Lymphogranuloma Inguinale

Lymphogranuloma inguinale is also known as:
* Lymphogranuloma venereum (LGV);
* Nicholas-Favre Disease;
* Sixth VenerealDisease;
* Tropical Bubo;

Lymphogranuloma inguinale is an infection of the lymph tissue in the genital area caused by a strain of Chlamydia trachomatis, the bacterium that produces Nongonococcal Urethritis (NGU).

The disease occurs most often  in:
* Africa;
* Central America;
* South America;
* Southeast Asia;
* The Caribbean;

Lymphogranuloma inguinale infects an average of about 250-400 people a year in the United States.

Symptoms

Lymphogranuloma inguinale has three stages:

Stage 1
* A small, painless sore similar to a pimple, blister/lesion/soft bump occurring at the point where the bacterium entered the body (usually the penis or vagina) that often goes unnoticed;
* Some people do not experience this and if they do healing is usually rapid without scarring ;
* The infection then spreads to the lymph nodes in the groin area and from there to the surrounding tissue, where it causes painful swelling closest to the point of infection;
* Discharge from the penis or vagina from 3-30 days after exposure;

Lymphogranuloma inguinale is found:

In Males
* On the coronal sulcus of males;

In Females
* On the cervix;
* On the fourchette;
* On the posterior vaginal wall ;
* On the vulva;

Lesions have also occurred:
* the oral cavity (tonsil);

Stage 2  (1-2 weeks after initial symptoms appear)
* Inflammation and swelling of lymph nodes and surrounding tissue;
* Lymph nodes closest to the infection continue to swell until a pus-filled bulge is created, called a bubo;
* Throbbing pain and fever;

The buboes can:
* Grow very big, until the skin covering them turns blue;
* Open through the skin, drain continuously and remain open (about 30% of cases);
* Can become infected by other bacteria;

In Women the buboes may cause:
* Erosion of the skin and tissue between the legs;
* Erosion of the vagina or rectum walls;
* Painful swelling in the groin;

Buboes near the anus may cause:
* Discharge from the rectum;
* Infection of the penis;
* Infection of the rectum;
* Swelling, bleeding and erosion of the lining of the rectum, which can spread upwards into the colon;
* The rectum may swell almost shut;

Buboes in the penis or vagina
* Affect the nodes on either or both sides of the groin;
* May cause sores or pus-filled sacks to develop on the genitals;

Buboes in the throat affect:
* The nodes in the jaw and neck;

Transmission

Lymphogranuloma inguinale is spread by direct sexual contact with the:
* genitals;
* mouth;
* rectum;

Note
* An individual is infectious for as long as the lesions remain active;
* Ejaculation is not necessary for the disease to be spread ;
* The germ is passed from partner to partner as long as there are sores;
* The infection is spread by unprotected sexual contact ;

In Pregnancy and Birth
Infected mothers can transmit the disease to their babies at birth

It can not be spread from person to person by casual contact, such as:
* clothing;
* door knobs;
* eating ustensils;
* swimming pools;
* toilet seats;

Diagnosis

Diagnosis is usually ascertained by:
* A blood test;
* A sample of the discharge for a culture test;
* Visual observation;

to rule-out or check for other STDs such as:
* Chancroid;
* Gonorrhoea;
* Genital Herpes;
* Syphilis;
As Chlamydiae are intracellular organisms samples must contain cellular material. This can be obtained:
* By aspiration from fluctuant lymph nodes or buboes with a needle;
* From the base of the ulcer;
* From rectal tissue;

Methods:
* Most methods are usually unable to distinguish Lymphogranuloma inguinale strains from other chlamydial strains;

Culture Test
* Culture on Cycloheximide treated cells from suspected lesions is the most specific method;
* The method:
* has a sensitivity of 75-85% ;
* has a sensitivity of 30-50% in the case of bubo aspirates (the pus has a toxic effect on the culture cells);
* is expensive;
* is labor intensive;
* is not not readily available;

Direct Immuno-fluorescence (DIF) 
* Material from a suspected lesion is used to detect Chlamydia trachomatitis.  A fourfold rise in antibodies (both IgM and IgG) usually shows active infection;
* This method:
* is  labor intensive;
* is sensitive;
* is only performed in a few specialized laboratories;
* requires the proper expertise for interpretation;

Enzyme immunoassay (EIA)
* This method is suitable for ulcer scrapes or bubo aspirates, but not for rectal samples;
* The method;
* is convenient;
* is objective;
* has a lower sensitivity than other methods;
* should be confirmed by a blocking test or another method;
* is not suitable for Test of Cure (TOC);

Other Methods
*Ligase chain reaction (LCR) or polymerase chain reaction (PCR) ;
* These methods are used to detect nucleic acid (DNA) by amplification techniques and are used for testing urethral, cervical or urine samples but are not often used for Lymphogranuloma inguinale;

Note
Screening for other possible causes of genital ulcerative disease should be carried out, such as for:
* HIV and AIDS;
* Genital Herpes;
* Haemophilus ducreyi;
* Klebsiella/Calymmatobacterium granulomatis;
* Serological syphilis;
* Treponema pallidum;

Lymph node biopsy may be used to make differential diagnoses with atypical infections and neoplasia.

Treatment
 

Lymphogranuloma inguinale is a very persistent bacterium, and Penicillins are ineffective in treatment and can  suppress the bacterium without killing it.

Early treatment is essential to reduce the severity of the chronic phase.

A 3 week program of antibiotics is recommended to kill the infection. 

Antibiotics used:
* Azithromycin;
* Chloramphenicol (effective against Chlamydia trachomatis);
* Doxycycline;
* Erythromycin;
* Isulfamethoxazole;
* Minocycline;
* Rifampicin;
* Sulfadiazine;
* Tetracycline;

Patients allergic to Cyclines should be treated with Erythromycin

Follow-Up:
Patients should be followed clinically until signs and symptoms have resolved.

Treatment for pregnant or lactating mothers
Pregnant and lactating women should be treated with Erythromycin.

Note:
In HIV patients:
* Delay in healing may occur;
* Development of multiple abscesses can occur;
* Latent Lymphogranuloma inguinale may be reactivated;
* Prolonged therapy may be required;

Prognosis

Complications
* A burst bubo can take months to heal completely and often leaves a deep scar or a hard mass of scar tissue;
* Buboes may ulcerate and discharge pus from multiple points creating chronic fistulas;
* Inflamed, swollen lymph glands may drain and bleed;
* Spontaneous remissions and exacerbations can occur usually within 8 weeks after treatment;
* Surgery may be needed to repair the internal and external scars and erosions caused by advanced infection;

The systemic spread of Chlamydia trachomatis may be associated with:
* Arthritis;
* Fever;
* Perihepatitis;
* Pneumonitis;

Stage 3
Most people recover after the secondary stage without any complication. In a few cases, however, mostly among women, the persistence and progressive spread of Chlamydia trachomatis in anal-genital tissues will cause chronic inflammation and destruction of tissues, which can lead to:
* Acute Proctocolitis (symptoms similar to Crohn's disease);
* Chronic granuloma, a disfiguring condition of the vulva;
* Fibrotic lesions;
* Fistulae;
* Proctitis;
* Stricture;
* Surgical repair, including reconstructive genital surgery may be necessary;

If left untreated the following problems can occur:
* An association with rectal cancer;
* Destruction of lymph nodes;
* Elephantiasis (extreme swelling) of the genitals;
* Persistent suppuration (formation and discharge of pus);
* Pyoderma (purulent skin disease);
* Rectal or intestinal blockages;
* Scarring;
* Serious tissue damage;
* The central nervous system can be attacked;

Prevention

* Avoid unprotected sex until treatment and follow-up have been completed;
* Carefully wash genitals after sex;
* If infected abstain from sex until the infection is cured;
* If you think you have come in contact with Lymphogranuloma inguinale contact your local STD clinic, health professional or urologist immediately;
* Latex condoms put on before sex and worn until the penis is withdrawn;
* Limit sexual relationships to a single, uninfected partner;
* Notify all sexual contacts immediately so they can obtain examination and treatment;

Note:
Before having sex it is advisable to check for anything unusual in your partner, such as:
* discharge;
* rashes;
* sores;
* swelling;

Douching or urinating after sex does not prevent STIs.

If you have had sexual contact with a person infected with Lymphogranuloma inguinale within 30 days before onset of the person's symptoms you should be:
* examined;
* tested for urethral or cervical chlamydial infection;
* treated if if the infection shows up in tests;
* receive presumptive treatment;

Related topics
* Sexual Health Advice & Leaflets