Lymphogranuloma venereum: causes, symptoms, diagnosis, treatment

Venereal lymphogranuloma (HSV) (synonyms: fourth venereal disease, Nicola Favre disease) is a sexually transmitted infection caused by pathogenic microorganisms of Chlamydia trachomatis types LI, L2, L3. In the world, the venereal lymphogranuloma is not common, although it accounts for 2-10% of cases of diseases accompanied by ulceration of the genitals, in India and Africa. The most common occurs at the age of 20-30 years. Men are more likely to go to a medical institution with an acute form of venereal lymphogranuloma, while women are more likely to get complications at a late stage of the disease.

The most frequent clinical manifestations of venereal lymphogranulomatosis in heterosexual men is painful inguinal and / or femoral lymphadenopathy, most often on the one hand. Women and active homosexual men may experience proctocolitis or inflammatory changes in the peritectal or perianal lymphatic tissue, which can lead to the formation of fistulas and strictures. Most patients who do not receive treatment develop a self-limiting genital ulcer, sometimes in the place of inoculation. Diagnosis is usually performed by serological methods and by excluding other causes of inguinal lymphadenopathy or genital ulcers.

Neither the degree of infectivity of the pathogen nor the reservoir of the disease is exactly known, although it is believed that the transmission of the venereal lymphogranuloma is mainly carried out by asymptomatic female carriers.

Symptoms of a venereal lymphogranuloma. The incubation period is from 3 to 12 days before the start of the first stage and 10-30 days before the start of the second stage.

There are 3 stages in the course of venereal lymphogranuloma. After inoculation, a small, painless papule or pustule appears, which can be eroded to form a small herpetiform sore (the first stage of the venereal lymphogranuloma). Primary focus in men is often localized on the neck of the glans penis, frenum of the foreskin, foreskin, glans penis and penis, scrotum, in women - on the back of the vagina, the frenum of the labia, the posterior lip of the cervix and the vulva. This lesion usually heals within a week and often the patients do not notice it. At this stage, mucopurulent discharge from the urethra in men and the cervix in women can be observed.

The second stage of the venereal lymphogranuloma occurs within 2-6 weeks after the appearance of the primary focus and is manifested by painful inflammation of the inguinal and / or femoral lymph nodes.

Venous lymphogranuloma is primarily a disease of the lymphatic system, which progresses to lymphadenitis. Infected macrophages penetrate into regional lymph nodes. This gives a typical picture of unilateral enlargement of the lymph nodes (in 65% of patients), infection and abscess. Painful lymph nodes are called buboes, they can merge and open up in a third of patients. In other cases they turn into solid, non-swollen formations. Although in most cases buboes heal without complications, some can progress, forming chronic fistulas. Approximately one third of patients have a "furrow sign", which arises from the increase in inguinal and femoral lymph nodes located above and below the puarth ligament.

Inguinal lymphadenopathy occurs in 20% of women with venereal lymphogranuloma. In women, primary lesions of the rectum, vagina, cervix or posterior urethra with involvement of deep iliac or perico-rectal lymph nodes are more common.

The result can be pain in the lower abdomen or back. In many women, characteristic inguinal lymphadenopathy does not develop; about a third of them go to the doctor with signs and symptoms of the second stage, while most men turn to the doctor at this stage of the disease. At this stage of the disease, common symptoms such as slight fever, chills, malaise, myalgia and arthralgia are often observed. In addition, the systemic spread of C. Trachomatis sometimes leads to the development of arthritis, pneumonia and perihepatitis. To rare systemic complications include heart lesions, aseptic meningitis and inflammatory diseases of the eyes.

The third stage of venereal lymphogranuloma is often called "genitoanorectal syndrome", it is more often observed in women. First proctitis develops, then - pararectal abscess, strictures, fistula and rectal stenosis, leading to the formation of "lymph node" (similar to hemorrhoids). In the absence of treatment, chronic lymphangitis leads to the formation of multiple scars, the development of strictures and fistulas, which can eventually lead to elephantiasis.

In laboratory studies in smears prepared from purulent discharge and stained according to Romanovsky-Giemsa, Chlamidia Trachomatis; and antibodies to Chlamidia Trachomatis were detected using ELISA. The results of serological reactions to syphilis are negative.

Laboratory diagnostics. Bacterioscopic method: detection of the pathogen in smears prepared from purulent discharge and stained but Romanovsky-Giemsa.

The culture method. The diagnosis of LVH can be made by isolating the culture of the microorganism and typing the cells in the sample. The material should be taken from the affected lymph node or the affected tissue with a swab. The technique is relatively insensitive: positive by 50%, even if cyclohexamide treated cells are McCoy cells or diethylaminoethyl-treated HeLa cells.

Complement fixation reaction in paired sera. Diagnostic is the titre of reactin 1:64 or 4-fold increase in antibody titer after 2 weeks (so-called "paired sera").

Alternative methods are the method of immunofluorescence using monoclonal antibodies and the PCR method.

The flow is unpredictable. Quite often, spontaneous remissions occur.

Treatment of venereal lymphogranuloma. Carry etiotropic treatment. It has a good effect in the early stages of the disease. The recommended scheme is doxycycline 100 mg 2 times a day for 21 days. As an alternative scheme appoint erythromycin 500 mg 4 times a day for 21 days.

The treatment is directed to the cause of the disease and to prevent tissue damage, since scarring is possible. If buboes are present, aspiration or incision through intact skin may be required followed by drainage. It is preferable to use doxycycline for treatment.

Recommended scheme

Doxycycline 100 mg orally 2 times a day for 21 days.

Alternative scheme

Erythromycin 500 mg orally 4 times a day for 21 days.

The activity of azithromycin against C. Trachomatis suggests that this drug can be effective in its use in multiple doses for 2-3 weeks, but clinical data on its use in this disease is not yet sufficient.

Follow-up

Patients should be observed until the resolution of symptoms and symptoms.

Management of sexual partners

The sex partners of patients with venereal lymphogranulomatosis should be examined, tested for urethral or cervical chlamydial infection and treated if they had sex with patients for 30 days preceding the onset of the last symptoms of venereal lymphogranulomatosis.

Special Remarks

Pregnancy

Pregnant and lactating women should have a erythromycin treatment regimen.

HIV infection

Persons with HIV infection and venereal lymphogranulomatosis should be treated according to the schemes presented earlier. Rare data on the combination of venereal and HIV-associated lymphogranulomatosis suggest that such patients need longer treatment, and that a slow resolution of the symptoms is possible.