Lymphogranuloma venereum (LGV) is a sexually transmitted disease caused by certain types of Chlamydia trachomatis bacteria. It is characterized by painful swelling and inflammation of the lymph nodes, especially in the groin region. The bacteria enters through breaks in the skin or mucous membranes and travels via lymphatic channels to multiply in lymph nodes. Symptoms include a primary skin lesion, followed by painful lymphadenitis or lymphangitis as the infection spreads. Without treatment, LGV can cause chronic complications such as lymph vessel scarring, elephantiasis, and rectal strictures. Doxycycline is usually prescribed for 21 days to treat the infection.

1. LYMPHOGRANULOMA
VENEREUM
(LGV)
Prof Sriram Chandra Mishra
Kayachikitsa Department
VYDS Ayurved Mahavidyalaya,
Khurja

2. Definition
Lymphogranuloma venereum (LGV) is a sexually
transmitted disease caused by the bacteria Chlamydia
trachomatis and is marked by painful swelling and
inflammation of the lymph nodes especially in the region of the
groin.
Also known as
• Climatic bubo
• Durand–nicolas–favre disease
• Poradenitis inguinale
• Strumous bubo
• Granuloma genitoinguinale

3. • Causative agent - Chlamydia trachomatis types L1, L2 and
L3
 Chlamydia trachomatis has 17 subtypes
 Additional variants have been described such as L2b, the strain
currently found in MSM (male sex with male)
• Incubation period - 1 - 4 weeks
• Penetration:
 It gains entrance through breaks in the skin or it can cross
the epithelial cell layer of mucous membranes.
 The organism travels from the site of inoculation down the
lymphatic channels to multiply within mononuclear
phagocytes of the lymph nodes it passes.

4. CLINICAL FEATURE
(Depends on the site of inoculation LGV)
• Inguinal disease (usually after inoculation of the genitalia)
or
• Anorectal syndrome (usually after inoculation via the rectum)
The clinical presentation is divided into
• Primary
• Secondary
• Tertiary patterns.

5. Primary Lesion (seen in about one third of infected men, but rarely in women)
• Small painless papule or pustule to small herpetiform ulcer
(Groups of lesions resembling herpes infection)
• Mucopurulent discharge
 In men - The coronal sulcus, frenulum, penile shaft, foreskin,
glans, scrotum, urethra or anus
 In women - The posterior vaginal wall, posterior lip of cervix,
vulva and fourchette.
 Oral cases may occur in men and women following oral
sexual intercourse.
• Usually heals within one week and often remains

6. Second stage:
Inguinal stage (begins 2 to 6 weeks after onset of primary lesion)
• Spreads to lymph nodes through lymphatic
drainage pathways.
• This causes lymphadenitis and lymphangitis in the
regional lymph drainage
 Painful inflammation, enlargement, suppuration and
abscesses of the inguinal and/or femoral lymph nodes or
walls of the lymphatic vessels
Lymphadenitis- inflammation of lymphatic gland
Lymphangitis - inflammation of lymphatic channel

7. • Buboes (grossly enlarged tender
nodes) ruptures forming sinus or
fistula.
• Some patients develop the Groove
sign (due to separation of the
enlarged inguinal and femoral lymph
nodes by the inguinal ligament).

8. Sites of lymphadenopathy
• In male - Inguino-femoral lymphadenopathy (the inoculation
site is located on the external genitalia)
• In female - Intra-abdominal or retroperitoneal
lymphadenopathy may lead to symptoms of lower
abdominal pain or low back pain. (The inoculation site is located in
the rectum, upper vagina, cervix, or posterior urethra and these regions
drain to the deep iliac or perirectal nodes)
• If oral infection occurs then the submaxillary and cervical
lymph glands (Cervical lymphadenopathy and buboes) are
affected.

9. Other symptoms
Systemic Illness
• Flu like symptoms (Low-grade fever, chills, headache)
• Nausea, vomiting
• Malaise, myalgias and arthralgias, arthritis
• Pneumonitis or hepatitis, cardiac involvement, aseptic
meningitis and ocular inflammatory disease.

10. Tertiary stage
Anogenitorectal syndromes (can occur up to 20 years after infection)
• Initially develops proctocolitis (inflammation of the rectum and colon)
• Followed by peri-rectal abscess, fistulas, strictures and
stenosis of the rectum
• Possibly leading to lymphorrhoids
(Haemorrhoid-like swellings of obstructed rectal lymphatic tissue
- Digital rectal examination or proctoscopy may reveal a granular
mucosa and enlarged nodes beneath it)

11. Without treatment
• Chronic progressive lymphangitis leads to chronic
oedema and sclerosing fibrosis, resulting in renal
strictures and fistulas of the involved region, which can
ultimately lead to elephantiasis, esthiomene and the
frozen pelvis syndrome, Mega colon.
(Esthiomene - the chronic ulcerative disease of the external
female genitalia -an 'eating away' of the genitalia - There is chronic
hypertrophy and granulomatous enlargement of the vulva with
ulceration and erosion.

12. Investigations
• Culture - Samples of tissue fluid from ulcers or buboes or from a
tissue sample from the patient's rectum
• C. trachomatis NAAT test (nucleic acid amplification tests)
• CT imaging may be used to assess the extent of
lymphadenopathy
• Complement fixation (CF) test
• Microimmunofluorescence (micro-IF) tests
• LGV biovar-specific DNA
• Polymerase chain reaction (PCR) assays, strand displacement
amplification (SDA) or transcription mediated amplification
(TMA)

13. Management
 Antibiotics
• Azithromycin 1 g orally once weekly for 21 days.
• Doxycycline 100mg twice a day orally for 21 days.
(all tetracyclines, including doxycycline, are contraindicated during
pregnancy and in children due to effects on bone development and tooth
discoloration)
• Erythromycin 500mg four times a day orally for 21 days.
 Drainage of the buboes or abscesses by needle aspiration or incision
 Dilatation of the rectal stricture
 Repair of rectovaginal fistulae

14. Partner notification
• Sexual contacts within the last 3 months should identify and
treated.
Prognosis
• If diagnosed in the primary/secondary stages, full cure is
expected
• Tertiary cases may have long-term complications despite
bacteriological cure
• Relapse may occur in some cases
Example - A case was reported of proctitis and inguinal buboes treated with doxycycline 21
days, azithromycin 20 days and moxifloxacin for a further 12 days because of progressive
worsening of inguinal symptoms. Despite extensive antibiotic treatment, the inguinal
lymphogranuloma lesions persisted; however, the patient recovered spontaneously after
three months.

15. DIFFERENTIAL DIAGNOSIS
• Haemophilus ducreyi (Soft Chancre): Painful chancroid with unilateral
painful swollen lymph node that contain pus, often become matted and
rupture
• Herpes (HSV-1,2): Vesicular appearance (unique blister like lesions). This
can be misdiagnosed as chancroid after they ruptured, but Herpes often
has systemic symptoms (myalgia, fever) while chancroid often do not.
• Chlamydia Trachomatis (lymphogranuloma venereum): Painless
matted pus containing inguinal lymph node that develop more slowly than
chancroid. Another way to distinguish it from chancroid is that the lymph
node enlargement appear after the skin lesion disappear while skin lesion
and enlarged lymph node appear together in chancroid.
• Treponema pallidum (Syphilis): painless ulcer, bilateral non pus lymph
node.
• Granuloma inguinale: painless ulcer that look like syphilis, but inguinal
lymph enlargement is often absence in this disease (present in syphilis)