Lymphogranuloma Venereum in Emergency Medicine
- Author: Andrew C Bushnell, MD, FACEP; Chief Editor: Rick Kulkarni, MD more...
Background
Lymphogranuloma venereum (LGV) is a sexually transmitted disease that primarily infects the lymphatics.
The disease originally was described in 1833 by Wallace. It was defined as a clinical and pathological entity in 1913 by Durand, Nicolas, and Favre.
LGV synonyms include lymphopathia venerea, tropical bubo, climatic bubo, strumous bubo, poradenitis inguinales, Durand-Nicolas-Favre disease, and lymphogranuloma inguinale.
Pathophysiology
LGV is caused by serovars L1, L2, and L3 of Chlamydia trachomatis. It gains entrance through skin breaks and abrasions, or it crosses the epithelial cells of mucous membranes. The organism travels via the lymphatics to multiply within mononuclear phagocytes in regional lymph nodes.
Transmission is predominantly sexual. However, transmission by fomites, nonsexual personal contact, and laboratory accidents has been documented. The creation of aerosols of this organism has been associated with infection and pulmonary symptoms.
LGV occurs in 3 stages. The majority of LGV infections in the primary and secondary stages may go undetected.
The primary stage is marked by the formation of a painless herpetiform ulceration at the site of inoculation.
The secondary stage is classically described as the inguinal syndrome in men, characterized by painful inguinal lymphadenitis and associated constitutional symptoms.
- Tender inguinal lymphadenopathy, usually unilateral, is the most common clinical manifestation.
- Lymphatic drainage from the penis is through the inguinal lymph nodes; thus, heterosexual men are affected most often in the inguinal lymph nodes.
- Homosexual men and women who are receptive to anal sex may develop perirectal and pelvic lymph node involvement. In women, these nodes may also become involved as a result of lymphatic spread from the cervix and posterior vaginal wall.
- Early in the course of the disease, the nodes appear fleshy and show diffuse reticulosis.
- Later, suppurative granulomatous lymphadenitis and perilymphadenitis occur with matting of the nodes. Frequently, these nodes coalesce to form stellate abscesses.
- Histologically, these abscesses are nearly diagnostic, but the clinical appearance may be similar to those seen in other infections, including catscratch fever and mycobacterial granulomatous infections.
The tertiary stage of LGV occurs years after the initial infection. In this stage, an anogenitorectal syndrome may occur with resultant rectal stricture or elephantiasis of the genitalia.
- This syndrome is found predominantly in women and homosexual men, because of the location of the involved lymphatics.
- This late stage is characterized by proctocolitis, which is caused by hyperplasia of intestinal and perirectal lymphatic tissue.
- This inflammation forms perirectal abscesses, ischiorectal abscesses, rectovaginal fistulas, anal fistulas, and rectal stricture. In very late stages, fibrosis and granulomas are characteristic.
- Chlamydial organisms are scarce at this stage.
Extragenital inoculation sites can produce regional lymphadenopathy. Examples are of mediastinal lymphadenopathy from inhalation of C trachomatis, or submandibular and cervical chain lymphadenopathy following inoculation after oral sex.
Epidemiology
Frequency
United States
Sporadic cases occur in North America, Australia, and most of Asia. Most cases in the United States involve recent travel to an endemic area where the patient was sexually active; therefore, obtaining a travel history is important. Historically, the average number of LGV cases in the United States has been fewer than 600 per year.
International
LGV is endemic in East and West Africa, India, Southeast Asia, South America, the Caribbean, and Australia.[1] Since 2003, an increasing epidemic of LGV with the L2 serovar has occurred in men who have sex with men in western Europe.
Mortality/Morbidity
- Given appropriate treatment, patients usually have complete resolution of symptoms.
- Death can occur from tertiary LGV if complete bowel obstruction from rectal stricture leads to perforation; this is rare, however.
Sex
LGV is diagnosed in men up to 6 times more frequently than in women.
Age
LGV infection is most common in the second and third decades when sexual activity is highest.
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