Lymphogranuloma venereum (LGV) is a sexually transmitted systemic disease (STD) caused by a parasitic organism closely related to certain types of bacteria. It affects the lymph nodes and rectal area, as well as the genitals, in humans. The name comes from two Latin words that mean a swelling of granulation tissue in the lymph nodes resulting from sexual intercourse. Granulation tissue is tissue that forms during wound or ulcer healing that has a rough or lumpy surface.
Although LGV is easily treated in its early stages, it can produce serious complications in its later stages. LGV is most likely to occur among people living in tropical or subtropical countries and among military personnel or tourists in countries or large cities with high rates of the disease. Prostitutes play a major role in carrying and transmitting LGV, as was documented during an outbreak in Florida in the late 1980s. There are about 1,000 documented cases of LGV in the United States in an average year.
Causes and symptoms
LGV is caused by Chlamydia trachomatis, a globe-shaped parasitic organism that reproduces only inside of living cells. C. trachomatis has 17 subtypes and is responsible for a wide range of infections in both men and women; however, only subtypes L1, L2, and L3 cause lymphogranuloma venereum. The parasite has a two-part lifecycle. In the first stage, it is inert and can survive outside of cells. In its second stage, it lacks a cell wall and actively reproduces after gaining entry to a cell. As the chlamydia organism reproduces inside the cell, it pushes the nucleus aside and forms an inclusion that can be identified with tissue staining. LGV differs from other diseases caused by C. trachomatis in that it affects the body's lymphatic system and not just the moist tissues of the genital region. In humans, the chlamydia organism is transmitted through vaginal or anal intercourse, oral sex, or contact with fluid from open ulcers or infected tissues.
Lymphogranuloma venereum has three stages. In its primary stage, the disease is more likely to be detected in men; it may go unnoticed in women. After an incubation period of four to 30 days, a small painless ulcer or blister develops in the genital area. Second-stage LGV develops between one and six weeks later. In this stage, the infection spreads to the lymphatic system, forming buboes (swellings) in the lymph nodes of the groin area.
The buboes often merge, soften, and rupture, forming sinuses and fistulas (hollow passages and ducts) that carry an infectious bloody discharge to the outside of the body. Patients with second-stage LGV may also have fever, nausea, headaches, pains in their joints, skin rashes, and enlargement of the spleen or liver. Third-stage LGV, which is sometimes called anogenitorectal syndrome, develops in about 25% of patients. In men, this stage is usually seen in homosexuals. Third-stage LGV is marked by rectal pain, constipation, a discharge containing pus or bloody mucus, and the development of strictures (narrowing or tightening of a body passage) in the rectum or vagina.
LGV can have a number of serious complications. C. trachomatis infections of any subtype are associated with long-term fertility problems in women. Strictures in the rectum can completely close off the lower bowel, producing eventual rupture of the bowel and inflammation of the abdominal cavity. The patient can develop chronic abscesses or fistulae in the anal area or in the vagina in women. Long-term blockages in the lymph nodes can produce elephantiasis, a condition in which the patient's upper legs and groin area become greatly enlarged. Patients with chronic LGV infection have a higher risk of developing cancer in the inflamed areas.
Chronic LGV can be reactivated in patients who become infected with the AIDS virus. These patients develop open ulcers in the groin that are difficult to treat.
The diagnosis of LGV is usually made on the basis of the patient's history, careful examination of the genital area and lymph nodes, and blood tests or cultures to confirm the diagnosis. In the early stages of the disease, the doctor will need to distinguish between LGV and such other STDs as syphilis and herpes. If the patient has developed buboes, the doctor will need to rule out tuberculosis, cat-scratch disease, bubonic plague, or tularemia (a disease similar to plague that is carried by rabbits and squirrels). If the patient has developed rectal strictures, the doctor will need to rule out tumors or colitis.
There are several blood tests that can be used to confirm the diagnosis of LGV. The most commonly used are the complement fixation (CF) test and the microimmunofluorescence (micro-IF) tests. Although the micro-IF test is considered more sensitive than the CF test, it is less widely available. An antibody titer (concentration) of 1:64 or greater on the CF test or 1:512 or greater on the microIF test is needed to make the diagnosis of LGV. In some cases, the diagnosis can be made from culturing C. trachomatis taken from samples of tissue fluid from ulcers or buboes, or from a tissue sample from the patient's rectum.
LGV is treated with oral antibiotics, usually tetracycline or doxycycline for 10-20 days, or erythromycin or trimethoprim sulfamethoxazole for 14 days. Pregnant women are usually treated with erythromycin rather than the tetracyclines, because this class of medications can harm the fetus.
Patients who have developed second-and third-stage complications may need surgical treatment. The doctor can treat buboes by withdrawing fluid from them through a hollow needle into a suction syringe. This procedure is called aspiration. Fistulas and abscesses also can be treated surgically. Patients who develop elephantiasis are usually treated by plastic surgeons. Patients with rectal strictures may need surgery to prevent bowel obstruction and rupture into the abdomen.
The prognosis for recovery for most patients is good, with the exception of AIDS patients. Prompt treatment of the early stages of LGV is essential to prevent transmission of the disease as well as fertility problems and other serious complications of the later stages.
Prevention of lymphogranuloma venereum has four important aspects:
- Avoidance of casual sexual contacts, particularly with prostitutes, in countries with high rates of the disease.
- Observance of proper safeguards by health professionals. Doctors and other healthcare workers should wear gloves when touching infected areas of the patient's body or handling soiled dressings and other contaminated items. All contaminated materials and instruments should be double-bagged before disposing.
- Tracing and examination of an infected person's recent sexual contacts.
- Monitoring the patient for recurring symptoms for a period of six months after antibiotic treatment.
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Hill, Edward C. "Gynecology." In Current Surgical Diagnosis and Treatment. 10th ed. Ed. Lawrence W. Way. Stamford: Appleton & Lange, 1994.
"Infectious Disease: Sexually Transmitted Diseases." In The Merck Manual of Diagnosis and Therapy. 17th ed. Ed. Robert Berkow. Rahway, NJ: Merck Research Laboratories, 1997.
Thomas, Isabelle, et al. "Lymphogranuloma Venereum." In Current Diagnosis. Vol. 9. Ed. Rex B. Conn, et al. Philadelphia: W. B. Saunders Co., 1997.
Rebecca J. Frey
Anogenitorectal syndrome—Another name for third-stage LGV.
Aspiration—A procedure in which pus or other fluid is removed from a body cavity through a hollow needle connected to a syringe.
Bubo—An inflamed swelling inside a lymph node, characteristic of second-stage LGV.
Elephantiasis—Abnormal enlargement of the legs and groin area caused by blockage of the lymphatic system, as a complication of LGV.
Fistula—A passageway formed by a disease or injury that drains fluid from an infected area to the outside or to other parts of the body.
Lymph—A clear yellowish fluid that circulates throughout the body, carrying white blood cells and fats. The system that produces and circulates lymph is called the lymphatic system; it includes lymph vessels, lymph nodes, the thymus gland, and the spleen.
Proctitis—Inflammation of the anus and rectum.
Stricture—An abnormal narrowing or tightening of a body passage. LGV can cause strictures to form in the patient's rectum, or in the vagina of female patients.