Lymphogranuloma venereum (LGV) is an uncommon sexually transmitted disease caused by certain serotypes of Chlamydia trachomatis. It occurs in three stages - primary genital lesion, painful inguinal lymphadenopathy, and potentially years later, proctocolitis. Diagnosis is based on clinical findings and tests for C. trachomatis. Treatment involves doxycycline or erythromycin for 21 days along with drainage of infected lymph nodes.

1. ►Lymphogranuloma venereum (LGV) is anLymphogranuloma venereum (LGV) is an
uncommon sexually transmitted diseaseuncommon sexually transmitted disease
(STD) caused by(STD) caused by Chlamydia trachomatisChlamydia trachomatis..
This condition is characterized by inguinalThis condition is characterized by inguinal
lymphadenopathy.lymphadenopathy.

2. ► C trachomatisC trachomatis is an obligate intracellular bacterium.is an obligate intracellular bacterium.
► Of the 15 known clinical serotypes, only the L1, L2, and L3Of the 15 known clinical serotypes, only the L1, L2, and L3
serotypes cause LGV.serotypes cause LGV.
► These serotypes are more virulent and invasive comparedThese serotypes are more virulent and invasive compared
to other chlamydial serotypes. Infection occurs after directto other chlamydial serotypes. Infection occurs after direct
contact with the skin or mucous membranes of an infectedcontact with the skin or mucous membranes of an infected
partner. The organism does not penetrate intact skin. Thepartner. The organism does not penetrate intact skin. The
organism then travels by lymphatics to regional lymphorganism then travels by lymphatics to regional lymph
nodes, where they replicate within macrophages and elicitnodes, where they replicate within macrophages and elicit
systemic disease. While transmission is predominantlysystemic disease. While transmission is predominantly
sexual, cases of transmission through laboratory accidents,sexual, cases of transmission through laboratory accidents,
fomites, and nonsexual contact have been reported.fomites, and nonsexual contact have been reported.

3. ► LGV occurs in 3 stages.LGV occurs in 3 stages.
► The first stage,primary lesion which is oftenThe first stage,primary lesion which is often
unrecognized, consists of a rapidly healing,unrecognized, consists of a rapidly healing,
painless genital papule or pustule.painless genital papule or pustule.
► The second stage, consisting of painful inguinalThe second stage, consisting of painful inguinal
lymphadenopathy, occurs 2-6 weeks after thelymphadenopathy, occurs 2-6 weeks after the
primary lesion.primary lesion.
► The third stage, which is more common in women,The third stage, which is more common in women,
may occur many years after the original infectionmay occur many years after the original infection
and is characterized by proctocolitis.and is characterized by proctocolitis.

4. First stage (primary LGV)First stage (primary LGV)
3-30 days after inoculation.3-30 days after inoculation.
► The initial lesion is usually a small, unnoticed painlessThe initial lesion is usually a small, unnoticed painless
papule, shallow ulcer, or herpetiform lesion in the genitalpapule, shallow ulcer, or herpetiform lesion in the genital
area.area.
 The most common sites of infection for men include theThe most common sites of infection for men include the
coronal sulcus, prepuce, glans, and scrotum.coronal sulcus, prepuce, glans, and scrotum.
 Rarely, symptoms of urethritis occur.Rarely, symptoms of urethritis occur.
► The initial lesion, especially in women, often goesThe initial lesion, especially in women, often goes
unnoticed by the patientunnoticed by the patient
► . The most common sites of infection in women include the. The most common sites of infection in women include the
posterior vaginal wall, posterior cervix, fourchette, andposterior vaginal wall, posterior cervix, fourchette, and
vulva.vulva.

5. Second stage (secondary LGV)Second stage (secondary LGV)
Inguinal syndromeInguinal syndrome
► Secondary LGV begins 2-6 weeks after the primary lesion.Secondary LGV begins 2-6 weeks after the primary lesion.
► Secondary LGV is characterized by painful lymph nodes (usuallySecondary LGV is characterized by painful lymph nodes (usually
unilateral) known as buboes.unilateral) known as buboes.
► Enlargement of the inguinal nodes above and the femoral nodes belowEnlargement of the inguinal nodes above and the femoral nodes below
the inguinal ligament leads to the classic groove sign, which isthe inguinal ligament leads to the classic groove sign, which is
observed in one third of affected men.observed in one third of affected men.
► Inguinal lymphadenopathy results from a primary lesion of the anteriorInguinal lymphadenopathy results from a primary lesion of the anterior
vulva, penis, or urethra.vulva, penis, or urethra.
► Perirectal or pelvic lymphadenopathy results from a primary lesionPerirectal or pelvic lymphadenopathy results from a primary lesion
involving the posterior vulva, vagina, or anus.involving the posterior vulva, vagina, or anus.
► Affected nodes often coalesce and form abscesses, which can ruptureAffected nodes often coalesce and form abscesses, which can rupture
and form sinus tracts.and form sinus tracts.

6. Second stage (secondary LGV)Second stage (secondary LGV)
► Painful, swollen lymph nodes coalesce to form buboes, which mayPainful, swollen lymph nodes coalesce to form buboes, which may
rupture in as many as one third of patients. Those that do not rupturerupture in as many as one third of patients. Those that do not rupture
harden, then slowly resolve.harden, then slowly resolve.
► Inguinal lymphadenopathy occurs in only 20-30% of females with LGV;Inguinal lymphadenopathy occurs in only 20-30% of females with LGV;
they more typically have involvement of the deep iliac or perirectalthey more typically have involvement of the deep iliac or perirectal
nodes and may only present with nonspecific back and/or abdominalnodes and may only present with nonspecific back and/or abdominal
pain.pain.
► This stage is when most men present and are diagnosed; most womenThis stage is when most men present and are diagnosed; most women
are not diagnosed in this stage because of their lack of inguinalare not diagnosed in this stage because of their lack of inguinal
lymphadenopathy.lymphadenopathy.
► Constitutional symptoms associated with the second stage includeConstitutional symptoms associated with the second stage include
fever, chills, myalgias, and malaise.fever, chills, myalgias, and malaise.

7. Third stage (tertiary LGV)Third stage (tertiary LGV)
genitoanorectal syndrome.genitoanorectal syndrome.
► Tertiary LGV most often manifests in women.Tertiary LGV most often manifests in women.
► Patients initially develop proctocolitis.Patients initially develop proctocolitis.
► Patients may present with perirectal fistulas, abscesses, strictures, andPatients may present with perirectal fistulas, abscesses, strictures, and
rectal stenosis.rectal stenosis.
► Hyperplasia of intestinal and perirectal lymphatics may formHyperplasia of intestinal and perirectal lymphatics may form
lymphorrhoids, which are similar to hemorrhoids.lymphorrhoids, which are similar to hemorrhoids.
► Patients may develop strictures and fistulous tracts secondary toPatients may develop strictures and fistulous tracts secondary to
repeated tissue scarring and repair.repeated tissue scarring and repair.
► Enlargement, thickening, and fibrosis of the labia may occur in women,Enlargement, thickening, and fibrosis of the labia may occur in women,
a condition termed esthiomene.a condition termed esthiomene.
► Chronic lymphatic obstruction may lead to elephantiasis of the genitals.Chronic lymphatic obstruction may lead to elephantiasis of the genitals.
► Penile and scrotal edema and distortion have been termed saxophonePenile and scrotal edema and distortion have been termed saxophone
penis.penis.

8. Third stage (tertiary LGV)Third stage (tertiary LGV)
► This condition is more common in women, secondary toThis condition is more common in women, secondary to
their lack of symptoms during the first two stages.their lack of symptoms during the first two stages.
► Rectal involvement is more common in men who have sexRectal involvement is more common in men who have sex
with men and in women who practice anal-receptivewith men and in women who practice anal-receptive
intercourse.intercourse.
► Tertiary LGV is characterized by proctocolitis.Tertiary LGV is characterized by proctocolitis.
► Symptoms include the following conditions:Symptoms include the following conditions:
 MalaiseMalaise
 Weight lossWeight loss
 Bloody purulent dischargeBloody purulent discharge
 FeverFever
 Rectal painRectal pain
 TenesmusTenesmus

9. Systemic spreadSystemic spread
►ArthritisArthritis
►Ocular inflammatory diseaseOcular inflammatory disease
►Cardiac involvementCardiac involvement
►Pulmonary involvementPulmonary involvement
►Aseptic meningitisAseptic meningitis
►Hepatitis or perihepatitisHepatitis or perihepatitis

10. D.DD.D
►Granuloma inguinaleGranuloma inguinale
CancerCancer
Hodgkin diseaseHodgkin disease
Inflammatory proctocolitisInflammatory proctocolitis
Mycobacterial infectionMycobacterial infection
Fungal infectionFungal infection

11. Laboratory StudiesLaboratory Studies
► The diagnosis is based on clinical findings,The diagnosis is based on clinical findings,
► Needle aspiration of an involved bubo is the best method to obtainNeedle aspiration of an involved bubo is the best method to obtain
tissue for culture.tissue for culture.
► supported by serologic tests for CT (complement fixation test with asupported by serologic tests for CT (complement fixation test with a
titer oftiter of >> 1:641:64
► a microimmuno-fluorescence test with a titer of >1:128)a microimmuno-fluorescence test with a titer of >1:128)
► direct identification of CT by culturedirect identification of CT by culture
► nonculture nucleic acid testing.nonculture nucleic acid testing.
► Serologic testing, which has not been well standardized, is notSerologic testing, which has not been well standardized, is not
considered specific for LGV, but can support a clinical diagnosis.considered specific for LGV, but can support a clinical diagnosis.
► Direct identification by commercially available methods is also notDirect identification by commercially available methods is also not
specific for LGV serovars of CT.specific for LGV serovars of CT.

12. TreatmentTreatment
►Medical CareMedical Care
►The complete treatment of patients withThe complete treatment of patients with
LGV includes appropriate antimicrobialLGV includes appropriate antimicrobial
coverage and drainage of infected buboes.coverage and drainage of infected buboes.
►The recommended medical treatment forThe recommended medical treatment for
LGV involves one of the following antibioticLGV involves one of the following antibiotic
regimens:regimens:
 Doxycycline 100 mg PO bid for 21 dDoxycycline 100 mg PO bid for 21 d
 Erythromycin base 500 mg PO qid for 21 dErythromycin base 500 mg PO qid for 21 d

13. Surgical CareSurgical Care
►Needle aspiration or incision and drainageNeedle aspiration or incision and drainage
of involved inguinal nodes may be requiredof involved inguinal nodes may be required
for pain relief and prevention of ulcerfor pain relief and prevention of ulcer
formation. Some of the late complications offormation. Some of the late complications of
the third stage of LGV may require surgicalthe third stage of LGV may require surgical
repair.repair.