Lymphogranuloma venereum represents a sexually-transmitted disease caused by specific serovars L1-3 of the obligate intracellular bacterium Chlamydia trachomatis.
The disease presents with a shallow ulcer or painless papule, and enlarged and tender lymph nodes (known as buboes) arise in the regional lymphatics. Lymphogranuloma venereum is also an important cause of proctitis in men who have sex with men.
It is important to rule out other potential causes of genital ulceration and inguinal lymphadenopathy before any therapeutic interventions. Early medical treatment is of immense value for preventing disease transmission, as well as for halting the development of complications and potentially mutilating sequelae.
Treatment Algorithm
The goal of therapy for lymphogranuloma venereum is to eradicate the putative microorganism. The treatment of choice (supported by more than fifty years of clinical experience) is doxycycline, 100 milligrams two times per day for a total of 21 days. This recommendation is based on numerous case series, and the regimen is characterized by convenient dosage, minimal toxicity and favorable pharmacokinetic profile.
The alternative approach is erythromycin base, 500 milligrams four times per day for a total of 21 days. The proposed three-week period in both instances is necessary since lymphogranuloma venereum is more invasive and problematic to eradicate when compared to uncomplicated infections of the genital tract. Treatments based on fluoroquinolones might also be effective, but there are no studies evaluating the optimal duration of treatment.
The activity of azithromycin against Chlamydia trachomatis suggests that this drug may also be effective, but at the moment we lack supporting clinical data. It is being used as a medication for pregnant women, although official recommendations still endorse erythromycin stearate regimen.
In addition to antibiotics, local management of buboes (primarily by incision and drainage, or by aspiration through intact skin) must be considered in order to prevent the development of fistulous tracts. Rectal strictures should be dilated at weekly intervals – either manually or with elastic bougies.
Follow-up and Prognosis
Patients should be monitored until symptoms and signs of the disease have resolved, which may occur within 3-6 weeks. Tests of cure should be performed approximately 3-4 weeks after effective treatment is completed in order to avoid false positive findings due to the presence of non-viable microorganisms (especially if molecular methods are used).
In any case, prognosis is excellent for acute infections that are treated with appropriate antimicrobial drugs. In instances of anatomical defects that may necessitate surgical interventions (such as strictures, sinus or fistulae), patients need to be followed up until their problem is resolved.
Partner management is also pivotal; individuals who have had sexual contacts with the affected patient within six months of the symptom appearance, or in instances of asymptomatic disease at the time of diagnosis, should be adequately examined, tested for Chlamydia trachomatis, and treated empirically immediately.
Prevention Efforts
In endemic areas of the world, lymphogranuloma venereum can be successfully prevented by avoiding casual sexual contact (particularly with commercial sex workers) and by practicing safe sexual habits (most notably by using condoms). As already mentioned, all sexual contacts must be traced and swiftly treated.
The use of enema prior to receptive anal intercourse should be discouraged, as it is linked to rectal chlamydial infections, and especially lymphogranuloma venereum proctitis. Health-seeking behavior and health literacy of those at risk must be encouraged.
In conclusion, there is a need for cheaper and improved screening tools if we are to detect cases in larger groups of people at risk. This is of utmost importance to prevent potential complications and stop transmission in the community. A deeper understanding of both microbial and immunological background of lymphogranuloma venereum will aid in successfully tackling this infection.
Further Reading