Lymphogranuloma Venereum Infection - Symptoms, Diagnosis, and Treatment

Introduction

Lymphogranuloma venereum is a sexually transmitted disease caused by the chlamydia species of bacteria, Chlamydia trachomatis. It is spread from person to person through unprotected vaginal, oral, or anal sex. It was historically considered rare in developed countries, but in recent years been increasingly recognized in Europe, the United Kingdom, and North America as causing outbreaks, particularly among men who have sex with men. It is most commonly seen in tropical and subtropical countries.

What Is Lymphogranuloma Venereum Infection?

Lymphogranuloma venereum is an ulcerative infection involving the lymphatics and lymph nodes; transmitted through unprotected vaginal, oral, or anal sex. It presents with painful and swollen blisters in the genital area caused by a specific aggressive strain of chlamydia bacteria.

What Causes Lymphogranuloma Venereum Infection?

Lymphogranuloma venereum infection is caused by; invasive and aggressive serotypes L1, L2, and L3 of Chlamydia trachomatis. These serotypes are more virulent than the other species of chlamydia. Also, this infection is different from the common genital chlamydia infection.

The infection occurs due to direct contact with: a break in the skin or mucous membrane; it does not penetrate intact skin. Instead, the bacteria enter the body and travel down the lymphatic channels to multiply within macrophages of the lymph nodes it passes through and causes systemic disease.

Who Is at Risk of the Disease?

• Lymphogranuloma venereum infection is seen in people worldwide, but people in tropical or subtropical climates are at risk of the disease.

• Sexually active people in the age group between 15 years to 40 years are at the highest risk of the disease.

• Although both men and women can get the disease, the disease depicts a slight male predilection, particularly in men who have sex with other men. However, it is diagnosed in the early stages in men - because of the visible signs; later stages with complications in women.

• People who are HIV (human immunodeficiency virus) positive are at risk of the disease.

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• People who have unprotected sex.

• People who share sex toys or use them without washing them after every use.

• People who work in the commercial sex trade.

• People who practice anal sex, fisting, and having sex with multiple partners.

What Are the Signs and Symptoms of Lymphogranuloma Venereum?

Some people show no symptoms but can pass the infection to a partner.

The symptoms depend on the area of entry of the organism:

• Entry Through the Mucous Lining of the External Sex Organ (Penis or Vagina): This is the inguinal syndrome - pus-filled abscesses in the groin region at the location of the lymph nodes.

• Anal Entry: This is the rectal syndrome - inflammation of the rectum, colon, and anus.

• Oral Entry: This is the pharyngeal syndrome - inflammation of lymph nodes in the neck and infection of pharyngeal tissue.

Symptoms at Each Stage of Lymphogranuloma Venereum:

• First Stage: The first or the primary stage occurs three to thirty days after the infection and presents with a self-limited painless small pus-filled lesion that may wear away to leave an open ulcer. These may be seen in the vaginal walls or the vulva in women and the scrotum or the penis in men. Hence, these usually go unnoticed, especially in females. The ulcer has no symptoms and goes away in a few days.

• Second Stage: This stage occurs two to six weeks after the primary lesion and presents with swelling of the groin or other lymph nodes. Other symptoms like fever, chills, and fatigue may also be present. Few people may develop a "groove sign" due to the pressure from the tight ligament that separates the groin lymph nodes. These lymph nodes join together to form "buboes," which may rupture and drain. And those that do not rupture may become hard and then slowly subside on their own. Only 20- 30 % of women may present enlarged inguinal lymph nodes and have only mild nonspecific back or belly pain. In the case of anal infection, blood or mucus may come out from the rectum. Men are usually diagnosed at this stage. However, it would be difficult to diagnose in women at this stage; because of the absence of enlarged inguinal lymph nodes.

• Third Stage: This stage is called genito-anorectal syndrome. The first symptoms in most women are seen at this stage. The symptoms include pain during defecation, abscesses, bloody purulent discharge, and scarring. Men and women who practice receptive anal sex may have a rectal infection (proctocolitis), especially in men who have sex with other men.

In the case of a genital tract infection, the lymphatic system may be damaged, resulting in swelling of the genitals, and draining from scarred areas of the skin due to the tissue infection.

How Is Lymphogranuloma Venereum Diagnosed?

The doctor would first take the patient's complete medical history, symptoms, and sexual history. Further, the doctor may perform a physical examination to check for inguinal lymph node enlargement, genital ulcers, or proctitis.

Confirmatory tests include:

• Blood Tests - To check for antibodies against Chlamydia trachomatis.

• Nucleic Acid Amplification Test (NAAT) - To look for Chlamydia trachomatis in samples taken from the groin, rectum, or lymph node.

• Direct tests for chlamydial antigens with immunoassays.

How Is Lymphogranuloma Venereum Treated?

Lymphogranuloma venereum infection is treated with antibiotics (Doxycycline, alternatively with Erythromycin or Azithromycin) for three weeks. Painful pus-filled lymph nodes are drained with a needle to relieve the discomfort. Patients should avoid sexual contact until 21 days until the course of antibiotic treatment is complete - to not pass the disease to others. All sexual partners of the patient within the month of onset of symptoms; should be notified and tested. If there are no symptoms, inform all the sexual partners of the previous six months.

What Are the Complications of Lymphogranuloma Venereum?

If the condition is left untreated, many complications may occur:

• Anal fistulas.

• Enlarged genitals.

• Infertility.

• Arthritis.

• Hepatitis.

• Pneumonitis.

• Rectal strictures.

• Obstruction of the lymphatic system.

How Can Lymphogranuloma Venereum Be Prevented?

• Do not engage in unsafe sex, including multiple sexual partners at a time.

• Use condoms, and practice protected sex.

• Do not share sex toys with others; wash and clean sex toys after a single use.

• Wash the genital region after sex.

• Notify all partners; if a sexually transmitted disease is suspected and get appropriate treatment as suggested by the healthcare provider.

Conclusion

Lymphogranuloma venereum is a bacterial infection transmitted through sexual intercourse. It may transmit through anal, vaginal, or oral sex. The disease is caused by an aggressive and invasive form of Chlamydia trachomatis. Symptoms of the disease include swollen lymph nodes in the groin and rectum region. The complications of the disease include infertility and enlarged genitals. However, with taking appropriate treatment, it is possible to acquire a complete recovery.