Lymphogranuloma Venereum (LGV) in MSM

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LGV is uncommon in developed countries, however, cases have occurred among men who have sex with men (MSM). Most of these men have presented with symptomatic proctitis. Typical symptoms include anorectal pain, discharge, tenesmus, and constipation. Asymptomatic cases of rectal LGV can also occur.
A high proportion of MSM with LGV have been HIV positive. LGV can also cause genital ulceration with inguinal bubo formation.
LGV is caused by Chlamydia trachomatis serovars L1, L2, and L3. The L2 serovar has predominated among LGV cases in MSM.

DIAGNOSIS

LGV will be detected using nucleic acid amplification testing for chlamydia. The LGV serovars can specifically be identified by amplification and sequencing of the C. trachomatis omp1 gene.
All MSM who present with symptoms of proctitis should be tested for chlamydia using a rectal swab. Please also refer to the MSHC treatment guideline on proctitis for other relevant tests.
If the chlamydia result is positive, then the testing laboratory should be notified so that the specimen can be genotyped to identify LGV. Aspirated fluid from inguinal buboes should also be sent for chlamydia testing and genotyping. It is MSHC policy to forward all positive anal chlamydia swabs in HIV positive MSM for genotyping even among those who are asymptomatic for proctitis.
Men who are asymptomatic contacts of LGV should be screened for chlamydia in the usual way with urine and an anal swab. If these are positive then genotyping should be ordered as above.
Serology for C. trachomatis can sometimes assist in the diagnosis of LGV, e.g., when the rectal swab is negative or if it is not possible to amplify the omp1 gene. High antibody titres are often found with LGV, which is not usually the case with uncomplicated genital chlamydial infection. Serology does not, however, distinguish between LGV and non-LGV serovars.

TREATMENT

All MSM who present with symptomatic proctitis that is positive for rectal C. trachomatis should be treated presumptively for LGV, irrespective of the result from omp1 gene sequencing which may not be available for several weeks.

Recommended treatment

  • Doxycycline 100mg orally twice daily for 21 days OR

Alternative treatment

  • Erythromycin 500mg orally four times daily for 21 days OR
  • Azithromycin 1gm orally once per week for 3 doses.
  • Doxycycline is preferred over azithromycin as clinical data are lacking for azithromycin.
FOLLOW UP

All MSM who have a positive anal chlamydia test should be carefully assessed for symptoms of proctitis (see above). Men who have positive anal chlamydia results, whether LGV or otherwise, should have a repeat anal swab for chlamydia at one month after commencing treatment as a test of cure. If rectal chlamydia persistent at 4 weeks send for LGV testing.

CONTACTS

Contact tracing for LGV should be initiated. All asymptomatic sexual partners of men with LGV should be screened for LGV (see above) and offered treatment with azithromycin 1 gram at the initial visit.

NOTIFICATION

LGV is notifiable to the Victorian Health Department by doctors and laboratories and a notification form should be completed.

Disclaimer
The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines. The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.

Last Updated January 2017