Azithromycin - An Alternative to Doxycycline for Lymphogranuloma Venereum Proctitis

Introduction

Lymphogranuloma venereum (LGV) is a condition caused by Chlamydia trachomatis serotypes L1, L2, or L3 and is a sexually transmitted infection (STI). It affects the lymph nodes, essential to the body’s defense against infections. Lymphogranuloma venereum proctitis refers to the inflammation of the rectum and anus due to a lymphogranuloma venereum infection. It is common among men who have sex with men and women who engage in anal sex. It may present similar to inflammatory bowel diseases with clinical findings of hemorrhagic discharge, anal pain, constipation, etc. Lymphogranuloma venereum proctitis outbreaks have been reported to be highest in HIV (human immunodeficiency virus)-infected men who have sex with men.

What Causes Lymphogranuloma Venereum Proctitis?

Lymphogranuloma venereum is caused by the virulent and aggressive serotypes of Chlamydia trachomatis- L1, L2, and L3. These enter the body through a break in the skin or mucus membrane. Once the bacteria enters the body, it passes through the lymphatic system and multiples in the macrophages of the lymph node, causing systemic symptoms. Lymphogranuloma venereum proctitis is the inflammation of the rectal and anal region seen, especially in men who have sex with men and women who engage in receptive anal sex.

What Are the Signs and Symptoms of Lymphogranuloma Venereum Proctitis?

Symptoms of Lymphogranuloma venereum usually start three to 12 days after contracting the bacteria. The symptoms appear in three stages:

Stage 1: The primary stage appears with pus-filled painless blisters that wear away, leaving an open sore. These appear on the penis or scrotum in men and the vulva or the vaginal walls in women. They may also appear as sore in the mouth and throat.

Stage 2: The second stage appears two to six weeks after the primary symptoms. It presents with swollen, tender lymph nodes in the groin and the rectum called “buboes,” which may rupture and drain. And those that do not rupture may become hard and go away on their own. Proctitis (inflammation of the anus and rectum) and blood and mucus discharge from the rectum are seen in the second stage.

Other symptoms include:

• Abdominal pain.

• Back pain.

• Pelvic pain in women.

• Body pain.

• Constipation.

• Painful urination.

• Constant urge to defecate.

• Pain while passing stool.

• Fatigue.

• Weight loss.

• Headache.

• Fever.

Stage 3: The third stage is called the genito-anorectal stage and occurs when the lymphogranuloma venereum has not been properly treated. The proctitis develops into a more extensive proctocolitis, especially in men who have sex with men or women who engage in receptive anal sex. Other symptoms include anal fistulas, abscesses, enlarged groin, rectal strictures, pain while defecating, purulent discharge, deformed genitals, and scarring.

Who Are at the Risk of Developing Lymphogranuloma Venereum?

• People who live in tropical and subtropical regions.

• People who engage in unprotected sex.

• Men who have sex with men.

• Women who engage in receptive anal sex.

• People who are diagnosed with HIV (human immunodeficiency virus).

• People who do not wash their sex toys after use.

• People who do not keep proper hygiene.

• People who are associated with the commercial sex trade.

How Is Lymphogranuloma Venereum Proctitis Diagnosed?

Lymphogranuloma venereum proctitis is diagnosed by a physical examination to check for enlarged lymph nodes in the groin and inflammation of the rectal and anal region. Other tests that can help confirm a Chlamydia trachomatis infection include:

• Blood test.

• NAAT (nucleic acid amplification test).

• Immunoassays.

What Is the Treatment for Lymphogranuloma Venereum Proctitis?

Lymphogranuloma venereum is treated with antibiotics; the currently approved regimen is 100 mg Doxycycline twice daily for 21 days. Further treatment modalities include pus drainage from the lesions.

Can Azithromycin Be an Alternative to Doxycycline for Lymphogranuloma Venereum Proctitis?

Although the current regimen for lymphogranuloma venereum proctitis is 100 mg Doxycycline twice daily for 21 days, high-quality evidence regarding this regimen is apparent. Few researchers in Spain conducted a prospective, nonrandomized, open-label trial to check the efficacy of macrolide antibiotics; using extended Azithromycin.

They included 125 men who had sex with men (MSM) with proctitis, had recent unprotected anal sex, and had a positive test for lymphogranuloma venereum. 96% of the subjects were HIV positive. Among these subjects, 82 received extended Azithromycin (1000 mg once a week for three weeks), and 43 received Doxycycline (100 mg twice daily for 21 days). 98% of the subjects who received Azithromycin showed sustained clinical improvement compared to 95% of those receiving Doxycycline. In addition, after four weeks of treatment, 97% of those receiving extended Azithromycin produced a negative DNA(Deoxyribonucleic acid)-LGV swab test compared with 100% of the Doxycycline subjects.

The study results suggest that a weekly dose of Azithromycin given for three weeks was as effective as the recommended Doxycycline regimen for treating lymphogranuloma venereum proctitis. Hence Azithromycin can be used as an alternative to Doxycycline for lymphogranuloma venereum proctitis because of its lower pill burden. Although, more-rigorous research on this regimen will be required before adopting the approach.

How Can Lymphogranuloma Venereum Proctitis Be Prevented?

• Practice safe and protected sex.

• Do not engage in sex with multiple partners at a time.

• Wash and keep sex toys clean after every use.

• If one is diagnosed with lymphogranuloma venereum, Inform all the partners that one has engaged within the previous six months.

Conclusion

Lymphogranuloma venereum is a sexually transmitted illness caused by the virulent and aggressive serotypes of Chlamydia trachomatis. Proctitis is one of the main manifestations of the disease and is characterized by an inflammation of the anal and rectal regions. It is more common in men who have sex with men and women who engage in anal-receptive sex. However, early diagnosis and prompt treatment can ensure the patient's complete recovery without complications. The current regimen for treating lymphogranuloma venereum proctitis is 100 mg of Doxycycline twice daily for 21 days. But a weekly dose of 1000 mg of Azithromycin for three weeks has shown to be as effective as Doxycycline. Therefore, considering the benefits of lower pill burden and similar efficacy, Azithromycin can be considered an alternative to Doxycycline for lymphogranuloma venereum proctitis. However, further research on this finding may be required.