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Lymphogranuloma venereum

Key sources
The following summarized guidelines for the evaluation and management of lymphogranuloma venereum are prepared by our editorial team based on guidelines from the European Academy of Dermatology and Venereology (EADV 2019) and the British Association for Sexual Health and HIV (BASHH 2013).
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Guidelines

1.Screening and diagnosis

Indications for testing: obtain testing for LGV in the following patients:
HIV-positive MSM or in MSM eligible for HIV pre-exposure prophylaxis
A
patients with other C. trachomatis positive sites - urethra/urine/pharynx - if symptoms persist despite receiving recommended treatment options
B
symptomatic patients with suspected LGV
contacts of confirmed LGV index cases
all MSM with a C. trachomatis positive anorectal sample irrespective of symptoms.
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  • Diagnosis

2.Diagnostic investigations

Initial diagnostic testing: obtain an NAAT to detect C. trachomatis nucleic acid in urethral, cervical, urine, rectal, and pharyngeal specimens.

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  • Specimen selection

  • Nucleic amplification tests

  • Serology

  • Culture

  • Rectal smear

  • Testing for other STIs

  • Assessment of sexual partners

3.Diagnostic procedures

Lymph node biopsy: histology of lymph nodes shows follicular hyperplasia and abscesses in patients with LGV, but such findings are not specific. Nonetheless, histopathologists need to be alert to these changes and include LGV in the differential diagnosis.

4.Medical management

General principles: as per EADV 2019 guidelines, consider initiating treatment for LGV in MSM with a C. trachomatis positive anorectal test result having severe proctitis, if no LGV diagnostic test is readily available.
C

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  • First-line therapy

  • Second-line regimens

  • Second-line therapy

  • Alternative regimens

  • Management of sexual partners

5.Therapeutic procedures

Aspiration of fluctuant buboes: drain fluctuant buboes via needle aspiration through healthy overlying skin. Consider repeating intervention to ensure reemerging buboes are drained.
B

6.Surgical interventions

Surgical incision: do not perform surgical incision of buboes due to potential complications such as chronic sinus formation.
D

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  • Reconstructive genital surgery

7.Patient education

General counseling: as per EADV 2019 guidelines, inform patients that:
LGV is a STI that can invade connective tissue and regional lymph nodes, but is curable with antibiotics
if left untreated it can have serious and permanent adverse sequelae
most of these complications are preventable if treatment is initiated at an early stage
in anorectal disease, symptoms should resolve within 1-2 weeks of commencing antibiotic therapy
in inguinal disease, symptoms might persist for many weeks and follow-up visits should be implemented.
B
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8.Follow-up and surveillance

Follow-up: follow-up all patients with LGV at the end of treatment in order to:
ensure treatment compliance, assess side effects, and ensure resolution of symptoms and signs of infection
check that adequate partner notification has been completed
address any patient concerns
arrange suitable follow-up testing for syphilis, gonorrhoea and blood-borne viruses including hepatitis B, C and HIV
B
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