Lymphogranuloma Venereum (LGV)

Lymphogranuloma venereum (LGV), also known by other names such as climatic bubo, Durand–Nicolas–Favre disease, and strumous bubo, is a sexually transmitted infection caused by invasive serovars L1, L2, L2a, L2b, or L3 of Chlamydia trachomatis. Primarily affecting the lymphatics and lymph nodes, LGV was considered rare in developed nations before 2003, but recent outbreaks in Europe and the United States have led to increased surveillance and awareness.

Signs and Symptoms

The clinical manifestations of LGV vary depending on the site of entry of the infectious organism and the stage of disease progression. The primary stage begins as a self-limited, painless genital ulcer at the contact site, typically appearing 3–12 days after infection. This stage often goes unnoticed, especially in women, as the initial ulceration can be located out of sight in the vaginal wall.

The secondary stage occurs 10–30 days later and is characterised by the spread of infection to the lymph nodes through lymphatic drainage pathways. In males, the most frequent clinical manifestation includes unilateral lymphadenitis and lymphangitis with tender inguinal and/or femoral lymphadenopathy. Anal sex may result in proctitis or proctocolitis, with symptoms such as anorectal pain, tenesmus, rectal discharge, diarrhoea, or abdominal cramps. In women, cervicitis, perimetritis, or salpingitis may occur, along with lymphangitis and lymphadenitis in deeper nodes.

During the course of the disease, lymph nodes may become enlarged and painful, progressing to necrosis, abscesses, fistulas, strictures, and sinus tracts. Late stages characterised by fibrosis and oedema, known as the third stage of LGV, are mainly permanent.

Diagnosis

Diagnosis is typically 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 two weeks and may not be specific for serotype due to cross-reactivity with other chlamydia species.

Culture is often used for identification of serotypes, although it is difficult and requires a special medium. Direct fluorescent antibody (DFA) tests, PCR, and restriction endonuclease pattern analysis of the amplified outer membrane protein A gene can also be used for diagnosis. Recently, a fast real-time PCR (TaqMan analysis) has been developed, providing accurate diagnosis within a day.

Treatment

Treatment involves antibiotics such as tetracycline, doxycycline, erythromycin, or azithromycin, and may include drainage of buboes or abscesses by needle aspiration or incision. Supportive measures may be necessary, such as dilatation of rectal strictures, repair of rectovaginal fistulae, or colostomy for rectal obstruction.

Sex partners of patients with LGV should be examined and tested for urethral or cervical chlamydial infection. Antibiotic treatment should be initiated for partners who had sexual contact with the patient during the 30 days preceding symptom onset. Patients with LGV should also be tested for other STIs due to high rates of comorbid infections.

Prognosis

Prognosis is highly variable, with spontaneous remission being common. Complete cure can be achieved with appropriate antibiotic treatment. Early treatment leads to a more favourable prognosis. Long-term complications may include genital elephantiasis, fistulas, strictures, and systemic spread resulting in conditions such as arthritis, pneumonitis, hepatitis, or perihepatitis.

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Self-assessment MCQs (single best answer)

What organism causes Lymphogranuloma Venereum (LGV)?

Which serovars of Chlamydia trachomatis are responsible for LGV?

What is the most common early clinical presentation of LGV?

Which stage of LGV is characterised by unilateral lymphadenitis and lymphangitis with tender inguinal and/or femoral lymphadenopathy?

Which diagnostic method provides the fastest and most accurate diagnosis of LGV within a day?

What is the primary mode of transmission for LGV?

Which antibiotic is NOT typically used in the treatment of LGV?

What complication is characterised by the development of fibrosis and oedema in LGV?

Which of the following supportive measures might be necessary for someone with LGV?

Why should sex partners of patients with LGV be tested and treated?