Lymphogranuloma venereum: diagnostic and treatment challenges

Figures & data

Table 1 Clinical features of lymphogranuloma venereum

Men	Women
First stage	First stage
– Painless papule/pustule/nodule/erosion/ulcer on penis/anus/* lip and oral cavity (tonsil)	– Painless papule/pustule/nodule/erosion/ulcer on vulva/posterior vaginal wall/cervix/anus/* lip and oral cavity
– Proctitis (symptoms: rectal pain, anorectal bleeding, mucoid and/or hemopurulent rectal discharge, tenesmus, constipation)	– Proctitis (symptoms: rectal pain, anorectal bleeding, mucoid and/or hemopurulent rectal discharge, tenesmus, constipation)
Second stage	Second stage
– Lymphadenitis	– Lymphadenitis
– Intra-abdominal or retroperitoneal lymphadenopathy	– Intra-abdominal or retroperitoneal lymphadenopathy
– Inguino and/or femoral lymph adenopathy (typically unilateral, heterosexuals)	– Inguino and/or femoral lymph adenopathy (typically unilateral, only 20% of women)
– Bubo formation (fluctuant and suppurative lymph nodes that may rupture)	– Bubo formation (fluctuant and suppurative lymph nodes that may rupture)
– Fever/arthritis/pneumonitis/perihepatitis/abnormal hepatic enzymes (systemic spread)	– Fever/arthritis/pneumonitis/perihepatitis/abnormal hepatic enzymes (systemic spread)
Third stage	Third stage
– Genito-anorectal syndrome (more often in women)	– Genito-anorectal syndrome (more often in women)
– Chronic proctitis	– Chronic proctitis
– Fistulae	– Fistulae
– Strictures	– Strictures
– Stenosis of rectum	– Stenosis of rectum
– Genital lymphedema (elephantiasis, “saxophone penis”)	– Genital lymphedema (elephantiasis)
– “Lymphorroids”	– “Lymphorroids”
	– Scarring of vulva (esthiomene)

Note:

* Rare cases.

Table 2 Recommended treatment regimens for lymphogranuloma venereum

Drug	Regimen	Mechanism/possible side effects	Comment
Doxycycline	100 mg twice daily for 21 days, orally	– Inhibits protein synthesis by binding to 30S ribosomal subunits of susceptible bacteria – Dyspepsia; nausea; diarrhea; photosensitivity; darkening of skin, nails, eyes, teeth, gums, or scars; esophageal ulceration; Fanconi syndrome (nephrotoxicity); steatosis (hepatotoxicity); headache and vision problems (secondary intracranial hypertension-pseudotumor cerebri)^Citation62^–^Citation65	– First choice, recommended by Centers for Disease Control – Contraindicated in pregnancy and breastfeeding – Antacids that contain aluminum, calcium, or magnesium or any product that contains iron such as vitamin or mineral supplements should not be taken
Erythromycin	500 mg four times daily for 21 days, orally	– Inhibits bacterial growth by blocking dissociation of peptidyl tRNA from ribosomes – Diarrhea, stomach pain, nausea, vomiting^Citation66,Citation67	Second choice; recommended by Centers for Disease Control
Azithromycin	1 g stat, orally 1g weekly for 3 weeks, orally	– Inhibits bacterial protein synthesis by binding to the 50S ribosomal subunit of the bacterial 70S ribosome – The same as for erythromycin	Should be considered as second choice, but evidence is lacking to recommend this drug currently
Tetracycline	500 mg four times daily for 21 days, orally	– The same as for doxycycline – The same side effects listed earlier for doxycycline	The same as for doxycycline
Minocycline	300 mg loading dose, followed by 200 mg twice daily for 21 days, orally	– The same as for doxycycline – Vertigo, dizziness, ataxia, tinnitus, and the side effects listed earlier for doxycycline^Citation68,Citation69	The same as for doxycycline
Moxifloxacin	400 mg once daily for 21 days, orally	– Blocks DNA gyrase enzyme (it is responsible for production and repair of bacterial DNA) and it leads to bacteria death – Nausea, dizziness, diarrhea, QT prolongation, and photosensitivity	– Administration should be separated from aluminum- and magnesium-containing antacids, sucralfate, and multivitamins because they can lower absorption of moxifloxacin and reduce its effectiveness – Should be used with caution with warfarin (increases risk for bleeding) and sotalol (abnormal heart rhythm)

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