LGV - Lymphogranuloma venereum
Overview
- Lymphogranuloma venereum (LGV) is a rare condition in Australia but an increase has been observed in men who have sex with men (MSM), many of whom have also been HIV positive
- These men usually present with symptoms of proctitis
- LGV among MSM is common in North Europe and North America, and is endemic in the general population in several tropical areas such as South-East Asia, Southern Africa and India.
Cause
LGV is caused by the bacterium Chlamydia trachomatis, serovars L1-3 (Non-LGV genital chlamydia is caused by the other serovars D-K)
Clinical presentation
| Male | Female |
| Symptoms | |
Primary:
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Primary:
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Secondary:
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Secondary:
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Tertiary:
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Tertiary:
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| Complications | |
| Long term tertiary sequelae are rarely seen in Australia, but may occur with chronic untreated infection. | |
See STI Altas for images.
Special considerations
The site of the primary lesion depends on the site of inoculation. Proctitis is characterised by rectal pain, bleeding, rectal discharge, tenesmus and changed bowel habit. LGV in Australia is usually symptomatic, hence routine screening of asymptomatic patients is not recommended.Diagnosis
| Diagnosis in males | ||
|---|---|---|
| Test | Site/Specimen | Consideration |
| Chlamydia NAAT (Initial test; in patients with proctitis symptoms) |
Rectal swab | Clinician collected or Self-collection of samples for NAAT testingVaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient. Write on request form “Proctitis: NAAT. If chlamydia positive please send for LGV testing” |
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LGV specific NAAT |
Performed on same rectal sample collected for initial test |
Ensure laboratory have sent positive chlamydia samples from MSM with proctitis for LGV typing to local reference laboratory. |
| Chlamydia NAAT (Initial test to investigate ulcer) |
Swab from ulcers |
Clinician collected viral transport swab rolled directly over lesion. Chlamydia NAAT is not a routine test for genital ulceration and should only be performed in those with high clinical suspicion of LGV. |
| MSM – Men who have sex with men NAAT – Nucleic Acid Amplification Test LGV – Lymphogranuloma venereum |
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| Diagnosis in females | ||
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LGV is a very uncommon infection in women in Australia. If suspected, referral to a local Sexual Health or Infectious Diseases clinic is advised. |
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LGV – Lymphogranuloma venereum |
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Specimen collection
Urethral swabs for microscopy should be collected when the patient has not urinated for at least 1 hour and only if the patient has frank urethral discharge. Squeeze the urethra to express the discharge and collect on urethral swab. It is not necessary to insert the swab into the urethra. Vaginal swab: instruct the patient to insert the swab into the vagina like a tampon and then remove and place into the transport tube. Rectal swab: instruct the patient to insert the swab into the anal canal 2-4cms and then remove and place into the transport tube. FPU (First pass urine): Collect approximately 20 ml (1/3 of the standard urine jar) of the first part of the urine stream in a specimen jar at the time you are consulting the patient. The patient does not need to have held their urine for more than 20 minutes prior to specimen collection. A midstream urine (MSU) or early morning specimen (i.e. first void urine) are not required for NAAT. Click here for information on how to describe self-collection technique to a patient.Clinician collected for NAAT/culture/microscopy
Rectal swabs should be collected by inserting a sterile swab 2-4cms into the anal canal and moving the swab gently side to side for 10-20 seconds.
Pharyngeal swabs should be collected from the tonsils and oropharynx.
High vaginal swab of vaginal discharge smeared onto a glass slide, air dried and sent for microscopy. Swab inserted into transport medium for culture.Self-collection of samples for NAAT testing
Investigations
- Lymphogranuloma venereum (LGV) in men who have sex with men (MSM) is associated with a high rate of co-infection with gonorrhoea, syphilis, hepatitis C and/or HIV co-infection. Herpes simplex virus (HSV) can also cause symptoms of proctitis, therefore HSV NAAT should be taken at the time of consultation. Tests for these conditions should be conducted at the time of initial consultation, and at follow up. In addition to syphilis serology, syphilis NAAT can be performed from any area of ulceration.
- If proctoscopy is performed, a red, ulcerated, oedematous mucosa is typical, and may be accompanied by mucopurulent discharge. A gram stain showing >20 white cells/high powered film is suggestive of LGV.
Management
| Principal Treatment Options | ||
|---|---|---|
| Situation | Recommended | Alternative |
| Suspected or confirmed LGV |
Doxycycline 100mg PO BD for 21 days |
Alternative regimens are not recommended due to lack of efficacy data. If alternative regimen required, seek specialist advice. |
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LGV - Lymphogranuloma venereum |
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Treatment advice
- Studies have shown that lymphogranuloma venereum (LGV) DNA can persist in the rectum for up to 16 days after initiation of treatment, hence a long course (21 days) is required.
- At initial consultation for the patient with proctitis with a suspicion of LGV, treat also for gonorrhoea and chlamydia, in addition to 100mg doxycycline BD for 21 days. Consider addition of valaciclovir 500mg PO, BD for 7 days. LGV serovar results may take some time to return from the laboratory.
Other immediate management
- Advise no sexual contact for 21 days whilst taking treatment
- Advise no sex with partners from the last 3 months until until the partners have been tested and treated if necessary
- Contact tracing
- Provide patient with factsheet
- Primary care professionals do not have to notify the state/territory health departments about LGV.
Special treatment situations
Special considerations
Consider seeking specialist advice before treating any complicated presentation.| Situation | Recommended | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Persistence of symptoms despite initial treatment | Check other STI tests were done at initial consult. Seek specialist advice | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Pregnant women
For more information go to the Therapeutic Goods Association's Prescribing medicines in pregnancy database and/or seek specialist advice.  |
Seek specialist advice |
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| Allergy to principal treatment choice | Seek specialist advice | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Inguinal buboes | These may require drainage through normal skin under ultrasound guidance - seek specialist advice |
Contact tracing
- Lymphogranuloma venereum (LGV) is rare in Australia, therefore contact tracing is of high priority and should be performed in all patients with confirmed infection.
- Male and female partners should be traced back for a minimum of 1 month prior to the development of primary symptoms, or since arrival from an LGV endemic area if infection likely to have occurred overseas.
- If asymptomatic, contact tracing for sex partners in the last 6 months is recommended.
See Australasian Contact Tracing Manual – LGV for more information.
Follow up
Review in 1 week provides an opportunity to:
- Review results from initial consultation.
- Confirm patient adherence with treatment and assess for symptom resolution
- Confirm contact tracing procedures have been undertaken or offer more contact tracing support
- Provide further sexual health education and prevention counselling.
Test of Cure (TOC)
- Test of cure by chlamydia Nucleic Acid Amplification Test (NAAT) should occur at 6 weeks (3 weeks after treatment completion).
- If TOC positive, seek specialist advice. This sample should be sent for Lymphogranuloma venereum (LGV) testing if positive to confirm LGV persistence. If negative, there is no need to send for LGV testing.
Retesting
- A full STI screen including syphilis, HIV (if negative initially) and hepatitis C testing should be performed at 3 months, and then as required depending on clinical guidelines e.g. guidelines for men who have sex with men (MSM)
Auditable outcomes
- 100% of patients diagnosed with lymphogranuloma venereum (LGV) have contact tracing completed (patient or provider).
- 100% of patients are recommended to repeat HIV and hepatitis C testing at 3 months.
References
BASHH LGV Guideline 2013- http://www.bashh.org/documents/2013%20LGV%20guideline.pdf
IUSTI-Europe LGV guideline 2013 http://www.iusti.org/regions/Europe/pdf/2013/LGV_IUSTI_guideline_2013.pdf
CDC LGV guideline 2010 http://www.cdc.gov/std/treatment/2010/genital-ulcers.htm#lymphogranuloma