Approach Considerations

The recommendation for first line treatment of LGV is 21 days of doxycycline (100 mg PO twice daily). This recommendation is based on limited evidence, however, and newer studies suggest that there is an opportunity for further research into the optimal treatment and duration. A retrospective study of patients in the United Kingdom treated with 7 days of doxycycline for rectal Chlamydia, and subsequently confirmed to be cases that were serovars of LGV, supported the argument that shorter courses of doxycycline for nonbubonic LGV might be reasonable.^[33] An open, non-randomized clinical trial compared 21 days of doxycyline with 1 gram of azithromycin weekly for 3three weeks and showed similar efficacy.^[34] Data in support of alternative treatment regimens are ultimately limited. Of note, the update to the 2015 CDC Sexually Transmitted Infection Guidelines (yet to be puslished), will continue to recommend 21 days of doxycycline. ^[35]

Medical Care

The complete treatment of patients with LGV includes appropriate antimicrobial coverage and drainage of infected buboes.

The recommended medical treatment for LGV involves one of the following antibiotic regimens:

Doxycycline 100 mg PO bid for 21 d
Erythromycin base 500 mg PO qid for 21 d

Doxycycline is the drug of choice in patients who are not pregnant. Pregnant and lactating females should be treated with either azithromycin or erythromycin (erythromycin treatment is often limited by side effects). HIV-positive patients should be treated the same as HIV-negative patients, although they may require prolonged treatment, with longer resolution of symptoms.

Infected patients should abstain from sexual intercourse until antibiotic therapy is completed and symptoms resolve. Some patients with severe disease have failed 21 days of doxycycline and may require more prolonged courses of therapy.^[36] Expert consultation is advised in this clinical scenario.

Sex partners who have had contact with the patient within the past 60 days should be evaluated and treated if symptomatic. If no symptoms are present, they should be treated for exposure as follows:

Doxycycline 100 mg PO BID for 7 days
Azythromycin 1 gm PO as a single dose^[37]
Of note, there have been cases of infection after azithromycin prophylaxis - which may prompt clinicians to avoid azithromycin as a post-exposure prophylaxis strategy. ^[36]

Surgical Care

Needle aspiration or incision and drainage of involved inguinal nodes may be required for pain relief and prevention of ulcer formation. Some of the late complications of the third stage of LGV may require surgical repair.

Consultations

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

Activity

No restrictions to physical activities are required; however, patients should abstain from sexual contact until the infection resolves completely.

Prevention

No vaccine is available to prevent LGV.

Condom use may reduce the risk of LGV transmission but does not prevent transmission from ulcerated areas not covered by the condom.

The emergence of cases of LGV among MSM in developed countries supports the need for careful screening of these patients. High rates of asymptomatic rectal chlamydia infection found in the MSM attending HIV/GUM clinics in the United Kingdom should prompt the clinician to routinely screen for rectal chlamydia in MSM, even in the absence of symptoms. This aids in the diagnosis of a subset of patients with LGV before symptoms are present. Treatment of this group of patients is essential in the attempt to eradicate the disease.^[38]

Patients, especially those traveling to endemic areas, should be counseled about safe-sex practices, including condom use. Advise the patient to refrain from intercourse with high-risk individuals.

Inform patients that recovery from infection does not confer immunity against future infection.

Further Outpatient Care

For patients who have had incision and drainage of buboes, appropriate outpatient follow-up care may be required to ensure complete healing and to prevent secondary infections.

Guidelines

Beigi, Richard H. Lymphogranuloma Venereum. Beigi, Richard H. Sexually Transmitted Diseases. 1st ed. West Sussex, UK: John Wiley & Sons, LTD; 2012. 49 - 52. [Full Text].
Oud EV, de Vrieze NH, de Meij A, de Vries HJ. Pitfalls in the diagnosis and management of inguinal lymphogranuloma venereum: important lessons from a case series. Sex Transm Infect. 2014 Jun. 90(4):279-82. [QxMD MEDLINE Link].
[Guideline] de Vries HJ, Zingoni A, Kreuter A, Moi H, White JA. 2013 European guideline on the management of lymphogranuloma venereum. J Eur Acad Dermatol Venereol. 2014 Mar 24. [QxMD MEDLINE Link].
de Vrieze NH, de Vries HJ. Lymphogranuloma venereum among men who have sex with men. An epidemiological and clinical review. Expert Rev Anti Infect Ther. 2014 Jun. 12(6):697-704. [QxMD MEDLINE Link].
Nieuwenhuis RF, Ossewaarde JM, Götz HM, Dees J, Thio HB, Thomeer MG, et al. Resurgence of lymphogranuloma venereum in Western Europe: an outbreak of Chlamydia trachomatis serovar l2 proctitis in The Netherlands among men who have sex with men. Clin Infect Dis. 2004 Oct 1. 39 (7):996-1003. [QxMD MEDLINE Link].
Rönn M, Hughes G, White P, Simms I, Ison C, Ward H. Characteristics of LGV repeaters: analysis of LGV surveillance data. Sex Transm Infect. 2014 Jun. 90 (4):275-8. [QxMD MEDLINE Link].
Soni S, Srirajaskanthan R, Lucas SB, Alexander S, Wong T, White JA. Lymphogranuloma venereum proctitis masquerading as inflammatory bowel disease in 12 homosexual men. Aliment Pharmacol Ther. July/2010. 32:59-65. [QxMD MEDLINE Link]. [Full Text].
Schachter J. Confirming positive results of nucleic acid amplification tests (NAATs) for Chlamydia trachomatis: all NAATs are not created equal. J Clin Microbiol. 2005. 43:1372-1373.
Kapoor S. Re-emergence of lymphogranuloma venereum. J Eur Acad Dermatol Venereol. April/2008. 22:409-16. [QxMD MEDLINE Link]. [Full Text].
White JA. Manifestations and management of lymphogranuloma venereum. Curr Opin Infect Dis. Feb/2009. 22:57-66. [QxMD MEDLINE Link].
de Voux A, Kent JB, Macomber K, Krzanowski K, Jackson D, Starr T, et al. Notes from the Field: Cluster of Lymphogranuloma Venereum Cases Among Men Who Have Sex with Men - Michigan, August 2015-April 2016. MMWR Morb Mortal Wkly Rep. 2016 Sep 2. 65 (34):920-1. [QxMD MEDLINE Link].
Hardick J, Quinn N, Eshelman S, Piwowar-Manning E, Cummings V, Marsigila VC, et al. O3-S6.04 Multi-site screening for lymphogranuloma venereum (LGV) in the USA. Sex Transm Infect. 2011. 87 (Suppl 1):[Full Text].
de Voux A, Kent JB, Macomber K, Krzanowski K, Jackson D, Starr T, et al. Notes from the Field: Cluster of Lymphogranuloma Venereum Cases Among Men Who Have Sex with Men - Michigan, August 2015-April 2016. MMWR Morb Mortal Wkly Rep. 2016 Sep 2. 65 (34):920-1. [QxMD MEDLINE Link].
Wolff K, Lowell G, Stephen K, et al. Lymphogranuloma Venereum. Wolff K, Lowell G, Stephen K, et al. Fitzpatrick's Dermatology in General Medicine. 7th. United States: McGraw-Hill; 2008. 1: Chapter 203. [Full Text].
Martin-Iguacel R, Llibre JM, Nielsen H, Heras E, Matas L, Lugo R, et al. Lymphogranuloma venereum proctocolitis: a silent endemic disease in men who have sex with men in industrialised countries. Eur J Clin Microbiol Infect Dis. August 2010. 29:917-25. [QxMD MEDLINE Link]. [Full Text].
Vanousova D, Zakouzka H, Jilich D, et al. First detection of Chlamydia trachomatis LGV biovar in the Czech Republic, 2010–2011. Eurosurvelliance. 2011. 17:article 2. [Full Text].
López-Vicente J, Rodríguez-Alcalde D, Hernández-Villalba L, Moreno-Sánchez D, Lumbreras-Cabrera M, Barros-Aguado C, et al. Proctitis as the clinical presentation of lymphogranuloma venereum, a re-emerging disease in developed countries. Rev Esp Enferm Dig. 2014 Jan. 106(1):59-62. [QxMD MEDLINE Link].
CDC. Lymphogranuloma venereum among men who have sex with men--Netherlands, 2003-2004. MMWR Morb Mortal Wkly Rep. 2004. 53:985-988. [QxMD MEDLINE Link]. [Full Text].
Stary G, Stary A. Lymphogranuloma venereum outbreak in Europe. J Dtsch Dermatol Ges. 2008 Nov. 6(11):935-40. [QxMD MEDLINE Link].
Gomes JP, Nunes A, Florindo C, Ferreira MA, Santo I, Azevedo J, et al. Lymphogranuloma venereum in Portugal: unusual events and new variants during 2007. Sex Transm Dis. 2009 Feb. 36(2):88-91. [QxMD MEDLINE Link].
Sethi G, Allason-Jones E, Richens J, Annan NT, Hawkins D, Ekbote A, et al. Lymphogranuloma venereum presenting as genital ulceration and inguinal syndrome in men who have sex with men in London, United Kingdom. Sex Transm Infect. 2008 Dec 9. [QxMD MEDLINE Link].
Robertson A, Azariah S, Bromhead C, Tabrizi S, Blackmore T. Case report: lymphogranuloma venereum in New Zealand. Sex Health. 2008 Dec. 5(4):369-70. [QxMD MEDLINE Link].
Cusini M, Boneschi V, Arancio L, Ramoni S, Venegoni L, Gaiani F, et al. Lymphogranuloma Venereum: the Italian experience. Sex Transm Infect. 2008 Nov 26. [QxMD MEDLINE Link].
Ward H, Alexander S, Carder C, Dean G, French P, Ivens D, et al. The prevalence of Lymphogranuloma venereum (LGV) infection in men who have sex with men: results of a multi-centre case finding study. Sex Transm Infect. 2009 Feb 15. [QxMD MEDLINE Link].
Acknowledgement: Maria Jose Borrego. ESSTI_ALERT: LGV Cases Reported inDenmark and Portugal. ESTTI/Health Protection Agency. June 2007. Available at http://www.essti.org/publications.php.
Saxon C, Hughes G, Ison C, UK LGV Case-Finding Group. Asymptomatic Lymphogranuloma Venereum in Men who Have Sex with Men, United Kingdom. Emerg Infect Dis. 2016 Jan. 22 (1):112-116. [QxMD MEDLINE Link].
Tinmouth J, Gilmour MW, Kovacs C, Kropp R, Mitterni L, Rachlis A, et al. Is there a reservoir of sub-clinical lymphogranuloma venereum and non-LGV Chlamydia trachomatis infection in men who have sex with men?. Int J STD AIDS. 2008 Dec. 19(12):805-9. [QxMD MEDLINE Link].
de Vries HJ, van der Bij AK, Fennema JS, Smit C, de Wolf F, Prins M, et al. Lymphogranuloma venereum proctitis in men who have sex with men is associated with anal enema use and high-risk behavior. Sex Transm Dis. 2008 Feb. 35(2):203-8. [QxMD MEDLINE Link].
Savage EJ, van de Laar MJ, Gallay A, van der Sande M, Hamouda O, Sasse A, et al. Lymphogranuloma venereum in Europe, 2003-2008. Euro Surveill. Dec/2009. 14:48. [QxMD MEDLINE Link]. [Full Text].
McLean CA, Stoner BP, Workowski KA. Treatment of lymphogranuloma venereum. Clin Infect Dis. 2007 Apr 1. 44 Suppl 3:S147-52. [QxMD MEDLINE Link].
Frickmann H, Essig A, Poppert S. Identification of lymphogranuloma venereum-associated Chlamydia trachomatis serovars by fluorescence in situ hybridisation--a proof-of-principle analysis. Trop Med Int Health. 2014 Apr. 19(4):427-30. [QxMD MEDLINE Link].
Zenilman J, Shahmanesh M. Laboratory Interventions. Sexually Transmitted Infections: Diagnosis, Management, and Treatment. Sudbury, MA: Jones & Bartlett Learning, LLC; 2012. chap 19.
Simons R, Candfield S, French P, White JA. Observed Treatment Responses to Short-Course Doxycycline Therapy for Rectal Lymphogranuloma Venereum in Men Who Have Sex With Men. Sex Transm Dis. 2018 Jun. 45 (6):406-408. [QxMD MEDLINE Link].
Blanco JL, Fuertes I, Bosch J, De Lazzari E, Gonzalez-Cordón A, Vergara A, et al. Effective treatment of Lymphogranuloma venereum proctitis with Azithromycin. Clin Infect Dis. 2021 Jan 19. [QxMD MEDLINE Link].
Derrell Powers. Centers for Disease Control and Prevention (CDC) Sexually Transmitted Infection (STI) Guide. www.cdc.gov. 18 December 2020;
Oud EV, de Vrieze NH, de Meij A, de Vries HJ. Pitfalls in the diagnosis and management of inguinal lymphogranuloma venereum: important lessons from a case series. Sex Transm Infect. 2014 Jun. 90 (4):279-82. [QxMD MEDLINE Link].
J Klausner, E Hook III. Lymphogranuloma Venereum. J Klausner, E Hook III. CURRENT Diagnosis & Treatment of Sexually Transmitted Diseases. 1. United States: McGraw-Hill; 2007. Chapter 17.
Annan NT, Sullivan AK, Nori A, Naydenova P, Alexander S, McKenna A, et al. Rectal chlamydia--a reservoir of undiagnosed infection in men who have sex with men. Sex Transm Infect. June/2009. 85:176-9. [QxMD MEDLINE Link]. [Full Text].
de Vries HJC, de Barbeyrac B, de Vrieze NHN, Viset JD, White JA, Vall-Mayans M, et al. 2019 European guideline on the management of lymphogranuloma venereum. J Eur Acad Dermatol Venereol. 2019 Oct. 33 (10):1821-1828. [QxMD MEDLINE Link].
[Guideline] World Health Organization. WHO Guidelines for the Treatment of Chlamydia trachomatis. World Health Organization. 2016. [QxMD MEDLINE Link]. [Full Text].