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Lymphogranuloma Venereum (LGV) in MSM

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Cause

  • Chlamydia trachomatis serovars L1, L2, and L3.
    • The L2 serovar has predominated among LGV cases in MSM.
  • LGV is uncommon in developed countries, however, cases have increasingly occurred among men who have sex with men (MSM) where it mainly causes rectal infection.

Clinical presentation

  • Can lead to proctitis with symptoms such as anorectal pain, discharge, tenesmus, bleeding and constipation.
    • In some cases, this can be severe and chronic, mimicking inflammatory bowel disease.
  • Asymptomatic cases of rectal LGV can also occur.
  • Less commonly, LGV can also cause genital ulceration with inguinal bubo (abscess) formation.
  • MSM who have a positive anal chlamydia test should be assessed for symptoms of proctitis.
    • MSM who present with symptoms of proctitis should be tested for chlamydia using an anal swab.
  • Men who are asymptomatic contacts of LGV should be screened for chlamydia with urine and an anal swab.

Diagnosis

Test

Site/Specimen

Comments

NAAT

Swab

Aspirated fluid from inguinal buboes

The LGV serovars can specifically be identified through genotyping of the chlamydia positive sample; however, not all laboratories are able to perform genotyping.

Serology for C. trachomatis

Blood

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.

Management

Index patient

Condition

Recommended

Extra comments

LGV

Doxycycline 100mg PO, twice daily for 21 days

OR

Azithromycin 1g PO, once per week for 3 doses.

Doxycycline is preferred over azithromycin as clinical data are lacking for azithromycin.

 

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

Sometimes LGV can be more severe. In these cases, more prolonged treatment or treatment with alternative antibiotics may be required. This should be discussed with a senior clinician. Men who have positive anal chlamydia results, whether LGV or otherwise, should have a repeat anal swab for chlamydia one month after commencing treatment as a test of cure.

 

Sexual partner(s)

  • 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 Doxycycline 100mg orally twice daily for 21 days.
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 Feb 2021

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