A recent Morbidity and Mortality Weekly Report (MMWR-October 29, 2004/53(42): 985-988) from the Centers for Disease Control and Prevention (CDC) alerted clinicians to an increase in the number of cases of LGV among men who have sex with men (MSM) in the Netherlands. Typically, fewer than 5 cases a year are reported in that country. As of September 2004, a total of 62 cases had been confirmed for 2004 and another 30 cases occurred in 2003. Only one patient had symptoms usually associated with LGV (i.e., inguinal adenopathy [buboes] and a painful genital ulcer); all other patients had gastrointestinal symptoms (e.g., bloody proctitis with a purulent or mucous anal discharge and constipation). Some of the patients in this LGV outbreak reported multiple sex partners in cities in Europe and the United States.

LGV is caused by Chlamydia trachomatis (CT) serotypes L1, L2 and L3. LGV is a rare disease in the United States. To date, 2 confirmed cases of rectal LGV have been reported in the United States in MSM who presented with similar symptoms as the cases in the Netherlands. Other suspected cases are being investigated.

CLINICAL FEATURES: The primary lesion produced by LGV is a small, non-painful genital papule, which can ulcerate at the site of inoculation after an incubation period of 3-30 days. This lesion can remain undetected within the urethra, vaginal vault, or rectum.Common clinical manifestations include 1) tender, unilateral, or bilateral inguinal and/or femoral adenopathy, which can become fluctuant; and 2) hemorrhagic proctitis or proctocolitis, which is associated with receptive anal intercourse. The clinical and histologic presentation of LGV protocolitis can be similar to the initial manifestations of inflammatory bowel disease. The laboratory criteria consistent with a diagnosis of LGV include a positive result (i.e., titer > 1:64) on a complement fixation test for chlamydiae or a high titer (typically >1:128 but can vary by laboratory)on a microimmuno-fluorescence serologic test for C. trachomatis. PCR testing may be available at CDC.

Treatment of LGV: The recommended treatment for lgv is doxycycline 100 mg orally, twice a day, for 21 days. Alternative treatment is 500 mg of erythromycin base orally, four times a day, for 21 days. Some experts believe that 1gram azithromycin administered orally, once weekly, for 3 weeks, is effective (however, clinical data are lacking). sex partners who had contact with the patient in the 30 days after onset of the patient’s symptoms should be evaluated. in the absence of symptoms, they should be treated with either 1 gram of azithromycin in a single oral dose or 100 mg of doxycycline orally, twice a day, for 7 days.

Recommended Approach

Clinicians who care for MSM should consider LGV in the diagnosis of compatible syndromes, particularly proctitis. Other manifestations of LGV include tender lymph nodes (inguinal and/or femoral which can become fluctuant) and anogenital ulcers (small, generally painless ulcer followed by the appearance of tender lymph nodes).
LGV is a reportable disease in RI. Contact the Office of Communicable Disease (HEALTH) if you suspect a case of LGV (222 2577) . We can provide guidance with appropriate specimen collection and laboratory testing of cases compatible with LGV as well as with partner services.
Perform testing for Neisseria gonorrhoeae and other STDs (syphilis; HIV and HSV as appropriate).
Cases compatible with LGV should be treated presumptively or until all tests used to support the diagnosis are negative for CT/LGV.

Specimen Collection Procedures (Clinicians)

Please submit both rectal specimens and serum from patients you suspect may have LGV.

Rectal specimen collection
Equipment

For immediate collection (i.e. the patient is in clinic now or will be in the next day): Use the small swab in the tube included in a standard DNA hybridization (GenProbe) or DNA amplification test (BD, GenProbe, TMA, Roche) for specimen collection not the large tipped cleaning swab. If these test kits are not available, you may use a sterile, DRY swab. Place the swab into a specimen collection tube (no fluid or jelled medium should be included in the tube).

Collection Technique

Blind rectal specimens should be collected prior to anoscopy or sigmoidoscopy. Insert swab 3-5 cm into rectum, rotate against rectal wall several times. Discard swabs grossly contaminated with feces and repeat collection. If anoscopy or sigmoidoscopy is performed, collect specimen from visible mucosal ulceration. Specimens obtained during direct visualization when performing anoscopy or sigmoidoscopy are preferable.

Serum collection
Collect approximately 5 mL of blood in red top vacutainer tube, and send to the State laboratory. Laboratory processing should include the following: prepare serum by incubating freshly drawn blood at 37º C for 30 minutes for clot to form. Then move to 4º C overnight to allow clot to contract. Serum should be separated by centrifugation at 10,000g for 10 minutes at 4º C.

Sex partner contacts

For sex partner contacts of a suspected or confirmed LGV case, you may also submit specimens for LGV testing if local lab urethral/urine testing is positive for C. trachomatis.

For more information on specimen collection/testing and other assistance, call the Office of Communicable Diseases at (401) 222-2577. Ask for Nancy Walsh, RN or Carol Browning, RN.

Highlights

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