Lymphogranuloma Venereum Clinical Presentation

  • Author: Pamela Arsove, MD, FACEP; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Nov 19, 2010
 

History

The clinical course of LGV consists of the following stages:

  • First stage (primary LGV)
    • This stage occurs 3-30 days after inoculation.
    • Primary LGV begins as a small, painless papule or pustule that may erode to form a small, asymptomatic herpetiform ulcer that usually heals rapidly without scarring.
    • The most common sites of infection for men include the coronal sulcus, prepuce, glans, and scrotum. Rarely, symptoms of urethritis occur.
    • The most common sites of infection in women include the posterior vaginal wall, posterior cervix, fourchette, and vulva.
    • The initial lesion, especially in women, often goes unnoticed by the patient.
  • Second stage (secondary LGV)
    • Secondary LGV begins 2-6 weeks after the primary lesion.
    • This second stage consists of painful regional lymphadenopathy (usually in the inguinal and/or femoral lymph nodes).
    • Painful, swollen lymph nodes coalesce to form buboes, which may rupture in as many as one third of patients. Those that do not rupture harden, then slowly resolve.
    • Inguinal lymphadenopathy occurs in only 20-30% of females with LGV; they more typically have involvement of the deep iliac or perirectal nodes and may only present with nonspecific back and/or abdominal pain.
    • This stage is when most men present and are diagnosed; most women are not diagnosed in this stage because of their lack of inguinal lymphadenopathy.
    • Constitutional symptoms associated with the second stage include fever, chills, myalgias, and malaise.
    • Systemic spread may lead to the following conditions:
      • Arthritis
      • Ocular inflammatory disease
      • Cardiac involvement
      • Pulmonary involvement
      • Aseptic meningitis
      • Hepatitis or perihepatitis
  • Third stage (tertiary LGV)
    • Tertiary LGV is termed genitoanorectal syndrome.
    • This condition is more common in women, secondary to their lack of symptoms during the first two stages.
    • Rectal involvement is more common in men who have sex with men and in women who practice anal-receptive intercourse.
    • Tertiary LGV is characterized by proctocolitis.
    • FUO
    • Symptoms include the following conditions:
      • Bloody purulent discharge
      • Rectal pain
      • Tenesmus
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Physical

Large fluctuant buboes or any otherwise unexplained perianal deformity in a young female should suggest a diagnosis of LGV.

  • First stage (primary LGV)
    • The initial lesion is usually a small, unnoticed painless papule, shallow ulcer, or herpetiform lesion in the genital area.
    • Initial lesions may be differentiated from the more common herpetic lesions by the lack of pain associated with the lesion. Differentiation from a syphilitic chancre is more problematic and requires serologic testing.
  • Second stage (secondary LGV)
    • Secondary LGV is characterized by painful lymph nodes (usually unilateral) known as buboes.
    • Enlargement of the inguinal nodes above and the femoral nodes below the inguinal ligament leads to the classic groove sign, which is observed in one third of affected men.
    • Inguinal lymphadenopathy results from a primary lesion of the anterior vulva, penis, or urethra.
    • Perirectal or pelvic lymphadenopathy results from a primary lesion involving the posterior vulva, vagina, or anus.
    • Affected nodes often coalesce and form abscesses, which can rupture and form sinus tracts.
  • Third stage (tertiary LGV)
    • Tertiary LGV most often manifests in women.
    • Patients initially develop proctocolitis.
    • Patients may present with perirectal fistulas, abscesses, strictures, and rectal stenosis.
    • Hyperplasia of intestinal and perirectal lymphatics may form lymphorrhoids, which are similar to hemorrhoids.
    • Patients may develop strictures and fistulous tracts secondary to repeated tissue scarring and repair.
    • Enlargement, thickening, and fibrosis of the labia may occur in women, a condition termed esthiomene.
    • Chronic lymphatic obstruction may lead to elephantiasis of the genitals.
    • Penile and scrotal edema and distortion have been termed saxophone penis.
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Causes

The L1, L2, and L3 serovars of C trachomatis cause LGV. Risk factors include residing in or visiting endemic areas, practicing anal-receptive intercourse, eschewing condoms, and working in the commercial sex trade.

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Contributor Information and Disclosures
Author

Pamela Arsove, MD, FACEP  Associate Residency Director, Department of Emergency Medicine, Hofstra Northshore Long Island Jewish School of Medicine; Attending Physician, Department of Emergency Medicine, Long Island Jewish Medical Center; Assistant Professor, Department of Emergency Medicine, Albert Einstein College of Medicine

Pamela Arsove, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Barbara Edwards, MD  Associate Physician, Division of Infectious Diseases, Department of Medicine, Long Island Jewish Medical Center; Assistant Professor, Department of Medicine, Albert Einstein College of Medicine of Yeshiva University

Barbara Edwards, MD is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America, and Society for Healthcare Epidemiology of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Kenneth C Earhart, MD  Deputy Head, Disease Surveillance Program, United States Naval Medical Research Unit #3

Kenneth C Earhart, MD is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Charles V Sanders, MD  Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine at New Orleans; Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans; Consulting Staff, Ochsner Medical Center

Charles V Sanders, MD is a member of the following medical societies: Alliance for the Prudent Use of Antibiotics, Alpha Omega Alpha, American Association for the Advancement of Science, American Association of University Professors, American Clinical and Climatological Association, American College of Physician Executives, American College of Physicians, American Federation for Medical Research, American Foundation for AIDS Research, American Geriatrics Society, American Lung Association, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Association for Professionals in Infection Control and Epidemiology, Association of American Medical Colleges, Association of American Physicians, Association of Professors of Medicine, Infectious Disease Society for Obstetrics and Gynecology, Infectious Diseases Society of America, Louisiana State Medical Society, Orleans Parish Medical Society, Royal Society of Medicine, Sigma Xi, Society of General Internal Medicine, Southeastern Clinical Club, Southern Medical Association, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology

Disclosure: Baxter International and Johnson & Johnson Royalty Other

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

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