Health | Dr Shay
Lymphogranuloma Venereum (LGV) This month, Dr Shay Keating explains what Lymphogranuloma Venereum (LGV) is, and the treatment for this illness, which can affect both men and women. Lymphogranuloma venereum (LGV) is caused by certain strains of the bacterium Chlamydia trachomatis. In industrialised countries it is a rare disease but is endemic in parts of Africa, Asia, South America and the Caribbean. In the last 5 years however there have been documented cases of LGV in men who have sex with men (MSM) in Europe, with no known links to endemic countries. The majority are known to be HIV positive and many had another STI (eg gonorrhoea) or hepatitis C at the time of infection. The clinical course of LGV is divided into three stages. Primary stage After an incubation period of 330 days, a small painless papule or pustule which may ulcerate appears at the site where the bacterium passed through the skin, usually the foreskin or glans of the penis in men, the vulva, vaginal wall or occasionally the cervix in women. Involvement in areas outside the genitals has been reported such as in the oral cavity. This stage may pass unnoticed and resolves without treatment. Secondary stage. The secondary stage occurs some weeks after the primary 60 EILE Magazine
lesion and involves the inguinal and femoral glands in the groin in men, the anus or rectum in women and MSM. The classical appearance of swollen inguinal and femoral glands gives rise to the ‘groove sign’ where both sets of glands are swollen and have a groove in between them. Though considered pathognomonic (a unique identifier) of LGV it only occurs in 15-20% of cases. The swollen glands are usually firm but may ulcerate and discharge Involvement of the anus or rectum predominantly in women and MSM has been described. Patients present with rectal pain often accompanied by bleeding with fever, chills and weight loss. Inoculation outside the genitals may also occur resulting in swollen glands, for example in the neck following oral sex. Eye involvement can give rise to conjunctivitis. Tertiary stage Chronic untreated LGV can result in scarring of the eyes and genital tract and lymphatic obstruction leading to elephantitis of the genitals. Rectal involvement can cause stricture formation in the anorectal area. Diagnosis and management Diagnosis of LGV is currently
by detection of the bacterium’ s genetic material (DNA) in samples obtained from the ulcer base or from rectal tissue, lymph nodes or from swabs of the rectum in MSM and women exposed rectally. A first-catch urine sample may also be used when lymphadenopathy is present and LGV is suspected. Patients should be advised to avoid unprotected sexual intercourse until they and their partner(s) have completed treatment and follow up. They should be screened for other causes of genital ulceration such as syphilis, herpes simples, chancroid and graunuloma inguinale (donovanosis). They should have a full STI check including HIV and hepatitis C, both of which have been associated with outbreaks of LGV in Europe. A lymph node biopsy may be indicated to rule out a lymphoma. Treatment is with oral antibiotics, commonly doxycycline, tetracycline or erythromycin for 21 days in uncomplicated cases. Persons who have had sexual contact with a patient who has LGV, within 30 days before the onset of symptoms, should be tested and treated if necessary. They should receive treatment based on the probability that they have the infection before
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