Download Article PDF/SlidesSexually transmitted infections (STIs) are among the most common infectious diseases in the United States today. More than 20 STIs have now been identified, and they affect more than 13 million men and women in this country each year.
The potential for HIV transmission is enhanced by the presence of STIs, and ulcerative STIs—by virtue of interrupting the body’s most important defense (skin/mucosal membranes)—are of particular concern. Overall, genital ulcer infections appear to increase HIV risk by a factor of 2.7 (approximately 170%). The presence of an ulcerative STD in an HIV-infected individual also appears to increase the likelihood that he or she will transmit HIV to an uninfected sexual partner. Another concern is that HIV infection is associated with non-classical presentations of genital ulcer disease, rendering such infections more difficult to diagnose and treat.
In the United States, most sexually transmitted genital ulcers are caused by genital herpes. Syphilis and chancroid ulcers are less common in the general population. Another STI, lymphogranuloma venereum, is still considered rare in the United States, but it is emerging as a source of concern for clinicians and public health officials alike. To review the standard approaches to diagnosing and treating these four ulcerative STIs—and to discuss some of the latest thinking surrounding these infections—Dr. Susan Blank from the New York City Department of Health and Mental Hygiene addressed the PRN membership during a standing-room-only February meeting.
| Lymphogranuloma venereum | Top of page |
Lymphogranuloma venereum (LGV) is caused by Chlamydia trachomatis serovars L1, L2, and L3. C. trachomatis serovar A is responsible for eye disease and serovars B through K are responsible for urogenital disease, most notably chlamydial urethritis and cervicitis.
LGV is endemic is many developing countries, including those in Africa, Southeast Asia, Central and South America, and the Caribbean. Recent outbreaks of LGV among men who have sex with men—most of whom are HIV positive—have been reported in Europe. According to a report published in an October 2004 issue of the U.S. Centers for Disease Control’s Morbidity and Mortality Weekly Report (MMWR), 92 cases were documented in the Netherlands between April 2003 and September 2004 (U.S. Centers for Disease Control, 2004). Soon thereafter, a similar report was published by health authorities in Great Britain (Macdonald, 2005).
In recent months, LGV has been reported in the United States, with 12 cases documented nationally (of which seven were documented in New York City). The appearance of this unusual ulcerative STI has been of concern to public health officials, given that an outbreak of LGV—especially if the rates of LGV/HIV coinfection mirror the 75% rates found in Europe—could increase rates of HIV transmission in the United States.
The primary lesion of LGV is a small genital or rectal papule, ulcer, or erosion that appears at the site of inoculation and may or may not be painful. These lesions may be clinically similar to the lesions of genital herpes, primary syphilis, or chancroid. The incubation period from exposure to developing a lesion is approximately three to 30 days.
Figure 1. Inguinal Adenopathy in Secondary Lymphogranuloma Venereum
The primary lesion of LGV is a small genital or rectal papule, ulcer, or erosion that appears at the site of inoculation and may or may not be painful. The secondary stage of LGV can also manifest as an inguinal syndrome, characterized by inguinal or femoral adenopathy that may go on to suppurate and ulcerate (buboes.)
A secondary stage of LGV can occur three to six months after exposure. It can manifest as an anogenitorectal syndrome, characterized by hemorrhagic or non-hemorrhagic proctitis/proctocolitis. Symptoms include purulent, mucous, or bloody anal discharge, rectal pain/spasms, tenesmus, or constipation. The secondary stage of LGV can also manifest as an inguinal syndrome (see Figure 1), characterized by inguinal or femoral adenopathy that may go on to suppurate and ulcerate (buboes). Left untreated, the secondary stage manifestations of LGV can progress to genitorectal fistulae, strictures, or genital elephantiasis.
With respect to the diagnosis of LGV, commercially available tests—including culture, nucleic acid amplification, nucleic acid hybridization, and serologies—can be used to confirm C. trachomatis infection. However, these tests are not specific enough to distinguish between the various chlamydial serovars and therefore cannot be used to confirm a diagnosis of LGV. Definitive testing is available through the CDC, with the help of the New York City Department of Health and Mental Hygiene’s Bureau of Sexually Transmitted Disease Control (BSTDC). Dr. Blank stated that all clinicians with a patient meeting the LGV case definition should call the BSTDC’s LGV desk: 212/788-4423 (see Sidebar).
Because a definitive diagnosis of LGV can take weeks, patients suspected of having LGV infection should be treated presumptively. The recommended treatment is doxycycline, 100mg orally twice a day for 21 days. An alternative treatment involves an erythromycin base, 500 mg orally every other day for 21 days. Some experts recommend azithromycin 1 g every week for three weeks. However, data are not available supporting the efficacy of this option for the treatment of LGV.
To prevent outbreaks of LGV, the NYC DOHMH recommends that sex partners during the six months prior to symptom onset in a possible case also be evaluated, tested for LGV, and treated. Symptomatic sex partners should be treated presumptively for LGV. Asymptomatic sex partners should be given post-exposure prophylaxis consisting of doxycycline 100 mg orally for 21 days. Clinicians requiring assistance in notifying or managing partners are encouraged to contact the BSTDC’s LGV desk.
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