Question
Lymphogranuloma venereum.
Answer
Lymphogranuloma venereum (LGV) is a sexually transmitted infection caused by the L1, L2, L3 serovars of Chlamydia trachomatis — distinct from the D–K serovars that cause uncomplicated genital chlamydial infection, in that LGV serovars are more invasive, spreading to and destroying regional lymphatic tissue.
Clinical stages:
- Primary stage: a small, often painless and easily overlooked genital papule/ulcer at the site of inoculation, which heals spontaneously within days.
- Secondary stage: painful, matted inguinal and/or femoral lymphadenopathy (buboes) developing weeks later, often with overlying erythema; buboes can suppurate and rupture, forming multiple draining sinuses — the classic and most recognized clinical feature. In women (and men practising receptive anal intercourse), primary infection of the rectum can instead lead to lymphadenopathy of the deep iliac/perirectal nodes, presenting as proctocolitis rather than an obvious bubo.
- Tertiary (late) stage: chronic lymphatic obstruction from long-standing untreated disease can cause genital elephantiasis, and rectal/anal strictures and fistulae from chronic proctitis (esthiomene).
Laboratory diagnosis: nucleic acid amplification test (NAAT/PCR) with LGV-specific genotyping (distinguishing LGV serovars from non-LGV serovars) is the preferred modern method; serology (complement fixation test, micro-immunofluorescence) can support diagnosis, particularly in later stages when direct detection may be difficult; aspirate from a fluctuant bubo (not incision, to avoid sinus formation) can be sent for culture/PCR.
Treatment: doxycycline for a prolonged course (typically 21 days, longer than for uncomplicated chlamydial infection, reflecting the more invasive nature of LGV); azithromycin as an alternative; treatment of sexual partners; aspiration (not incision/drainage) of fluctuant buboes if needed for symptomatic relief.