Lymphogranuloma Venereum (LGV)

Background

Lymphogranuloma venereum (LGV) is a sexually transmitted infection caused by specific serovars of Chlamydia trachomatis that have the ability to invade and replicate in regional lymph nodes. This distinguishes LGV from other chlamydial infections, leading to more severe clinical manifestations.^[1]

Infections caused by LGV serotypes L1, L2, and L3 can present with genital ulcers, followed by painful inguinal and/or femoral lymphadenopathy, which may be the primary clinical symptoms. LGV also can involve the rectum, leading to ulceration, proctocolitis, and symptoms such as rectal pain, discharge, and bleeding, often resembling gastrointestinal conditions.^[2]

If left untreated, LGV can lead to complications such as disfiguring genital ulcers and lymphatic obstruction.^[3] The infection is more commonly diagnosed in men, particularly among men who have sex with men (MSM), and increasingly is reported in high-income countries.^{[4, 5, 6, 7, 8, 9]} Prompt diagnosis, appropriate treatment, and ongoing monitoring are essential to prevent long-term sequelae and reduce transmission of LGV in affected populations. Medical providers should remain vigilant in recognizing and managing LGV, especially in populations experiencing an increase in cases.

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Pathophysiology

Chlamydia trachomatis is an obligate intracellular bacterium. Of the 15 known clinical serotypes, only the L1, L2, and L3 serotypes cause LGV. These serotypes are more virulent and invasive compared to other chlamydial serotypes. Infection occurs after direct contact with the skin or mucous membranes of an infected partner. The organism does not penetrate intact skin. The organism travels by lymphatics to regional lymph nodes, where it replicates within macrophages and causes systemic disease. Although transmission is predominantly sexual, cases of transmission through laboratory accidents, fomites, and nonsexual contact have been reported.

The L2b serovar has been identified to play a more important role than previously expected. After the diagnosis of 92 cases of LGV in the Netherlands among MSM, Schachter et al evaluated samples obtained from rectal swabs between 1979 and 1985 from patients infected with HIV in San Francisco and between 2000 and 2005 in Amsterdam.^[10] The study revealed the same serotype circulating among patients with HIV and LGV during 1979 to 1985. This indicates the L2b serovar has been present and unrecognized for many years.

LGV occurs in 3 stages. The first stage, which often is unrecognized, consists of a rapidly healing, painless genital papule or pustule. The second stage, consisting of painful, often unilateral inguinal lymphadenopathy, occurs 2-6 weeks after the primary lesion. The third stage, which is more common in women and MSM, may have a delayed presentation and is characterized by proctocolitis.

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Epidemiology

Frequency

United States

LGV historically is a rare disease in developed countries, but is best thought of as a re-emerging STI.^[9]  Since 2003, sporadic outbreaks of LGV proctitis have been reported among MSM in North America, Europe, and Australia.^{[11, 12]} However, in the United States, a precise understanding of the prevalence is unknown for a combination of reasons: LGV as such is not a nationally notifiable condition - aside from the requirements to report Chlamydia infections; some states will attempt to track cases of LGV based on syndrome reporting, but most laboratories do not have the capability to either grow or serotype Chlamydia.^[13]  

No universal surveillance data exist for this disease. Twenty-four states still mandate reporting of LGV cases to the US Centers for Disease Control and Prevention (CDC), which provides limited data for disease prevalance. Since 1972, rates of LGV had declined, with 113 known cases reported to the CDC in 1997. In November 2004, the CDC began offering assistance to test for LGV in the United States. Between November 2004 and January 2006, LGV was identified in 180 specimens, with 27 specimens identified as being obtained from MSM. Of note, chlamydia rates have not decreased since 2012.^[14] A study published in 2011 reporting LGV surveillance data from multiple sites in the United States found that less than 1% of the samples obtained from rectal swabs of MSM that were positive for C trachomatis tested positive for LGV.^[15]   Much like in the United Kingdom, increasing reports of clusters of LGV transmission in the United States, particularly among MSM patients, have occurred.^[16]

International

LGV is an uncommon disease, although it may account for 2-10% of patients with genital ulcer disease in selected areas of India and Africa.^[17] The disease most commonly is found in areas of the Caribbean, Central America, Southeast Asia, and Africa. Since 2003, however, the emergence of documented LGV infections, mostly among MSM, but also in women, has prompted increased surveillance and reporting of this disease in developed countries.^{[18, 19]} Proctitis is reemerging as a presentation of LGV in developing countries.^[20]

After a cluster of 92 cases was identified in the Netherlands between 2003 and 2004 (where fewer than 5 cases were reported yearly),^[21] many countries have begun active surveillance for LGV, and an increasing number of cases has been identified. Evidence exists that among MSM, LGV is endemic in the United Kingdom; between 2004-2008, LGV was documented in 854 isolates by the National Reference Center there.^{[22, 23, 24, 25, 26, 27, 28]}  Evidence supporting the endemicity of LGV in the United Kingdom continues to be published, particularly from the LGV Enhanced Surveillance system which collected data from 2004-2010.^[9]  Over this 6-year period of data collection, 1370 cases were reported, of which 28 were females, heterosexual males or unknown, with the rest being MSM. Of note, nearly 80% of the patients with a single episode of LGV also were living with HIV; further complicating this rise in cases is evidence from the United Kingdom that a higher percentage of these cases may be asymptomatic.^[29]

An Austrian study found that LGV represented 23% of rectal CT-infections in MSM, and that 45% of LGV cases were asymptomatic.^[30] A French study found on universal testing of CT-positive anorectal samples that rates of LGV being asymptomatic were high, and increased from 36.1% in 2020 to 52.4% in 2022.^[31] A study in Australia demonstrated an increase in the proportion of asymptomatic LGV cases when universal screening of CT-positive rectal samples in men over the age of 25 years was used in place of only screening in the setting of symptoms or HIV-positivity.^[32] A recent study in Moscow, Russia of MSM seen by proctologists found 37.3% were CT positive, and of those, 68.8% were LGV positive.^[33]

Mortality/Morbidity

With appropriate treatment, the disease is easily eradicated. Death is a rare complication but could possibly result from a small bowel obstruction or perforation secondary to rectal scarring.^[3]

Morbidity is common, especially during the third stage of the disease, and includes such conditions as proctocolitis, perirectal fissures, abscesses, strictures, and rectal stenosis. A chronic inflammatory response may lead to hyperplasia of the intestinal and perirectal lymphatics, causing lymphorrhoids, which are similar to hemorrhoids. Strictures and fistulous tracts may lead to chronic lymphatic obstruction, resulting in elephantiasis, thickening or fibrosis of the labia, and edema or gross distortion of the penis and scrotum. Reports show an association between adenocarcinoma (primarily rectal adenocarcinoma) and chronic untreated LGV.

Race

In North America and Europe, most reported cases of LGV have been identified among white males infected with HIV who acquired the condition after having sex with other men after travel or living in endemic areas, and typically after having multiple anonymous sexual contacts.

Sex

LGV is an STI and probably affects both sexes equally, although it is more commonly reported in men. This predilection may be because early manifestations of LGV are more apparent in men and thus are diagnosed more readily. Men typically present with the acute form of the disease, whereas women often present later, after developing complications from late disease.^[3]

Most cases in Europe and North America have been identified among White, frequently HIV-positive MSM patients presenting with proctitis.^{[27, 34, 35, 36]}

Age

LGV may affect any age but has a peak incidence in the sexually active population aged 15-40 years.

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Prognosis

With prompt and appropriate antibiotic therapy, the prognosis is excellent and patients typically make a full recovery.

Patients must be informed that reinfection and relapses may occur.

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Patient Education

Inform patients how to avoid high-risk sexual activities by using condoms and avoiding sexual intercourse with high-risk sexual partners.

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History

The clinical course of LGV consists of the following stages.^[1]

First stage (primary LGV)

The first stage includes the following:

• This stage occurs 3-30 days after inoculation.
• Primary LGV begins as a small, painless papule or pustule that may erode to form a small, asymptomatic herpetiform ulcer that usually heals rapidly without scarring.

Second stage (secondary LGV)

The second stage includes the following:

• Secondary LGV begins 2-6 weeks after the primary lesion.
• This second stage consists of painful regional lymphadenopathy (usually in the inguinal and/or femoral lymph nodes).
• Painful, swollen lymph nodes coalesce to form buboes, which may rupture in as many as one third of patients. Those that do not rupture harden, then slowly resolve.
• Constitutional symptoms associated with the second stage include fever, chills, myalgias, and malaise.

Third stage (tertiary LGV)

The third stage includes the following:

• Tertiary LGV is termed genitoanorectal syndrome.
• This condition is more common in women, secondary to their lack of symptoms during the first two stages.
• Rectal involvement is more common in men who have sex with men (MSM) and in women who practice anal-receptive intercourse.
• Tertiary LGV is characterized by proctocolitis. Although infectious proctitis is more commonly associated with inflammatory bowel disease, sexually transmitted diseases (STDs) must be considered in the work-up of this diagnosis, especially in MSM. In this patient population, the incidence of infectious proctitis attributed to STDs is on the rise.
• Fever of unknown origin (FUO)

Symptoms include the following conditions:

• Bloody purulent discharge
• Rectal pain
• Tenesmus

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Physical

Large fluctuant buboes or any otherwise unexplained perianal deformity in a young female should suggest a diagnosis of LGV.^[1]

First stage (primary LGV)

The first stage includes the following:

• The initial lesion is usually a small, painless papule, shallow ulcer, or herpetiform lesion in the genital area, which may go unnoticed in the urethra, vagina, or rectum.
• Initial lesions may be differentiated from the more common herpetic lesions by the lack of pain associated with the lesion. Differentiation from a syphilitic chancre is more problematic and requires serologic testing.

Second stage (secondary LGV)

The second stage includes the following:

• Secondary LGV is characterized by painful lymph nodes (usually unilateral) known as buboes.
• Enlargement of the inguinal nodes above and the femoral nodes below the inguinal ligament leads to the classic groove sign, which is observed in one third of affected men.
• Inguinal lymphadenopathy results from a primary lesion of the anterior vulva, penis, or urethra.
• Perirectal or pelvic lymphadenopathy results from a primary lesion involving the posterior vulva, vagina, or anus.
• Affected nodes often coalesce and form abscesses, which can rupture and form sinus tracts.

Third stage (tertiary LGV)

The third stage includes the following:

• Tertiary LGV most often manifests in women.
• Patients initially develop proctocolitis.
• Patients may present with perirectal fistulas, ulcers, abscesses, strictures, and rectal stenosis.
• Hyperplasia of intestinal and perirectal lymphatics may form lymphorrhoids, which are similar to hemorrhoids.
• Patients may develop strictures and fistulous tracts secondary to repeated tissue scarring and repair.
• Enlargement, thickening, and fibrosis of the labia may occur in women, a condition termed esthiomene.
• Chronic lymphatic obstruction may lead to elephantiasis of the genitals.
• Penile and scrotal edema and distortion have been termed saxophone penis.

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Causes

The L1, L2, and L3 serovars of C trachomatis cause LGV. Risk factors include residing in or visiting endemic areas, practicing anal-receptive intercourse, eschewing condoms, and working in the commercial sex trade.

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Complications

Bubo rupture may lead to fistulas and sinus tracts. This complication typically occurs during the first stage (primary LGV) of infection.

Proctocolitis may lead to fissures, fistulas, abscess, scarring, and strictures.

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Approach Considerations

Diagnosing lymphogranuloma venereum (LGV) presents challenges due to the limited availability of serovar-specific testing. Diagnosis often relies on clinical symptoms, risk factors, Chlamydia trachomatis NAAT testing, and the exclusion of other potential causes. PCR-based genotyping is crucial for identifying LGV strains, and NAAT testing of rectal specimens is essential, especially in cases of severe proctocolitis.^{[1, 3, 37]}

While chlamydia serology tests are not typically used for LGV diagnosis due to standardization issues, confirmation of LGV may involve elevated antibody levels or genotyping through PCR-based NAAT. Patients suspected of LGV may experience symptoms such as genital ulcers, swollen lymph nodes, or proctitis, particularly if they have had exposure to high-risk regions. Specialized labs may offer tests for chlamydial antigens like immunoassays or immunofluorescence.^{[1, 3]}  Needle aspiration of buboes is preferred to obtain culture samples, although technically challenging.^{[1, 3]}

Early and accurate LGV diagnosis is crucial to prevent complications.

Complement fixation testing can reveal a strong immunologic response in LGV, with elevated titers often exceeding 1:1024. A serum complement fixation titer greater than 1:64, in the appropriate clinical context, is considered diagnostic. Immunofluorescent testing and PCR are reliable diagnostic tools, although they may not widely available for commercial use.^{[1, 3]}

Comprehensive evaluation of all sexual partners is imperative, and post-treatment monitoring for six months is recommended to ensure effective resolution of the infection. Early and accurate diagnosis of LGV is crucial for appropriate management and to prevent complications or spread of the infection.^{[1, 3]}

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Laboratory Studies

Diagnosing lymphogranuloma venereum (LGV) presents challenges due to the limited availability of serovar-specific testing. Diagnosis often relies on clinical symptoms, risk factors, Chlamydia trachomatis NAAT testing, and the exclusion of other potential causes.^[38] PCR-based genotyping is crucial for identifying LGV strains, and NAAT testing of rectal specimens is essential, especially in cases of severe proctocolitis.^{[1, 3, 37]}

While chlamydia serology tests typically are not used for LGV diagnosis due to standardization issues, confirmation of LGV may involve elevated antibody levels or genotyping through PCR-based NAAT. Patients suspected of LGV may experience symptoms such as genital ulcers, swollen lymph nodes, or proctitis, particularly if they have had exposure to high-risk regions. Specialized labs may offer tests for chlamydial antigens like immunoassays or immunofluorescence.^{[1, 3, 39]}

Thorough evaluation of all sexual partners is critical to prevent further spread of the infection, and post-treatment monitoring for 6 months is recommended to ensure successful resolution. Early and accurate LGV diagnosis is crucial to prevent complications. Detection of C trachomatis-specific DNA, along with genotyping for LGV serovars, are instrumental for laboratory diagnosis. NAATs are effective in confirming Chlamydia presence. Needle aspiration of buboes is preferred to obtain culture samples, although technically challenging.^{[1, 3]}

Complement fixation testing can reveal a strong immunologic response in LGV, with elevated titers often exceeding 1:1024. A serum complement fixation titer greater than 1:64, in the appropriate clinical context, is considered diagnostic. Immunofluorescent testing and PCR are reliable diagnostic tools, although they may not widely available for commercial use.^{[1, 3]}

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Procedures

Needle aspiration of involved buboes may be performed to ease discomfort or to obtain tissue for culture.

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Histologic Findings

Histologic findings of lymph node biopsies performed in the second and third stages of the disease typically reveal stellate abscesses.^{[1, 3]}

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Approach Considerations

In suspected cases of lymphogranuloma venereum (LGV), prompt and appropriate treatment based on clinical symptoms is crucial before confirmatory test results are available.^{[1, 40]} Presumptive treatment is recommended for individuals presenting with proctocolitis, severe inguinal lymphadenopathy with bubo formation, recent genital ulcers, or when other potential causes have been ruled out. The primary objective of treatment is to eliminate the infection, prevent further tissue damage, and address complications such as scarring.

For individuals diagnosed with LGV, close monitoring until resolution of signs and symptoms is essential. Screening for other sexually transmitted infections, including HIV, gonorrhea, and syphilis, is necessary, with consideration for pre-exposure prophylaxis (PrEP) for those who are HIV negative. Chlamydia retesting around 3 months post-treatment and at subsequent medical visits within a year is recommended to ensure successful eradication of the infection.^{[1, 40]}

Partners of individuals with confirmed or suspected LGV should be evaluated, examined, and tested for chlamydial infection, with presumptive treatment for asymptomatic partners who had recent sexual contact. Treatment protocols during pregnancy should consider potential risks, such as tooth discoloration with doxycycline use, and alternative options like azithromycin can be considered. Monitoring and appropriate management are critical for pregnant individuals with LGV.^{[1, 40]}

It is important to provide comprehensive care, including monitoring, testing, and treatment, for individuals with both LGV and HIV. Prolonged therapy may be necessary in HIV-positive individuals due to potential delays in symptom resolution. Careful follow-up and tailored treatment plans are essential for effectively managing LGV and its complications, particularly in populations with unique medical considerations like pregnant individuals and those with concurrent HIV infection.^{[1, 40]}

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Medical Care

In suspected cases of lymphogranuloma venereum (LGV), treatment should begin promptly based on clinical symptoms before confirmatory test results are available.^{[1, 40]} Presumptive treatment is recommended for individuals presenting with symptoms such as proctocolitis, severe inguinal lymphadenopathy with bubo formation, recent genital ulcers, or when other potential causes have been ruled out. The primary goal of treatment is to eliminate the infection, prevent further tissue damage, and address potential complications like scarring.

The preferred treatment regimen for LGV includes a 21-day course of doxycycline 100 mg orally twice daily.^{[1, 40]} Alternatively, erythromycin 500 mg orally 4 times daily for 21 days or azithromycin 1 g orally once weekly for 3 weeks also can be used. It is essential to complete the full course of treatment as prescribed to ensure effective eradication of the infection.

Refractory Cases

In cases where tissue swelling or complications persist despite bacterial clearance, drainage of buboes may be necessary for symptom relief.^{[1, 40]}  Surgical intervention may be required for buboes and sinus tracts, whereas rectal strictures usually can be managed with dilation.

Partner Screening and Therapy

Partners of individuals with confirmed or suspected LGV also should be evaluated, tested for chlamydial infection, and receive presumptive treatment if they had sexual contact within the past 60 days.^{[1, 40]}  Regardless of LGV presence, treatment options for sexual partners may include a single dose of azithromycin 1 g orally or doxycycline 100 mg orally twice daily for 7 days. It is crucial to provide comprehensive care and follow-up to both patients and their partners to effectively manage and prevent the spread of LGV.

Evidence for Treatment Regimens

Studies have indicated that shorter courses of doxycycline, such as a 7-day regimen, may be effective for treating non-bubonic cases of lymphogranuloma venereum (LGV).^[41]  The use of a 7-day doxycycline treatment has been supported for asymptomatic or mild cases, which is consistent with CDC recommendations for asymptomatic sexual contacts of individuals diagnosed with LGV.^{[40, 42]}  In a study in South Africa, all patients with LGV biovar who received a single dose of azithromycin tested negative upon repeat testing.

An observational trial comparing a 21-day regimen of doxycycline with a 3-week course of azithromycin demonstrated similar efficacy.{ref43However, data supporting alternative treatment regimens for LGV remain limited. Despite these findings, the 2021 CDC Sexually Transmitted Infection Guidelines continue to recommend a 21-day course of doxycycline as the first-line therapy for LGV.^[40]

The recommended 21-day course of doxycycline for symptomatic lymphogranuloma venereum (LGV) has demonstrated high effectiveness, with a cure rate exceeding 98.5%. While shorter courses of doxycycline, as observed in a small study of MSM with rectal LGV, showed a 97% cure rate, further randomized prospective studies are warranted to explore the efficacy of abbreviated doxycycline treatment for LGV. In cases involving complications like fistulas, buboes, or severe disease, longer treatment durations may be necessary.^[40]

A study from Spain reported a 97% cure rate for rectal LGV using a regimen of azithromycin 1 g weekly for 3 weeks, supported by pharmacokinetic data. Additionally, fluoroquinolone-based treatments may be effective for LGV, although the optimal treatment duration remains unclear. The clinical significance of asymptomatic LGV is not well understood; however, a 7-day course of doxycycline has been shown to be effective in these cases. More research is needed to optimize treatment strategies for different manifestations of LGV and further evaluate alternative treatment regimens for this infection.^[40]

Post-therapy Monitoring

Following a diagnosis of lymphogranuloma venereum (LGV), patients should be closely monitored until signs and symptoms have resolved. It is essential for individuals diagnosed with LGV to undergo testing for other sexually transmitted infections, particularly HIV, gonorrhea, and syphilis. Those with negative HIV results should be offered pre-exposure prophylaxis (PrEP) for HIV prevention.^[40]

Patients treated for LGV should undergo chlamydia retesting around 3 months post-treatment, with retesting at the next medical visit within a year if the 3-month interval is not feasible. Sexual partners who had contact with an individual diagnosed with LGV within 60 days before symptom onset should be examined, evaluated, and tested for chlamydial infection. Asymptomatic partners should receive presumptive treatment with a chlamydia regimen, such as doxycycline.^[40]

Treatment During Pregnancy

Concerning treatment during pregnancy, there may be a risk of tooth discoloration with doxycycline use, although the extent of this risk is not well-defined. Doxycycline is generally safe for use during breastfeeding. For pregnant women, azithromycin may be a suitable LGV treatment option, typically given as 1 g weekly for 3 weeks. Erythromycin is an alternative but may lead to more frequent gastrointestinal side effects. Pregnant individuals treated for LGV should have a test of cure performed four weeks after an initial positive chlamydia test.^[40]

Treatment with HIV Coinfection

For individuals with both LGV and HIV, the same treatment regimens should be followed as in those without HIV. Prolonged therapy might be required for those with HIV due to potential delays in symptom resolution. Close monitoring and appropriate treatment strategies are crucial for managing LGV and its associated complications, particularly in special populations such as pregnant individuals and those with concurrent HIV infection.^[40]

Treatment Regimens

The recommended medical treatment for LGV involves one of the following antibiotic regimens, per the CDC guidelines^[40] :

• Doxycycline 100 mg PO bid for 21 days
• Azithromycin 1 gm PO once weekly for 3 weeks*
• Erythromycin base 500 mg PO qid for 21 days

*Consider test of cure with NAAT 4 weeks after completion if using this regimen.

Doxycycline is the drug of choice in patients who are not pregnant. Pregnant and lactating individuals should be treated with either azithromycin or erythromycin (erythromycin treatment often is limited by side effects). HIV-positive patients should be treated the same as HIV-negative patients, although they may require prolonged treatment, with longer resolution of symptoms.

Infected patients should abstain from sexual intercourse until antibiotic therapy is completed and symptoms resolve. Some patients with severe disease have failed 21 days of doxycycline and may require more prolonged courses of therapy.^[43]  Expert consultation is advised in this clinical scenario.

Sex partners who have had contact with the patient within the past 60 days should be evaluated and treated if symptomatic. If no symptoms are present, they should be treated for exposure as follows:

• Doxycycline 100 mg PO BID for 7 days
• Azythromycin 1 gm PO as a single dose^[44]
• Of note, there have been cases of infection after azithromycin prophylaxis - which may prompt clinicians to avoid azithromycin as a post-exposure prophylaxis strategy^[43]

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Surgical Care

Needle aspiration or incision and drainage of involved inguinal nodes may be required for pain relief and prevention of ulcer formation. Some of the late complications of the third stage of LGV may require surgical repair.

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Consultations

Surgical consultation for lymphadenopathy is generally not required unless extensive buboes require further exploration. For tertiary disease, appropriate surgical consultation is indicated.

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Activity

No restrictions to physical activities are required; however, patients should abstain from sexual contact until the infection resolves completely.

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Complications

If left untreated, LGV proctocolitis can progress to chronic colorectal fistulas and strictures, along with reactive arthropathy.^{[1, 3]} Whereas rectal LGV sometimes can be asymptomatic, heterosexual individuals may experience symptoms such as tender inguinal or femoral lymphadenopathy and transient genital ulcers or papules that may resolve before medical attention is sought. Severe lymphadenopathy can lead to abscess formation, accompanied by oral ulcers and cervical swelling. Complications of LGV include the development of abnormal rectovaginal connections, rare occurrences of encephalitis, infections in the joints, eyes, heart, or liver, persistent genital inflammation, and scarring and narrowing in the rectal region. Early detection and treatment are vital in preventing these potentially serious outcomes.

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Prevention

No vaccine is available to prevent LGV.

Condom use may reduce the risk of LGV transmission but does not prevent transmission from ulcerated areas not covered by the condom.

The emergence of cases of LGV among MSM in developed countries supports the need for careful screening of these patients. High rates of asymptomatic rectal chlamydia infection found in the MSM attending HIV/GUM clinics in the United Kingdom should prompt the clinician to routinely screen for rectal chlamydia in MSM, even in the absence of symptoms. This aids in the diagnosis of a subset of patients with LGV before symptoms are present. Treatment of this group of patients is essential in the attempt to eradicate the disease.^[45]

Patients, especially those traveling to endemic areas, should be counseled about safe-sex practices, including condom use. Advise the patient to refrain from intercourse with high-risk individuals.

Inform patients that recovery from infection does not confer immunity against future infection.

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Further Outpatient Care

For patients who have had incision and drainage of buboes, appropriate outpatient follow-up care may be required to ensure complete healing and to prevent secondary infections.

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Guidelines Summary

Clinical practice guidelines on the treatment of lymphogranuloma venereum were published by the US Centers for Disease Control and Prevention (CDC) in its Sexually Transmitted Infections Treatment Guide, 2021.^[40]

The 2019 European guideline on the management of lymphogranuloma venereum was published in October 2019.^[46]

The World Health Organization (WHO) published recommendations for the treatment of lymphogranuloma venereum in 2016.

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Clinical Practice Guideline on Treatment of Lymphogranuloma Venereum by the CDC

The following table outlines the recommended regimen and alternative regimens for treating lymphogranuloma venereum^{[40, 3]} :

Table 1. Recommended and Alternative Treatment Regimens

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See Table

Effective management of LGV involves adhering to the prescribed treatment regimen for the specified duration. Patients should be closely monitored to ensure resolution of symptoms and prevent complications. Screening for other sexually transmitted infections and offering PrEP to high-risk individuals is also encouraged. Regular follow-up and testing are essential components of comprehensive care for individuals with LGV, especially in the context of concurrent conditions like HIV or pregnancy. Consulting healthcare professionals for tailored advice and guidance is recommended for optimal treatment outcomes.

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The 2019 European guideline on the management of lymphogranuloma venereum

The 2019 European guideline on the management of lymphogranuloma venereum is summarized below^[46] :

• LGV should be considered in patients with symptoms such as genital ulcers, inguinal lymphadenopathy, and proctitis, particularly in men who have sex with men.
• Healthcare providers should perform serological tests and obtain samples for nucleic acid amplification testing (NAAT) to diagnose LGV.
• Treatment for LGV typically involves a three‐week course of doxycycline, with alternative antibiotics such as azithromycin used in cases of doxycycline intolerance.
• Patients with confirmed LGV should be referred to genitourinary medicine or sexual health clinics for further management and follow-up.
• Patients with LGV should be monitored for treatment response, particularly in cases of extragenital manifestations, to ensure complete resolution of symptoms and prevent potential complications.

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WHO Guidelines on the Treatment of Lymphogranuloma Venereum

WHO recommendations for the treatment of lymphogranuloma venereum (LGV) are as follows^[47] :

Table 2. WHO Recommendations for Treatment of Lymphogranuloma Venereum 

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See Table

It is important for clinicians to consider these treatment recommendations when managing patients with lymphogranuloma venereum (LGV) while taking into account contraindications and alternative options based on individual patient factors.

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Medication Summary

The goal of therapy is to eradicate the organism.

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Doxycycline (Bio-Tab, Doxy, Doryx, Vibramycin, Vibra-Tabs)

• Dosing, Interactions, etc.

Clinical Context:  Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.

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Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Totally eradicate the causative organism or organisms.

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Azithromycin (Zithromax, Zmax)

• Dosing, Interactions, etc.

Clinical Context: 

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Erythromycin (E.E.S., E-Mycin, Eryc, Ery-Tab, Erythrocin)

• Dosing, Interactions, etc.

Clinical Context:  Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections. In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half of the total daily dose may be taken q12h. For more severe infections, double the dose.

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