A comparison of two methods for the diagnosis of lymphogranuloma venereum

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.

Three cases of reactive arthritis secondary to lymphogranuloma venereum

We describe 3 cases of sexually acquired reactive arthritis following rectal lymphogranuloma venereum (LGV) infection in London men who have sex with men. While sexually acquired reactive arthritis is well recognized following urogenital Chlamydia trachomatis infections, the association with rectal infection by LGV-associated serovars of C. trachomatis has been seldom reported, and thus the organism might not be sought by clinicians. The recognition of the various clinical syndromes of LGV by all clinicians, including rheumatologists, is essential given the endemicity of LGV in European men who have sex with men.

Screening for asymptomatic lymphogranuloma venereum co-infection in men who have sex with men newly diagnosed with HIV, hepatitis C or syphilis

Patients diagnosed with lymphogranuloma venereum have high rates of co-infection with HIV, syphilis and hepatitis C. The aim of this enhanced surveillance was to screen all men who have sex with men (MSM) newly diagnosed with HIV, syphilis or hepatitis C for co-infection with asymptomatic lymphogranuloma venereum as part of the recommended sexual health screen. Of the 145 patients screened, 21 patients were diagnosed with rectal Chlamydia trachomatis, one with both rectal and urethral chlamydia and six with urethral chlamydia. One rectal chlamydia-positive sample, when tested, was equivocal for lymphogranuloma venereum. Our data suggested that there was not a pool of asymptomatic lymphogranuloma venereum infection in MSM recently diagnosed with HIV, hepatitis C and syphilis. However, there have been recent reports of an increased incidence of asymptomatic lymphogranuloma venereum, raising the question whether lymphogranuloma venereum should be screened for in high risk asymptomatic MSM. The prevalence of asymptomatic rectal chlamydia infections was 19%.

An audit on the management of lymphogranuloma venereum in a sexual health clinic in London, UK

We performed an audit on the management of lymphogranuloma venereum (LGV) against the British Association of Sexual Health and HIV (BASHH) guidelines. Sixty-three cases of LGV were diagnosed in 60 men who have sex with men (MSM). Fifty-six out of 63 (89%) episodes were treated in accordance with the guidelines. Although all eligible patients were offered an HIV test, 10% and 29% of patients were not offered syphilis or hepatitis C tests, respectively, at the time of LGV diagnosis. Partner notification was not possible in a third of cases. Several patients were re-infected with rectal Chlamydia trachomatis in the three months following LGV diagnosis, emphasizing the importance of rescreening to detect new infections as well as treatment failures in MSM at ongoing high risk of sexually transmitted infection acquisition.

Lymphogranuloma venereum proctitis masquerading as inflammatory bowel disease in 12 homosexual men

BACKGROUND

Lymphogranuloma venereum (LGV) is a recognized cause of proctitis. Symptoms, endoscopy and histology findings are similar in IBD and LGV proctitis.

AIMS

To characterize the clinical, endoscopic and histological features seen in men diagnosed initially with IBD and subsequently with LGV proctitis, and to attempt isolation of Chlamydia trachomatis DNA from the stored rectal biopsy specimens of these patients using real-time PCR.

METHODS

Clinical data were collated from confirmed or suspected cases of LGV proctitis where endoscopy and biopsy had been performed as part of the investigation of clinical symptoms. LGV was confirmed by the detection of LGV-specific DNA from rectal swab specimens, with supportive evidence from Chlamydial serology. Stored histological specimens from rectal biopsies were analysed retrospectively for LGV-specific DNA with molecular techniques.

RESULTS

Rectal biopsies had been obtained from twelve cases of LGV proctitis. Mucosal ulcers, cryptitis, crypt abscesses and granulomas were common histological findings. Extraction of LGV-specific DNA from rectal biopsy specimens enabled confirmation of three suspected cases.

CONCLUSIONS

During the recent LGV proctitis epidemic among UK men who have sex with men, it has become apparent that this infection may closely resemble IBD. Gastroenterologists should remain alert to LGV as a cause of proctitis in this group.

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.