Dermatologic Manifestations of Lymphogranuloma Venereum

Updated: Apr 19, 2023
  • Author: Jose A Plaza, MD; Chief Editor: Dirk M Elston, MD  more...
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Practice Essentials

Lymphogranuloma venereum (LGV) is a primarily cutaneous, and sometimes systemic, sexually transmitted disease (STD), which primarily affects lymphatic tissue of the groin. LGV is caused by unique serotypes L1, L2, and L3 of Chlamydia trachomatis. LGV occurs only sporadically in North America, but it is endemic in many parts of the developing world. An outbreak of LGV proctocolitis has been reported among men who have sex with men in North America and Europe, and many of these individuals were co-infected with HIV. [1, 2, 3, 4, 5, 6, 7, 8, 9]  LGV co-infections with mpox (monkeypox) have also been reported. [10] Rectal lesions from mpox infection may predispose patients to C trachomatis infection and LGV. [11]

See the image below.

Lymphogranuloma venereum is caused by the invasive Lymphogranuloma venereum is caused by the invasive serovars L1, L2, or L3 of Chlamydia trachomatis. This young adult experienced the acute onset of tender, enlarged lymph nodes in both groins. Courtesy of Wikimedia Commons (Herbert L. Fred, MD, and Hendrik A. van Dijk,

Signs and symptoms

See Presentation.


Lymphogranuloma venereum (LGV) diagnosis is hampered by the difficulty in culturing the organism. The best results have been obtained using aspirates from an involved inguinal lymph node and from bacterial typing of the culture after growth. Culture requires growth in cycloheximide-treated McCoy or HeLa cells, and even under these conditions, yields of only 30-50% are reported.

Serologic tests for LGV also are available and produce a strong reaction by complement fixation. Tests typically are positive within 2 weeks of disease onset and have a sensitivity of 80%. The difficulty is in separating the various serotypes of Chlamydia species, including those involved in conjunctivitis; however, in the appropriate clinical setting, an antibody titer of 1:64 or greater or a 4-fold increase in titer is supportive of an LGV diagnosis. Other types of chlamydial infections rarely demonstrate a titer of greater than 1:16. Antibody titers do not correlate well with clinical severity of the disease.

Other testing modalities for LGV include microimmunofluorescence and polymerase chain reaction (PCR). [12]  The usefulness of these methods is limited by availability. [13, 14, 15]

Other testing in LGV may include screening for coexistence of other sexually transmitted diseases (STDs). As with all STDs, consider concomitant infections and perform screening tests.

Necessary procedures for lymphogranuloma venereum LGV may include aspiration of buboes to speed healing and relieve discomfort.

Histologic findings

The histologic features of the initial lymphogranuloma venereum (LGV) genital papule are generally nonspecific (ulceration and granulation tissue in dermis). In the lymph nodes, stellate abscesses with surrounding epithelioid cells and macrophage giant cells represent the characteristic lesion. Special stains do not demonstrate the infecting organism in skin or lymph nodes. Tissue cultures of a skin lesion or lymph node are necessary to demonstrate the infection.

The cause of ulcerative proctitis in the setting of LGV was diagnosed in a one case by clinical presentation, lesion biopsy, and polymerase chain reaction (PCR) results. [16]


The treatment of choice for lymphogranuloma venereum (LGV) is doxycycline (100 mg orally bid for 21 d). [17, 18]  Although azithromycin is effective against other chlamydial strains and may prove to be effective against infection with LGV serovars, no controlled treatment trials support the use of azithromycin treatment for LGV. Incision and drainage may result in nonhealing fistula formation, which can be minimized by draining involved lymph nodes from above the inguinal ligament. Symptomatic treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and local heat for pain relief may be useful adjuncts.

Immunocompromised persons, such as those with HIV infection, should receive the same treatment as immunocompetent persons; however, given the lack of data, patients with HIV infection and other immunocompromising conditions should be followed closely to assess resolution of symptoms. [19]

Surgery often is necessary for repair of late LGV complications such as fistulas and strictures.

Surgical consultation for lymphadenopathy is generally not required unless extensive buboes require further exploration. For tertiary disease, appropriate surgical consultation is indicated.



Lymphogranuloma venereum (LGV) is caused by C trachomatis, an obligate intracellular pathogen (ie, the bacterium lives within human cells), and strains L1, L2, and L3 have been associated with infection. LGV is primarily a disease of lymphatic tissue. Because Chlamydia species cannot traverse the intact epithelial barrier, access to lymphatic vessels is gained through microtrauma in the skin or mucous membranes. The pathogen then enters the draining lymph nodes, causing lymphangitis or lymphadenitis. The causal pathologic process involves thrombolymphangitis and perilymphangitis and the consequent spread of the inflammatory reaction from the affected lymph nodes to surrounding tissues.



The causal organism of lymphogranuloma venereum (LGV) is C trachomatis, serotypes L1, L2, and L3; L2 is the most common.

Risk factors include the following:

  • Visiting endemic areas

  • Engaging in unprotected sex

  • Engaging in anal intercourse

  • History of multiple sex partners

  • Rectal gonorrhea [20]




United States

Lymphogranuloma venereum (LGV) is rare in the United States, and the true incidence is not known.


Lymphogranuloma venereum (LGV) is most common in Southeast Asia, Africa, Central America, and the Caribbean. LGV accounts for 2-10% of genital ulcer disease in India and Africa. [21]

Race, sex, and age

Lymphogranuloma venereum (LGV) is found more commonly in Blacks.

LGV is significantly more common in men than in women.

The peak range for lymphogranuloma venereum LGV is in individuals aged 15-40 years.



Prognosis is excellent if lymphogranuloma venereum (LGV) is treated early; however, late complications can cause significant morbidity. Progression to the third phase of LGV can result in serious and permanent sequelae such as genital deformity, fistulas, and rectal strictures, among others. Complete cure is achieved by early recognition of LGV and appropriate antibiotic treatment.


Patient Education

Instruct patients that infection confers little or no protective immunity. Refer sexual contacts for evaluation and possible treatment. Encourage safe sex.