STD Quarterly

CDC warning: Family planners should be on the lookout for lymphogranuloma venereum

Usually rare LGV cases spiked in European countries in 2003-2004

An outbreak of a type of Chlamydia trachomatis, lymphogranuloma venereum (LGV) has occurred in the Netherlands and other European countries, which has led infectious disease officials with the Centers for Disease Control and Prevention (CDC) to ask U.S. clinicians to look out for LGV cases.

Clinicians may find it difficult to diagnose LGV since its symptoms are not recognized as typical symptoms of an STD and are similar to those that are caused by other conditions and infections, notes Catherine McLean, MD, medical epidemiologist with the CDC Division of STD Prevention. "So it’s important to alert health care providers to watch for these symptoms in their patients, especially among MSM [men who have sex with men], and evaluate and treat patients as appropriate," she says.

The systemic STD LGV is extremely rare in the United States and Europe, although its prevalence is greater in Africa, Southeast Asia, Central and South America, and Caribbean countries.1 However, from April 2003 to September 2004, there were 92 confirmed cases of LGV reported among MSM in the Netherlands.1

"Typically, five cases a year are reported," McLean notes. "It’s a fairly impressive increase, and this particular increase involved gay and bisexual men, and 77% of those in whom HIV status is known were HIV-positive."

There also were reported increases in LGV cases in Belgium, France, and Sweden, she says.

Dutch medical investigators have reported that men diagnosed with LGV during the 2004 outbreak all were Caucasian MSM younger than 50 who had further sexual contacts with MSM in Germany, Belgium, the United Kingdom, and France.2,3

"The increases have been linked to HIV, and nearly all of those affected reported risk behaviors such as unprotected anal sex," McLean notes. "The majority also attended casual sex parties."

LGV can increase HIV risk

LGV, like other ulcerative STDs, can increase the risk of HIV transmission, she says.

Although the recent outbreak has been associated with MSM populations, LGV also can be transmitted to women, so health care providers in HIV, STD, and other clinics need to watch for symptoms of the disease, McLean says.

A South African study of HIV-1 infection and genital ulcer disease found that LGV infection was higher among females.4

Here are the chief symptoms:

  • LGV infection may begin with a small genital papule, which can ulcerate within a month of infection. It may be difficult to detect the lesion if it’s within the urethra, vaginal vault, or rectum.1
  • LGV also may cause tender and swollen lymph nodes and gastrointestinal problems, including inflammation and bleeding from the rectum and colon. This symptom may be similar to inflammatory bowel disease.1

Symptoms hard to pinpoint

Another obstacle to diagnosis is that HIV patients may report some of these same symptoms caused by other conditions and infections, McLean says.

The real challenge will be for clinicians to evaluate patients for the more common causes of gastrointestinal problems, while keeping in mind that LGV could be the cause, she says. Diagnosis of LGV is based mainly on the clinical findings, although it may be helpful to conduct a serologic test for C. trachomatis to support the diagnosis. Clinicians also could use nonculture nucleic acid testing to identify C. trachomatis from a lesion or site of infection, such as the rectum.1 However, this method is not specific for LGV, and the Food and Drug Administration (FDA) has not approved the use of rectal swabs for nonculture nucleic acid testing.1

When presented with symptoms that could be LGV, clinicians also might consider the patient’s HIV status; recent history of high-risk sexual behavior, especially unprotected, receptive anal intercourse; and whether the patient recently has traveled or had sexual contact with a European MSM, McLean says.

"Although LGV is infrequently diagnosed, sexual contact with European MSM may be a factor, but certainly is not required," McLean says. "The most important thing is for health care providers to watch for these symptoms and think of LGV in their patients who have these symptoms."

Once LGV is diagnosed, it’s treatable with antibiotics. The CDC recommends these treatments:

  • The most recommended choice is 100 mg doxycycline, twice a day for 21 days.1
  • An alternative is 500 mg 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 treated if diagnosed with LGV. If these sex partners do not have any symptoms, the CDC recommends they be treated with 1 g azithromycin in a single dose or with 100 mg doxycycline, twice a day for seven days.1

Left untreated, LGV infection could cause chronic scarring, constipation, rectal pain, and abscesses, McLean reports.

References

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

2. Nieuwenhuis RF, Ossewaarde JM, Gotz 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; 39:996-1,003.

3. Gotz HM, Ossewaarde JM, Nieuwenhuis RF, et al. A cluster of lymphogranuloma venereum among homosexual men in Rotterdam with implications for other countries in Western Europe. Ned Tijdschr Geneeskd 2004; 148:441-442.

4. Moodley P, Sturm PD, Vanmali T, et al. Association between HIV-1 infection, the etiology of genital ulcer disease, and response to syndromic management. Sex Transm Dis 2003; 30:241-245.