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Chapter 17. Lymphogranuloma Venereum

Christopher S. Hall, MD, MS

  • • In North America, lymphogranuloma venereum typically presents as a proctitis syndrome; elsewhere, genital ulcer disease followed by inguinal lymphadenopathy with or without bubo formation may predominate.
  • • Diagnostic tests include culture and typing for Chlamydia trachomatis and molecular assays.
  • • Patients should be asked about gender of sex partners and travel to areas of endemic disease or outbreaks, and behavioral risk assessment should be performed to elicit risks for transmission.
  • • In patients with suspected infection, screening for other STDs, including HIV, is warranted.

Lymphogranuloma venereum (LGV) is a systemic sexually transmitted disease (STD) caused by L1, L2, and L3 serovars (subtypes) of Chlamydia trachomatis. LGV occurs worldwide as several clinical syndromes, the most common of which are characterized by papules or ulcers with inguinal lymphadenopathy, followed by proctitis (see Table 17–1). Although LGV is classically an invasive, inflammatory infection, patients may present without significant lymphadenopathy or with mild symptoms. Asymptomatic infection also has been observed.

Table 17–1. Characteristic Syndromes Associated with Lymphogranuloma Venereum.
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Table 17–1. Characteristic Syndromes Associated with Lymphogranuloma Venereum.
SyndromePertinent HistorySymptoms
Lymphadenopathy syndrome
Primary stageIncubation 3–30 d• Typically small, painless genital papule with or without urethritis or cervicitis that may ulcerate
• Usually unrecognized by patient and resolves without treatment
Secondary stageOccurs 2–6 wk after primary stage• One or more regional lymph nodes that may ulcerate (ie, bubo); inguinal or femoral nodes may cause “groove” sign
• One third of buboes may rupture
• Genital ulcers may be manifest concurrently with lymphadenitis
Proctitis and proctocolitisRisk factors include anal intercourse or other anal penetration• Rectal discharge, bleeding, pain on defecation (tenesmus), and later, frank colitis; inguinal lymph node involvement is unusual
• Fever or other constitutional symptoms (ie, weight loss, fatigue) may be present

LGV is endemic in some regions (Africa, Southeast Asia, Central and South America, and Caribbean countries) while occurring sporadically in others. It remains infrequent in the United States. However, case clusters have been reported in the northern hemisphere since 2002. Notably, an outbreak of 92 cases of proctitis caused by LGV was described among men who have sex with men (MSM) in the Netherlands in 2003–2004. Since then, case clusters have been reported in Belgium, France, Sweden, and Canada, with fewer than two dozen confirmed cases reported throughout the United States by 2005.

Recent outbreaks and case clusters demonstrate the need for heightened awareness of this STD in the United States. LGV should be considered in those at risk for STDs, especially MSM and others reporting unprotected receptive anal intercourse who present with rectal complaints or lymphadenopathy. Such patients, along with any patient with a compatible clinical presentation, should be asked about travel to areas of endemic disease or outbreaks. Given the ulcerative nature of this more invasive chlamydial infection, the risk of facilitating HIV acquisition and transmission is ...

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