Prevalence and predictors of Lymphogranuloma venereum in a high risk population attending a STD outpatients clinic in Italy

Whole Genome Sequencing of a Chlamydia trachomatis Strain Responsible for a Case of Rectal Lymphogranuloma Venereum in Italy

Lymphogranuloma venereum (LGV) is a systemic sexually transmitted infection caused by Chlamydia trachomatis serovars L1 to L3. The current LGV cases in Europe are mainly characterized by an anorectal syndrome, spreading within men who have sex with men (MSM). Whole-genome sequencing of LGV strains is crucial to the study of bacterial genomic variants and to improve strategies for contact tracing and prevention. In this study, we described the whole genome of a C. trachomatis strain (LGV/17) responsible for a case of rectal LGV. LGV/17 strain was isolated in 2017 in Bologna (North of Italy) from a HIV-positive MSM, presenting a symptomatic proctitis. After the propagation in LLC-MK2 cells, the strain underwent whole-genome sequencing by means of two platforms. Sequence type was determined using the tool MLST 2.0, whereas the genovariant was characterized by an ompA sequence evaluation. A phylogenetic tree was generated by comparing the LGV/17 sequence with a series of L2 genomes, downloaded from the NCBI website. LGV/17 belonged to sequence type ST44 and to the genovariant L2f. Nine ORFs encoding for polymorphic membrane proteins A-I and eight encoding for glycoproteins Pgp1-8 were detected in the chromosome and in the plasmid, respectively. LGV/17 was closely related to other L2f strains, even in the light of a not-negligible variability. The LGV/17 strain showed a genomic structure similar to reference sequences and was phylogenetically related to isolates from disparate parts of the world, indicative of the long-distance dynamics of transmission.

Chlamydia trachomatis anorectal infections by LGV (L1, L2 and L2b) and non-LGV serotypes in symptomatic patients in Buenos Aires, Argentina

BACKGROUND

Chlamydia trachomatis (CT) can infect the anorectum producing various signs and symptoms. There is scarce literature regarding the differences between LGV and non-LGV CT anorectal manifestations. We compare the clinical spectrum of LGV and non-LGV infections.

METHODS

Patients over 18 years with presumptive infectious anorectal symptoms were examined in two healthcare centres in Buenos Aires. The patients were studied and treated according to current sexually transmitted infection guidelines. Anorectal swabs were collected to detect and genotype CT.

RESULTS

A three-year-long study on 317 patients with anorectal symptoms showed 45.11% CT infection (85% LGV strains). Of 140 samples, 92 were sequenced: 80/119 LGV (L2b 45%, L1 32.5% and L2 22.5%) and 12/21 non-LGV. Older age and HIV+ status were significantly higher in the LGV group. Anal discharge, bleeding, severe proctitis and anal ulcers were more common in the LGV group. Multivariate logistic regression analysis revealed that HIV infection, anorectal bleeding and oro-anal sex are independent predictors of LGV infection.

CONCLUSIONS

In patients with anorectal symptoms, LGV serovars predominate over non-LGV ones. Clinical manifestations are not pathognomonic of a specific biovar. If genotyping is not available, having clinical predictors may help to presume an LGV infection and define length of treatment.

Lymphogranuloma venereum genovariants in men having sex with men in Italy

Objectives

Lymphogranuloma venereum (LGV) is an STI caused by Chlamydia trachomatis serovars L1-L3. In Europe, the current epidemic is caused mainly by L2b genovariant, although increasing cases associated with other L2 variants have been reported. Here, we assessed the distribution of rectal LGV genovariants among men having sex with men (MSM) in Italy.

Methods

From 2016 to 2020, all the anorectal swabs collected from MSM attending the STI Clinic of St. Orsola-Malpighi Hospital in Bologna and positive for C. trachomatis were stored. LGV infection was confirmed by a pmpH PCR, and, subsequently, a fragment of the ompA gene was amplified and sequenced. Sequences were aligned to reference strains representing different LGV variants.

Results

LGV cases accounted for one-third of all chlamydial rectal infections with a total prevalence of 4.1% (76/1852). Total number of LGV cases per year remained constant. LGV was mainly found in symptomatic patients (>65%), older than 30 years, with a high burden of other STIs (63.7% HIV-positive, 35.5% with concurrent rectal gonorrhoea, 19.7% with early syphilis). A decreasing trend in HIV-LGV co-infection was noticed over time. Three main LGV genovariants were detected (L2f, 46.1%; L2b, 23.0%; L2-L2b/D-Da, 16.9%), together with other known L2b variants (mainly L2bV2 and L2bV4). Two novel L2b ompA variants with non-synonymous single-nucleotide polymorphisms were found. Over time, the percentage of L2f cases dropped gradually, with a significant increase in L2-L2b/D-Da cases (p=0.04).

Conclusions

In our area, LGV is endemic among MSM with different circulating genovariants. Active surveillance and genotyping programmes are needed to reduce re-establishing of LGV infection.

Rectal Lymphogranuloma Venereum, Buenos Aires, Argentina

Among 34 men with proctitis in Buenos Aires, Argentina, 16 (47%) had Chlamydia trachomatis infection, 11 (68.8%) of which were biovar lymphogranuloma venereum. The outbreak was probably local, as in Europe. In Argentina, lymphogranuloma venereum should be a suspected cause of proctitis in HIV-infected men who have had unprotected anal sex with men.

Lymphogranuloma venereum proctitis mimicking inflammatory bowel diseases in 11 patients: a 4-year single-center experience

Lymphogranuloma venereum (LGV) is a sexually transmitted disease caused by Chlamydia trachomatis (CT) serovars L1–L3. Our study wants to underline the similarities between rectal LGV and idiopathic inflammatory bowel diseases (IBD), which can share clinical, endoscopic and histopathological findings.

Observational study of anorectal Chlamydia trachomatis infections in France through the lymphogranuloma venereum surveillance network, 2010-2015

The objective of this article is to describe the epidemiology of lymphogranuloma venereum (LGV) and non-LGV Chlamydia trachomatis anorectal infections in France and to examine the characteristics of the affected populations via a voluntary sentinel surveillance system for LGV between 2010 and 2015. Anorectal samples positive for C. trachomatis (CT) were sent by the participating laboratories to the National Reference Center for CT for LGV identification. Biological and clinical data were collected by biologists and clinicians. There were 1740 LGV episodes and 2248 non-LGV episodes. Continuous monitoring highlighted a sharp increase in the number of LGV and non-LGV anorectal infections, which were 2.3-fold and 6.5-fold, respectively. Most of the infections occurred in men who have sex with men. LGV patients were older than non-LGV patients and were more frequently human immunodeficiency virus (HIV)-positive compared to non-LGV patients. Anorectal LGV was significantly associated with residence in Paris, HIV co-infection, concurrent syphilis and bloody anal discharge. Undocumented patient characteristics were strongly associated with anorectal LGV. The anorectal LGV epidemic is poorly controlled in France. Early detection and prompt treatment of patients and their sexual partners are required to prevent transmission in the context of pre-exposure prophylaxis (PrEP) for HIV infection.

Sexually transmitted rectal infections in a cohort of 'men having sex with men'

PURPOSE

We assessed the prevalence and predictors of Chlamydia trachomatis, Neisseriagonorrhoeae and Mycoplasmagenitalium rectal infections in a population of 'men having sex with men' (MSM).

METHODOLOGY

From January to November 2017, 165 MSM attending a STI outpatients clinic in Bologna (Italy) and reporting unsafe anal intercourses were enrolled. An ano-rectal swab was collected from each patient: chlamydial and gonococcal infections were diagnosed by a commercial NAAT, whereas an in-house quantitative PCR was used for M. genitalium detection. In addition, 131 urine samples and 84 pharyngeal swabs underwent testing for C. trachomatis and N. gonorrhoeae. A molecular C. trachomatis typing, a serological screening for anti-Chlamydia IgG and IgA, as well as the assessment of HIV, HCV and syphilis infections, were performed.Results/Key findings. The prevalence of C. trachomatis, N. gonorrhoeae and M. genitalium rectal infections was 27.2, 25.4 and 4.8 %, respectively. Globally, 63.1 % of cases were asymptomatic and up to 80 % of chlamydial and gonococcal infections would have been missed if the rectal site had not been tested. All the patients with rectal M. genitalium carriage were asymptomatic and characterized by low bacterial loads (<2500 DNA copies/reaction). Lymphogranuloma venereum (LGV) prevalence was 12.1 % with a considerable proportion of asymptomatic infections (35 %). The presence of symptoms, age >30, HIV-positivity and elevated levels of anti-Chlamydia antibodies were the most significant predictors of LGV.

CONCLUSIONS

Sexually transmitted rectal infections are frequent and often asymptomatic among MSM. LGV prevalence is high in our country and there is increasing evidence of symptomless cases.

Urine metabolome in women with Chlamydia trachomatis infection

The aim of this study was to characterize the urine metabolome of women with Chlamydia trachomatis (CT) uro-genital infection (n = 21), comparing it with a group of CT-negative subjects (n = 98). By means of a proton-based nuclear magnetic resonance (¹H-NMR) spectroscopy, we detected and quantified the urine metabolites of a cohort of 119 pre-menopausal Caucasian women, attending a STI Outpatients Clinic in Italy. In case of a CT positive result, CT molecular genotyping was performed by omp1 gene semi-nested PCR followed by RFLP analysis. We were able to identify several metabolites whose concentrations were significantly higher in the urine samples of CT-positive subjects, including sucrose, mannitol, pyruvate and lactate. In contrast, higher urinary levels of acetone represented the main feature of CT-negative women.

These results were not influenced by the age of patients nor by the CT serovars (D, E, F, G, K) responsible of the urethral infections. Since the presence of sugars can increase the stability of chlamydial proteins, higher levels of sucrose and mannitol in the urethral lumen, related to a higher sugar consumption, could have favoured CT infection acquisition or could have been of aid for the bacterial viability. Peculiar dietary habits of the subjects enrolled, in term of type and amount of food consumed, could probably explain these findings. Lactate and pyruvate could result from CT-induced immunopathology, as a product of the inflammatory microenvironment. Further studies are needed to understand the potential role of these metabolites in the pathogenesis of CT infection, as well as their diagnostic/prognostic use.

A Case of Reactive Arthritis Associated With Lymphogranuloma Venereum Infection in a Woman

We report the first case of reactive arthritis associated with lymphogranuloma venereum (LGV) in an Italian human immunodeficiency virus-negative woman with urogenital and rectal Chlamydia trachomatis L2 serovar infection. The LGV-associated arthritis has to be considered even when classic symptoms of arthritis are missing and in case of asymptomatic or cryptic LGV localizations.

Treatment Outcomes for Rectal Lymphogranuloma Venereum in Men Who Have Sex with Men Using Doxycycline, Azithromycin, or Both: A Review of Clinical Cases

BACKGROUND

Treatment for rectal lymphogranuloma venereum where doxycycline 100 mg twice daily for 21 days was used-either alone or together with azithromycin 1 g single dose-resulted in microbiological cure of 97%. These data support doxycycline 100 mg twice daily for 21 days as the preferred treatment for rectal lymphogranuloma venereum.

Sexually transmitted infections of the lower gastrointestinal tract

The World Health Organization estimates that there is greater than one million new cases of sexually transmitted infections (STIs) every day. In many countries, STIs are at an unprecedented high, including the USA, where nearly 20 million new cases were reported in 2016. Although morbidity associated with STIs is usually seen in the context of genitourinary disease, these pathogens may also affect the gastrointestinal tract and cause anal pain, abdominal pain, or diarrhea. It is important to recognize patterns of injury associated with these pathogens, especially those that may mimic other gastrointestinal diseases, such as idiopathic inflammatory bowel disease (IBD). This review focuses upon STIs of the lower gastrointestinal tract, organized by the most common site of involvement: the anus, rectum, and colon.

Inguinal and anorectal Lymphogranuloma Venereum: a case series from a sexually transmitted disease center in Rome, Italy

BACKGROUND

Lymphogranuloma venereum (LGV) is a sexually transmitted infection caused by L1, L2, L3 serovars of C. trachomatis (CT). Since 2003, LGV cases have been increasing in Europe. Aim of this report is to describe the LGV cases diagnosed in the largest STI center in Rome, Italy, from 2000 to 2016. This report shows that two clinically and epidemiologically different series of cases exist, and that, at present, the ano-rectal LGV represents the clinical variant occurring more frequently among men having sex with men (MSM), particularly those HIV-infected.

CASE PRESENTATION

Ten cases of LGV were observed. Three were diagnosed in 2009 in HIV-negative heterosexuals patients that presented the classical genito-ulcerative form with lymphadenopathy. Seven cases were observed in 2015-2016 in HIV-infected MSM, that presented the rectal variant and L2b serovar infection; 4 of these had been misclassified as a chronic bowel disease. Chlamydia infection was confirmed by CT-specific PCR (ompA gene nested PCR), followed by sequence analysis to identify the serovar. All the patients were treated with doxycycline for 3 weeks, obtaining a complete response with healing of both clinical symptoms and dermatological lesions.

CONCLUSIONS

Our findings suggest that, in case of persistent rectal symptoms in HIV-infected MSM, LGV should be taken into account and investigated through molecular analyses, in order to achieve a correct diagnosis and management of the patients.

Systematic Review and Meta-Analysis of Doxycycline Efficacy for Rectal Lymphogranuloma Venereum in Men Who Have Sex with Men

A high microbial cure rate was shown with 100 mg doxycycline twice daily for 21 days.

Rectal lymphogranuloma venereum (LGV) has reemerged as a sexually transmitted infection among men who have sex with men (MSM), particularly those who are HIV-positive. We undertook a systematic review and meta-analysis to determine the efficacy of doxycycline (100 mg 2×/d for 21 days) for rectal LGV in MSM. Nine studies were included: 4 prospective, 4 retrospective, and 1 combined retrospective and prospective. In total, 282 MSM with rectal LGV were included in the studies. All studies reported using nucleic acid amplification tests to assess microbial cure. Most patients (>80%) had symptomatic rectal infection. The fixed-effects pooled efficacy for doxycycline was 98.5% (95% CI 96.3%–100%, I² = 0%; p = 0.993). Doxycycline at 100 mg twice daily for 21 days demonstrated a high microbial cure rate. These data support doxycycline at this dosage and duration as first-line therapy for rectal LGV in MSM.

Enhanced surveillance of a lymphogranuloma venereum outbreak in Sydney 2010-2012

OBJECTIVES

To investigate an increase in lymphogranuloma venereum (LGV) notifications in New South Wales (NSW).

METHODS

Enhanced surveillance of notified LGV cases in NSW between May 2010 and April 2012 using doctor and patient questionnaires.

RESULTS

Thirty-seven doctors who had diagnosed 67 (76%) of 88 notified anorectal LGV infections were interviewed. The majority (n=33, 89%) of treating doctors were formally trained and accredited in HIV management and prescribing, and most (n=32, 86%) worked in a public sexual health clinic or a general practice with a high caseload of men who have sex with men (MSM). All 67 cases were MSM who resided in inner-city Sydney and all were serovar L2b. Anal symptoms had been present in 64 cases (96%, 95%CI 87-99%) for a median of 8 days (range 2-1,825) prior to presentation. Almost one-third (n=20) had another concurrent STI diagnosed. Most (82%) of the 22 interviewed patients reported being HIV positive and having other STIs diagnosed over the past year. In the preceding month, all 22 men reported condomless anal sex and the median number of casual sexual partners was 5 (range 0-100).

CONCLUSIONS

Characteristics of LGV cases in NSW are similar to those described worldwide, suggesting that a sexually adventurous subgroup of MSM are at particular risk of infection.

IMPLICATIONS

Education of non-sexual-health clinicians on LGV risk factors, presentation, testing and management may allow more timely diagnosis and notification of contacts to reduce LGV transmission in the community.

Chlamydia trachomatis infection prevalence and serovar distribution in a high-density urban area in the north of Italy

The aim of this study was to assess Chlamydia trachomatis (CT) infection prevalence and serovar distribution in a high-density urban area in the north of Italy, by comparing different groups of subjects divided on the basis of the type of care provider they referred to (STI Clinic, gynaecologists or general practitioners). From January 2011 to May 2014, all the specimens submitted to the Microbiology Laboratory of St Orsola Hospital in Bologna for CT detection were tested by PCR assay. For positive specimens, molecular genotyping based on RFLP analysis was performed. Total prevalence of CT infection was 8.1 %, with significant differences between subgroups (P<0.01) but stable during the study period. The STI Clinic was mainly responsible for CT diagnosis, whereas the lowest infection prevalence was detected in gynaecological clinics, despite the high number of tests performed. Extra-genital samples were almost exclusively collected from males at the STI Clinic. Interestingly, 13.3 % of patients providing extra-genital specimens were positive for CT on rectal and/or pharyngeal swabs, and 4.4 % of cases would have been missed if extra-genital sites had not been tested. The most common serovar was E, and serovar distribution was influenced by gender (P<0.01), age (P<0.01), care provider (P=0.01) and anatomical site (P<0.01). The L2 serovar was detected only in extra-genital samples from males at the STI Clinic. Knowledge about care providers' contributions in CT testing and diagnosis is essential for infection control. CT typing is crucial for appropriate management of specific infections, such as lymphogranuloma venereum in extra-genital samples of high-risk populations.

Evaluation of the Versant CT/GC DNA 1.0 assay (kPCR) for the detection of extra-genital Chlamydia trachomatis and Neisseria gonorrhoeae infections

Screening for extra-genital Chlamydia trachomatis and Neisseria gonorrhoeae infections is a crucial component for sexually transmitted diseases management, even if at present days no commercial methods have been approved for use on pharyngeal and rectal specimens by the US FDA or have received the conformity CE marking. Here we report the analytical sensitivities of the Versant CT/GC 1.0 assay (Siemens Healthcare Diagnostics, Tarrytown, NY, USA) on rectal and pharyngeal swabs, and an evaluation about the suitability for this assay with two widely used swab collection devices (E-Swab and eNAT, Copan, Brescia, Italy). The limits of detection for rectal and pharyngeal specimens with the Versant assay were 10 copies/ml and 1.0 copies/ml, for C. trachomatis and N. gonorrhoeae, respectively. False positive results due to the presence of non-gonococcal Neisseria species were excluded when clinical rectal and pharyngeal samples containing organisms identified as N. meningitidis, N. sicca, N. flavescens and N. subflava were tested. Due to its sensitivity and specificity, the Versant assay represents a good choice for the diagnosis of chlamydial and/or gonococcal infections not only in genito-urinary samples, but also on rectal and pharyngeal swabs.