs penis and vagina can lead to the inguinal syndrome named after the formation of buboes or abscesses in the groin inguinal region where draining lymph nodes are located. The rectal syndrome arises if the infection takes place via the rectal mucosa through anal sex and is mainly characterized by proctocolitis symptoms. The pharyngeal syndrome is rare, starts after infection of pharyngeal tissue and buboes in the neck region can occur. Primary stage LGV may begin as a self-limited painless genital ulcer that occurs at the contact site 3-12 days or longer in this primary stage. Rarely do women notice a primary infection, because the initial ulceration where the organism penetrates the mucosal layer are located out of sight in the vaginal wall. Also in men fewer than 1/3 of those infected notice the first signs of LGV. This primary stage heals in a few days. Erythema nodosum occurs in 10% of cases. Secondary stage The secondary stage occurs from 10-30 days later most often, but has occurred up to 6 months later. The infection is then spread to the lymph nodes through lymphatic drainage pathways. The most frequent presenting clinical manifestation of LGV among males whose primary exposure was genital is unilateral, in 2/3 of cases, lymphadenitis and lymphangitis, often tender inguinal and/or femoral lymphadenopathy because of the drainage pathway for their likely infected areas. Lymphangitis of the dorsal penis may also occur and resembles string or cord. If the route was anal sex the infected person may experience lymphadenitis and lymphangitis noted above or may have proctitis, inflammation limited to the rectum the distal 10--12 cm that may be associated with anorectal pain, tenesmus, or rectal discharge, or proctocolitis, inflammation of the colonic mucosa extending to 12 cm above the anus and is associated with symptoms of proctitis plus diarrhea or abdominal cramps and or inflammatory involvement of perirectal or perianal lymphatic tissues. In females cervicitis, perimetritis, or salpingitis may occur as well as the lymphangitis and lymphadenitis in deeper nodes. Because of lymphatic drainage pathways, some end up with an abdominal mass which seldom suppurates and only 20-30% end up with inguinal lymphadenopathy. Systemic signs: fever, decreased appetite, and malaise, may occur as well. Diagnosis is more difficult in women and men who have sex with men MSM who may not have the inguinal symptoms. Over the course of the disease, lymph nodes enlarge, enlarged nodes are called buboes, and become painful at first which may occur in any infection of the same areas as well. The next most common thing is inflammation, thinning and fixation of the overlying skin. Lastly in the progression are necrosis, fluctuant and suppurative lymph nodes, abscesses, fistulas, strictures, and sinus tracts all may occur. During the infection and when it subsides and healing takes place, fibrosis may occur. This can result in varying degrees of lymphatic obstruction, chronic edema, and strictures. These late stages characterised by fibrosis and edema are also known as the third stage of LGV and are mainly permanent. Prognosis Highly variable. Spontaneous remission is common. Complete cure can be obtained with proper antibiotic treatment. Course is more favorable with early treatment. Bacterial superinfections may complicate course. Death can occur from bowel obstruction or perforation. Follicular conjunctivitis due to autoinoculation of infectious discharge. Long term complications Genital elephantiasis or esthiomene, which is the dramatic end-result of lymphatic obstruction, which may occur because of the strictures themselves, or fistulas. This is usually seen in females, may ulcerate and often occurs 1-20 years after primary infection. Fistulas of, but not limited to, the penis, urethra, vagina, uterus, or rectum. Also, surrounding edema often occurs. Rectal or other strictures and scarring. Systemic spread may occur, possible results are arthritis, pneumonitis, hepatitis, or perihepatitis. Diagnosis The diagnosis usually is made serologically through complement fixation and by exclusion of other causes of inguinal lymphadenopathy or genital ulcers. Serologic testing has a sensitivity of 80% after 2 weeks. Serologic testing may not be specific for serotype has some cross reactivity with other chlamydia species and can suggest LGV from other forms because of their difference in dilution, 1:64 more likely to be LGV and lower than 1:16 is likely to be other chlamydia forms emedicine. For idenification of serotypes, culture is often used. Culture is difficult. Requiring a special media, cycloheximide-treated McCoy or HeLa cells, and yields are still only 30-50%. DFA, or direct fluorescent antibody test, PCR of likely infected areas and pus, are also sometimes used. DFA test for the L-type serovar of C trachomatis is the most sensitive and specific test, but is not readily available. If polymerase chain reaction PCR tests on infected material are positive, subsequent restriction endonuclease pattern analysis of the amplified outer membrane protein A gene can be done to determine the genotype. Recently a fast realtime PCR Taqman analysis has been developed to diagnose LGV. With this method an accurate diagnosis is feasible within a day. It has been noted that one type of testing may not be thorough enough. Further recommendations As with all STD's sex partners of patients who have LGV should be examined and tested for urethral or cervical chlamydial infection. After a positive culture for chlamydia, clinical suspicion should be confirmed with testing to distinguish serotype. Antibiotic treatment should be started if they had sexual contact with the patient during the 30 days preceding onset of symptoms in the patient. Patients with a sexually transmitted disease need to be tested for other STD's. Antibiotics are not without risks and prophylaxtic broad antibiotic coverage is not recommended. Treatment Treatment involves antibiotics and may involve drainage of the buboes or abscesses by needle aspiration or incision. Further supportive measure may need to be taken: dilatation of the rectal stricture, repair of rectovaginal fistulae, or colostomy for rectal obstruction. Common antibiotic treatments include: tetracycline, doxycycline all tetracyclines, including doxycycline, are contraindicated during pregnancy and in children due to effects on bone development and tooth discoloration, and erythromycin. References and external links ^ eMedicine - Lymphogranuloma Venereum : Article by Andrew C Bushnell. Retrieved on 2007-10-26. ^ synd/1431 at Who Named It ^ N. J. Durand, J. Nicolas, M. Favre. Lymphogranulomatose inguinale subaiguë d'origine génitale probable, peut-être vénérienne. Bulletin de la Société des Médecins des Hôpitaux de Paris, 1913, 3 sér., 35: 274-288. ^ Thomas H. Maugh II. Virulent Chlamydia Detected Largely Among Gay Men in U.S. Los Angeles Times: 11 May 2006 ^ Michael Brown. LGV in the UK: almost 350 cases reported and still predominantly affecting HIV-positive gay men Aidsmap: 17 May 2006 Original article from the public domain resource 1998 Guidelines for Treatment of Sexually Transmitted Diseases MMWR 47RR-1;1-118 Publication date: 23 January 1998 at http://wonder.cdc.gov/wonder/prevguid/p0000480/p0000480.asp#head007005000000000 note that this has not been modified since 1998, and may be out of date. Centers for Disease Control and Prevention. Proctitis, proctocolitis, and enteritis. Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep 2002 10 May;51RR-6:66-7. Fitzpatrick's color atlas and synopsis of clinical dermatology 5th ed. Wolff et al. Rosen T. Brown: Genital ulcers - evaluation and treatment. Dermatology Clin. 1998;16:673. Nederlands tijdschrift voor geneeskunde. vol. 148, no. 51 18 December 2004: 2544-6. Dermatology. vol. 209, no. 3 2004: 230-2. MMWR. Morbidity and mortality weekly report. vol. 53, no. 42 29 October 2004 : 985-8. International journal of STD AIDS. vol. 13, no. 6 2002 Jun: 427-9. http://www.essti.org/ Emerging Infectious Diseases vol. 11 no. 7 July 2005: 1090-2. 1 Emerging Infectious Diseases vol. 11 no. 8 August 2005: 1311-2. Emerging Infectious Diseases vol. 11 no. 11 November 2005: 1787-8. Clinical Infectious Diseases vol. 42 no. 2 January 15, 2006: 186-94. v d e Sexually transmitted diseases and infections STD/STI primarily A50-A64, 090-099 Bacterial Chancroid Haemophilus ducreyi Chlamydia Chlamydia trachomatis Donovanosis Granuloma Inguinale Lymphogranuloma venereum LGV Gonorrhea Neisseria gonorrhoeae Syphilis Treponema pallidum Ureaplasma urealyticum Protozoal Trichomoniasis Trichomonas vaginalis Parasitic Crab louse/crabs Scabies Viral AIDS HIV-1/HIV-2 Cervical cancer Genital warts condyloma Human papillomavirus HPV Hepatitis B Herpes simplex virus HSV1/HSV2 Molluscum contagiosum MCV General inflammation female: Cervicitis Pelvic inflammatory disease PID male: Epididymitis Prostatitis either: Proctitis Urethritis/Non-gonococcal urethritis NGU Other Ectopic pregnancy Premature birth Infertility Reactive arthritis v d e Infectious diseases - Bacterial diseases primarily A00-A79, 001-041,080-109 G+ Firmicutes Clostridium Pseudomembranous colitis - Botulism - Tetanus - Gas gangrene Bacilli class Coccus Strep-: Alpha pneumoniae, mutans, viridans - Beta A pyogenes Scarlet fever, Erysipelas, Rheumatic fever, Streptococcal pharyngitis, B agalactiae - D Entero- Staphylo- - Toxic shock syndrome Bacillus shape Bacillus Anthrax - Listeria Listeriosis Actinobacteria Actinomycetales Actinomycosis/Actinomycetoma Whipple's disease - Corynebacterium Diphtheria, Erythrasma - Nocardia Nocardiosis, Maduromycosis Mycobacterium M. tuberculosis Tuberculosis: Ghon focus/Ghon's complex - Pott disease - brain Meningitis, Rich focus - cutaneous Scrofula, Bazin disease, Lupus vulgaris, Prosector's wart - Miliary M. leprae Leprosy Nontuberculous: Mycobacterium avium Lady Windermere syndrome - Mycobacterium ulcerans Buruli ulcer G- Spirochetal Treponema: Syphilis Bejel - Yaws - Pinta Borrelia: Relapsing fever - Lyme disease Erythema chronicum migrans, Neuroborreliosis other/multiple/unknown: Noma - Trench mouth - Rat-bite fever Sodoku - Leptospirosis Intracellular Mycoplasmatales Mycoplasma pneumonia - Ureaplasma infection Chlamydiae Chlamydophila Psittacosis - Chlamydia Chlamydia, Lymphogranuloma venereum, Trachoma Proteobacteria primarily rods, except Neisseria =cocci α/ Intra- Rickettsiales/ Rickettsioses/ Anaplasmataceae Typhus Murine typhus, Epidemic typhus spotted fever Rocky Mountain spotted fever, Boutonneuse fever, Rickettsialpox Ehrlichiosis Human granulocytic ehrlichiosis, Human monocytic ehrlichiosis OTHER: Coxiella Q fever - Bartonella Trench fever - Orientia Scrub typhus Rhizobiales Brucellosis - Cat scratch fever - Bartonellosis Bacillary angiomatosis β Neisseriaceae: Meningococcus Meningococcal disease, Waterhouse-Friderichsen syndrome - Gonorrhea Burkholderiales: Glanders - Melioidosis - Pertussis γ Enterobacteriaceae: Salmonella Typhoid fever, Paratyphoid fever, Salmonellosis - Yersinia pestis Plague/Bubonic plague - Klebsiella Rhinoscleroma, Donovanosis - Shigella Shigellosis - Escherichia coli/O157:H7 - Proteus Pasteurellaceae: Pasteurella Pasteurellosis - Haemophilus Brazilian purpuric fever, Chancroid - Actinobacillus Actinobacillosis other: Francisella Tularemia - Vibrio Cholera - Legionella Legionellosis - Pseudomonas - Serratia ε Campylobacteriosis - Helicobacter Bacteroidetes Bacteroides Other Gardnerella Retrieved from http://en..org/wiki/Lymphogranuloma_venereum Categories: Sexually transmitted diseases and infections Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages Deutsch Español Français Italiano Nederlands Português Suomi Svenska This page was last modified on 29 August 2008, at 16:23
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