Lymphogranuloma venereum

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Special considerations

The site of the primary lesion depends on the site of inoculation: it could be on the genitals, perianal area or rarely in the mouth. 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.

NAAT – Nucleic acid amplification test

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

Specimen collection guidance

Clinician collected | Self-collection

Investigations:

• LGV in men who have sex with men (MSM) is associated with a high rate of co-infection with gonorrhoea, syphilis, hepatitis C and  human immunodeficiency virus (HIV). 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.
• LGV testing is recommended for men who have sex with men living with HIV with a positive chlamydia rectal swab (even if they are asymptomatic) and all men who have sex with men with chlamydial proctitis.
• 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 on high powered film is suggestive of LGV.

Treatment advice

• Studies have shown that 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 HSV. LGV serovar results may take some time to return from the laboratory.

Other immediate management

• Advise no sexual contact for 21 days while taking treatment.
• Advise no sex with partners from the last 3 months 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 or territory health departments about LGV.

Special considerations

Consider seeking specialist advice before treating any complicated presentation.

• LGV is rare in Australia, therefore contact tracing is of high priority and should be performed in all patients with confirmed infection.
• All partners should be traced back for a minimum of 3 months before 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.

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.
• Educate about condom use, contraception, HIV PrEP/PEP, safe injecting practices, consent, CST and vaccinations for HAV, HBV and HPV as indicated.

Test of cure

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

Retesting

Full STI testing including syphilis, HIV (if negative initially) and hepatitis C testing should be performed at 3 months, and then as required depending on clinical guidelines e.g. guidelines for men who have sex with men.

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

1. White J, O’Farrell N, Daniels D; British Association for Sexual Health and HIV. 2013 UK National Guideline for the management of lymphogranuloma venereum: Clinical Effectiveness Group of the British Association for Sexual Health and HIV (CEG/BASHH) Guideline development group. Int J STD AIDS 2013;24:593-601. Available at: http://std.sagepub.com/content/24/8/593 (last accessed 13 October 2021).
2. de Vries HJ, Zingoni A, White JA, Ross JD, Kreuter A. 2013 European Guideline on the management of proctitis, proctocolitis and enteritis caused by sexually transmissible pathogens. Int J STD AIDS. 2014 Jun;25(7):465-74. Available at: http://std.sagepub.com/content/25/7/465 (last accessed 13 October 2021).
3. Centers for disease Control and Prevention (CDC). Lymphogranuloma Venereum (LGV) [internet]. Available at: https://www.cdc.gov/std/treatment-guidelines/lgv.htm (last accessed 13 October 2021).