First Case of Urethritis Due toChlamydia trachomatisGenovar L2b

Chlamydia trachomatis Biovar L2 Infection in Women in South Africa

We detected Chlamydia trachomatis biovar L2 in vaginal swab specimens of 7 women with vaginal discharge in South Africa. Whole-genome sequencing directly from clinical specimens identified a closely related cluster of strains. The clinical role of this infection in the context of syndromic management should be clarified.

Did L Strains Responsible for Lymphogranuloma Venereum Proctitis Spread Among People With Genital Chlamydia trachomatis Infection in France in 2013?

We retrospectively analyzed 1802 nonrectal Chlamydia trachomatis-positive specimens to determine if the L strains responsible for rectal Lymphogranuloma venereum in men who have sex with men could spread to the heterosexual population. No evidence for Lymphogranuloma venereum transmission among heterosexuals in France was observed in 2013. L2b strains seem to be restricted to the men who have sex with men population.

Hypervirulent Chlamydia trachomatis clinical strain is a recombinant between lymphogranuloma venereum (L(2)) and D lineages

Chlamydia trachomatis is an obligate intracellular bacterium that causes a diversity of severe and debilitating diseases worldwide. Sporadic and ongoing outbreaks of lymphogranuloma venereum (LGV) strains among men who have sex with men (MSM) support the need for research on virulence factors associated with these organisms. Previous analyses have been limited to single genes or genomes of laboratory-adapted reference strain L₂/434 and outbreak strain L₂b/UCH-1/proctitis. We characterized an unusual LGV strain, termed L₂c, isolated from an MSM with severe hemorrhagic proctitis. L₂c developed nonfusing, grape-like inclusions and a cytotoxic phenotype in culture, unlike the LGV strains described to date. Deep genome sequencing revealed that L₂c was a recombinant of L₂ and D strains with conserved clustered regions of genetic exchange, including a 78-kb region and a partial, yet functional, toxin gene that was lost with prolonged culture. Indels (insertions/deletions) were discovered in an ftsK gene promoter and in the tarp and hctB genes, which encode key proteins involved in replication, inclusion formation, and histone H1-like protein activity, respectively. Analyses suggest that these indels affect gene and/or protein function, supporting the in vitro and disease phenotypes. While recombination has been known to occur for C. trachomatis based on gene sequence analyses, we provide the first whole-genome evidence for recombination between a virulent, invasive LGV strain and a noninvasive common urogenital strain. Given the lack of a genetic system for producing stable C. trachomatis mutants, identifying naturally occurring recombinants can clarify gene function and provide opportunities for discovering avenues for genomic manipulation.

Lymphogranuloma venereum (LGV) is a prevalent and debilitating sexually transmitted disease in developing countries, although there are significant ongoing outbreaks in Australia, Europe, and the United States among men who have sex with men (MSM). Relatively little is known about LGV virulence factors, and only two LGV genomes have been sequenced to date. We isolated an LGV strain from an MSM with severe hemorrhagic proctitis that was morphologically unique in tissue culture compared with other LGV strains. Bioinformatic and statistical analyses identified the strain as a recombinant of L₂ and D strains with highly conserved clustered regions of genetic exchange. The unique culture morphology and, more importantly, disease phenotype could be traced to the genes involved in recombination. The findings have implications for bacterial species evolution and, in the case of ongoing LGV outbreaks, suggest that recombination is a mechanism for strain emergence that results in significant disease pathology.

Lymphogranuloma venereum proctocolitis: a silent endemic disease in men who have sex with men in industrialised countries

Lymphogranuloma venereum (LGV) is a sexually transmitted disease (STD) caused by serovars L1-L3 of Chlamydia trachomatis. Rare in the western world prior to 2003, different outbreaks or clusters of LGV have been reported in Europe, North America and Australia among men who have sex with men (MSM) over the past few years. The majority were HIV infected MSM with high-risk sexual behaviour and a high rate of concomitant STD, including hepatitis C. Most of them presented with a proctitis syndrome and only a few with the classical bubonic form. A previously non-described serovar, L2b, has been identified as the main causative agent of the epidemic. A delay in diagnosis has been the rule because of the misleading symptomatology of LGV proctitis, the unfamiliarity of the disease to physicians, and the lack of a routine diagnostic test for LGV serovars. It is crucial to increase the awareness of the disease among physicians for prompt diagnosis and treatment, to avoid complications, and to stop ongoing transmission. It has additional public health implications since LGV may facilitate the transmission and acquisition of HIV and other STD.

Genital Chlamydia trachomatis infections

Chlamydia trachomatis infections affect young, sexually active persons. Risk factors include multiple partners and failure to use condoms. The incidence of infection has increased in the past 10 years. Untreated C. trachomatis infections are responsible for a large proportion of salpingitis, ectopic pregnancy, infertility and, to a lesser extent, epididymitis. Screening is a possible intervention to control the infection, which is often asymptomatic. The emergence of lymphogranuloma venereum proctitis in men who have sex with men, in Europe, and of a variant with a deletion in the cryptic plasmid, in Sweden, are new features of C. trachomatis infections in the last years. A diagnosis is best made by using nucleic acid amplification tests, because they perform well and do not require invasive procedures for specimen collection. Single-dose therapy has been a significant development for treatment of an uncomplicated infection of the patient and his or her sexual partner.

Manifestations and management of lymphogranuloma venereum

PURPOSE OF REVIEW

This review was prompted by a sustained outbreak of lymphogranuloma venereum that has been observed among men who have sex with men (MSM) worldwide since 2004. Recent developments in the epidemiology, diagnosis and management of the infection are summarized.

RECENT FINDINGS

Between the early 1980s and 2003, lymphogranuloma venereum was rarely seen in the developed world. In 2003, a cluster of cases was seen in the Netherlands occurring mostly in HIV-positive MSM with high levels of sexual risk. With the assistance of novel molecular diagnostic techniques, more than a thousand cases of Chlamydia trachomatis L2 serovar disease have now been reported in MSM worldwide. Almost all have presented with rectal infection, usually manifesting as severe proctitis, with ulcer adenopathy syndrome seldom seen. Oral doxycycline remains the recommended treatment and has proven effective in the recent outbreak. Conflicting data exist regarding the prevalence of asymptomatic infection, and our understanding of the exact modes of transmission remains incomplete.

SUMMARY

Lymphogranuloma venereum appears to have reestablished endemicity among MSM populations in many industrialized nations. In the relative absence of recent publications from its traditional endemic regions it can be assumed that these populations remain afflicted by the infection as well.

Lymphogranuloma venereum outbreak in Europe

Lymphogranuloma venereum (LGV) is a venereal disease caused by Chlamydia trachomatis biovars L1 to L3. Unlike other anogenital C. trachomatis infections, LGV preferably affects lymphatic tissue after invasion through an epithelial surface. LGV has been considered an exotic tropical disease in Europe. This changed in 2003 as there was an outbreak of LGV in Rotterdam followed by additional reports from other European countries and North America. Most patients were HIV-positive men who presented with proctitis. Most of these patients were infected by C. trachomatis L2b biovar, a variant that was first identified in patients from Amsterdam. This review will address the recent developments of the LGV outbreak in Europe and discuss epidemiology, clinical manifestations, new subtypes of LGV genotypes and appropriate diagnostic measures.

First case of "bubonulus" in L2 lymphogranuloma venerum

Since 2003, an ongoing lymphogranuloma venereum (LGV) proctitis outbreak has been reported in industrialised countries with a new variant designated L2b. Only men who have sex with men (MSM) are affected and most are HIV co-infected; delayed or incorrect diagnoses are frequent. We report a rare clinical case of LGV primary stage called "bubonulus" with penile adenopathy and secondary local acute lymphoedema in an MSM seropositive man. This is the first case described of this clinical presentation with a L2b genovar strain, occurring immediately after use of a sex toy. It suggests that this presentation is favoured by host immunity and behavioural factors. These factors may also play a part in the new outbreak of LGV.