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Lymphogranuloma Venereum (LGV)

Posted August 2007 — Currently Under Revision


I. INTRODUCTION

Lymphogranuloma venereum (LGV) is a sexually transmitted infection (STI) caused by unique serovars of Chlamydia trachomatis (L1, L2, L3) that are unlike those that typically cause urethritis, cervicitis, and proctitis (A-K). It occurs only sporadically in North America but is endemic in many parts of the developing world. A recent outbreak of LGV proctocolitis has been reported among men who have sex with men (MSM) in North America and Europe. Many of these individuals were co-infected with HIV.

HIV alters the natural history and response to therapy of many STIs; however, its impact on LGV remains unclear. No current evidence exists to support a difference in acquisition, natural history, or response to therapy of LGV in the setting of HIV co-infection.

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II. PRESENTATION

RECOMMENDATION:

Clinicians should include LGV as part of the differential diagnosis of genital ulcer disease, inguinal lymphadenopathy, or proctocolitis, especially in men who have sex with men.

LGV progresses over several clinical stages. The incubation period is between 3 days and 1 month after exposure. Infection is initially characterized by a small and often innocuous non-tender papule, vesicle, or ulcer, which is often overlooked by the patient. This lesion occurs at the place of contact with an infected partner and thus may involve almost any aspect of the genital or rectal tissue. Lesions in the urethra or cervix can provoke symptoms of urethritis or cervicitis. Over time, these primary lesions resolve without therapy.

The hallmark of LGV is unilateral or bilateral tender lymphadenopathy that dramatically evolves 2 to 6 weeks after the primary lesion. Lymphadenopathy may or may not be associated with signs of lymphangitis. The involved lymph nodes increase rapidly in size, and pain and erythema are common. If adjacent to one another, several involved lymph nodes may coalesce. The central areas of such lymph nodes can then undergo necrosis. Fluctuant and suppurative lymph nodes then develop, causing the classic ‘bubo’ of LGV. The bubo may then rupture and drain purulent material, which is associated with relief from symptoms. The ‘groove sign’ characteristic of LGV is seen if both the inguinal and the femoral nodes are involved. Resolving buboes can result in significant scarring. In women, lymphatic drainage patterns result in potential involvement of deep pelvic lymph nodes with attendant pelvic, abdominal, and lower back pain.

In both men and women, infection occurring as a result of anal intercourse can cause proctocolitis. Symptoms include fever, pain, tenesmus, and bloody rectal discharge. Colonic mucosal ulcerations develop and may be replaced by progressively enlarging areas of granulation tissue, which, in time, lead to fistulas and strictures. For these reasons, LGV has been occasionally misdiagnosed as Crohn’s disease. Of note, non-LGV serovars also occasionally cause a less aggressive form of proctocolitis. Invasive LGV is characterized by constitutional symptoms such as fever, chills, and malaise. Superinfection with other bacterial species may also complicate the presentation.

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III. DIAGNOSIS

RECOMMENDATION:

Clinicians should diagnose LGV through the presence of consistent clinical findings, such as inguinal lymphadenopathy and erosive proctocolitis, as well as the absence of other definable pathologies.

The diagnosis of LGV is made most commonly on the basis of consistent clinical findings. No reliable diagnostic tests are widely available that can consistently assist clinicians to make a diagnosis of LGV.

Although direct testing for Chlamydia trachomatis can be performed using nucleic acid amplification tests (NATs), cell culture, or immunofluorescence tests, these tests have limited applicability for LGV due to lack of sensitivity or specificity for these specific serovars. In addition, commercially available NATs for chlamydia are not FDA-approved for use on rectal specimens. Urine, urethral, and cervical specimens that test positive for Chlamydia trachomatis using FDA-approved tests do not provide the genotyping needed for LGV serovar determination. Such specimens, as well as those from rectal swabs and purulent material aspirated from buboes, may yield a useful diagnostic specimen upon which genotyping of LGV-specific serovars can be performed; however, genotyping can only be performed in select laboratories. Clinicians interested in such testing should contact their local health departments for instructions on proper specimen collection (see Appendix A for contact information for local health departments and Appendix B for testing and shipping instructions). Treatment, however, should not await LGV serovar determination.

Serologic testing for chlamydia, including complement fixation (CF) and microimmunofluorescence (MIF), has never been adequately standardized, and results from laboratory to laboratory may vary. Serologic tests do not differentiate between LGV and non-LGV serovars. When serologic testing is performed, higher serum antibody levels may be seen in the presence of LGV compared with non-LGV chlamydia infections due to the invasive nature of LGV. CF titers >1:64 and MIF titers >1:256 are strongly suggestive of LGV, particularly when accompanied by consistent clinical findings. Studies have not demonstrated altered LGV testing parameters in the presence of HIV; however, it is likely that serologic tests would be less specific.

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IV. TREATMENT

RECOMMENDATIONS:

Doxycycline (100 mg PO bid) for 21 days is the preferred treatment regimen for LGV.

Treatment should not await LGV serovar determination, even in the context of clinicians electing to investigate LGV-specific genotyping.

The treatment of choice for LGV is doxycycline 100 mg PO bid for 21 days. Other tetracyclines can be used as alternatives. Data supporting the use of non-tetracycline alternatives are limited. Erythromycin 500 mg PO qid for 21 days is the standard alternative, although frequency of dosing and gastrointestinal upset limit its utility. Some experts have recommended azithromycin 1g PO once weekly for 3 weeks, but data to support this option are also lacking. There are no data to support the use of alternative regimens in HIV-infected patients.

In individuals with tender, swollen inguinal lymphadenopathy, relief can be achieved by prompt aspiration or incision and drainage.

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V. MANAGEMENT OF PARTNERS

RECOMMENDATION:

Clinicians should consider both HIV and STI exposures to partners when HIV-infected patients present with a new STI. Clinicians should also assess for the presence of other STIs (see Management of STIs in HIV-Infected Patients). (AIII)

A. Management of HIV Exposure in Partners

Updated March 2012

RECOMMENDATIONS:

When HIV-infected patients present with a new STI, clinicians should offer assistance with notifying partners of both the potential HIV and STI exposures or should refer patients to other sources for partner notification assistance ( Partner Services in New York State or CNAP in New York City). Partners without confirmed HIV infection should undergo HIV testing at baseline, 1, 3, and 6 months. Confirmatory testing according to New York State regulations must be performed to confirm HIV diagnoses.

Clinicians must report confirmed cases of HIV according to New York State Public Health Law (for more information about required reporting, see www.health.ny.gov/diseases/aids/regulations/index.htm).

Clinicians should educate patients with non-HIV-infected partners or partners of unknown HIV status to be vigilant for any post-exposure acute HIV symptoms in their partners, such as febrile illness accompanied by rash, lymphadenopathy, myalgias, and/or sore throat (see Diagnosis and Management of Acute HIV Infection). (AIII)

Partners who present within 36 hours of an HIV exposure should be evaluated as soon as possible for initiation of post-exposure prophylaxis therapy (see HIV Prophylaxis Following Non-Occupational Exposure). (AII)

Presentation of a new STI in HIV-infected patients suggests exposure of both HIV and the STI to their partners. In this case, offering HIV non-occupational post-exposure prophylaxis (nPEP) to partners is usually not an option because the period prior to STI symptom onset is usually longer than the 36-hour window for initiating HIV nPEP. Therefore, sequential HIV testing of partners without confirmed HIV infection should be performed for early identification of potential HIV acquisition. However, if a patient with an HIV exposure does present within 36 hours, evaluation for nPEP should occur (see HIV Prophylaxis Following Non-Occupational Exposure).

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B. Management of LGV Exposure

RECOMMENDATION:

Clinicians should encourage partners of patients with LGV whose exposure occurred within 60 days prior to symptom onset to be examined and treated with a full 21-day course of doxycycline.

Partners of patients with LGV who had sexual contact with the patient within 60 days prior to symptom onset should be examined and treated. No data on which to base the optimal contact interval have been published; some clinicians may treat partners whose exposure occurred up to 6 months prior to the patient’s symptom onset.

The appropriate length of LGV treatment in asymptomatic, sexual contacts remains under investigation. In New York State, in accordance with the treatment guidelines for contacts of other sexually transmitted diseases, a full 21-day course of doxycycline is recommended. The Centers for Disease Control and Prevention and the British Association for Sexual Health and HIV recommend that sex partners who had contact within 30 days of the patient’s symptoms should be evaluated and treated with regimens for uncomplicated chlamydia infection (azithromycin 1g PO in a single dose, or doxycycline 100 mg PO bid for 7 days).1,2

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REFERENCES

1. Centers for Disease Control and Prevention. 2006 Sexually Transmitted Diseases Treatment Guidelines. MMWR 2006;55. Available at: www.cdc.gov/std/treatment/2006/genital-ulcers.htm#genulc5

2. British Association for Sexual Health and HIV. 2006 National Guideline for the Management of Lymphogranuloma Venereum (LGV). Available at: www.bashh.org/documents/92/92.pdf

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APPENDIX A: NEW YORK STATE DEPARTMENT OF HEALTH STD COUNTY COORDINATORS

New York City Department of Health
125 Worth Street, Room 207
New York, NY 10013

Steve Rubin
1-212-788-4413
srubin@health.nyc.gov

Albany County Department of Health
175 Green Street
Albany, NY 12201

Marcia Fabiano
1-518-447-4640
mfabiano@albanycounty.com

Allegany County Department of Health
County Office Building
7 Court Street
Belmont, NY 14813

Theresa Gaeta
1-585-268-9250
gaetatv@alleganyco.com

Broome County Health Department
225 Front Street
Binghamton, NY 13905

Michael Whalen
1-607-778-2894
mwhalen@co.broome.ny.us

Cattaraugus County Department of Health
1701 Lincoln Avenue, Suite 4010
Olean, NY 14760

Mary Ann Power
1-716-373-8050
mapower@cattco.org

Cayuga County Health Department
Communicable Disease
8 Dill Street
Auburn, NY 13021

Brenda Kelly
1-315-253-1456
bkelly@cayugacounty.us

Chautauqua County Department of Health
Hall R Clothier Building
Mayville, NY 14757

Marcia Clark
1-716-753-4491
marciac@health.co.chautauqua.ny.us

Chemung County Health Department
PO Box 588
103 Washington Street
Elmira, NY 14901

Melissa Klossner
1-607-737-2028
mklossner@co.chemung.ny.us

Chenango County Health Department
5 Court Street
Norwich, NY 13815

Bonnie Curry
1-607-337-1668
bonniec@co.chenango.ny.us

Clinton County Health Department
133 Margaret Street
Plattsburgh, NY 12901

Nancy Smith
1-518-565-4840
smithn@co.clinton.ny.us

Columbia County Health Department
71 North Third Street
Hudson, NY 12534

Mary Agoglia
1-518-565-4863
agoglia@govt.co.columbia.ny.us

Cortland County Health Department
60 Central Avenue
Cortland, NY 13045

Sue Smith
1-607-753-5036
ssmith@cortland-co.org

Cortland County Health Department
Jacobus Center
60 Central Avenue
Cortland, NY 13045

Carol Keegan
1-607-753-5027
ckeegan@cortland-co.org

Delaware County Public Health
99 Main Street
Delhi, NY 13753

Joelle Underwood
1-607-746-3166
joelle.underwood@co.delaware.ny.us

Dutchess County Department of Health
Communicable Disease
387 Main Street
Poughkeepsie, NY 12601

Andrew Evans
1-845-486-3452
aevans@co.dutchess.ny.us

Erie County Department of Health
1500 Broadway
Buffalo, NY 14212

Diane Land
1-716-891-2037
landd@erie.gov

Essex County Health Department
132 Water Street
Elizabethtown, NY 12932

Laurel Doyle
1-518-873-3514
ldoyle@co.essex.ny.us

Franklin County Department of Health
335 West Main Street
Malone, NY 12953

Lisa Masso
(518) 891-4471
lmasso@westelcom.com

Fulton County Health Department
2714 State Highway 29
PO Box 415
Johnstown, NY 12095

Beverly Blowers
1-518-736-5720
b.blowers@co.fulton.ny.us

Genesee County Department of Health
3837 West Main Street
Batavia, NY 10420

Ginny Sellan
1-585-344-2580
gsellan@co.genesee.ny.us

Greene County Health Department
PO Box 771
411 Main Street
Acra, NY 12414

Nanette Cance
1-518-719-3600
ncance@discovergreene.com

Barbara Caldara
1-518-719-3580
bcaldara@discovergreene.com

Hamilton County Health Department
Box 250
White Birch Lane
Indian Lake, NY 12842

Avis Warner
1-518-648-6141
warnera@capital.net

Herkimer County Department of Health
301 North Washington Street, Suite 2355
Herkimer, NY 13350

Carol O’Neill
1-315-867-1430
coneill@herkimercounty.org

Jefferson County Department of Health
531 Meade Street
Watertown, NY 13601

Dawn Remington
1-315-786-3731
dawnr@co.jefferson.ny.us

Lewis County Department of Health
7785 North State Street
Lowville, NY 13367

Mary Kimbrell
1-315-376-5449
mary@health.co.lewis.ny.us

Livingston County Department of Health
2 County Campus
Mount Morris, NY 14510

Colleen Vokes
1-585-243-7535
cvokes@co.livingston.ny.us

Madison County Health Department
447 North Main Street
Oneida, NY 13421

Donna Barrett
1-315-363-5490
dbarrett@co.madison.ny.us

Monroe County Department of Health
691 Saint Paul Street, 4th Floor
Rochester, NY 14605

Kimberly Smith
1-585-753-5375
ksmith@monroecounty.gov

Kelli McMahon
1-585-753-5361
kmcmahon@monroecounty.gov

Montgomery County Department of Health
Communicable Disease
20 Park Street
PO Box 1500
Fonda, NY 12068

Nancy Minch
1-518-853-3531
nminch@co.montgomery.ny.us

Nassau County Health Department (STD)
Bureau of STD Control
240 Old Country Road, Room 604
Mineola, NY 11501

Carolyn McCummings
1-516-571-2402
carolyn.mccummings@hhsnassaucountyny.us

Niagara County Department of Health
Trott Building, Nursing
1001 11th Street
Niagara Falls, NY 14301

Laurie Schoenfeldt
1-716-278-1960
laurie.schoenfeldt@niagaracounty.co

Niagara County Health Department
1001 11th Street, 3rd Floor
Niagara Falls, NY 14301

Mary Huczel
1-716-278-1907
mary.huczel@niagaracounty.com

Oneida County Department of Health
406 Elizabeth Street
Utica, NY 13501

Patrice Bogan
1-315-798-5888
pbogan@co.oneida.ny.us

Onondaga County Department of Health
Communicable Disease Control
421 Montgomery Street, Room 80
Syracuse, NY 13202

Diane Rothermel
1-315-435-3224
hldroth@ongov.net

Ontario County Health Department
Bureau of STD Control
3019 County Complex Drive
Canandaigua, NY 14424

Kate Ott
kate.ott@co.ontario.ny.us

Orange County Department of Health
141 Broadway
Newburgh, NY 12550

Marilyn Ejercito
1-845-568-5333
mejercito@co.orange.ny.us

Orleans County Department of Health
14012 Route 31, West
Albion, NY 14411

Beverly Parmele
1-585-589-3269
bparmele@orleansny.com

Oswego County Department of Health
70 Bunner Street
Oswego, NY 13126

Tina Burgois
1-315-349-3568
tinab@oswegocounty.com

Otsego County Health Department
197 Main Street
Cooperstown, NY 13326

Heidi Bond
1-607-547-6458
bondh@otsegocounty.com

Putnam County Health Department
1 Geneva Road
Brewster, NY 10509

Karen Tuchman
1-845-278-6558
karen.tuchman@putnamcountyny.com

Rensselaer County Health Department
1600 7th Avenue
Troy, NY 12180

Lisa Casale
1-518-270-2641
idevito-casale@rensco.com

Rockland County Department of Health
Communicable Disease
50 Sanatorium Road, Building D
Pomona, NY 10970

Amanda Hessels
1-845-364-2663
hesselsa@co.rockland.ny.us

Connie Maietta
1-845-364-2663
maiettac@co.rockland.ny.us

Saratoga County Health Department
31 Woodlawn Avenue
Saratoga Springs, NY 12866

Nadine Sleasman
1-518-584-7460

Schenectady County Department of Health
107 Nott Terrace, Room 304
Schenectady, NY 12305

Lisa Ayers
1-518-386-2824
lisa.ayers@countyofschenectady.com

Schoharie County Health Department
276 Main Street
Schoharie, NY 12157

Diane Maklae
1-518-295-8365
dmaklae@co.schoharie.ny.us

Schuyler County Health Department
106 South Perry Street
Watkins Glen, NY 14891

Jennifer Mehta
jmehta@co.schuyler.ny.us

Schuyler County Health Department
Mill Creek Center
106 South Perry Street
Watkins Glen, NY 14891

Barbara Besley
1-607-535-8140
bbesley@co.schuyler.ny.us

Marcia Kasprzyk
1-607-535-8140
mkasprzyk@co.schuyler.ny.us

Seneca County Health Department
31 Thubber Drive
Waterloo, NY 13165

Pat Jensen
1-315-539-1936
pjensen@co.seneca.ny.us

Saint Lawrence County Public Health Department
80 State Highway 310, Suite 2
Canton, NY 13617

Becky Trejos
1-315-386-2325
btrejos@co.st-lawrence.ny.us

Steuben County Health Department
3 Pultney Square East
Bath, NY 14810

Gail Wechsler
1-607-664-2438
gailw@co.steuben.ny.us

Suffolk County Department of Health
Suffolk County STD
887 Kellum Street, Room 165
Lindenhurst, NY 11757

Mary Pat Boyle
1-631-854-4042
marypat.boyle@suffolkcountyny.gov

Sullivan County Department of Health
PO Box 590
Liberty, NY 12754

Tracy Gaughan
1-845-292-0100
tracy.gaughan@co.sullivan.ny.us

Tioga County Department of Health
1062 State Route 38, Box 120
Owego, NY 13827

Sally Wheeland
1-607-687-8593
wheelands@co.tioga.ny.us

Tompkins County Health Department
401 Harris B Bates Drive
Ithaca, NY 14850

Carol Mohler
1-607-274-6604
cmohler@tompkins-co.org

Ulster County Department of Health
300 Flatbush Avenue
Kingston, NY 12401

Linda Taylor-Legg
1-845-340-3070
ltyl@co.ulster.ny.us

Warren County Department of Health
1340 State Route 9
Lake George, NY 12845

Pat Belden
1-518-761-6580
beldenp@co.warren.ny.us

Washington County Health Department
415 Lower Main Street
Hudson Falls, NY 12839

Matthew Brown
1-518-746-2400
mbrown@co.washington.ny.us

Wayne County Health Department
1519 Nye Road, Suite 200
Lyons, NY 14489

Rosemary Strub
1-315-946-5748
rstrub@co.wayne.ny.us

Westchester County Department of Health
STD Control
145 Huguenot Avenue, 8th Floor
New Rochelle, NY 10800

Enrico Caprari
1-914-813-5217
efc3@westchestergov.com

Wyoming County Department of Health
338 North Main Street
Warsaw, NY 14569

Luanne Meyer
1-585-786-8890
lmeyer@wyomingco.net

Yates County Health Department
431 Liberty Street
Penn Yan, NY 14527

Annemarie Flanagan
1-315-536-5160
aflanagan@yatescounty.org

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APPENDIX B: INSTRUCTIONS FOR OBTAINING CHLAMYDIA PCR TESTING

Currently, the Wadsworth Center of the New York State Department of Health can perform chlamydia PCR testing to identify Chlamydia trachomatis and the L2 serovar on anorectal specimens. Clinicians interested in such testing should first contact their local health departments for instructions on proper specimen collection. New York State Department of Health STD County Coordinator contact information is provided below.

Depending on the location of the clinician, samples for LGV testing should be sent to the following laboratories:
For those facilities located within New York City, dry rectal swabs or those samples in BD ProbeTec buffer may be sent to the New York City Department of Health and Mental Hygiene Public Health Laboratory for Chlamydia trachomatis NAT testing. Positive samples will then be forwarded to the Wadsworth Center for LGV serovar determination. Inquiries prior to shipment should be directed to 1-212-447-6887.

For those facilities located outside of New York City, dry swabs or those in BD ProbeTec buffer collected for Chlamydia trachomatis LGV testing should be sent as soon as possible directly to:

The Wadsworth Center Bacteriology Laboratories
New York State Department of Health
120 New Scotland Avenue
Albany, NY 12208

Overnight shipment on cold ice packs is preferred. Please do not use wet or dry ice. Please note that the Wadsworth Center does not accept samples for routine Chlamydia trachomatis testing. Inquiries prior to shipment should be directed to 1-518-474-4177.

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