Observed Treatment Responses to Short-Course Doxycycline Therapy for Rectal Lymphogranuloma Venereum in Men Who Have Sex With Men

AEDV Expert Document on the Management of Ulcerative Venereal Infections

Currently, ulcerative sexually transmitted infections, including syphilis, herpes simplex virus (HSV), lymphogranuloma venereum (LGV), chancroid, donovanosis and, more recently, monkeypox (MPOX), represent a growing challenge for health care professionals. The incidence of syphilis and LGV has increased in recent years in Spain. Additionally, HSV, syphilis and chancroid can also increase the risk of HIV acquisition and transmission. The population groups most vulnerable to these infections are young people, men who have sex with men (MSM) and commercial sex workers. It is important to make a timely differential diagnosis since genital, anal, perianal, and oral ulcerative lesions may pose differential diagnosis with other infectious and non-infectious conditions such as candidiasis vulvovaginitis, traumatic lesions, carcinoma, aphthous ulcers, Behçet's disease, fixed drug eruption, or psoriasis. For this reason, the dermatologist plays a crucial role in the diagnosis and management of sexually transmitted infections. This chapter presents the main epidemiological, clinical and therapeutic features associated with these infections.

[Translated article] AEDV Expert Document on the Management of Ulcerative Venereal Infections

Currently, ulcerative sexually transmitted infections, including syphilis, herpes simplex virus (HSV), lymphogranuloma venereum (LGV), chancroid, donovanosis and, more recently, monkeypox (MPOX), represent a growing challenge for health care professionals. The incidence of syphilis and LGV has increased in recent years in Spain. Additionally, HSV, syphilis and chancroid can also increase the risk of HIV acquisition and transmission. The population groups most vulnerable to these infections are young people, men who have sex with men (MSM) and commercial sex workers. It is important to make a timely differential diagnosis since genital, anal, perianal, and oral ulcerative lesions may pose differential diagnosis with other infectious and non-infectious conditions such as candidiasis vulvovaginitis, traumatic lesions, carcinoma, aphthous ulcers, Behçet's disease, fixed drug eruption, or psoriasis. For this reason, the dermatologist plays a crucial role in the diagnosis and management of sexually transmitted infections. This chapter presents the main epidemiological, clinical and therapeutic features associated with these infections.

Rectal Lymphogranuloma Venereum Among Men Who Have Sex With Men: 7 Versus 21 Days Doxycycline Effectiveness

ABSTRACT

This is a retrospective study on men who have sex with men (MSM) diagnosed with rectal lymphogranuloma venereum (LGV), treated with 7 or 21 days of doxycycline between 2015 and 2022. Overall, 143 MSM were included: 58 (41%) had LGV. One hundred percent of microbiologic cure was found among MSM with symptomatic or asymptomatic LGV treated with 7 and 21 days of doxycycline.

Lymphogranuloma venereum of the neck in a young man living with HIV: a rare extragenital presentation

Lymphogranuloma venereum (LGV) is a sexually transmitted infection caused by an invasive form of Chlamydia trachomatis, typically affecting the anogenital area with regional lymphatic involvement. Extragenital manifestations are rare but can occur, particularly if the bacterium is inoculated out of the genital tract. To our knowledge, only 13 cases of symptomatic neck LGV have been published so far in the medical literature. We describe a case of a young man living with HIV with bilateral, rapid-growing and painful neck swelling, whose definite diagnosis was challenging. The patient underwent extensive investigation, including repeated ultrasound-guided fine-needle aspirations, microbiological exams and histological characterisation. Genotyping revealed C. trachomatis L2 serovar, confirming LGV as a final diagnosis, affecting neck lymph nodes. Treatment with doxycycline combined with surgical drainage led to clinical resolution. This case emphasises the importance of a comprehensive testing strategy to identify LGV, especially in individuals reporting unprotected oral sex, with unexplained neck lymphadenitis.

Effective Treatment of Lymphogranuloma Venereum With a 7-Day Course of Doxycycline

BACKGROUND

Lymphogranuloma venereum (LGV) remains endemic in the United Kingdom, primarily among gay, bisexual or other men who have sex with men (GBMSM). Current treatment guidelines recommend 21 days of doxycycline, but recent evidence suggests shorter antibiotic duration is as effective. We evaluated clinical outcomes in a cohort with LGV treated with 7 days of doxycycline.

METHODS

We reviewed case notes of all LGV cases at a South London sexual health service between November 2016 and September 2022, treated with only 7 days of doxycycline and anonymized data were collected from electronic patient records.

RESULTS

Fifty-two individuals with detected LGV-specific DNA were treated with 7 days of doxycycline 100 mg twice daily. All were GBMSM, median age of 35 years (range, 21-64 years), 21 (40%) were living with HIV, and 18 (35%) had concomitant sexually transmitted infections. Thirty-four (65%) were asymptomatic, whereas 18 (35%) reported symptoms: 7 (13%) urethral, 11 (21%) anorectal, and 2 (4%) other symptoms. Twenty-two (42%) were prescribed additional antimicrobials; however, none were active against Chlamydia trachomatis . All 52 underwent follow-up testing (range, 4-481 days). Chlamydia trachomatis was detected in one individual, but negative for LGV-specific DNA, and so considered to be a reinfection. All other cases were C. trachomatis -negative, indicating successful LGV eradication.

CONCLUSIONS

Our data support the approach of offering a 7-day doxycycline course routinely for asymptomatic or clinically mild C. trachomatis infections, and contacts of LGV infection, regardless of their LGV status. This may simplify patient management, reduce cost, and improve antimicrobial stewardship.

Proctitis: An Approach to the Symptomatic Patient

Proctitis is an inflammatory condition of the distal rectum that can be associated with common sexually transmitted infections (STIs), such as gonorrhea, chlamydia, and syphilis. For persons presenting with ulcerative findings on examination, in addition to syphilis, Mpox, lymphogranuloma venereum, and herpes simplex virus should be in the differential. Providers should also be aware that there are evolving data to support a role for Mycoplasma genitalium in proctitis. Performing a comprehensive history, clinical evaluation including anoscopy, and rectal nucleic amplification STI testing may be useful in identifying the cause of proctitis and targeting treatment.

Diagnosis and Treatment of Sexually Transmitted Infections: A Review

IMPORTANCE

Approximately 1 in 5 adults in the US had a sexually transmitted infection (STI) in 2018. This review provides an update on the epidemiology, diagnosis, and treatment of gonorrhea, chlamydia, syphilis, Mycoplasma genitalium, trichomoniasis, and genital herpes.

OBSERVATIONS

From 2015 to 2019, the rates of gonorrhea, chlamydia, and syphilis increased in the US; from 1999 to 2016, while the rates of herpes simplex virus type 1 (HSV-1) and HSV-2 declined. Populations with higher rates of STIs include people younger than 25 years, sexual and gender minorities such as men and transgender women who have sex with men, and racial and ethnic minorities such as Black and Latinx people. Approximately 70% of infections with HSV and trichomoniasis and 53% to 100% of extragenital gonorrhea and chlamydia infections are asymptomatic or associated with few symptoms. STIs are associated with HIV acquisition and transmission and are the leading cause of tubal factor infertility in women. Nucleic acid amplification tests have high sensitivities (86.1%-100%) and specificities (97.1%-100%) for the diagnosis of gonorrhea, chlamydia, M genitalium, trichomoniasis, and symptomatic HSV-1 and HSV-2. Serology remains the recommended method to diagnose syphilis, typically using sequential testing to detect treponemal and nontreponemal (antiphospholipid) antibodies. Ceftriaxone, doxycycline, penicillin, moxifloxacin, and the nitroimidazoles, such as metronidazole, are effective treatments for gonorrhea, chlamydia, syphilis, M genitalium, and trichomoniasis, respectively, but antimicrobial resistance limits oral treatment options for gonorrhea and M genitalium. No cure is available for genital herpes. Effective STI prevention interventions include screening, contact tracing of sexual partners, and promoting effective barrier contraception.

CONCLUSIONS AND RELEVANCE

Approximately 1 in 5 adults in the US had an STI in 2018. Rates of gonorrhea, chlamydia, and syphilis in the US have increased, while rates of HSV-1 and HSV-2 have declined. Ceftriaxone, doxycycline, penicillin, moxifloxacin, and the nitroimidazoles are effective treatments for gonorrhea, chlamydia, syphilis, Mycoplasma genitalium, and trichomoniasis, respectively, but antimicrobial resistance limits oral therapies for gonorrhea and Mycoplasma genitalium, and no cure is available for genital herpes.

Chlamydia and Gonorrhea

Gonorrhea and chlamydia rates have risen to record-high levels in the United States over the past decade. Because these infections are often asymptomatic, effective clinical management relies on screening of asymptomatic patients, particularly women younger than 25 years and men who have sex with men. If undetected and untreated, gonorrhea and chlamydia can lead to infertility, ectopic pregnancy, and chronic pelvic pain and can facilitate HIV acquisition and transmission. Primary care providers need to be aware of recent changes in recommended treatments for both infections.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11-14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

Effectiveness of doxycycline 100 mg twice daily for 7 days and azithromycin 1 g single dose for the treatment of rectal Chlamydia trachomatis infection among men who have sex with men

OBJECTIVES

To compare the effectiveness of doxycycline 100 mg twice daily for 7 days and azithromycin 1 g single dose for the treatment of rectal Chlamydia trachomatis infection among MSM in a real clinical setting.

METHODS

A prospective study was performed to compare the effectiveness of doxycycline and azithromycin for the treatment of rectal C. trachomatis among MSM in Tokyo, Japan. Subjects diagnosed with rectal C. trachomatis infection were treated and test-of-cure examination (TOC) was performed at least 3 weeks after the treatment. Treatment of rectal C. trachomatis infection was decided prospectively in a time-dependent manner; in the period between January 2017 and October 2018, azithromycin was administered to all subjects, whereas from October 2018 through March 2020, doxycycline was administered to all subjects. Effectiveness of these treatments was calculated by the number of rectal C. trachomatis-negative subjects at TOC divided by the number of subjects treated.

RESULTS

Two hundred and ninety-six MSM with rectal C. trachomatis infection were treated with azithromycin (80 patients) and doxycycline (216 patients) in a time-dependent manner. Of the 296 MSM, 274 (92.6%) were treated successfully [67 (83.7%, 95% CI = 79.6%-87.9%) in the azithromycin group versus 207 (95.8%, 95% CI = 94.5%-97.2%) in the doxycycline group, P < 0.001]. To evaluate factors associated with treatment failure, we performed logistic regression analysis. In univariate and multivariate analysis, only doxycycline treatment was inversely associated with treatment failure (OR = 0.29, 95% CI = 0.084-0.976, P = 0.046).

CONCLUSIONS

The treatment with doxycycline 100 mg twice daily for 7 days was superior to that with azithromycin 1 g single dose for rectal C. trachomatis among MSM in a real-world setting.

Single-Dose Azithromycin for Genital Lymphogranuloma Venereum Biovar Chlamydia trachomatis Infection in HIV-Infected Women in South Africa: An Observational Study

ABSTRACT

We conducted an observational study of lymphogranuloma venereum (LGV) biovar Chlamydia trachomatis infection in HIV-infected women in South Africa. The LGV biovar was detected in vaginal specimens of 17 (20%) of 85 women with C. trachomatis infection; 29% were symptomatic. All cases were negative for the LGV biovar after single-dose azithromycin.

Cervical and Oropharyngeal Lymphogranuloma Venereum: Case Report and Literature Review

Lymphogranuloma venereum (LGV) is a sexually transmitted infection caused by invasive serovars of Chlamydia trachomatis. There have been only a few case reports of oropharyngeal C. trachomatis infection complicated with cervical LGV. We report a case of a HIV-positive male patient with cervical LGV that presented a poor evolution despite appropriate treatment.

Lymphogranuloma Venereum: An Increasingly Common Anorectal Infection Among Men Who Have Sex With Men Attending New York City Sexual Health Clinics

Using Chlamydia trachomatis anorectal specimens routinely tested for lymphogranuloma venereum (LGV) (2008-2011) and samples of archived specimens tested for LGV (2012-2015), we observed increased LGV positivity among men who have sex with men attending NYC Sexual Health Clinics. Using clinical data, we determined predictors of anorectal LGV that may guide clinical management.

Lymphoganuloma venereum in the Western world, 15 years after its re-emergence: new perspectives and research priorities

PURPOSE OF REVIEW

Lymphogranuloma venereum (LGV) is a serious sexually transmitted infection caused by Chlamydia trachomatis. If left untreated LGV can cause irreversible late sequelae. LGV is endemic among a high-risk population of men who have sex with men (MSM), and largely reported in Western metropoles.

RECENT FINDINGS

Although the majority of LGV patients are HIV positive, in recent years the proportion of HIV-negative MSM with LGV is rising. This could indicate a shift toward lower risk populations. Apart from a few European countries, no proper LGV surveillance efforts have been implemented so far. Moreover, a considerable proportion of the infections are asymptomatic. As a result, the true magnitude of the LGV epidemic is underestimated.Depending on the stage and location of infection, LGV manifests in a variety of clinical presentations. Among MSM, anorectal infections are overreported as opposed to genital LGV infections in a ratio of 15 to 1, respectively. Therefore, other modes of transmission apart from anal sex are here discussed.

SUMMARY

To improve surveillance, cheaper and more practical screening methods are needed. Moreover, randomized clinical trials are needed to evaluate more simple treatment modalities as opposed to the currently recommended 3-week course of doxycycline.

2019 European guideline on the management of lymphogranuloma venereum

New or important issues in this updated version of the 2013 European guideline on the management of lymphogranuloma venereum (LGV): EPIDEMIOLOGY: Lymphogranuloma venereum continues to be endemic among European men who have sex with men (MSM) since 2003. Lymphogranuloma venereum infections in heterosexuals are extremely rare in Europe, and there is no evidence of transmission of LGV in the European heterosexual population.

AETIOLOGY AND TRANSMISSION

Chlamydia trachomatis serovars/genovars L2b and L2 are the causative strains in the majority of cases in Europe.

CLINICAL FEATURES

Among MSM, about 25% of the anorectal LGV infections are asymptomatic. Genital infections among MSM are rare; the ratio of genital vs. anorectal LGV infections is 1 in 15.

DIAGNOSIS

To diagnose LGV, a sample tested C. trachomatis positive with a commercial nucleic acid amplification test (NAAT) platform should be confirmed with an LGV discriminatory NAAT.

TREATMENT

Doxycycline 100 mg twice a day orally for 21 days is the recommended treatment for LGV. This same treatment is recommended also in asymptomatic patients and contacts of LGV patients. If another regimen is used, a test of cure (TOC) must be performed.

Infections caused by Chlamydia trachomatis (including lymphogranuloma venereum) and Mycoplasma genitalium

Sexually transmitted infections caused by Chlamydia trachomatis, including lymphogranuloma venereum and Mycoplasma genitalium have increased in last decade. This epidemiological scenario presents new challenges in order to improve and strengthen our control and prevention strategies. The routine clinical diagnosis of urethritis and cervicitis must be combined with the active search for the causal agent in men with symptoms of dysuria or proctitis, and in women with pelvic inflammatory disease. We should also include sexually transmitted infections screening in asymptomatic patients with sexual risk behaviours or sexual contact with patients diagnosed with an sexually transmitted infection. The microbiological diagnosis must be based on molecular techniques capable of detecting Chlamydia trachomatis (discriminating between L genotypes associated with lymphogranuloma venereum and other genotypes) and Mycoplasma genitalium (ideally including the identification of macrolide-resistant strains). A faster and specific diagnosis will allow for a targeted treatment with a suitable antibiotic regimen. We also recommend including contact tracing of sexual partners and, occasionally, a cure test. Finally, sexually transmitted infection screening must be widely implemented in those population groups with a high prevalence of sexually transmitted infections.