- Jonathan M Zenilman, MD
Jonathan M Zenilman, MD
- Professor of Medicine
- Johns Hopkins University
Lymphogranuloma venereum (LGV) is a genital ulcer disease caused by the L1, L2, and L3 serovars of Chlamydia trachomatis . This infection is found most frequently in tropical and subtropical areas of the world , but has been increasingly reported among men who have sex with men (MSM) in temperate climates [3-8]. The diagnosis is difficult to establish on clinical grounds alone and frequently relies upon either serologic testing [9,10], culture, or more recently, nucleic acid amplification testing (NAAT) of direct specimens.
LGV will be reviewed here. Other manifestations of C. trachomatis infection are discussed separately. (See "Overview of trachoma" and "Clinical manifestations and diagnosis of Chlamydia trachomatis infections".)
Although previously rare in temperate climates, lymphogranuloma venereum (LGV) infection has been increasingly reported in developed countries since 2003. Large outbreaks have been reported in Western Europe and North America, primarily in men who have sex with men (MSM) [3-8], with the largest outbreak reports from New York City  and the United Kingdom (UK) . The majority of these cases have presented as proctitis. A close epidemiologic link between the outbreaks in the Netherlands and New York City was suggested through molecular typing of the serovars.
The vast majority of MSM who have acquired LGV are also HIV-infected (76 percent in one report) . This is a major public health concern since enhanced shedding of HIV during clinical proctitis could increase the risk of HIV transmission to uninfected men . In the UK outbreak of 327 cases of LGV, 4 percent of the patients also had a new diagnosis of HIV infection . Thirty-nine percent had a diagnosis of another sexually transmitted infection and approximately 19 percent were also infected with hepatitis C virus.
Prior to the outbreaks in MSM, LGV was primarily endemic in heterosexuals in areas of East and West Africa, India, parts of Southeast Asia, and the Caribbean where it is manifested as the classic form of disease with genital ulcers and lymphadenopathy (without proctitis) . However, LGV is not the predominant cause of genital ulcer disease in a number of these regions despite a high frequency of exposure as evidenced by C. trachomatis antibodies [13,14]. This was illustrated in a survey of 196 patients with genital ulcers from Madagascar, 79 percent of whom had chlamydial antibodies . LGV was confirmed by multiplex polymerase chain reaction (PCR) in only 16 (8 percent). This contrasted with much higher rates of infection with chancroid, syphilis, and HSV of 33, 29, and 10 percent, respectively. (See "Chancroid" and "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection" and "Pathogenesis, clinical manifestations, and treatment of early syphilis".)
- Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64:1.
- Scieux C, Barnes R, Bianchi A, et al. Lymphogranuloma venereum: 27 cases in Paris. J Infect Dis 1989; 160:662.
- Rosen T, Brown TJ. Cutaneous manifestations of sexually transmitted diseases. Med Clin North Am 1998; 82:1081.
- Blank S, Schillinger JA, Harbatkin D. Lymphogranuloma venereum in the industrialised world. Lancet 2005; 365:1607.
- Nieuwenhuis RF, Ossewaarde JM, Götz HM, et al. Resurgence of lymphogranuloma venereum in Western Europe: an outbreak of Chlamydia trachomatis serovar l2 proctitis in The Netherlands among men who have sex with men. Clin Infect Dis 2004; 39:996.
- Van der Bij AK, Spaargaren J, Morré SA, et al. Diagnostic and clinical implications of anorectal lymphogranuloma venereum in men who have sex with men: a retrospective case-control study. Clin Infect Dis 2006; 42:186.
- Meyer T, Arndt R, von Krosigk A, Plettenberg A. Repeated detection of lymphogranuloma venereum caused by Chlamydia trachomatis L2 in homosexual men in Hamburg. Sex Transm Infect 2005; 81:91.
- Herida M, Sednaoui P, Couturier E, et al. Rectal lymphogranuloma venereum, France. Emerg Infect Dis 2005; 11:505.
- Behets FM, Brathwaite AR, Hylton-Kong T, et al. Genital ulcers: etiology, clinical diagnosis, and associated human immunodeficiency virus infection in Kingston, Jamaica. Clin Infect Dis 1999; 28:1086.
- Ndinya-Achola JO, Kihara AN, Fisher LD, et al. Presumptive specific clinical diagnosis of genital ulcer disease (GUD) in a primary health care setting in Nairobi. Int J STD AIDS 1996; 7:201.
- Pathela P, Blank S, Schillinger JA. Lymphogranuloma venereum: old pathogen, new story. Curr Infect Dis Rep 2007; 9:143.
- Ward H, Martin I, Macdonald N, et al. Lymphogranuloma venereum in the United kingdom. Clin Infect Dis 2007; 44:26.
- Behets FM, Andriamiadana J, Randrianasolo D, et al. Chancroid, primary syphilis, genital herpes, and lymphogranuloma venereum in Antananarivo, Madagascar. J Infect Dis 1999; 180:1382.
- Brathwaite AR, Figueroa JP, Ward E. A comparison of prevalence rates of genital ulcers among persons attending a sexually transmitted disease clinic in Jamaica. West Indian Med J 1997; 46:67.
- Viravan C, Dance DA, Ariyarit C, et al. A prospective clinical and bacteriologic study of inguinal buboes in Thai men. Clin Infect Dis 1996; 22:233.
- Bauwens JE, Orlander H, Gomez MP, et al. Epidemic Lymphogranuloma venereum during epidemics of crack cocaine use and HIV infection in the Bahamas. Sex Transm Dis 2002; 29:253.
- Mabey D, Peeling RW. Lymphogranuloma venereum. Sex Transm Infect 2002; 78:90.
- Chen JC, Stephens RS. Trachoma and LGV biovars of Chlamydia trachomatis share the same glycosaminoglycan-dependent mechanism for infection of eukaryotic cells. Mol Microbiol 1994; 11:501.
- Hadfield TL, Lamy Y, Wear DJ. Demonstration of Chlamydia trachomatis in inguinal lymphadenitis of lymphogranuloma venereum: a light microscopy, electron microscopy and polymerase chain reaction study. Mod Pathol 1995; 8:924.
- Jones RB, Batteiger BE. Chlamydia trachomatis (trachoma, perinatal infections, lymphogranuloma venereum, and other genital infections). In: Principles and Practice of Infectious Diseases, Fifth Edition, Mandell GL, Bennett JE, Dolin R (Eds), Churchill Livingstone, Philadelphia 2000. p.1989.
- Hagley M, Carne CA, Gorgees N. A case of cat scratch disease masquerading as lymphogranuloma venereum. Int J STD AIDS 1999; 10:334.
- Bauwens JE, Lampe MF, Suchland RJ, et al. Infection with Chlamydia trachomatis lymphogranuloma venereum serovar L1 in homosexual men with proctitis: molecular analysis of an unusual case cluster. Clin Infect Dis 1995; 20:576.
- Lynch CM, Felder TL, Schwandt RA, Shashy RG. Lymphogranuloma venereum presenting as a rectovaginal fistula. Infect Dis Obstet Gynecol 1999; 7:199.
- Papagrigoriadis S, Rennie JA. Lymphogranuloma venereum as a cause of rectal strictures. Postgrad Med J 1998; 74:168.
- Chen CY, Chi KH, Alexander S, et al. The molecular diagnosis of lymphogranuloma venereum: evaluation of a real-time multiplex polymerase chain reaction test using rectal and urethral specimens. Sex Transm Dis 2007; 34:451.
- Bachmann LH, Johnson RE, Cheng H, et al. Nucleic acid amplification tests for diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis rectal infections. J Clin Microbiol 2010; 48:1827.
- van der Snoek EM, Ossewaarde JM, van der Meijden WI, et al. The use of serological titres of IgA and IgG in (early) discrimination between rectal infection with non-lymphogranuloma venereum and lymphogranuloma venereum serovars of Chlamydia trachomatis. Sex Transm Infect 2007; 83:330.
- Chen CY, Chi KH, Alexander S, et al. A real-time quadriplex PCR assay for the diagnosis of rectal lymphogranuloma venereum and non-lymphogranuloma venereum Chlamydia trachomatis infections. Sex Transm Infect 2008; 84:273.
- McLean CA, Stoner BP, Workowski KA. Treatment of lymphogranuloma venereum. Clin Infect Dis 2007; 44 Suppl 3:S147.
- Schachter J, Moncada J, Liska S, et al. Nucleic acid amplification tests in the diagnosis of chlamydial and gonococcal infections of the oropharynx and rectum in men who have sex with men. Sex Transm Dis 2008; 35:637.
- Hampton T. Lymphogranuloma venereum targeted: those at risk identified; diagnostic test developed. JAMA 2006; 295:2592.
- Lister NA, Tabrizi SN, Fairley CK, Garland S. Validation of roche COBAS Amplicor assay for detection of Chlamydia trachomatis in rectal and pharyngeal specimens by an omp1 PCR assay. J Clin Microbiol 2004; 42:239.
- National guideline for the management of lymphogranuloma venereum. Clinical Effectiveness Group (Association of Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases). Sex Transm Infect 1999; 75 Suppl 1:S40.
- Drugs for sexually transmitted infections. Treat Guidel Med Lett 2004; 2:67.
- de Vries HJ, Morré SA, White JA, Moi H. European guideline for the management of lymphogranuloma venereum, 2010. Int J STD AIDS 2010; 21:533.
- de Vrieze NH, van Rooijen M, Speksnijder AG, de Vries HJ. Urethral lymphogranuloma venereum infections in men with anorectal lymphogranuloma venereum and their partners: the missing link in the current epidemic? Sex Transm Dis 2013; 40:607.
- Oud EV, de Vrieze NH, de Meij A, de Vries HJ. Pitfalls in the diagnosis and management of inguinal lymphogranuloma venereum: important lessons from a case series. Sex Transm Infect 2014; 90:279.
- Risk factors
- STAGES OF INFECTION
- Primary infection
- Secondary infection
- Late lymphogranuloma venereum
- Nucleic acid amplification testing
- Skin testing
- Medical therapy for lymphogranuloma venereum
- Aspiration of buboes
- Empiric therapy for proctitis
- Treatment during pregnancy
- MANAGEMENT OF SEX PARTNERS
- HIV AND OTHER SEXUALLY TRANSMITTED DISEASES
- SUMMARY AND RECOMMENDATIONS