LGV - Lymphogranuloma venereum

LGV

Overview

  • Lymphogranuloma venereum (LGV) is a rare condition in Australia but an increase has been observed in men who have sex with men (MSM), many of whom have also been HIV positive
  • These men usually present with symptoms of proctitis
  • LGV among MSM is common in North Europe and North America, and is endemic in the general population in several tropical areas such as South-East Asia, Southern Africa and India.

Cause

LGV is caused by the bacterium Chlamydia trachomatis, serovars L1-3 (Non-LGV genital chlamydia is caused by the other serovars D-K)

Clinical presentation

Male Female
Symptoms
Primary:
  • small ulcer/nodule on penis/anus (may go unnoticed)
  • proctitis
Primary:
  • small ulcer/nodule on vulva/anus (may go unnoticed)
  • proctitis
Secondary:
  • inguino-femoral lymph node swelling and/or discharge (Bubo), +/- erythema
Secondary:
  • inguino-femoral lymph node swelling and/or discharge (Bubo), +/- erythema
Tertiary:
  • chronic proctitis, fistulae, strictures, genital oedema
Tertiary:
  • chronic proctitis, fistulae, strictures, genital oedema, scarring of vulva (Esthiomene)
Complications
Long term tertiary sequelae are rarely seen in Australia, but may occur with chronic untreated infection.

See STI Altas for images.

Special considerations

The site of the primary lesion depends on the site of inoculation. Proctitis is characterised by rectal pain, bleeding, rectal discharge, tenesmus and changed bowel habit. LGV in Australia is usually symptomatic, hence routine screening of asymptomatic patients is not recommended.

Diagnosis

Diagnosis in males
TestSite/SpecimenConsideration
Chlamydia NAAT
(Initial test; in patients with proctitis symptoms)
Rectal swab   Clinician collected or
self-collected rectal swab.

Write on request form “Proctitis: NAAT. If chlamydia positive please send for LGV testing

LGV specific NAAT
(Subsequent test performed on positive rectal chlamydia test in symptomatic MSM)

Performed on same rectal sample collected for initial test

Ensure laboratory have sent positive chlamydia samples from MSM with   proctitis for LGV typing to local reference laboratory.
Chlamydia NAAT
(Initial test to investigate ulcer)


Swab from ulcers

Clinician collected viral transport swab rolled directly over lesion.

Chlamydia NAAT is not a routine test for genital ulceration and should only be   performed in those with high clinical suspicion of LGV.
MSM – Men who have sex with men 
NAAT – Nucleic Acid Amplification Test 
LGV – Lymphogranuloma venereum
Diagnosis in females

LGV is a very uncommon infection in women in Australia. If suspected, referral to a local Sexual Health or Infectious Diseases clinic is advised.

LGV – Lymphogranuloma venereum

Specimen collection

Clinician collected |
self-collection

Investigations

  • Lymphogranuloma venereum (LGV) in men who have sex with men (MSM) is associated with a high rate of co-infection with gonorrhoea, syphilis, hepatitis C and/or HIV co-infection. Herpes simplex virus (HSV) can also cause symptoms of proctitis, therefore HSV NAAT should be taken at the time of consultation. Tests for these conditions should be conducted at the time of initial consultation, and at follow up. In addition to syphilis serology, syphilis NAAT can be performed from any area of ulceration.
  • If proctoscopy is performed, a red, ulcerated, oedematous mucosa is typical, and may be accompanied by mucopurulent discharge. A gram stain showing >20 white cells/high powered film is suggestive of LGV.

Management

Principal Treatment Options
SituationRecommendedAlternative
Suspected or confirmed LGV

Doxycycline 100mg PO BD for 21 days 

Alternative regimens are not recommended due to lack of efficacy data. If alternative regimen required, seek specialist advice. 

LGV - Lymphogranuloma venereum

Treatment advice

  • Studies have shown that lymphogranuloma venereum (LGV) DNA can persist in the rectum for up to 16 days after initiation of treatment, hence a long course (21 days) is required.
  • At initial consultation for the patient with proctitis with a suspicion of LGV, treat also for gonorrhoea and chlamydia, in addition to 100mg doxycycline BD for 21 days. Consider addition of valaciclovir 500mg PO, BD for 7 days. LGV serovar results may take some time to return from the laboratory.

Other immediate management

  • Advise no sexual contact for 21 days whilst taking treatment
  • Advise no sex with partners from the last 3 months until until the partners have been tested and treated if necessary
  • Contact tracing
  • Provide patient with factsheet
  • Primary care professionals do not have to notify the state/territory health departments about LGV.

Special treatment situations

Special considerations

Consider seeking specialist advice before treating any complicated presentation.
SituationRecommended
Persistence of symptoms despite initial treatment Check other STI tests were done at initial consult. Seek specialist advice
Pregnant women
pregnancy
Seek specialist advice

Allergy to principal treatment choice Seek specialist advice
Inguinal buboes These may require drainage through normal skin under ultrasound guidance - seek specialist advice

Contact tracing

  • Lymphogranuloma venereum (LGV) is rare in Australia, therefore contact tracing is of high priority and should be performed in all patients with confirmed infection.
  • Male and female partners should be traced back for a minimum of 1 month prior to the development of primary symptoms, or since arrival from an LGV endemic area if infection likely to have occurred overseas.
  • If asymptomatic, contact tracing for sex partners in the last 6 months is recommended.

See Australasian Contact Tracing Manual – LGV for more information.

Follow up

Review in 1 week provides an opportunity to:

  • Review results from initial consultation.
  • Confirm patient adherence with treatment and assess for symptom resolution
  • Confirm contact tracing procedures have been undertaken or offer more contact tracing support
  • Provide further sexual health education and prevention counselling.

Test of Cure (TOC)

  • Test of cure by chlamydia Nucleic Acid Amplification Test (NAAT) should occur at 6 weeks (3 weeks after treatment completion).
  • If TOC positive, seek specialist advice. This sample should be sent for Lymphogranuloma venereum (LGV) testing if positive to confirm LGV persistence. If negative, there is no need to send for LGV testing.

Retesting

Auditable outcomes

  • 100% of patients diagnosed with lymphogranuloma venereum (LGV) have contact tracing completed (patient or provider).
  • 100% of patients are recommended to repeat HIV and hepatitis C testing at 3 months.

References

BASHH LGV Guideline 2013- http://www.bashh.org/documents/2013%20LGV%20guideline.pdf

IUSTI-Europe LGV guideline 2013 http://www.iusti.org/regions/Europe/pdf/2013/LGV_IUSTI_guideline_2013.pdf

CDC LGV guideline 2010 http://www.cdc.gov/std/treatment/2010/genital-ulcers.htm#lymphogranuloma

 

Last Updated: Friday, 20 May 2016