Lymphogranuloma Venereum
A sexually transmitted infection caused by specific strains of Chlamydia trachomatis
Quick Facts
- Type: Sexually Transmitted Infection
- ICD-10: A55
- Cause: Chlamydia trachomatis L1-L3
- Treatment: Antibiotics (21-day course)
Overview
Lymphogranuloma venereum (LGV) is a sexually transmitted infection caused by specific serovars (L1, L2, and L3) of Chlamydia trachomatis. Unlike the more common genital chlamydial infections, LGV is characterized by invasive, systemic, and chronic disease that progresses through distinct stages. The infection primarily affects the lymphatic system and can cause significant complications if left untreated.
LGV was first described in the early 20th century and is endemic in parts of Africa, Asia, South America, and the Caribbean. In developed countries, it was historically rare but has seen a resurgence, particularly among men who have sex with men (MSM) in urban areas. The infection is highly transmissible and can spread through various forms of sexual contact, including anal, vaginal, and oral sex.
The disease typically progresses through three stages: a primary stage with small, painless genital lesions; a secondary stage characterized by painful lymph node enlargement; and a tertiary stage involving chronic complications such as lymphatic obstruction, rectal strictures, and genital elephantiasis. Early diagnosis and treatment with appropriate antibiotics can prevent progression to the more serious tertiary stage and reduce transmission to sexual partners.
Symptoms
LGV symptoms progress through distinct stages and can vary significantly between individuals. The presentation may differ based on the site of infection and the patient's immune status.
Primary Symptoms
Primary Stage (3-30 days after exposure)
- Small genital lesion: Usually painless papule, vesicle, or shallow ulcer
- Urethral discharge: In men with urethral involvement
- Cervicitis: In women, often asymptomatic
- Rectal symptoms: With receptive anal sex
- Oral lesions: With oral sexual contact
Secondary Stage (2-6 weeks after exposure)
- Painful lymph node enlargement (bubo): Most characteristic feature
- Fever and chills: Systemic symptoms
- Headache: Common systemic complaint
- Muscle and joint aches: Generalized body pains
- Nausea and vomiting: GI symptoms
- Rash: Skin manifestations in some cases
Lymph Node Involvement
- Inguinal lymphadenopathy: Enlarged groin lymph nodes
- Femoral lymphadenopathy: Upper thigh lymph node enlargement
- "Groove sign": Separation of inguinal and femoral nodes by inguinal ligament
- Fluctuant buboes: Lymph nodes that may rupture and drain
- Perirectal lymphadenopathy: With anorectal infection
Anorectal Syndrome
- Rectal pain and tenesmus
- Bloody or purulent rectal discharge
- Constipation
- Fever and constitutional symptoms
- Perirectal abscess formation
Tertiary Stage (months to years)
- Genital elephantiasis: Chronic lymphatic obstruction
- Rectal strictures: Narrowing of the rectum
- Fistula formation: Abnormal connections between organs
- Chronic ulceration: Non-healing sores
- Lymphedema: Swelling due to lymphatic blockage
Causes
Lymphogranuloma venereum is caused by specific serovars of Chlamydia trachomatis that have increased virulence and invasive properties compared to the more common urogenital chlamydial strains.
Causative Organism
- Chlamydia trachomatis serovars L1, L2, L3: More invasive than serovars A-K
- Obligate intracellular bacteria: Cannot survive outside host cells
- Complex life cycle: Elementary and reticulate body forms
- Lymphotropic properties: Tendency to invade lymphatic system
Transmission Routes
Sexual Transmission
- Vaginal intercourse: Penile-vaginal contact
- Anal intercourse: Insertive or receptive anal sex
- Oral sex: Oral-genital or oral-anal contact
- Genital-to-genital contact: Without penetration
Less Common Routes
- Vertical transmission: Mother to child during birth (rare)
- Contaminated objects: Fomites (extremely rare)
- Laboratory exposure: Occupational exposure to specimens
Pathophysiology
- Initial infection: Organisms enter through mucous membranes
- Local multiplication: Replication in epithelial cells
- Lymphatic spread: Migration to regional lymph nodes
- Inflammatory response: Host immune reaction causes tissue damage
- Chronic inflammation: Persistent infection leads to fibrosis
Factors Affecting Transmission
- Infectious load: Amount of organism present
- Mucosal integrity: Presence of cuts or abrasions
- Immune status: Compromised immunity increases susceptibility
- Concurrent STIs: Other infections may facilitate transmission
- Sexual practices: Receptive anal sex carries higher risk
Risk Factors
Several factors increase the risk of acquiring LGV or developing complications from the infection:
Behavioral Risk Factors
- Unprotected sexual activity: Sex without condoms or dental dams
- Multiple sexual partners: Increased exposure risk
- Men who have sex with men (MSM): Higher prevalence in this population
- Receptive anal intercourse: Particular risk for anorectal LGV
- Sex work: Commercial sex work increases exposure
- Anonymous sexual encounters: Difficult to trace and treat contacts
Geographic Risk Factors
- Endemic areas: Parts of Africa, Asia, South America, Caribbean
- Urban areas: Higher prevalence in metropolitan regions
- Travel to endemic regions: Increased exposure risk
- Areas with limited healthcare: Delayed diagnosis and treatment
Medical Risk Factors
- HIV infection: Increased susceptibility and severity
- Immunosuppression: Medications or conditions affecting immunity
- Other STIs: Concurrent infections facilitate transmission
- Previous LGV infection: Reinfection is possible
- Uncircumcised men: Slightly increased risk
Social Risk Factors
- Drug use: Injection drug use or substances affecting judgment
- Alcohol abuse: Risky sexual behavior when intoxicated
- Incarceration: Higher STI prevalence in correctional facilities
- Homelessness: Limited access to healthcare and prevention
- Sex for drugs/money: Transactional sex
Age and Gender Factors
- Young adults: Higher sexual activity and risk-taking
- Male gender: Higher reported incidence
- Adolescents: Limited access to sexual health services
Healthcare Access Factors
- Limited access to STI testing and treatment
- Inadequate sexual health education
- Stigma preventing healthcare seeking
- Lack of partner notification and treatment
Diagnosis
Diagnosing LGV requires a combination of clinical assessment, laboratory testing, and consideration of epidemiological factors. Early diagnosis is crucial for effective treatment and prevention of complications.
Clinical Assessment
Medical History
- Sexual history: Recent sexual contacts and practices
- Travel history: Visits to endemic areas
- Symptom timeline: Onset and progression of symptoms
- Previous STIs: History of sexually transmitted infections
- HIV status: Current HIV status and treatment
Physical Examination
- Genital examination: Looking for lesions or discharge
- Lymph node assessment: Palpation of inguinal, femoral nodes
- Anorectal examination: If indicated by symptoms or exposure
- Oral examination: For pharyngeal involvement
- Skin examination: Looking for rash or other manifestations
Laboratory Testing
Direct Detection
- Nucleic acid amplification tests (NAATs): PCR for C. trachomatis
- Specimen collection: Swabs from affected sites
- Urine testing: For urethral infections
- Rectal specimens: For anorectal LGV
Serological Testing
- Complement fixation test: Traditional serological method
- Microimmunofluorescence: More specific serological test
- ELISA-based tests: Enzyme-linked immunosorbent assays
- LGV-specific PCR: Molecular typing to confirm L-serovars
Specialized Testing
- Lymph node aspiration: For diagnosis in bubo stage
- Biopsy: Rarely needed, for chronic complications
- Culture: Less commonly used due to technical requirements
- Antigen detection: Direct fluorescent antibody testing
Supportive Tests
- Complete blood count: May show elevated white blood cells
- Erythrocyte sedimentation rate: Marker of inflammation
- C-reactive protein: Acute phase reactant
- Liver function tests: If systemic involvement suspected
Differential Diagnosis
- Other STIs: Herpes simplex, syphilis, chancroid
- Bacterial infections: Other causes of lymphadenitis
- Viral infections: Epstein-Barr virus, cytomegalovirus
- Malignancy: Lymphoma, metastatic cancer
- Inflammatory conditions: Crohn's disease, Behçet's disease
Contact Investigation
- Identification of sexual partners within 60 days
- Testing and treatment of exposed contacts
- Partner notification procedures
- Contact tracing for outbreak control
Treatment Options
LGV treatment requires prolonged antibiotic therapy to ensure eradication of the organism and prevent complications. Treatment recommendations differ from those for uncomplicated chlamydial infections.
First-Line Treatment
Doxycycline (Preferred)
- Dosage: 100 mg orally twice daily for 21 days
- Mechanism: Inhibits bacterial protein synthesis
- Effectiveness: High cure rates (>95%)
- Contraindications: Pregnancy, children under 8 years
Alternative Treatments
Erythromycin
- Dosage: 500 mg orally four times daily for 21 days
- Use: When doxycycline contraindicated
- Side effects: GI upset, drug interactions
Azithromycin
- Dosage: 1 g orally weekly for 3 weeks
- Advantages: Better tolerance, weekly dosing
- Limited data: Less clinical experience than doxycycline
Special Populations
Pregnancy
- Erythromycin: 500 mg QID for 21 days (preferred)
- Azithromycin: 1 g weekly for 3 weeks (alternative)
- Avoid doxycycline: Risk of dental staining in fetus
- Close monitoring: For treatment response and complications
HIV-Positive Patients
- Same antibiotic regimens as HIV-negative patients
- May require longer treatment courses
- Monitor for treatment failure
- Consider drug interactions with HIV medications
Symptomatic Treatment
- Pain management: NSAIDs or acetaminophen
- Fever reduction: Antipyretics as needed
- Bubo management: Aspiration if fluctuant
- Topical care: Sitz baths for anorectal symptoms
Surgical Intervention
- Bubo drainage: Aspiration or incision and drainage
- Stricture management: Dilation or surgical repair
- Fistula repair: Surgical correction of chronic complications
- Reconstructive surgery: For severe genital elephantiasis
Partner Treatment
- Sexual partners: Treat all partners within 60 days
- Empirical treatment: Start before test results available
- Same regimen: Use same antibiotics as index case
- Abstinence: No sexual activity until treatment completed
Follow-Up Care
- Clinical response: Improvement in symptoms within 3-7 days
- Test of cure: Not routinely recommended if asymptomatic
- Symptom persistence: Evaluate for treatment failure or reinfection
- Long-term monitoring: For chronic complications
Treatment Failure
- Extend treatment duration to 42 days
- Consider alternative antibiotics
- Rule out reinfection
- Assess compliance with treatment
- Evaluate for resistant organisms
Prevention
Preventing LGV involves comprehensive sexual health strategies, safe sexual practices, and public health measures to control transmission.
Primary Prevention
Safe Sexual Practices
- Consistent condom use: Latex or polyurethane condoms for all sexual contact
- Dental dams: For oral-anal contact
- Mutual monogamy: With tested, uninfected partner
- Abstinence: Complete avoidance of sexual contact
Risk Reduction
- Limit sexual partners: Reduce number of concurrent partners
- Partner selection: Avoid high-risk partners
- Avoid anonymous sex: Know sexual partners
- Substance use reduction: Avoid drugs and alcohol before sex
Secondary Prevention
Regular Screening
- High-risk populations: MSM, sex workers, multiple partners
- STI screening: Comprehensive testing for all STIs
- HIV testing: Regular HIV screening for high-risk individuals
- Annual screening: For sexually active individuals
Early Detection and Treatment
- Symptom awareness: Education about LGV symptoms
- Prompt medical care: Seek care for genital symptoms
- Contact tracing: Identify and treat sexual partners
- Partner notification: Inform partners of exposure
Public Health Measures
Education and Awareness
- Sexual health education: Comprehensive programs for all ages
- Risk awareness: Information about LGV and transmission
- Community outreach: Targeted programs for high-risk groups
- Healthcare provider training: Recognition and treatment of LGV
Access to Care
- STI clinics: Accessible, confidential testing and treatment
- Free or low-cost services: Remove financial barriers
- Same-day treatment: Rapid testing and immediate treatment
- Partner services: Contact tracing and partner treatment
Travel Prevention
- Pre-travel counseling: Sexual health advice for travelers
- Condom availability: Access to protection while traveling
- Post-travel screening: Testing after travel to endemic areas
- Avoid high-risk activities: Commercial sex, unprotected sex
Special Population Prevention
Men Who Have Sex with Men
- Targeted prevention programs
- Pre-exposure prophylaxis (PrEP) for HIV
- Regular STI screening
- Community-based interventions
Sex Workers
- Access to condoms and health services
- Regular STI screening and treatment
- Violence prevention and safety measures
- Drug treatment programs
Vaccine Development
- No current vaccine available
- Research ongoing for chlamydial vaccines
- Challenges in vaccine development
- Future prevention strategies
When to See a Doctor
Seek Immediate Medical Care
- Severe pelvic or abdominal pain
- High fever (>38.5°C/101.3°F) with genital symptoms
- Large, painful, or draining lymph nodes
- Severe rectal pain or bleeding
- Signs of systemic illness (severe fatigue, widespread rash)
- Inability to urinate or severe urinary symptoms
Schedule Urgent Appointment
- New genital sores or ulcers
- Painful or swollen lymph nodes in groin
- Unusual genital or rectal discharge
- Persistent fever with sexual exposure history
- Rectal symptoms after anal sexual contact
- Oral symptoms after oral sexual contact
Routine Screening
- Regular STI screening for sexually active individuals
- After unprotected sexual contact
- When starting new sexual relationship
- Annual screening for high-risk individuals
- Before discontinuing condom use with partner
Partner Notification
- If diagnosed with LGV, notify all sexual partners
- Partners from past 60 days need evaluation
- Partners should seek testing even if asymptomatic
- Complete treatment before resuming sexual activity
Follow-up Care
- If symptoms persist after treatment
- For monitoring of chronic complications
- Regular HIV testing if high-risk
- Ongoing sexual health counseling
Frequently Asked Questions
LGV is caused by specific, more invasive strains of Chlamydia trachomatis (L1-L3) that cause systemic disease and lymph node involvement. Regular chlamydia typically causes localized urogenital infection. LGV requires longer antibiotic treatment (21 days vs. 7 days) and can cause serious complications if untreated.
Yes, LGV can be completely cured with appropriate antibiotic treatment, typically 21 days of doxycycline. However, any structural damage (strictures, lymphedema) that occurred before treatment may be permanent and require additional management. Early treatment prevents most complications.
Yes, all sexual partners within the past 60 days should be notified, tested, and treated. LGV is highly contagious and partners may be infected even if they have no symptoms. Partner treatment is essential to prevent reinfection and stop transmission.
Yes, you can be reinfected with LGV since infection doesn't provide lasting immunity. After completing treatment, you can become infected again through sexual contact with an infected person. Continued safe sex practices and regular STI screening are important for prevention.
Yes, LGV and other STIs can increase the risk of HIV transmission by causing genital ulcers and inflammation that make HIV infection more likely. People with LGV should be tested for HIV and take extra precautions to prevent HIV infection, including considering PrEP if at high risk.
References
- Centers for Disease Control and Prevention. Sexually Transmitted Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187.
- Stamm WE. Lymphogranuloma venereum. Sex Transm Infect. 1999;75(2):90-92.
- Schachter J, Moncada J, Liska S, et al. Nucleic acid amplification tests in the diagnosis of chlamydial and gonococcal infections of the oropharynx and rectum in men who have sex with men. Sex Transm Dis. 2008;35(7):637-642.
- World Health Organization. Guidelines for the Management of Sexually Transmitted Infections. WHO. 2023.
- Spaargaren J, Fennema HS, Morré SA, et al. New lymphogranuloma venereum Chlamydia trachomatis variant, Amsterdam. Emerg Infect Dis. 2005;11(7):1090-1092.