Keep spotlight on LGV: New cases reported

The next patient at your STD (sexually transmitted diseases) clinic is a young man with a mucoid/purulent anal discharge and a lymph node enlargement in the groin area. He discloses that he has experienced rectal bleeding and constipation and says he has had unprotected sex with four men in the last three months. What is your next move?

Suspect lymphogranuloma venereum (LGV). Whitman-Walker Clinic in Washington, DC, announced in February 2006 that it had identified four LGV cases. The four cases are believed to be the first documented incidents of LGV in Washington-area men who have sex with men, says Philippe Chiliade, MD, the clinic’s medical director.

LGV, a form of Chlamydia trachomatis not usually present in the United States and other industrialized countries, has been on the radar screens of public health officials since a 2004 outbreak in the Netherlands.1 LGV can infect both sexes, although new cases diagnosed so far are among men having sex with men.

Focus on cases

When public health officials raised the initial alert about LGV, Whitman-Walker Clinic began looking at how best to identify potential cases of the STD, explains Chiliade. Given the clinic’s strong focus on meeting the life needs of the gay, lesbian, bisexual, and transgender community and those living with HIV/AIDS, clinic personnel took immediate steps to increase their awareness of potential cases, he says.

Whitman-Walker clinicians use a nucleic acid amplification test (NAAT) of a rectal swab to help detect LGV in patients who have had unprotected anal intercourse. Because the Food and Drug Administration has not cleared the use of rectal swabs for NAATs, laboratories must apply for a Clinical Laboratory Improvement Amendment waiver to perform rectal NAATs, says Chiliade. (Editor’s note: Investigators at the University of Alabama in Birmingham in collaboration with CDC investigators are conducting a clinical trial to evaluate the performance of three commercial NAATs in detecting Chlamydia trachomatis and Neisseria gonorrhoeae in pharyngeal and rectal swab specimens. CTU will report on their findings in an upcoming issue.)

If NAAT testing is positive, the clinic sends samples to the CDC for final confirmation of an LGV diagnosis, says Chiliade. The CDC recommends the following treatment approaches:

  • The most recommended choice is 100 mg of doxycycline, twice a day for 21 days.1
  • An alternative is 500 mg of erythromycin, administered orally four times a day for 21 days.1
  • The patient’s sex partners from 30 days prior to the onset of symptoms should be evaluated, and they should receive LGV treatment if they are diagnosed with LGV. If these sex partners do not have any symptoms, the CDC recommends they be treated with 1 g of azithromycin in a single dose or with 100 mg of doxycycline, twice a day for seven days.1

Because those infected with LGV may present with no visible symptoms, clinic officials are screening for high-risk behavior (such as unprotected anal intercourse) and performing NAATs, says Chiliade.

Challenges in diagnosis

Few health departments are testing for LGV, as there are no commercially available LGV tests and laboratories must develop their own, says John Papp, PhD, team leader of the Chlamydia Laboratory in the Laboratory, Reference, and Research Branch at the CDC’s Division of STD Prevention. Clinicians who suspect LGV can contact their state or local health department, which will consult with the CDC as necessary for testing assistance, says Papp.

Health care providers should continue to watch for symptoms of LGV in gay and bisexual men and evaluate and treat patients whenever appropriate, Papp notes. CDC reference testing is meant to confirm cases and is not intended to assist clinicians in management of suspected cases of the disease, Papp explains.

Reference

  1. Lymphogranuloma venereum among men who have sex with men — Netherlands, 2003-2004. MMWR 2004; 53: 985-988.

Resource

The Centers for Disease Control and Prevention’s Division of STD Prevention offers resources for LGV diagnosis and treatment on its web site, www.cdc.gov/std. Click on "Chlamydia" on the division’s opening page; then click on "LGV Project" to access the resources, which include versions of a provider information sheet, patient information form, and specimen collection form.