Lymphogranuloma Venereum (LGV) Treatment & Management

Updated: Jun 22, 2021
  • Author: John L Kiley, MD; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
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Treatment

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]  

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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]

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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.

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Consultations

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

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Activity

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

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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.

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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.

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