Lymphogranuloma Venereum

What is lymphogranuloma venereum (LGV) ?

Lymphogranuloma venereum, also known in french as Nicolas-Favre disease, is a sexually transmitted illness. The pathogen or bacteria responsible for this infection is Chlamydia Trachomatis. There are several different types of chlamydia trachomatis, with the majority of infectious sub-types only capable of inducing a superficial infection of the skin. The more virulent sub-types L1-L3 are capable of provoking a much more serious infection including generalized symptoms and associated genital ulcerations.

Is LGV frequent ?

It must be stated first off, that LGV infections are mostly concentrated in the tropical and sub-tropical regions of the world. In these latter regions, LGV is implicated in approximately 2-10 % of genital ulcerations (open sores). In Canada, an LGV infection is typically a sporadic, infequent affliction that is imported from afar by individuals engaging in sexual activities at risk (tourists, immigrants and military personnel, etc.).

How is the microbe responsible for LGV transmitted?

This infection is transmitted via sexual relations with an individual infected and in the contagious phase of lymphogranuloma venereum. Sexual contact includes genital-genital, genital-oral and/or genital-anal relations. Penetration is not required for disease transmission.

What is the incubation period for LGV ?

The incubation period for LGV (the time interval between sexual contact and the appearance of symptoms) varies on average from 10 to 14 days. At times the incubation period may be as long as up to 6 weeks after sexual contact with an infected partnerl.

What are the symptoms of LGV ?

This infection is frequently divided into three stages.

1st Stage

Subsequent to the incubation period, a small non-painful papule (pimple) appears and evolves over several days into a superficial ulcer (open wound). In the majority of individuals infected this stage passes unnoticed given its rapid healing (and this, even without treatment).

2nd Stage

2 – 4 weeks after the primary lesion has healed, LGV passes into the second stage of infeciton with the development of swollen inguinal (groin region) lymph nodes (the activity centers of your immune system). These lymph nodes (on the same side as the initial pimple and ulcer) become swollen and are generally quite painful. There is quite often an associated redness over the region of the swollen lymph nodes. At times, these nodes may actually open up to the outside of the skin and drain a creamy white pus. The second stage may also be accompanied by generalized symptoms including : fever, fatigue, headaches, nausea and vomiting and occasional limb pains (arms and legs).

3rd Stage

If treatment is not initiated, these ulcerations or open sores can become badly scarred causing significant obstruction of the lymphatic vessels (the conduits that remove and transport excess body fluids). This latter complication can result in the disorder known as elephantiasis, wherein, extremely abnormal and excessive swelling of the genitals occurs. Generalized symptoms, similar to those described in the second stage can also occur in the third stage.

Men and LGV

The initial LGV papule may appear on the gland (penile head), the foreskin, the shaft or body of the penis, or the entrance to the urethra (known as the meatus). The anus or rectum may also be affected, as can the scrotum or thighs. The genital ulcer may at times be accompanied by a purulent (pus) urethral discharge in men. When elephantiasis occurs in the advanced stages of LGV in men, the genital swelling is characterized by an increased volume of the penis or scrotum. When the initial infection manifests at the level of the anorectal region (anus and rectum), there may be eventual rectal complications including difficulty with defecation (having bowel movements).

Women and LGV

In women, LGV is primarily located in the vagina, on the labia majora or minora, and/or the peri-anal region. Very rarely is LGV localized to the uterine cervix (entrance to the uterus found at the end of the vagina). In the case of women, extra-genital lesions (outside of the genital zone) are infrequent. The genital ulceration(s) may be accompanied by a purulent (pus) cervical or vaginal discharge in women. When elephantiasis occurs in the advanced stages of LGV in women, it is characterized by a dramatic increase in the volume of the genital labia. When the initial infection manifests at the level of the anorectal region (anus and rectum), there may be eventual rectal complications including difficulty with defecation (having bowel movements).

LGV and pregnancy?

In the event of a diagnosis of LGV during pregnancy, the risk of transmission from the mother to newborn is primarily during the passage through the birth canal during spontaneous vaginal delivery. Antibiotics available for use in the treatment of LGV are selected based on their safety profile during the different stages of pregnancy. Your physician will assist you in determining the best antibiotic for you.

How is LGV diagnosed ?

LGV is difficult to diagnose based on the clinical examination alone. This difficulty is greater when in the context of regions of the world where the incidence of LGV is very low (not many cases). The technique of culturing the base of the ulcer or wound with a cotton or dacron-based swab is only helpful in identifying the microbe responsible in 30 % of cases…not great!! This being said, if the clinical diagnosis and history (travel or high risk partner) are present, and highly suspicious of LGV, the diagnosis may be confirmed by the dosing of anti-chlamydial antibody levels (this is a blood test specific to the microbe responsible for the infection). This type of serological (blood) confirmation requires two samples – the first at the beginning when LGV is suspected and two weeks later (after the symptoms have commenced)..It generally takes two weeks for the antibody levels to rise and be detected in the blood. These same antibodies may remain elevated in the blood for long periods of time even after treatment has been completed and LGV is cured.

Is there a treatment for LGV ?

The treatment of choice for LGV remains the antibiotic doxycycline, taken by mouth (per os) for a period of three weeks. There are alternatives to doxycycline for those individuals allergic, intolerant or pregnant. Pregnant women should not take doxycycline as it may increase the risk for birth defects. On occasion, if the inguinal lymph nodes are greatly swollen, it may be necessary for your doctor to incise (open) and drain or aspirate (via a needle) the node in an attempt to prevent the potential ulcerations, scarring and their associated complications. Patients who are also infected with HIV/AIDS may be treated with the same medications, however, the duration of treatment may be prolonged if resolution of lesions and symptoms is not rapid.

Your physician will assist you in determining which medication is appropriate for you.

Who is at risk of contracting LGV ?

The risk of contracting LGV is greatest when an individual has unprotected sexual relations (without a condom), with or without vaginal, anal or oral penetration by the penis with :

• A new sexual partner (male or female), even an occasional partner, if they have never undergone an STI screen to rule out the possibility of a sexually transmitted illness including LGV;
• A partner who has multiple sexual partners (without you being necessarily aware of this fact);
• More than one sexual partner;
• A one night stand or anonymous sexual partner;
• A sexual partner who works in the sex-trade (escort, prostitute, etc.);
• A partner from a tropical or sub-tropical country.

How can an individual infected with LGV prevent transmission?

• The systematic use of a condom ensures a good measure of prevention with respect to all sexually transmitted illnesses, including LGV. The condom must be used appropriately and must not be expired (check the date).
• In the presence of a papule (pimple), ulcer or unusual redness, it is important to refrain from sexual activities and to consult your physician.
• It is important to discuss issues of sexual health with all sexual partners. Ask your current or new sexual partner about their previous sexually transmitted illness history. Have they ever done screening test?
• Ensure that all sexual partners (in the previous 1 to 90 days, or one to three months) are advised of your diagnosis of LGV so as to effectively break the chain of transmission of this infection. This is important so as to ensure the prevention of reinfection.

How can I avoid contracting LGV ?

• Use a latex or polyurethane condom (male, female or dental dam- for oral-genital sex) at all times with all partners, and particularly recent or new sexual partners.
• Sexual abstinence or a stable monogamous sexual relationship with a partner free of sexually transmitted illnesses, and free of genital lesions is an effective means of preventing LGV as well as other STI’s in the sexually active adult.