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Lymphogranuloma Venereum in Emergency Medicine

  • Author: Andrew C Bushnell, MD, MBA, FACEP; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
 
Updated: Oct 20, 2015
 

Background

Lymphogranuloma venereum (LGV) is a sexually transmitted disease that primarily infects the lymphatics.[1]

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.

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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.

Primary stage

The primary stage is marked by the formation of a painless herpetiform ulceration at the site of inoculation.

Secondary stage

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.

Tertiary stage

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

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.

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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.[2] Since 2003, an increasing epidemic of LGV with the L2 serovar has occurred in men who have sex with men in western Europe and Australia.[3, 4, 5, 6]

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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Contributor Information and Disclosures
Author

Andrew C Bushnell, MD, MBA, FACEP Regional Medical Director, TeamHealth

Andrew C Bushnell, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Additional Contributors

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, American Medical Informatics Association, Medical Association of Georgia

Disclosure: Nothing to disclose.

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