GP Clinical: Guide to lymphogranuloma venereum

An increasingly common STI is being misdiagnosed as a bowel disease, writes Dr Lisa Collins.

Lymphogranuloma venereum (LGV) is a sexually transmitted infection caused by Chlamydia trachomatis. There are 15 serotypes of C trachomatis which are associated with different clinical diseases. The A, B and C serovars are associated with endemic trachoma, and serotypes D-K cause the STI.

LGV is caused by serotypes L1, L2 and L3. Unlike the oculogenital strains A-K, which cause mucosal disease, the LGV serotypes are invasive via the lymphatic system. It is because of the invasive nature of the disease that many patients present with systemic features as well as localised symptoms.

The disease is endemic in parts of Africa, India, South East Asia, Central and South America and the Caribbean, where it is a cause of genital ulcer disease. Its incidence is unknown.

In 2003 an outbreak of LGV was reported among men who have sex with men (MSMs) in Europe. Many of the cases reported sexual contacts from abroad, including the UK (Clin Infect Dis 2004; 39: 996).

Following the launch of an enhanced surveillance programme by the Health Protection Agency to raise awareness of LGV, by the end of 2005 almost 300 cases of LGV had been diagnosed in the UK. Most reported cases have been in London (72 per cent) and Brighton (14 per cent).

LGV is now a widespread geographic problem in the UK and undoubtedly is being both under-diagnosed and misdiagnosed.

HIV association

LGV is an invasive disease which can in itself cause significant morbidity for the patient. Moreover, from a public health viewpoint, prompt diagnosis and management of LGV is especially important as it has been associated with the transmission of HIV, syphilis and hepatitis C.

The incidence of HIV in the UK continues to increase, with 5,560 new cases reported to date for 2005. Currently, 1,712 new cases have been diagnosed in MSMs, who are at the highest risk of acquiring HIV, and there is evidence that transmission is continuing at a substantial rate. Most patients diagnosed with LGV are Caucasian and 80 per cent are HIV positive. Transmission is associated with high-risk sexual practices.

Clinical features

Patients present with a proctitis. Symptoms include perianal irritation, rectal pain, tenesmus and mucopurulent discharge. The patient might have rectal bleeding and bloody diarrhoea or constipation secondary to rectal pain and oedema.

Systemic symptoms can be marked, with fever, anorexia and weight loss.

The history can easily be confused with that of an infective diarrhoea or inflammatory bowel disease, and LGV might not be considered as a differential diagnosis.

Even after referral for a gastroenterology opinion, patients are often misdiagnosed with ulcerative colitis because even rectal biopsies are non-specific and not diagnostic.

It is therefore essential to broach the subject of sexuality. Any male patient with rectal symptoms should be asked whether he has ever had sex with another man.

A general examination for stigmata of HIV infection such as oral candida or generalised lymphadenopathy is helpful. Genital examination should always include inspection of the perianal region.

Rarely the primary lesion of LGV might be seen. This is typically a pustule which then ulcerates.

A standard nucleic acid amplification test (NAAT) for chlamydia is taken from the ulcer. Proctoscopy in LGV usually reveals a mucopurulent discharge.

The mucosa might be ulcerated and might exhibit some contact bleeding. If it is missed, LGV, by its invasive nature, can cause complications with rectal abscess formation, fistulae and rectal stricture.

Some cases of large bowel obstruction have been described, requiring surgical intervention.

Differential diagnoses include inflammatory bowel disease, anal fissure and other sexually transmitted infections such as gonorrhoea, syphilis and herpes and, in HIV-positive patients, cyto-megalovirus.

Diagnosis

A definitive diagnosis of LGV requires a positive rectal chlamydia NAAT taken at proctoscopy.

In suspected cases, a blood test for chlamydia serology will also help confirm the diagnosis. Testing for other sexually transmitted infections, and serology for HIV, syphilis and hepatitis C should be undertaken.

Unfortunately, there are no randomised control trials on treatment for LGV. First-line recommended treatment is with doxycycline 100mg twice daily for three weeks.

An alternative is erythromycin 500mg four times daily for three weeks. Treatment with cefixime should also be given to cover proctitis secondary to gonorrhoea.

At two weeks, the diagnosis of LGV from the rectal chlamydia swab can usually be confirmed. The serology usually takes longer.

The patient should also be assessed to check compliance with medication and resolution of symptoms.

Abstinence from sexual intercourse should also be recommended.

Contact tracing

At this stage, the results of serological tests for HIV, syphilis and hepatitis C should be reviewed.

Contact tracing, where possible, should be instigated, and the enhanced surveillance form should be completed and returned to the HPA.

At seven weeks the patient should be assessed again for resolution of symptoms and a rectal chlamydia swab repeated as a 'test of cure'.

There are reported cases of failure of first-line treatment and of re-infection.

Serology for HIV, syphilis, hepatitis C and chlamydia should be repeated.

At three to six months serology for HIV, syphilis and hepatitis C are repeated, as is serology for chlamydia.

LGV SYMPTOMS
- Proctitis.
- Perianal irritation.
- Rectal pain.
- Tenesmus.
- Mucopurulent discharge.
- Rectal bleeding.
- Bloody diarrhoea.
- Constipation.
- Oedema in the rectum.
- Fever.
- Anorexia.

KEY POINTS
- Recent resurgence of LGV in men who have sex with men in Europe.
- Frequently presents with a proctitis and systemic symptoms.
- Often misdiagnosed as ulcerative colitis or Crohn's disease.
- Associated with transmission of HIV, syphilis and hepatitis C.

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