Venereal lymphogranuloma A55

Rare notifiable infectious disease caused by Chlamydia trachomatis (L1-L3), which belongs to the group of sexually transmitted diseases (STDs) and is endemic and occurs mainly in tropical countries.

Chlamydia trachomatis serotype L1-L3, an obligate intracellular bacterium. The heat shock protein 70 and heparin-like glycosaminoglycans are responsible for the attachment of Chlamydia trachomatis to the host cell.

Rare in the western world, more common venereal disease in the tropics and subtropics. Endemic in East and West Africa, India, Southeast Asia, the Caribbean and South America. In a large Spanish collective, LGV infections were detected in >90% of cases in MSM (men who had sex with men) populations. In this population, the incidence rate was 282/100,000, and co-infection with HIV was almost always present.

95% of those affected are men, predominantly MSM (men who have sex with men).

Incubation period 5-10 days (sometimes several weeks).

• Stage I: Primary lesion (penis/vulva or genito-rectal): Painless papules the size of a millet or rice grain, transition to papulovesicle or papulopustule, which ulcerates flat and drains serous secretion. Flat, greasy ulcer. The primary infection may also present as erosive proctitis or colitis.
• Stage II: Bubons 2-4 weeks after the primary lesion unilateral or bilateral to hen's egg size painful swelling of the inguinal lymph nodes; good on the surface, cannot be moved against the skin. The surface of the nodes is first red, then blue-red and finally reddish-brown. Abscess formation, perforation to the outside. Formation of fistula with emptying of a creamy whitish-grey, crumbly pus. Incised scarring. If the primary lesion is located in the vagina or rectum: Infection of the perirectal and para-aortic lymph nodes. "Intra-abdominal bubo": fixed swollen glands on the inside of the iliac crest.
• Stage III: Elephantiasis genitoanorectalis ulcerosa, Esthiomène, anorectal symptom complex. Final stage with ulcers, strictures and fibrosis in the urethra, genital tract and rectum. Elephantiasis genitalium: Enlarged labia of rubbery consistency, smooth bulges, deep furrows, papillomatous growths. Also elephantiasis of scrotum and/or penis.
  • Anorectal symptom complex with haemorrhoids and condylomata acuminata. Involvement of the Gerota lymph nodes with consecutive severe congestion above the anus. Thickened, hardened, infiltrated, retracted rectum with numerous ulcers. Perianal and perirectal fistula formation. Thin, bloody stool.

In stages I and II antibiotic therapy with sulfonamides, doxycycline (e.g. Supracycline) 2 times/day 100 mg for 3 weeks, cotrimoxazole (e.g. Cotrimox Wolff 2 times/day 2 tbl.) for 14 days.

Alternatively Ofloxacin (e.g. Tarivid) 2 times/day 300 mg for 7-14 days, Tetracycline (e.g. Tetracycline Wolff Kps.) 4 times/day 500 mg for 14 days or Erythromycin (e.g. Erythrocin Filmtbl.) 4 times/day 500 mg for 14 days.

If necessary, tetracycline in combination with cotrimoxazole. In stage III, surgical measures in the presence of elephantiasis.

Caution! Co-treatment of the partner.

Pregnant and lactating women should be treated with azithromycin 1.5g p.o. once or alternatively with erythromycin 500mg 4x daily p.o for 7d (or 2x daily p.o. for 14d).

Classical courses with ulcers on the penis and regional lymph node swelling are observed increasingly rarely; thus, infections also occur under the picture of chronic proctitis.

Caution. There is a risk of sterility in women!

26-year-old man with clearly enlarged and pressure-painful inguinal lymph node swelling (see figure). This was preceded 3 months ago by an unprotected contact with an unknown partner.

Findings: No genital ulcer (had existed earlier).

Urethra and rectal swabs for chlamydia: negative.

Laboratory: Chlamydia: LPS IgM ELISA: positive; Syphilis: TPHA test: negative, VDRL: negative.

In case of persistent lymphadenopathy, the inguinal lymph node was punctured and a chlamydia infection by serovar L 2 was confirmed by DNA detection.

Therapy: Doxycycline 200mg/day p.o. for 3 weeks

Course: Healing of the findings.

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