Lymphogranuloma venereum

Lymphogranuloma venereum is sexually transmitted. It causes painless genital papules or ulcers that disappear in a few days. Painful inguinal lymphadenopathy is the most common presentation in heterosexuals. The incubation period is 3-28 days (primary lesion) and 10 days to months (buboes).

CASES/YEAR
1,000 (US); 500,000 (Global)
AGENT TYPE
Bacteria
OTHER NAMES
Lymphogranuloma inguinale; Tropical bubo; LGV; Chlamydia trachomatis (L-1,L-2, or L-3 immunotypes) infection;
ACUITY
Acute-Moderate
INCUBATION
3 days to 4 weeks for primary lesion; 10 days to months for buboes; [CCDM]
INITIAL SYMPTOMS
Painless genital papules, vesicles, or ulcers that disappear in a few days; Painful, unilateral, inguinal lymphadenopathy is the most common presentation in heterosexuals; [5MCC-2020]
PRECAUTIONS
Standard
COMMENTS
FINDINGS
Stage 1 is a painless papule or ulcer that may be hidden in male urethra or female cervix. Stage 2 is regional lymph node enlargement and suppuration. Patients may have fever and other systemic symptoms. Stage 3 in untreated patients is chronic inflammation that may be debilitating. Inguinal buboes (regional lymphadenopathy) are more common in males while females are more likely to have involvement of the pelvic lymph nodes and rectovaginal wall. LGV is one of the causes of proctitis in homosexual males. LGV may cause enlargement of the genitalia in both males and females. [CCDM, p. 369-70] Chronically inflamed lymph vessels can become obstructed leading to edema, fistulas, scarring, and chronic swelling of genital tissues. [Merck Manual, p. 1707] It mainly presents as painful inguinal lymphadenopathy after heterosexual transmission. The primary lesion is a 2-10 mm papule, pustule, or vesicle, usually just one and usually not detected. The suppurative nodes with draining fistulae resolve spontaneously in several months. [Harrisons, p. 422, 426] A mild conjunctivitis with swelling of the lids and preauricular adenopathy has been described. [PPID, p. 1503] Cervical lymphadenopathy may accompany an oropharyngeal infection. [PMID 18712700] After the ulcer heals, patients may have inguinal lymphadenopathy and signs of a systemic illness (fever, headache, and leukocytosis). [Cecil, p. 1980] Pharyngeal infections from orogenital sex cause cervical adenopathy, and cases have been reported of buboes and spread to supraclavicular/mediastinal nodes and secondary pericarditis. [Cohen, p. 588-9]

EPIDEMIOLOGY:
Rare in industrialized countries; [Harrison ID, p. 707]
DIAGNOSTIC
Genital specimens: NAAT not FDA cleared for rectal but some labs have CLIA validation; Direct immunofluorescence; Serology may support diagnosis; [ABX Guide] Culture (+) in about 30% of buboe aspirates or infected tissues; [PPID, p. 2317]
SCOPE
Endemic in Arica, India, Southeast Asia, South America, and the Caribbean; [Cecil, p. 1980] Increasing incidence since 2003 in developed countries among HIV-infected males with proctitis; [CCDM, p. 370]
SIGNS & SYMPTOMS
  • >arthralgia
  • >fever
  • >myalgia
  • E pharyngitis
  • E stomatitis
  • G abdominal pain
  • G blood in stool
  • G fecal leukocytes
  • H leukocytosis
  • H lymphadenopathy
  • N headache
  • N stiff neck
  • O conjunctivitis, acute
  • O oculoglandular syndrome
  • S lymphadenitis, acute
  • S lymphangitis
  • S papules or plaques
  • S pustule
  • S skin blister or vesicles
  • S skin or subcutaneous nodule
  • S ulcer of skin
  • *arthritis
  • *bowel obstruction
  • *encephalitis
  • *erythema nodosum
  • *hepatitis
  • *mediastinitis
  • *meningitis
  • *pericarditis
  • *pneumonia
  • *pneumonitis
  • *weight loss
ANTIMICROBIC

Yes

VACCINE

No

ENTRY
Skin or Mucous Membranes (Includes Conjunctiva), Sexual Contact
RESERVOIR
Human
RISK FACTORS
TREATMENT
"With this lack of widely available LGV-specific diagnostic tests, it is recommended that patients with a clinical presentation of LGV or LGV proctitis be treated presumptively." [PPID, p. 2317]
REFERENCES FOR CASES/YEAR
1. (US) <100 cases/year reported in US; [Cecil, 24th Ed, p. 1920] Use correction factor of 10 for reported diseases;
2. (Global) Endemic in Africa, South America, and parts of Asia, but rare in North America, Europe, and Australia except for outbreaks in male homosexuals; [Gorbach, p. 252] 849 cases were diagnosed between 2003 and 2008 in England & Wales; 99% of patients were male homosexuals with proctitis; [Public Health England website] <100 cases/year reported in US; Outbreaks in Europe and Canada since 2003 among HIV-positive men who had proctitis; [Cecil, 24th Ed, p. 1920] An uncommon cause of genital ulcers in Africa; 10% of patients with buboes in a STD clinic in Bangkok were infected with LGV; A large epidemic was reported in the Bahamas among "crack" cocaine users; [PMID 12081191] Guesstimate: Assume incidence is 10% that of chancroid = 10% X 5 million = 500,000;