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Lymphogranuloma Venereum: Treatment & Medication
Updated: Aug 17, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
- Aspiration of fluctuant buboes may prevent spontaneous rupture and reduce morbidity.
- Antibiotics are needed to treat ongoing infection.
- Patients with lymphogranuloma venereum (LGV) have been known to harbor other sexually transmitted diseases.
- Symptomatic treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) may be beneficial.
- Local heat may provide some pain relief.
Consultations
- In the acute bubonic stage, consultation with a surgeon may be considered for the aspiration of fluctuant nodes.
Medication
The goal of therapy is to eradicate the pathogen.
Antibiotics
Therapy must cover all likely pathogens in the context of the clinical setting.
Doxycycline (Doryx, Bio-Tab, Vibramycin)
Broad-spectrum, synthetically derived bacteriostatic antibiotic in the tetracycline class. Almost completely absorbed, concentrates in bile, and is excreted in urine and feces as a biologically active metabolite in high concentrations.
Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. May block dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Sexual contacts of confirmed cases seen within 30 d of confirmed case diagnosis need to receive a prophylactic regimen of either azithromycin or doxycycline.
Adult
100 mg PO bid for 21 d
Pediatric
<8 years: Not recommended
>8 years: 2-5 mg/kg/d PO in 1-2 divided doses; not to exceed 200 mg/d
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can increase hypoprothrombinemic effects of anticoagulants; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Erythromycin (EES, Ery-Tab, Erythrocin)
Inhibits RNA-dependent protein synthesis, possibly by stimulating dissociation of peptidyl tRNA from ribosomes. This inhibits bacterial growth. In children, age, weight, and severity of infection determine proper dosage. When bid dosing desired, half-total daily dose may be taken every 12 h. For more severe infections, dose may be doubled.
Adult
500 mg PO qid for 21 d
Pediatric
30-50 mg/kg/d PO divided q6-8h
May increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; lovastatin and simvastatin increase risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; adverse GI effects common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Sulfisoxazole
Sulfonamide derivative that exerts its bacteriostatic action by antagonizing para-aminobenzoic acid (PABA), an essential component in folic acid synthesis. Microorganisms susceptible to this medication are those that depend on folic acid synthesis for growth and cannot use exogenous folic acid.
Adult
500 mg PO qid for 21 d
Pediatric
<2 months: Not recommended
>2 months: 100 mg/kg/d PO divided q6h for 21 d
May enhance warfarin's anticoagulant effects, and hemorrhage could occur; may enhance thiopental anesthetic effects; cyclosporine may increase risk of nephrotoxicity; may increase serum hydantoin levels; may worsen methotrexate-induced bone marrow suppression; may increase sulfonylurea concentrations and cause hypoglycemia in diabetic patients; may prolong tolbutamide bioavailability; coadministration with diuretics may increase incidence of thrombocytopenia with purpura; indomethacin may increase free drug concentration; when used concomitantly with methenamine mandelate, may form precipitate in acidic urine; probenecid and salicylates may displace from plasma albumin, resulting in increased free-drug concentrations and potentiating its toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat group A beta-hemolytic streptococcal infections; does not eradicate streptococci or prevent sequelae, such as rheumatic fever and glomerulonephritis
Azithromycin (Zithromax)
Acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected.
Concentrates in phagocytes and fibroblasts as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues.
Recent evidence suggests that use of azithromycin for 3 wk is a sufficient course. However, more studies using this regimen need to be completed.
Sexual contacts of confirmed cases seen within 30 d of confirmed case diagnosis need to receive a prophylactic regimen of either azithromycin or doxycycline.
Adult
1 g PO qwk for 3 wk
Prophylactic regimen: 1 g PO once
Pediatric
Not established
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
More on Lymphogranuloma Venereum |
| Overview: Lymphogranuloma Venereum |
| Differential Diagnoses & Workup: Lymphogranuloma Venereum |
 Treatment & Medication: Lymphogranuloma Venereum |
| Follow-up: Lymphogranuloma Venereum |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
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].
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].
[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].
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].
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].
[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].
Fitzpatrick TB, Johnson RA, Polano MK, et al. Color Atlas and Synopsis of Clinical Dermatology. McGraw-Hill Inc; 1992:398-400.
Gilleece Y, Sullivan A. Management of sexually transmitted infections in HIV positive individuals. Curr Opin Infect Dis. Feb 2005;18(1):43-7. [Medline].
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].
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.
Kropp RY, Wong T. Emergence of lymphogranuloma venereum in Canada. CMAJ. Jun 21 2005;172(13):1674-6. [Medline].
Mabey D, Peeling RW. Lymphogranuloma venereum. Sex Transm Infect. Apr 2002;78(2):90-2. [Medline].
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.
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.
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.
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.
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.
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].
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].
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].
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].
van Weel J. Rare sexually transmitted disease hits Europe. Lancet Infect Dis. Dec 2004;4(12):720. [Medline].
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.
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].
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
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
