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Lymphogranuloma Venereum

The responsible organism for lymphogranuloma venereum (LGV) is Chlamydia trachomatis, immunotypes L1, L2, and L3.

The incubation period for this organism is normally 10 to 14 days, with a range of 3 days to 6 weeks.

  1. Pathophysiology
    1. LGV is primarily an infection of lymphatics and lymph nodes.
    2. After innoculated onto the mucosal surface, the organisms seek their way to the draining lymphatic and lymph nodes to cause lymphangitis and lymphadenitis.
    3. The latter may become necrotic and results in loculated abscesses, fistulas, and sinus tract. As the infection subsides, fibrosis will replace the acute inflammation with resultant obliteration of lymphatic drainage, chronic edema, and stricture formation.
  2. Clinical Features
    1. The clinical presentation of LGV depends on the sex of the patient, mode of sexual contact (e.g. vaginal or anal sex) and the stage of the disease.
    2. The transient primary lesion may easily missed which could be a papule, a shallow ulcer or erosion, a small herpetiform lesion (commonest), or non-specific urethritis.
    3. The incubation period averages 1 to 3 weeks. In male, it is usually found in the coronal sulcus, prepuce or glans.
    4. In women, it is usually found in the posterior wall of the vagina, vulva or cervix.
    5. The secondary stage appears in two main settings. Swelling of the inguinal lymph nodes is the presentation in the inguinal syndrome which are more common in men. It has an incubation period of 10 to 30 days.
    6. The nodes are firm, slightly painful and enlarge over 1 to 2 weeks and are unilateral in two third of the cases.
    7. Constitutional symptoms are common and associated with the systemic spread of the chlamydia. However spontaneous recovery occurs in a great majority of the cases.
    8. If the femoral nodes are involved, it produces the classical "groove sign".
    9. In women, inguinal lymphadenitis is unusual, however, the iliac lymph nodes may be involved and lead to pelvic adhesions. When this occurs the patient may complain of lower abdominal pain made worse when lying supine.
    10. The anorectal syndrome is a more common presentation in women and homosexual male who practise anal intercourse. They may complain of anal pruritis, rectal pain and tenesmus. Protoscopic examination may show multiple, discrete superficial ulcerations with irregular borders appear on the rectal mucosa. Complications includes rectal stricture, perirectal abscesses, anal fistula and "lymphorrhoids" which are perianal outgrowths of lymphatic tissue.
    11. Antibiotic treatment in the secondary stages will prevent progression of the disease to the late stage which may include genital elephantiasis, genital ulcers and fistulas, urethral and rectal stricture, perineal sinuses, rectovaginal fistulae and "frozen pelvis".
  3. Other Manifestations:
    1. Esthiomene (Greek, "eating away") is a primary infection of the lymphatics of the external genitalia and may cause chronic pregressive lymphangitis, chronic edema, and sclerosing fibrosis of the subcutaneous tissue of these structures.
    2. Follicular conjunctivitis due to autoinoculation of infectious discharge.
    3. Primary LGV lesions of the mouth and pharynx as the result of fellatio or cunnilingus.
    4. Erythema nodosum may occur during the early stages of infection..
  4. IMP Points
    1. Sec Stage –LN- suppurative buboes- spontaneous rupture- one third of the cases.
    2. 20% of patients have enlargement of both inguinal and femoral nodes,(groove sign)
  5. Diagnosis
    1. Diagnosis of LGV is based on both clinical and laboratory investigations which may include the following:
    2. Mild leukocytosis with an increase in monocytes and eosinophils.
    3. Elevated gamma-globulin concentration due to an increase of IgA, IgG, and IgM.
    4. Complement fixation test with titres of 1:64 or greater, however the test may cross react with other chlamydial antibodies.
    5. Microimmunofluorescent test which is diagnostic when the titre is greater or equal to 1:512.
    6. Isolation of the organism from bubo pus.
    7. Histological identification of chlamydia in infected tissue.
    8. Diagnosis of LGV is made with cultural isolation of the organism. This method, however, has a recovery rate of less than 30%. Therefore diagnosis is based on serology associated with appropriate clinical findings.
    9. A complement fixation titer (LGV-CF) of greater than 1:16 is strongly suggestive of this diagnosis.
    10. Serology is normally positive within 2 weeks of onset. Antibody titers do not necessarily correspond with disease activity and may not decline after treatment, as in syphilis.
  6. Treatment
    Lymphogran loma Venereum (LGV):
    Doxycycline 100 mg orally twice a day for14 days.
  7. Special Considerations:
    Pregnancy - Pregnant and lactating women should be treated with erythromycin.
    HIV Infection - Persons with both LGV and HIV infection should receive the same regimens as those who are HIV-negative. Prolonged therapy may be required, and delay in resolution of symptoms may occur.

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