What is Lymphogranuloma Venereum Proctocolitis?
In August 2018, the Centers for Disease Control and Prevention (CDC) shared some alarming statistics at the National STD Prevention Conference. They reported that sexually transmitted infections (STIs) continue to increase at a concerning pace. In 2017, almost 2.3 million cases of chlamydia, gonorrhea, and syphilis were diagnosed in the US. This beats the previous record set in 2016 by over 200,000 cases, and it marks the fourth straight year of significant increases in such diagnoses. Chlamydia was the most commonly reported condition at the CDC. Due to the increase in STIs, some diseases that were once thought to be extinct have come back. One example is Lymphogranuloma venereum (LGV).
Lymphogranuloma venereum (LGV) is a sexually transmitted disease caused by the L1, L2, and L3 serovars of the bacteria Chlamydia trachomatis. It was first identified in 1833 by Wallace, who initially thought the infection was caused by climate and named it as “tropical bubo.” However, in 1912, Rost concluded that the disease was sexually transmitted. LGV symptoms can vary based on where the bacteria enters the body. Historically, the infection typically presented as a temporary genital ulcer and painful groin lymph node swelling, also known as “buboes.” If not treated, the disease would progress, spreading throughout the body and causing various complications. With the introduction of antibiotic therapy, LGV had almost disappeared from Western societies. However, since 2003, outbreaks of an LGV variant primarily affecting the rectum, known as LGV proctocolitis, have emerged in Western Europe and North America and disproportionately affect men who have sex with men.
What Causes Lymphogranuloma Venereum Proctocolitis?
The chances of getting LGV, a type of sexual disease, is linked to lifestyle and sexual behaviors. LGV is caused by the Chlamydia bacteria, which needs to directly enter the body to cause an infection. In the specific case of LGV proctocolitis, which involves inflammation of the rectum and colon, the infection is commonly passed on through anal sex.
Similar to other sexually transmitted diseases, having sex with multiple partners or being promiscuous raises the risk of getting LGV. It’s also noted that LGV proctocolitis affects gay men more than other groups. Hence, studies have been conducted to identify the behaviors within this community that might increase the risk of getting LGV.
From these studies, it was discovered that gay men with LGV were more likely to have unprotected anal sex, including fisting, have multiple or one-time sexual partners, use recreational drugs and alcohol, particularly GHB and methamphetamines, and share sex toys.
Risk Factors and Frequency for Lymphogranuloma Venereum Proctocolitis
Before 2003, LGV was not common in most Western countries. It used to be prevalent mainly in tropical regions like East and West Africa, India, Southeast Asia and the Caribbean. The United States even stopped mandatory reporting of the disease in 1995 due to its low occurrence. However, in 2003, an outbreak of LGV among HIV-positive men in Rotterdam, the Netherlands, sparked concern. The disease started showing up in several major European cities.
In response, countries in Western Europe and North America began keeping a closer watch on high-risk patients. But, even after a decade, many European countries did not require LGV to be reported. Today, only 24 states in the U.S. mandate the reporting of LGV cases. This inconsistency has made it difficult to understand the true scope of the disease.
Despite these challenges, current data suggests that LGV is increasing, particularly among men who have sex with men (MSM). Because of the European outbreak in 2004, enhanced strategies were put in place in several European countries. This led to the formation of the European Surveillance of Sexually Transmitted Infections network, which allowed for data sharing and alert creation.
- From 2004 to 2008, 1693 LGV cases were identified in eight European countries, all showing an upward trend.
- In 2014, 1416 LGV cases were reported from 21 European countries – a significant 32% increase from the previous year.
- Most cases (87%) were reported from France, the Netherlands, and the United Kingdom, and nearly all reports were among MSM.
In the US, specific data on LGV is not easily available. However, it is worth noting that Chlamydia infection cases have been increasing yearly according to the CDC’s data.
HIV positive people, particularly MSM, have been affected disproportionately by LGV. Most confirmed LGV cases occur in HIV-positive patients according to a meta-analysis. This research suggests HIV-positive MSM could be more than eight times more likely to have HIV than those with non-LGV Chlamydia infections. Factors like improved survival and ‘serosorting’ – choosing sexual partners based on their HIV status – might be contributing to this trend.
It’s important to note that the high prevalence of LGV in HIV-infected MSM could be due to both risky sexual behavior and their weakened immune system. One potential theory is that HIV infection could weaken the immune response in the gut area, making those individuals more susceptible to other infections like Syphilis and Chlamydia. This notion is especially relevant as the rectal area could be a main point of infection transmission during sexual intercourse.
Signs and Symptoms of Lymphogranuloma Venereum Proctocolitis
Lymphogranuloma venereum (LGV) is a disease that develops in three distinct stages, each with its own unique set of symptoms. The symptoms you experience depend on what stage of the disease you’re in and where the bacteria entered your body.
Primary LGV emerges 3 to 30 days after you’re exposed to the bacterium. Mostly men who engage in anal receptive intercourse have reported this new resurgence of LGV. This stage causes symptoms such as rectal bleeding, discharge from the rectum, rectal pain, and changes in bowel habits such as constipation. Sometimes, the early signs of LGV can mimic other conditions, making it hard to diagnose.
Secondary LGV appears 2 to 6 weeks after the initial exposure and happens when the bacterium invades the lymphatic system. If you have LGV proctocolitis, this might cause lower abdominal and back pain. You might also feel systemic symptoms like fever, chills, general weakness, muscle ache, joint pain, lung inflammation, and liver inflammation. Very rarely, this stage could lead to myocarditis, aseptic meningitis, and eye inflammation. Some people might develop reactive arthritis after LGV proctocolitis has been confirmed.
Tertiary LGV occurs if the infection hasn’t been treated. This stage reveals a steady local tissue destruction due to chronic inflammation. If you have chronic perirectal lymphatic blockage, it might cause hemorrhoid-like swellings termed as “lymphorroids”. You might also develop fistulas, strictures, and stenosis caused by chronic lymphangitis and progressive sclerosing fibrosis. These symptoms may resemble those of inflammatory bowel disease. Some people suffering from persistent LGV proctitis can develop megacolon. Chronic pelvic pain might also happen due to frozen pelvis syndrome.
The symptoms you might experience at these different stages include:
- Rectal bleeding
- Rectal discharge
- Rectal pain
- Changes in bowel habits
- Lower abdominal and back pain
- Fever
- Chills
- General weakness
- Muscle ache
- Joint pain
- Lung inflammation
- Liver inflammation
- Hemorrhoid-like swellings called ‘lymphorroids’
- Development of fistulas, strictures, and stenosis
- Chronic pelvic pain
Testing for Lymphogranuloma Venereum Proctocolitis
The process of diagnosing LGV proctocolitis, an inflammation of the rectum and colon, involves several steps. Initially, doctors conduct a typical lab test and analyze stool samples. These steps are done to rule out other widespread infections like Salmonella, Escherichia, and more.
Following this, more detailed examinations like imaging scans and endoscopy are carried out. Endoscopy involves inserting a small camera into your body (through the rectum in this case) to get a detailed view of the affected area. Endoscopic biopsy is an exam where your doctor removes a small piece of tissue from your body (usually rectum or colon) to check for viral infections, cancer, or inflammation that may be causing your symptoms. However, these findings may not specifically indicate LGV proctocolitis and could suggest other medical conditions.
If your doctor has a strong reason to believe that you have LGV proctocolitis, especially if you have known risk factors, they will try to identify a particular bacterium called Chlamydia trachomatis. Identifying this bacterium is not an easy task because it lives inside human cells, so typical bacterial tests won’t work. Instead, Nucleic acid amplification tests (NAATs) are used, which are techniques that can amplify and detect tiny amounts of DNA or RNA in a person’s sample. These tests have high accuracy, and the results can help diagnose the bacteria.
Once the infection is confirmed, the next step is to identify the specific variant (serovars L1-3) of the Chlamydia trachomatis bacteria causing the infection. This can be done by performing LGV-specific DNA tests (NAATs). If these tests come back positive, a 21-day course of antibiotics is recommended as an effective treatment for LGV proctocolitis.
Unfortunately, not all medical facilities have the capability to perform these specific tests. In such scenarios, other methods like Chlamydia-specific blood tests may be considered. However, these tests are less sensitive and specific. If the specific variant identification isn’t possible, doctors might still prescribe a 21-day antibiotic regimen if the patient meets certain criteria, like showing inflammation in the initial colonoscopy or being HIV positive.
Interestingly, these diagnostic strategies can also be applied to screen individuals who are at high risk but do not show symptoms, particularly those who participate in receptive anal intercourse.
Treatment Options for Lymphogranuloma Venereum Proctocolitis
The Centers for Disease Control and Prevention (CDC) recommends treating patients with symptoms of LGV infection. LGV, or lymphogranuloma venereum, is a sexually transmitted infection that can cause symptoms such as inflammation of the rectum and colon (proctocolitis), genital ulcers, and swollen lymph nodes (lymphadenopathy). The main treatment for LGV is antibiotics.
According to both American and European guidelines, the primary recommended treatment includes a specific type of antibiotic called doxycycline. If doxycycline doesn’t work or isn’t suitable for a patient, like in the case of pregnant individuals, another antibiotic called erythromycin can be used.
Another antibiotic called azithromycin, taken once a week for three weeks, may be easier for some patients to stick to. However, there’s still ongoing research to determine how effective this method is.
To avoid re-infection, all sexual partners should be tested as well. Also, preventive measures and proper use of birth control methods are emphasized during check-ups with patients who are at risk of LGVs.
Another possible treatment approach is suitable for patients showing symptoms of LGV proctocolitis. This involves beginning treatment with doxycycline and another antibiotic called ceftriaxone while waiting for lab test results. If the tests confirm a Chlamydia infection, the kind of bacteria that causes LGV, the treatment should continue for three weeks or until all symptoms have gone away.
What else can Lymphogranuloma Venereum Proctocolitis be?
When doctors are considering a diagnosis, they think about other conditions that might cause similar symptoms. For LGV, a type of sexually transmitted infection, the different stages could be confused with other medical conditions:
For primary LGV, they would consider:
- Infectious proctocolitis caused by common organisms or other STIs like Neisseria, CMV, HSV, and amoebiasis, if the patient has diarrhea or pain
- Dysentery or inflammatory bowel disease, if there are altered bowel habits, pain, bloody diarrhea
- Malignancy
- Irritable bowel syndrome, if there’s pain and altered bowel habits
- Hemorrhoids, if the patient has rectal pain and bloody output
For secondary LGV, they would rule out:
- Routine infectious colitis or influenza, if there are constitutional symptoms, muscle pains and joint pains
- Hepatitis, if there’s abnormal liver function tests
- Rectal carcinoma or lymphoma
- Inflammatory bowel disease
Lastly, for tertiary LGV, they might think about:
- Inflammatory bowel diseases like Crohn’s disease or ischemic colitis, if there’s evidence of fistula or stricture formation
- C. difficile megacolon
- Malignancy
What to expect with Lymphogranuloma Venereum Proctocolitis
The chances of recovery are generally good, but it largely depends on quickly identifying the problem, the patient’s willingness to take long-term antibiotic treatment, and avoiding risky behaviors. It’s important to note that the problem could happen again if the person continues to be exposed to the same risk factors.
Possible Complications When Diagnosed with Lymphogranuloma Venereum Proctocolitis
If an infection is not treated for an extended period, it can lead to more serious problems. These issues indicate progression to a more advanced stage of LGV, a sexually transmitted infection. Some symptoms of this stage include:
- Narrowing or tightening in parts of the colon
- An excessively large colon
- Leakage of lymphatic fluid from the body
- Abnormal connections or passageways in the body, known as fistulas
- Chronic pelvic pain due to a condition called frozen pelvis syndrome
Preventing Lymphogranuloma Venereum Proctocolitis
Recognizing the early warning signs and symptoms of LGV (a type of sexually transmitted infection) as soon as possible can help improve the treatment success. If there’s a delay in diagnosing LGV, it might be because the disease imitates other diseases or because the patient hasn’t shared enough about their sexual history. People who are at high risk should be educated about the early signs and symptoms, how the disease spreads, how to prevent transmission using safe sex practices, and the risks of having multiple sexual partners. Testing for LGV should also be recommended and considered for high-risk people who don’t show any symptoms, or those who come in with other sexually transmitted infections.
