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DESCRIPTION
Lymphogranuloma Venereum is also known as LGV, Lymphogranuloma Inguinale, lymphopathia venerea, tropical bubo, climatic bubo, strumous bubo, poradenitis inguinales and Durand-Nicolas-Favre disease. LGV is a contagious venereal disease that involves the genitals and lymph glands and is caused by the invasive serovars L1, L2, or L3 of Chlamydia trachomatis. This disease is found mostly in tropical and subtropical areas. It is considered rare in North America.
OVERVIEW
LGV was first described by Wallace in 1833 and again by Durand, Nicolas, and Favre in 1913. LGV is primarily an infection of lymphatics and lymph nodes. Chlamydia trachomatis is the bacteria responsible for LGV. It gains entrance through breaks in the skin, or it can cross the epithelial cell layer of mucous membranes. The organism travels from the site of inoculation down the lymphatic channels to multiply within mononuclear phagocytes of the lymph nodes it passes. In the United States, Europe, Australia and most of Asia and South America LGV is generally considered to be a rare disease. However, a recent outbreak in the Netherlands among gay men has led to an increase of LGV in Europe and the United States. A majority of these patients are HIV co-infected. Since the 2004 Dutch outbreak 341 cases have been reported in the UK and 80 cases in the US, but infectious-disease experts fear the actual number is substantially larger because this form of chlamydia is difficult to diagnose and many health care providers are not aware of its existence.
Soon after the initial Dutch report national and international health authorities launched warning initiatives and multiple LGV cases where identified in several more European countries (Belgium, France, the UK, Germany, Sweden, Italy and Switzerland) and the US and Canada. All cases reported in Amsterdam and France and a considerable part of LGV infections in the UK and Germany are caused by a newly discovered Chlamydia variant L2b, a.k.a the Amsterdam variant. The L2b variant could be traced back and was isolated from anal swabs of MSM who visited the STI city clinic of San Francisco in 1981. This finding suggests that the recent LGV outbreak among MSM in industrialized countries is a slowly evolving epidemic. As of end 2005, new LGV cases are continued to be reported in the Netherlands and other European countries at rates approaching one or two cases per week in each country.
MoonDragon's Obgyn Information: Chlamydia
FREQUENT SIGNS & SYMPTOMS
The following begin 1 to 4 weeks after exposure and progress in order:
- A painless blister on the genitals which ulcerates (becomes an open and runny sore) and then heals quickly.
- Enlarged lymph glands in the groin that form large, red, tender masses.
- Multiple areas of deep infection that discharge thick pus and blood-stained material.
Other symptoms include:
- Fever.
- Muscle aches and pain, including backache.
- Headaches.
- Joint pain.
- Appetite loss.
- Vomiting.
The clinical manifestation of LGV depends on the site of entry of the infectious organism (the sex contact site) and the stage of disease progression. Inoculation at the mucous lining of external sex organs (penis and vagina) can lead to the inguinal syndrome named after the formation of buboes or abscesses in the groin (inguinal) region where draining lymph nodes are located. The rectal syndrome arises if the infection takes place via the rectal mucosa (through anal sex) and is mainly characterized by proctocolitis symptoms. The pharyngeal syndrome is rare, starts after infection of pharyngeal tissue and bubo's in the neck region can occur.
PRIMARY STAGE
LGV may begin as a self-limited painless genital ulcer that occurs at the contact site 3-12 days or longer in this primary stage. Rarely do women notice a primary infection, because the initial ulceration where the organism penetrates the mucosal layer are located out of sight in the vaginal wall. Also in men fewer than 1/3 of those infected notice the first signs of LGV. This primary stage heals in a few days. Erythema nodosum occurs in 10% of cases.
SECONDARY STAGE
The secondary stage occurs from 10-30 days later most often, but has occurred up to 6 months later. The infection is then spread to the lymph nodes through lymphatic drainage pathways. The most frequent presenting clinical manifestation of LGV among males whose primary exposure was genital is unilateral, in 2/3 of cases, lymphadenitis and lymphangitis, often tender inguinal and/or femoral lymphadenopathy because of the drainage pathway for their likely infected areas. Lymphangitis of the dorsal penis may also occur and resembles string or cord. If the route was anal sex the infected person may experience lymphadenitis and lymphangitis noted above or may have proctitis, inflammation limited to the rectum (the distal 10-12 cm) that may be associated with anorectal pain, tenesmus, or rectal discharge, or proctocolitis, inflammation of the colonic mucosa extending to 12 cm above the anus and is associated with symptoms of proctitis plus diarrhea or abdominal cramps and or inflammatory involvement of perirectal or perianal lymphatic tissues. In females cervicitis, perimetritis, or salpingitis may occur as well as the lymphangitis and lymphadenitis in deeper nodes. Because of lymphatic drainage pathways, some end up with an abdominal mass which seldom suppurates and only 20-30% end up with inguinal lymphadenopathy. Systemic signs: fever, decreased appetite, and malaise, may occur as well. Diagnosis is more difficult in women and homosexual men who may not have the inguinal symptoms.
Over the course of the disease, lymph nodes enlarge, enlarged nodes are called buboes, and become painful at first (which may occur in any infection of the same areas as well). The next most common thing is inflammation, thinning and fixation of the overlying skin. Lastly in the progression are necrosis, fluctuant and suppurative lymph nodes, abscesses, fistulas, strictures, and sinus tracts all may occur. During the infection and when it subsides and healing takes place, fibrosis may occur. This can result in varying degrees of lymphatic obstruction, chronic edema, and strictures. These late stages characterized by fibrosis and edema are also known as the third stage of LGV and are mainly permanent.
CAUSES
LGV is a contagious venereal disease that involves the genitals and lymph glands and is caused by the invasive serovars L1, L2, or L3 of Chlamydia trachomatis. The bacterium Chlamydia, which is transmitted by sexual activity has an incubation period of about 3 to 12 days.
RISK INCREASES WITH
Travel to a country with a tropical or subtropical climate or where an outbreak of LGV is occurring.
Anal sexual intercourse.
Unprotected sexual activity with new partners.
PREVENTIVE MEASURES
Use condoms during sexual intercourse with new partners. See Condoms & STDs for more information.
Don't engage in sexual activity with an infected person.
Limit your number of sex partners.
Carefully wash genitals after sexual relations.
If you think you are infected or have been exposed to LGV, avoid any sexual contact and visit your health care provider. Notify all sexual contacts immediately so they can obtain examination and treatment.
EXPECTED OUTCOME
Out come is highly variable. Spontaneous remission is common. Usually curable in 6 months if treatment is successful. If not, the disorder is incurable, although it does not reduce life expectancy. Complete cure can be obtained with proper antibiotic treatment. Course is more favorable with early treatment. Bacterial superinfections may complicate course. Death can occur from bowel obstruction or perforation. Follicular conjunctivitis due to autoinoculation of infectious discharge.
POSSIBLE COMPLICATIONS
Chronic infection.
Interference with bowel and bladder function.
Long-Term Complications: Genital elephantiasis or esthiomene, which is the dramatic end-result of lymphatic obstruction, which may occur because of the strictures themselves, or fistulas. This is usually seen in females, may ulcerate and often occurs 1-20 years after primary infection. Fistulas of, but not limited to, the penis, urethra, vagina, uterus, or rectum. Also, surrounding edema often occurs. Rectal or other strictures and scarring. Systemic spread may occur, possible results are arthritis, pneumonitis, hepatitis, or perihepatitis.
TREATMENT
GENERAL MEASURES
DIAGNOSIS
Diagnostic tests may include laboratory studies, such as a blood test to rule out syphilis; a culture of the discharge from the lesions and antibody tests for the Chlamydia organism.
The diagnosis usually is made serologically (through complement fixation) and by exclusion of other causes of inguinal lymphadenopathy or genital ulcers. Serologic testing has a sensitivity of 80% after 2 weeks. Serologic testing may not be specific for serotype (has some cross reactivity with other chlamydia species) and can suggest LGV from other forms because of their difference in dilution, 1:64 more likely to be LGV and lower than 1:16 is likely to be other chlamydia forms. For identification of serotypes, culture is often used. Culture is difficult. Requiring a special media, cycloheximide-treated McCoy or HeLa cells, and yields are still only 30-50%. DFA, or direct fluorescent antibody test, PCR of likely infected areas and pus, are also sometimes used. DFA test for the L-type serovar of C trachomatis is the most sensitive and specific test, but is not readily available. If polymerase chain reaction (PCR) tests on infected material are positive, subsequent restriction endonuclease pattern analysis of the amplified outer membrane protein A gene can be done to determine the genotype. Recently a fast realtime PCR (Taqman analysis) has been developed to diagnose LGV. With this method an accurate diagnosis is feasible within a day. It has been noted that one type of testing may not be thorough enough.
As with all STD's, sex partners of patients who have LGV should be examined and tested for urethral or cervical chlamydial infection. After a positive culture for chlamydia, clinical suspicion should be confirmed with testing to distinguish serotype. Antibiotic treatment should be started if they had sexual contact with the patient during the 30 days preceding onset of symptoms in the patient. Patients with a sexually transmitted disease need to be tested for other STD's. Antibiotics are not without risks and prophylaxtic broad antibiotic coverage is not recommended.
TREATMENT
Treatment involves antibiotics. Common antibiotic treatments include:
- Tetracycline.
- Doxycycline (all tetracyclines, including doxycycline, are contraindicated during pregnancy and in children due to effects on bone development and tooth discoloration).
- Sulfamethoxazole.
- Erythromycin.
Heat applied to affected area may help discomfort.
Surgery to drain affected lymph glands (buboes) or remove an abscess (a collection of pus as a result of an infection) by needle aspiration or incision. Further supportive measure may need to be taken: dilatation of the rectal stricture, repair of rectovaginal fistulae, or colostomy for rectal obstruction. Fistulas are an abnormal passage between two organs or from an internal organ to the body surface.
Your sexual contacts should be examined also. Treatment will be necessary for all sexual partners that have been infected with LGV.
Lymphogranuloma venereum (LGV) is caused by C. trachomatis serovars L1, L2, or L3. The disease occurs rarely in the United States. The most common clinical manifestation of LGV among heterosexuals is tender inguinal and/or femoral lymphadenopathy that is most commonly unilateral. Women and homosexually active men may have proctocolitis or inflammatory involvement of perirectal or perianal lymphatic tissues resulting in fistulas and strictures. A self-limited genital ulcer sometimes occurs at the site of inoculation. However, by the time patients seek care, the ulcer usually has disappeared. The diagnosis of LGV is usually made serologically and by exclusion of other causes of inguinal lymphadenopathy or genital ulcers. Complement fixation titers =1:64 are consistent with the diagnosis of LGV. The diagnostic utility of serologic methods other than complement fixation is unknown.
Treatment: Treatment cures infection and prevents ongoing tissue damage, although tissue reaction can result in scarring. Buboes may require aspiration through intact skin or incision and drainage to prevent the formation of inguinal/femoral ulcerations. Doxycycline is the preferred treatment.
Recommended Regimen: Doxycycline 100 mg orally twice a day for 21 days.
Alternative Regimen: Erythromycin base 500 mg orally four times a day for 21 days.
Some STD specialists believe azithromycin 1.0 g orally once weekly for 3 weeks is likely effective, although clinical data are lacking.
Follow-Up: Patients should be followed clinically until signs and symptoms have resolved.
Management of Sex Partners: Persons who have had sexual contact with a patient who has LGV within the 30 days before onset of the patient's symptoms should be examined, tested for urethral or cervical chlamydial infection, and treated.
SPECIAL CONSIDERATIONS
Pregnancy: Pregnant and lactating women should be treated with erythromycin. Azithromycin may prove useful for treatment of LGV in pregnancy, but no published data are available regarding its safety and efficacy. Doxycycline is contraindicated in pregnant women.
HIV Infection: Persons with both LGV and HIV infection should receive the same regimens as those who are HIV-negative. Prolonged therapy may be required, and delay in resolution of symptoms may occur.
http://www.cdc.gov/std/treatment/2-2002TG.htm#LymphogranulomaVenereum
MEDICATION
Antibiotics to fight infection are taken for 21 days or as prescribed by your health care provider.
You may use non-prescription drugs, such as acetaminophen for minor pain.
Stronger pain relievers may be prescribed.
ACTIVITY
After treatment, resume normal activity as soon as symptoms improve. Don't resume sexual relations until completely healed. The use of safe sex practices, such as the use of condoms, will help prevent re-infection.
DIET
No special diet. However, it is important to maintain a health dietary lifestyle to support your immune system and help in the healing process. Nutritional supplements may need to be taken to enhance your daily diet.
DIETARY SUGGESTIONS & RECOMMENDATIONS FOR CHLAMYDIA
Eat a diet consisting mainly of fresh vegetables and fruits, plus brown rice, raw seeds and nuts, turkey, white fish, and whole grains.
Avoid highly processed, fried, and junk foods, as well as chicken. Approximately one third of all chickens sold in this country contain pathogenic bacteria such as salmonella. Turkey is acceptable; such bacteria are not found in turkey.
Drink only steam-distilled water, sugar-free juices, and herbal teas.
Take acidophilus (or eat fresh homemade yogurt with active cultures) to replenish the "friendly" bacteria destroyed by antibiotics.
HERBAL & HOLISTIC RECOMMENDATIONS
HERBS
Andiroba & Copaiba Oil. Apply to irritated area as needed. Relieves vaginal and rectal inflammation.
Arjuna Capsules. Take 500 mg every 8 hours. Contains luteolin, which kills gonorrhea and chlamydia bacteria. Arjun (Terminalia arjuna), 485 mg, 120 Vcaps
Astragalus Tincture. Use as directed on label. Helps to protect the immune system. and aids in healing. Astragalus Root Tincture, 100% Organic, 2 fl. oz.
Barberry, Coptis, Goldenseal or Oregon Grape root Tincture. Take 15-30 drops in 1/4 cup water 3 times daily. Contains berberine, which kills gonorrhea and chlamydia bacteria. Do not use barberry, coptis, goldenseal or Oregon grape root if you are pregnant or have gallbladder disease. Do not take these herbs with supplemental vitamin B-6 or with protein supplements containing the amino acid histidine. Do not take goldenseal on a daily basis for more than one week at a time, and DO NOT USE IT DURING PREGNANCY. Use it only under a health care provider's supervision. Do not use goldenseal if you have cardiovascular disease or glaucoma. Barberry Tincture, 100% Organic, 2 fl. oz., Goldenseal Root (Hydrastis canadensis) Tincture, 100% Organic, 2 fl. oz., Oregon Grape Root (Wild) Tincture, 100% Organic, 2 fl. oz.
Epimedium Tablets or Extract. Take as directed on the label or by dispensing herbalist. Use after suspected exposure. Antibacterial. Stimulates urination to keep bacteria from attaching to lining of urethra. Do not use epimedium if you have any kind of prostate disorder. Horny Goat Weed (Epimedium) Express Liquid Extract, 2 fl. oz.
Scutellaria Capsules. Take 1,000-2,000 mg 3 times daily. May act against antibiotic-resistant strains of gonorrhea and chlamydia. Do not use scutellaria if you have diarrhea. Blue Scullcap (Scutellaria lateriflora), Standardized, Nature's Way, 100 mg, 60 Vcaps, Scullcap Tincture, 100% Organic, 2 fl. oz.
Echinacea, pau d'arco and red clover aid in healing. Take in capsule, tincture or extract form or drink as tea. Take as directed on label. Echinacea Purpurea, Nature's Way, 400 mg, 100 Caps, Echinacea Tincture (Children), Orange Flavor, Alcohol Free, 100% Organic, 1 fl. oz., Echinacea Immune Support Tea, Yogi Tea, Certified Organic, 16 Tea Bags, Pau D'Arco (Purple Lapacho) Tincture, 100% Organic, 2 fl. oz., Pau D'Arco Tea, Incan Purple Lapacho, 48 Tea Bags, Pau D'Arco Extract, Incan Lapacho, 100% Natural Herbal, 4 fl. oz., Red Clover (Trifolium pratense) Herb Powder, 4 oz. Bulk, Red Clover Blossom & Herb, Nature's Way, 500 mg, 100 Caps, Red Clover Tincture, 100% Organic, 2 fl. oz.
TRADITIONAL CHINESE MEDICINE (TCM) FORMULAS
Dong Quai, Gentiana Longdancao, and Aloe Pill: A traditional Chinese herbal formula that treats gonorrhea and chlamydia with accompanying herpes infection. Do not use these herbs if you are trying to become pregnant.
Eight-Ingredient Pill with Rehmannia (Rehmannia-Eight Combination): A traditional Chinese herbal formula that increases urination, effectively flushing bacteria out of the genitourinary tract before they can cause damage. Use after suspected exposure.
Peony and Licorice Decoction: A traditional Chinese herbal formula that treats gonorrhea and chlamydia complicated by cramping and abdominal pain or pain around the anus. Do not use Peony and Licorice Decoction if you have an estrogen-sensitive disease, such as breast cancer, endometriosis, or fibrocystic breasts.
Note: Bulk herbs are available through Mountain Rose Herbs. See link below.
Mountain Rose Bulk Herbs
Mountain Rose Aromatherapy Oils
Mountain Rose Herbs, Aromatherapy Oils A-B
Mountain Rose Herbs, Aromatherapy Oils C-E
Mountain Rose Herbs, Aromatherapy Oils F-L
Mountain Rose Herbs, Aromatherapy Oils M-P
Mountain Rose Herbs, Aromatherapy Oils Q-Z
Mountain Rose Herbs, Aromatherapy Oils: Oil Blends & Resins
Mountain Rose Herbs, Aromatherapy Oils: Diffusers, Nebulizers, & Burners
Mountain Rose Herbs, Aromatherapy Oils: Oil Kits
Click Here To Visit Herbal Remedies Product Page
NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF...
If you or a family member has symptoms of lymphogranuloma venereum or you feel you have been exposed to LGV and need testing to confirm the infection.
The following occur during treatment:
- Temperature rises to 101°F (38°C) or higher.
- Pain cannot be relieved with simple pain medicine.
New, unexplained symptoms develop. Drugs used during treatment may produce side effects.
