SAN FRANCISCO — Lymphogranuloma venereum, once common among gay men but rare in the United States for the last decade, may be poised to make a comeback, Gail Bolan, M.D., said at a meeting on HIV management sponsored by the University of California, San Francisco.
The Centers for Disease Control and Prevention recently reported on an outbreak of lymphogranuloma venereum (LGV) among men who have sex with men in the Netherlands (MMWR 2004;53:985-8).
There has been one confirmed U.S. case of the opportunistic infection out of Emory University (Atlanta), and the New York City Department of Health and Mental Hygiene announced the discovery of two others in New York in February. Another possible case from San Francisco has not yet been confirmed, said Dr. Bolan, chief of the sexually transmitted disease control branch of the California Department of Health Services, in Berkeley.
LGV is common in Africa, Southeast Asia, Central and South America, and the Caribbean but has been rare in developed countries in recent years.
The outbreak in the Netherlands included 92 confirmed cases during an 18-month period in 2003 and 2004, compared with an average of 5 cases annually during previous years.
Chlamydia trachomatis is the causative organism in LGV, but only certain serotypes are involved, not the ones responsible for garden-variety chlamydia infections. The classic presentation includes inguinal adenopathy (buboes). These start as painless papules, nodules, or ulcers that resolve spontaneously.
In the outbreak in the Netherlands, however, only one of the patients had a genital bubo. Most patients presented with GI symptoms, including bloody proctitis and mucopurulent anal discharge.
Other symptoms in this presentation, which is sometimes mistaken for Crohn's disease, include bleeding, tenesmus, fever, and constitutional symptoms. Anoscopy shows diffuse friability and discrete ulcerations.
The destructive granulomatous process can cause complications such as scarring, genital elephantiasis, fistulas, rectal strictures, and perianal abscesses.
The CDC's study of the Netherlands outbreak identified several risk factors, including unprotected receptive anal intercourse or fisting; casual-sex gatherings; and other concurrent STDs. Of the patients whose HIV status was known, 77% were HIV-positive.
A positive chlamydia test from the mucosal site or a bubo aspirate is necessary to confirm the diagnosis. For rectal lesions, it's better to get a swab under control by anoscopy than by taking a blind rectal swab, Dr. Bolan said.
But the available serologic tests are poorly standardized, she added. It's better, when possible, to confirm the presence of the specific LGV serotype by polymerase chain reaction sequencing or tissue culture and monoclonal antibodies.
The CDC's treatment guidelines recommend oral doxycycline, 100 mg b.i.d., for 21 days. Oral erythromycin, 500 mg four times daily for 21 days, is an alternative. Some experts also recommend oral azithromycin, 1 g weekly for 3 weeks, but this has never been formally evaluated.
Partners of affected patients (within the 30 days prior to the onset of symptoms) need evaluation. If these individuals are asymptomatic, they should be treated with doxycycline, 100 mg b.i.d., for 7 days, or with a single dose of 1 g of azithromycin.
Dr. Bolan stated that she has no financial relationships relevant to her presentation.