Lymphogranuloma venereum (LGV) is caused by the L1, L2, and L3 serotypes of C trachomatis and primarily affects lymphatic tissue. Primary LGV causes a self-limited painless genital ulceration that may not be noticed by the patient. The presence of pain and/or surrounding erythema, warmth, or tenderness of the area should raise concerns for an alternative diagnosis. Secondary LGV occurs several weeks later and causes painful femoral or inguinal lymphadenopathy. This may occur both above and below the inguinal ligament, causing the “groove sign” suggestive of LGV. Enlarged lymph nodes, or buboes, may spontaneously rupture. Patients with rectal exposure may present with rectal pain, drainage, and tenesmus due to proctocolitis, which may be mistaken for inflammatory bowel disease. Untreated disease can cause sinus tracts to skin, anogenital fibrosis, and strictures.
Management and Disposition
Treat with doxycycline 100 mg orally twice daily for 21 days. Alternatives are erythromycin 500 mg orally four times daily for 21 days or azithromycin 1 g orally once weekly for 3 weeks. Buboes should be aspirated or incised and drained to prevent rupture and subsequent fistula formation. Send sample of drainage for culture if diagnosis is in question. Asymptomatic sexual partners should be empirically treated with a single dose of azithromycin 1000 mg orally or doxycycline 100 mg orally twice daily for 7 days. Symptomatic sexual partners should undergo the full treatment course.
Lymphogranuloma Venereum. Unilateral left lymphadenopathy in a patient with lymphogranuloma venereum. (Photo contributor: Lawrence B. Stack, MD.)
Lymphogranuloma Venereum—Groove Sign. The appearance of the “groove sign” is due to inguinal node enlargement above and femoral node enlargement below Poupart’s ligament and is seen in 33% of patients with LGV. (Image appears with permission of VisualDx, www.visualdx.com.)
LGV is typically a clinical diagnosis initially; although C trachomatis testing is widely available, specific serotype testing is not.
Concurrent infection with other STIs is common.
Delayed diagnosis and treatment can result in sequelae such as genital elephantiasis, anal fistulae and strictures, and infertility.