Lymphogranuloma Venereum

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Basics

Lymphogranuloma venereum (LGV) is an uncommon systemic sexually transmitted infection (STI) caused by Chlamydia trachomatis. Classically endemic in tropical regions, Europe and North America have seen a rise in LGV outbreaks, primarily among men having sex with men (MSM), particularly among HIV-positive individuals (1).

Description

  • Initially presents as a painless anogenital, vesicular, or ulcerative lesion(s) at the site of inoculation, followed by tender inguinal/femoral lymphadenopathy. If untreated, proctocolitis can occur causing severe inflammation and scarring, with potential for mistaken diagnosis as inflammatory bowel disease (2).
  • Historically classified as a disease of the tropics and rare in developed countries, but outbreaks have been reported in Europe, North America, and Australia with especially increasing prevalence in Europe among the MSM population (3)
  • System(s) affected: lymphatic, immunologic, hematologic, gastrointestinal, reproductive
  • Synonym(s): tropical bubo; climatic bubo; Durand-Nicolas-Favre disease; lymphogranuloma inguinale; fourth, fifth, or sixth venereal disease (2)

Epidemiology

  • Predominant age: 15 to 40 years; peak sexual activity
  • Predominant sex: males (men commonly present in acute stage, whereas women diagnosed at later stage) (2)

Incidence
Variable, with a recent rise in outbreaks across Europe and North America (3). In 2016, 2,043 cases of LGV were reported in Europe, with France, the Netherlands, and the United Kingdom accounting for 86% of these cases (1). In Quebec, 328 confirmed cases of LGV were reported from January 1, 2013 to December 31, 2016 (4).

Prevalence
Endemic among heterosexual population in tropical areas, including Southeast Asia, Southern Africa, and India (1,2); increasing prevalence in the United States and Europe among MSM and HIV-positive populations and more recent reported cases in Canada and Australia as well (1,3,4)

Pregnancy Considerations
May be acquired perinatally from the birth canal; congenital transmission is not known to occur.

Etiology and Pathophysiology

  • 3 of the 15 known strains of C. trachomatis (serovars L1, L2, L3) cause LGV. The L2 serovar can be further separated in L2, L2’, L2a, or L2b (2).
  • Strains of C. trachomatis that cause urethritis infect only squamocolumnar cells. LGV strains are more invasive, replicate in macrophages, and can spread to lymphatic tissue at the site of infection, leading to systemic illness. The L2b serovar is particularly virulent and becoming more prevalent in Europe (5).
  • Transmitted via unprotected vaginal, anal, or oral intercourse
  • Tissue damage occurs from lymphatic inflammation and obstruction (2).

Risk Factors

  • HIV positive (particularly HIV-positive MSM) (6)
  • Unprotected intercourse
  • Multiple sexual partners
  • Anal intercourse (5)
  • Previous history of STI or hepatitis B/C (4)
  • Residing in tropics or Europe (3)
  • Uncircumcised penis

General Prevention

Condoms may provide some protection against genital–anogenital transmission but have no impact on transmission between other sites (2)[C].

Commonly Associated Conditions

HIV, gonorrhea, chlamydia (cervicitis, urethritis), hepatitis B, hepatitis C, herpes simplex virus, syphilis

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