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1. LYMPHOGRANULOMA VENEREUM

ESSENTIALS OF DIAGNOSIS

  • Evanescent primary genital lesion.

  • Inguinal buboes with suppuration and draining sinuses.

  • Proctitis and rectal stricture in women or in men who have sex with men.

  • Positive complement fixation test.

General Considerations

Lymphogranuloma venereum (LGV) is an acute and chronic sexually transmitted disease caused by C trachomatis types L1–L3. The disease is acquired during intercourse or through contact with contaminated exudate from active lesions. The incubation period is 5–21 days. After the genital lesion disappears, the infection spreads to lymph channels and lymph nodes of the genital and rectal areas. Inapparent infections and latent disease are not uncommon.

Clinical Findings

A. Symptoms and Signs

In men, the initial vesicular or ulcerative lesion (on the external genitalia) is evanescent and often goes unnoticed. Inguinal buboes appear 1–4 weeks after exposure, are often bilateral, and have a tendency to fuse, soften, and break down to form multiple draining sinuses, with extensive scarring. In women, the genital lymph drainage is to the perirectal glands. Early anorectal manifestations are proctitis with tenesmus and bloody purulent discharge; late manifestations are chronic cicatrizing inflammation of the rectal and perirectal tissue. These changes lead to obstipation and rectal stricture and, occasionally, rectovaginal and perianal fistulas. They are also seen with anal coitus.

B. Laboratory Findings

The complement fixation test may be positive (titers greater than 1:64), but cross-reaction with other chlamydiae occurs. Although a positive reaction may reflect remote infection, high titers usually indicate active disease. Nucleic acid detection tests are sensitive but are not FDA approved for rectal specimens and cannot differentiate LGV from non-LGV strains.

Differential Diagnosis

The early lesion of LGV must be differentiated from the lesions of syphilis, genital herpes, and chancroid; lymph node involvement must be distinguished from that due to tularemia, tuberculosis, plague, neoplasm, or pyogenic infection; and rectal stricture must be distinguished from that due to neoplasm and ulcerative colitis.

Treatment

If diagnostic testing for LGV is not available, patients with a clinical presentation suggestive of LGV should be treated empirically. The antibiotic of choice is doxycycline (contraindicated in pregnancy), 100 mg orally twice daily for 21 days. Erythromycin, 500 mg orally four times a day for 21 days, is also effective. Azithromycin, 1 g orally once weekly for 3 weeks, may also be effective.

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de Vries  HJ  et al. 2013 European guideline on the management of lymphogranuloma venereum. J Eur Acad Dermatol Venereol. 2015 Jan;29(1):1–6.
[PubMed: 24661352]
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Workowski  KA  et al; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015 Jun 5;64(RR-03):1–137. Erratum in: MMWR Recomm Rep. 2015 Aug 28;64(33):924.
[PubMed: 26042815]

2. CHLAMYDIAL URETHRITIS & CERVICITIS

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