Anus and perianal area
Inflammatory diseases
Lymphogranuloma venereum

Author: Arvind Rishi, M.D. (see Authors page)

Revised: 27 September 2017, last major update September 2014

Copyright: (c) 2002-2017, PathologyOutlines.com, Inc.

PubMed Search: Lymphogranuloma venereum anus

Cite this page: Rishi, A. Lymphogranuloma venereum. PathologyOutlines.com website. http://pathologyoutlines.com/topic/anusLGV.html. Accessed October 22nd, 2017.
Definition / general
  • Sexually transmitted chronic ulcerative disease
  • Causative organism Chlamydia trachomatis L1, L2, and L3 serovars
  • Complications: strictures, perirectal abscess, fistulas and sinuses, squamous cell carcinoma
  • Rectal strictures are more common in women
Terminology
  • Three stages of infection:
    • Primary infection:
      • Small often unnoticed ulceration, erosion or erythematic area
      • Usually self healing
      • Incubation period of 3 - 12 days following an exposure to the causative organism
    • Secondary infection:
      • Due to the extension of infection to the draining lymph nodes
      • LGV causing serovars produce severe disease with systemic symptoms as compared to serovars A to K
      • Manifests 2 - 6 weeks after primary infection
      • Characterized by enlarged and painful lymph nodes
      • Lymph nodes may rupture and form cutaneous sinuses
      • Anorectal disease presents as GI bleed, discharge, rectal ulcer, anal pain or constipation
      • Clinically and histologically mimics inflammatory bowel disease
    • Late infection:
      • Complications of longstanding disease in the form of strictures, fistulas, genital lymphedema and infertility
Epidemiology
  • Endemic disease in the tropical and subtropical regions of Asia, Africa, South America and Africa
  • Increased incidence in western population, especially men who have sex with men (MSM)
  • Associated coinfections:
    • Up to 76% also infected with HIV (Clin Infect Dis 2007;44:26)
    • Other sexually transmitted disease in 39%
    • Hepatitis C infection in 20%
Sites
  • Rectum (LGV proctitis)
  • Perianal skin
  • Draining lymph nodes
Pathophysiology
  • Mainly involves lymphatic system causing lymphangitis, necrosis and abscess formation
  • Produces more generalized lymphoproliferative response
  • Binds through heparan sulfate receptors
  • Recombination of serovars had been reported between serovars L2 and D in cases with hemorrhagic proctitis (MBio 2011;2:e00045)
Diagnosis
  • Culture of the organism
    • Sampling by direct aspirate from the infected lymph node, perianal swab or rectal swab
    • Positive culture is confirmatory but the yield is usually low
    • Culture is positive in 20 - 30% of cases and depends on the stage of the illness
    • Most common positive culture is during the secondary stage of illness
    • Primary stage is usually missed for sampling because of subtle clinical feature
    • Chlamydia cultures are not widely available and are done only at referral centers
  • Serology
    • Complement fixation test and immunofluorescence test
    • Complement fixation test measures antibody against group specific lipopolysaccharide antigen
    • Serological tests are supportive only in the presence of appropriate clinical findings
    • Rising titer is significant for the presence of the disease
    • Titer of greater than 1:64 is considered supportive
    • Limitation:
      • Cannot distinguish recent from past infection
      • Cannot distinguish individual serotypes
      • Limited diagnostic potential in an isolated site infection
  • Nucleic acid amplification test (NAAT)
    • A polymerase chain reaction (PCR) based test
    • Sensitivity and specificity greater than 95%
    • Ease of sampling (swab) and transport of the specimen
    • Routine additional testing following a positive NAAT screening test for C. trachomatis no longer recommended by CDC
Case reports
Clinical images

Images hosted on other servers:

44 year old woman: inguinal bubo and fistula

Groove sign (squamous cell carcinoma, not LGV)

Microscopic (histologic) description
  • Granulomatous proctitis resembling Crohn's disease
  • Follicular infiltrates of lymphocytes, histiocytes and plasma cells, neural hyperplasia, extensive fibrosis
  • See also Lymph nodes - Lymphogranuloma venereum
Microscopic (histologic) images

Images hosted on other servers:

Chlamydia inclusion bodies

Chlamydia elementary
bodies (coarser granules
within vacuoles)

C. trachomatis inclusion bodies (brown)

Lymph node: neutrophilic microabscesses

Electron microscopy images

Images hosted on other servers:

Eukaryotic cell with C. trachomatis

Differential diagnosis