Lymphogranuloma Venereum in Emergency Medicine Clinical Presentation
- Author: Andrew C Bushnell, MD, MBA, FACEP; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD more...
Primary lymphogranuloma venereum (LGV)
The primary lesion of LGV occurs after an incubation period of 3-21 days following an exposure.
The initial lesion may be a painless papule, shallow erosion, ulcer, or grouping of lesions with a herpetiform appearance.
If the primary lesion is in the urethra, symptoms of a nonspecific urethritis may occur.
The most common sites of primary infection in men include the coronal sulcus, frenulum, prepuce, penis, urethra, glans, and scrotum.
In women, the most common sites of the primary lesion include the posterior vaginal wall, fourchette, posterior lip of the cervix, and vulva.
The primary lesion is noticed in one third of affected men but rarely is observed in affected women.
Primary lesions of the mouth can result from oral sexual exposure.
The secondary stage of LGV occurs after a usual incubation period of 10-30 days, but it may be up to 6 months. This stage is characterized by the formation of enlarged, tender regional lymph nodes known as buboes.
Patients may experience constitutional symptoms, which can include fever, headache, malaise, chills, nausea, vomiting, and arthralgias.
This late stage is characterized by proctocolitis.
Symptoms include anal pruritus, bloody mucopurulent rectal discharge, fever, rectal pain, tenesmus, constipation, pencil-thin stools, and weight loss.
Often, the diagnosis is considered initially on the basis of physical findings. Clinical findings of large fluctuant buboes or draining sinuses are suggestive of the diagnosis of LGV. The presence of rectal stricture and/or perineal deformity in a young woman is highly suggestive of LGV.
The initial lesion may be a painless papule, shallow erosion, ulcer, or herpetiform grouping of lesions.
A cordlike lymphangitis of the dorsal penis may develop in primary LGV. This may progress to the formation of a solitary, large, tender lymphoid nodule, or bubonulus. These bubonuli may rupture to form sinuses and/or fistulas.
Buboes, which are enlarged, tender regional lymph nodes, may be present. The location of lymph node involvement is related directly to the site of the primary lesion. Inguinal lymphadenopathy occurs if the primary lesion involves the anterior vulva, penis, or urethra. Perirectal and pelvic lymphadenopathy result if the primary lesion involves the posterior vulva, vagina, or anus. Lymphadenitis of the submaxillary and cervical glands occurs if the site of primary inoculation is the mouth.
Seventy-five percent of all patients have deep iliac nodal involvement, which seldom suppurates.
In the classic presentation of the heterosexual man with inguinal lymph node involvement, a groove depression (groove sign) overlying the inguinal ligament is noted. This is caused by proliferation of inguinal and femoral lymph nodes, which are separated by the inguinal (Poupart) ligament. However, this presentation is seen in only 20% of affected men.
Two thirds of patients with inguinal involvement have unilateral inguinal bubo formation with edema and erythema of the overlying skin. Frequently these nodes coalesce to form stellate abscesses. One third of these abscesses rupture; two thirds involute. Prior to a rupture, the skin overlying the buboes may become a dark livid color. After a rupture, pain decreases; however, a discharge may continue for weeks to months with the formation of a fistula or sinus tract.
Cutaneous manifestations may accompany infection, including erythema multiforme, scarlatiniform eruption, urticaria, and, in 10% of cases, erythema nodosum.
Complications of LGV that may be noted on physical examination include arthritis, conjunctivitis, and hepatomegaly. Pericarditis, pneumonia, and meningoencephalitis rarely occur.
This stage is characterized by proctocolitis.
Lymphorrhoids or perianal condylomata may be observed on examination of the rectum. These structures appear similar to hemorrhoids and are the result of an obstruction of lymphatics. They are composed of dilated lymph vessels with perilymphatic inflammation.
Rectal examination at this stage also may reveal a granular mucosa and palpable, enlarged lymph nodes under the bowel wall. Stricture usually occurs 2-5 cm above the anocutaneous margin, and digital examination above the stricture may reveal smooth healthy mucosa.
In very late stages, fibrosis and granulomas are characteristic. In women, esthiomene (eating away) occurs, which results in hypertrophic, chronic granulomatous enlargement of the vulva and subsequent ulceration. This may not appear for 1-20 years after the primary infection. In men, elephantiasis of the genitalia can occur.
The causal organism is C trachomatis, serovars L1, L2, and L3.
Serovar L2 is the most common cause.
Risk factors include the following:
Residing in or visiting tropical/developing countries
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