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Lymphogranuloma Venereum: Differential Diagnoses & Workup

Author: Andrew C Bushnell, MD, FACEP, Department of Surgery, Division of Emergency Medicine, Assistant Professor, University of Vermont College of Medicine
Contributor Information and Disclosures

Updated: Aug 17, 2009

Differential Diagnoses

Catscratch Disease
Chancroid
Syphilis

Other Problems to Be Considered

Inguinal syndrome differential
Incarcerated inguinal hernia
Tularemia
Hodgkin disease
Plague
Genital herpes
Granuloma inguinale
Mycobacterial disease

Anogenitorectal syndrome differential
Rectal stricture from cancer
Trauma
Actinomycosis
Schistosomiasis
Inflammatory proctitis

Esthiomene differential
Filariasis
Mycosis

Workup

Laboratory Studies

  • Initial laboratory analysis may reveal mild leukocytosis.
  • These nonspecific results do not aid the clinician in the diagnosis of lymphogranuloma venereum (LGV).
  • Previously, the Frei test was the only method available to identify a chlamydial infection. Currently, the Frei intradermal test is only of historical interest.
    • The test was based on a positive hypersensitivity to an intradermal standardized antigen, lymphogranuloma venereum, which indicated past or present chlamydial infection. The Frei test would become positive 2-8 weeks after infection.
    • Unfortunately, the Frei antigen is common to all chlamydial species and is not specific to LGV. Commercial manufacturing of Frei antigen was discontinued in 1974.
  • Complement fixation (CF) is more sensitive than the Frei skin test, but it has some cross-reactivity with other chlamydial species.
    • CF sensitivity is 80% for LGV.
    • A test titer of 1:16 is strongly suggestive of LGV and a titer of >1:64 indicates active LGV.
    • A 4-fold rise or fall in titer further supports the diagnosis.
  • The microimmunofluorescence test for the L-type serovar of C trachomatis is a more sensitive and specific test. A titer greater or equal to 1:512 is diagnostic. Availability of this test is the limiting factor.
  • Application of nucleic acid amplification techniques have been used to confirm the diagnosis with much greater certainty. Polymerase chain reaction (PCR) assays have been used for diagnosis recently in several outbreaks. PCR is a far superior test but has limited availability to reference laboratories. Recently, multiplexed real-time PCR assays have been developed for the rapid detection of Chlamydia trachomatis and specific serovars.2 As these tests are refined and approved for widespread use, they will speed detection and diagnosis.
  • Dermatopathology is not pathognomonic for LGV, and cytology using Giemsa stain or iodine stain fails to provide a high percentage of diagnoses.
  • Definitive diagnosis may be made by aspiration of the bubo and growth of the aspirated material in cell culture. C trachomatis can be cultured in as many as 30% of cases.

Imaging Studies

  • CT scan may be useful if retroperitoneal adenitis or intraabdominal abscess is suspected, but it is rarely necessary in the ED.
  • Lymphography does not outline buboes, but it may demonstrate the extent of lymph node involvement. This rarely is ordered in the ED.
  • A barium enema may reveal the characteristic elongated stricture in rectal LGV.

Other Tests

  • Venereal Disease Research Laboratory (VDRL) test or rapid plasma reagin (RPR), PCR assays for Haemophilus ducreyi and HSV-2, and HIV antibodies should be considered because patients with LGV may also have contracted other sexually transmitted diseases.

Procedures

  • A bubo may be aspirated to speed the healing, but this is not necessary for culture since other diagnostic methods are more sensitive and specific.

More on Lymphogranuloma Venereum

Overview: Lymphogranuloma Venereum
Differential Diagnoses & Workup: Lymphogranuloma Venereum
Treatment & Medication: Lymphogranuloma Venereum
Follow-up: Lymphogranuloma Venereum
References
Further Reading
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References

  1. Lee DM, Fairley CK, Owen L, Horvath L, Chen MY. Lymphogranuloma venereum becomes an established infection among men who have sex with men in Melbourne. Aust N Z J Public Health. Feb 2009;33(1):94. [Medline].

  2. Halse TA, Musser KA, Limberger RJ. A multiplexed real-time PCR assay for rapid detection of Chlamydia trachomatis and identification of serovar L-2, the major cause of Lymphogranuloma venereum in New York. Mol Cell Probes. Oct 2006;20(5):290-7. [Medline].

  3. [Guideline] Behavioral counseling to prevent sexually transmitted infections: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. Oct 7 2008;149(7):491-6, W95. [Medline].

  4. Bremer V, Meyer T, Marcus U, Hamouda O. Lymphogranuloma venereum emerging in men who have sex with men in Germany. Euro Surveill. Sep 2006;11(9):152-4. [Medline].

  5. CDC. Lymphogranuloma venereum among men who have sex with men--Netherlands, 2003-2004. MMWR Morb Mortal Wkly Rep. Oct 29 2004;53(42):985-8. [Medline].

  6. [Guideline] Centers for Disease Control and Prevention, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55(RR-11):1-94. [Medline].

  7. Fitzpatrick TB, Johnson RA, Polano MK, et al. Color Atlas and Synopsis of Clinical Dermatology. McGraw-Hill Inc; 1992:398-400.

  8. Gilleece Y, Sullivan A. Management of sexually transmitted infections in HIV positive individuals. Curr Opin Infect Dis. Feb 2005;18(1):43-7. [Medline].

  9. Herida M, de Barbeyrac B, Sednaoui P, Scieux C, Lemarchand N, Kreplak G. Rectal lymphogranuloma venereum surveillance in France 2004-2005. Euro Surveill. Sep 2006;11(9):155-6. [Medline].

  10. Jones R. Chlamydia trachomatis (trachoma, perinatal infections, lymphogranuloma venereum, and other genital infections). In: Mandell G, Bennett J and Dolin R, eds. Principles and Practice of Infectious Diseases. 4th ed. Churchhill-Livingston; 1995:1679-93.

  11. Kropp RY, Wong T. Emergence of lymphogranuloma venereum in Canada. CMAJ. Jun 21 2005;172(13):1674-6. [Medline].

  12. Mabey D, Peeling RW. Lymphogranuloma venereum. Sex Transm Infect. Apr 2002;78(2):90-2. [Medline].

  13. Perine P, Osoba A. Lymphogranuloma venereum. In: Holmes K, Mardh P, Sparling P, eds. Sexually Transmitted Diseases. New York, NY: McGraw-Hill Inc; 1990:195-202.

  14. Pointer J. Genital infections. In: Rosen P, Barkin R, Braen G, eds. Emergency Medicine Concepts and Clinical Practice. 3rd ed. Mosby-Year Book; 1992:1966.

  15. Ronald A, Alfa M. Chancroid, lymphogranuloma venereum, and granuloma inguinale. In: Gorbach S, Bartlett J, and Blacklow N, eds. Infectious Diseases. 2nd ed. Philadelphia, Pa: WB Saunders Co;1998:1012-3.

  16. Sparling P. Sexually transmitted disease. In: Wyngaarden J, Smith L, and Bennett J, eds. Cecil Textbook of Medicine. 19th ed. Philadelphia, Pa: WB Saunders Co; 1992:1759-61.

  17. Stamm W, Holmes K. Chlamydial infections. In: Wilson J, Braunwald E, Isselbacher K, eds. Harrison's Principles of Internal Medicine. 12th ed. New York, NY: McGraw-Hill Inc; 1991:767-8.

  18. Stark D, van Hal S, Hillman R, Harkness J, Marriott D. Lymphogranuloma venereum in Australia: anorectal Chlamydia trachomatis serovar L2b in men who have sex with men. J Clin Microbiol. Mar 2007;45(3):1029-31. [Medline].

  19. van de Laar MJ. The emergence of LGV in western Europe: what do we know, what can we do?. Euro Surveill. Sep 2006;11(9):146-8. [Medline].

  20. van de Laar MJ, Fenton KA, Ison C,. Update on the European lymphogranuloma venereum epidemic among men who have sex with men. Euro Surveill. 2005;10(6):E050602.1. [Medline].

  21. van de Laar MJ, Koedijk FD, Gotz HM, de Vries HJ. A slow epidemic of LGV in the Netherlands in 2004 and 2005. Euro Surveill. Sep 2006;11(9):150-2. [Medline].

  22. van Weel J. Rare sexually transmitted disease hits Europe. Lancet Infect Dis. Dec 2004;4(12):720. [Medline].

  23. Von Lichtenberg F. Infectious disease. In: Cotran R, Kumar V, and Robbins S, eds. Robbins Pathologic Basis of Disease. 4th ed. Philadelphia, Pa: WB Saunders Co; 1989:328.

  24. Ward H, Martin I, Macdonald N, Alexander S, Simms I, Fenton K. Lymphogranuloma venereum in the United kingdom. Clin Infect Dis. Jan 1 2007;44(1):26-32. [Medline].

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Further Reading

Clinical guidelines

New York State Department of Health. Lymphogranuloma venereum (LVG). New York (NY): New York State Department of Health; 2007 Aug. 11 p.

Clinical Effectiveness Group, British Association for Sexual Health and HIV (BASHH). National guideline for the management of lymphogranuloma venereum (LVG). London (UK): British Association for Sexual Health and HIV (BASHH); 2006. 14 p.

Herring A, Richens J, LGV Incident Group, Health Protection Agency. Lymphogranuloma venereum (LGV). In: Ross J, Ison C, Carder C, Lewis D, Mercey D, Young H. Sexually transmitted infections: UK national screening and testing guidelines. London (UK): British Association for Sexual Health and HIV (BASHH); 2006 Aug. p. 57-62.

U.S. Preventive Services Task Force. Behavioral counseling to prevent sexually transmitted infections: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008 Oct 7;149(7):491-6, W95. 3

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Keywords

lymphogranuloma venereum, lymphopathia venerea, tropical bubo, climatic bubo, strumous bubo, poradenitis inguinales, Durand-Nicolas-Favre disease, lymphogranuloma inguinale, LGV, sexually transmitted disease, STD, Chlamydia trachomatis, C trachomatis

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Contributor Information and Disclosures

Author

Andrew C Bushnell, MD, FACEP, Department of Surgery, Division of Emergency Medicine, Assistant Professor, University of Vermont College of Medicine
Andrew C Bushnell, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Eric M Kardon, MD, FACEP, Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center
Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Jeter (Jay) Pritchard Taylor III, MD, Compliance Officer, Attending Physician, Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina; Medical Director, Department of Emergency Medicine, Palmetto Health Baptist
Jeter (Jay) Pritchard Taylor III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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