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Lymphogranuloma venereum (LGV) is a sexually transmitted disease due to specific Chlamydia variants that is rare in developed countries. It is endemic in East and West Africa, India, Southeast Asia, South and Central America, and some Caribbean Islands; and accounts for 7%–19% of genital ulcer diseases in areas of Africa and India.1,2 The peak incidence occurs in persons 15–40 years of age, in urban areas, and in individuals of lower socioeconomic status. Men are six times more likely than women to manifest clinical infection.3 The incidence of LGV is low in the developed world where cases are usually limited to travelers or military personnel returning from endemic areas. Since 2003, however, outbreaks of LGV have appeared in Europe, Australia, and North America, particularly in the form of proctitis, among human immunodeficiency virus (HIV) positive men who have sex with men (MSM).4–11
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LGV is contracted by direct contact with infectious secretions, usually through any type of unprotected intercourse, whether oral, vaginal, or anal. Transmission efficiency is unknown.12,13 Sexual practices such as fisting and sex-toy sharing may be other routes of transmission.4 In a recent study that compared sexual behaviors in men with LGV and men with non-LGV chlamydial proctitis, fisting was a major predisposing factor.14 An epidemic of LGV has been reported among “crack” cocaine users in the Bahamas.15
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Due to underdiagnosis and underreporting, the epidemiology of LGV remains poorly understood. Common diagnostic laboratory methods are nonspecific and not readily available in endemic areas. Even in industrialized countries, only a few laboratories offer specific assays to LGV serovars. Without such assays, many LGV cases are misdiagnosed as common chlamydial urogenital infection. Underdiagnosis of LGV is also largely due to the presence of an asymptomatic carrier state. Women, in particular, may harbor asymptomatic persistent infection in the cervical epithelium, thus serving as reservoirs of the infection as they do for other urogenital chlamydial infections and gonorrhea. Recently, a large study conducted in the United Kingdom found that only 6% of MSM were asymptomatic carriers of LGV Chlamydia serovars; the majority of cases of LGV in the rectum and urethra were symptomatic.16 Infectivity in men usually ceases after healing of the primary mucosal lesion. Interestingly, most of the detected cases in the recent outbreaks are in men who practice receptive anal sex, suggesting that a high proportion of men who practice insertive anal sex are ...