Lymphogranuloma venereum Outbreak in Gay Men

Abstract & Commentary

Synopsis: Health-care providers should be vigilant for LGV, especially among MSM exposed to persons from Europe, and be prepared to diagnose the disease and provide appropriate treatment to patients and their exposed sex partners.

Source: Van de Larr, et al. Lymphogranuloma venereum Among Men Who Have Sex With Men—Netherlands, 2003-2004. MMWR. 2004;53(42):985-988.

Van de Laar et al report an outbreak of Lymphogranuloma venereum (LGV) among 92 gay men in the Netherlands over a 17-month period. (the Netherlands typically has fewer than 5 cases per year.) Only 1 patient had symptoms typically associated with LGV (inguinal lymphadenopathy and painless genital ulcer). All other patients had predominant gastrointestinal symptoms including bloody proctitis with purulent or mucous anal discharge and constipation.

Laboratory diagnosis in these well-studied cases included PCR amplification from rectal swab specimens, followed by restriction endonuclease analysis of the outer membrane protein A gene to determine genotype. Confirmed cases were defined as clinical symptoms (or contact with a case), positive PCR for C. trachomatis, and L1, L2, or L3 genotype confirmed by PCR. Probable cases met the first 2 criteria and had a positive serologic test for C. trachomatis. Possible cases met only the first criterion and had a positive serologic test.

Comment by Dean Winslow, MD, FACP

Since this MMWR report was issued at the end of October 2004, an alarming number of cases of LGV have been reported from cities in the United States, also predominantly in gay men. On December 22, San Francisco Department of Public Health reported 9 cases of LGV during the month of November (the first cases of LGV in San Francisco since 2001).1

Additional cases have recently been reported from France, Sweden, Atlanta, and Houston.2 Any possible epidemiological link between these cases is unknown at this time.

LGV is caused by the L1, L2, or L3 strain of C. trachomatis (serovars A, B, Ba, and C produce trachoma and strains D-K cause the more commonly encountered oculogenital syndromes).3 The organism generally gains entrance to the body across epithelial cells of genital or anorectal mucosa or abrasions in the skin, and is almost always sexually transmitted, but transmission by fomites, nonsexual contact, and laboratory exposure has been rarely reported. A generally painless ulcer at the site of inoculation is often observed early in the course of the disease, followed by painful regional lymphadenitis and often prominent constitutional symptoms. In heterosexual men, tender, generally unilateral lymphadenopathy is often observed and can be noted both above and below the inguinal ligament, resulting in a groove sign (the differential diagnosis includes secondary syphilis, cat scratch disease, and other causes of lymphadenitis). Suppuration may occur. In homosexual men who practice receptive anal intercourse (and occasionally in women after heterosexual exposure due to lymphatic spread from the cervix or posterior vaginal wall), prominent perirectal and pelvic lymphnode involvement is seen. Later in the course of the illness (often years after initial infection), rectal stricture or elephantiasis of the genitalia may occur. Hyperplasia of intestinal and perilymphatic tissue often results in proctocolitis. Later, perirectal abscess, other pelvic abscesses, rectovaginal, and anal fistulas may be seen. In these late stages, it may be difficult to detect C. trachomatis.

Various nucleic acid amplification tests for C. trachomatis LGV-associated strains have been studied in the investigational setting. Commercially available complement fixation and microimmunofluorescence tests for C. trachomatis antibodies are relatively sensitive and specific for diagnosis of LGV. If acute phase sera are drawn early in the course of infection, a 4-fold rise in titer is observed. However, if serologic testing is not performed until the third week of illness, a stable positive titer of >1:64 (CF) or 1:128 (MIF) is considered diagnostic (titers this high are rarely seen with infection, due to the more common oculogenital strains).

Whereas uncomplicated C. trachomatis infections with oculogenital syndromes can be successfully treated with either a 7-day course of doxycycline or a single dose of azithromycin, successful treatment of LGV requires a 3 week course of treatment, with the preferred agent being doxycycline 100 mg BID. While effective in treating the systemic symptoms and proctocolitis associated with LGV, the lymphadenopathy may be slow to respond, and there may be little beneficial effect of treatment on the late complications described above.

Dean Winslow, MD, Chief, Division of AIDS Medicine, Clinical Professor of Medicine, Stanford University School of Medicine, Santa Clara Valley Medical Center Section Editor, HIV, is Associate Editor for Infectious Disease Alert.

References

1. San Francisco Monthly STD Report (Data for November 2004); report prepared December 22, 2004.

2. Gullion J, et al. HAN Advisory, Texas Department of State Health Services, December 23, 2004.

3. Stamm WE, et al. Chlamydia trachomatis (Trachoma, Perinatal Infections, Lymphogranuloma Venereum, and Other Genital Infections).

4. Mandell, et al. Principles and Practice of Infectious Diseases. Elsevier. 2005;2239-2255.