Chlamydia and LGV guide: Risk factors and clinical manifestations

Risk factors and manifestations of Chlamydia trachomatis infections (including lymphogranuloma venereum (LGV)).

On this page

• Risk Factors
• Transmission
• Clinical Manifestations
  • Chlamydia
  • LGV
• References

Risk factors

Common risk factors for chlamydia:

• Sex with a person who has chlamydia without barrier protection
• Sex without barrier protection with a new partner
• More than two sexual partners in the previous 12 months
• Previous sexually transmitted and blood-borne infection (STBBI)
• Being sexually active and less than 25 years
• Being born to a pregnant person with chlamydia
• Member of a vulnerable population

In Canada, the United States, and Europe, the subpopulation at highest risk of LGV is gay bisexual and other men who have sex with men (gbMSM), particularly those:^{Footnote 1Footnote 2Footnote 3Footnote 4Footnote 5Footnote 6}

• With hepatitis C (HCV), human immunodeficiency virus (HIV) or other STBBI^{Footnote 7}
• Who engage in anal or oral group sex without barrier protection
• With multiple sexual partners^{Footnote 7}
• Who engage in high-risk activities such as “fisting”, which may damage mucosal tissue^{Footnote 8}

Other activities that may increase potential exposure to STBBIs include anonymous sexual partnering, street involvement and substance use.

Transmission

C. trachomatis is transmitted through vaginal, anal or oral sexual activity when there is contact with mucous membrane exudate from people with chlamydia.^{Footnote 1Footnote 9Footnote 10Footnote 11Footnote 12}

Vertical transmission can occur if a pregnant person with chlamydia has not been screened and treated during the prenatal period.^{Footnote 13Footnote 14Footnote 15}

Autoinoculation may also occur from an infected genital site to the conjunctivae or the rectum.^{Footnote 16}

Clinical manifestations

Chlamydia

Approximately 50% of males and 70% of females with chlamydia infection are asymptomatic.^{Footnote 17} The incubation period is usually two to three weeks but can be as long as six weeks. If not treated, chlamydia infection may persist for many months.

Chlamydia signs and symptoms

In symptomatic individuals, clinical presentation often reflects the site of infection.

Most common signs and symptoms (if present):

• Dysuria
• Inflammation of the lining of the rectum (proctitis)
• Excessive tearing, discharge, inflammation, swelling or redness of the conjunctivae (conjunctivitis)

Females:

• Purulent or mucopurulent exudate in the endocervical canal or easily induced/sustained bleeding or friability at the endocervical os (cervicitis)
• Change in vaginal discharge
• Lower abdominal pain
• Abnormal vaginal bleeding
• Dyspareunia

Males:

• Urethral discharge
• Inflammation of the urethra, with or without urethral discharge (urethritis)
• Urethral itch
• Testicular pain

Neonates and infants:

• Excessive tearing, discharge, inflammation, swelling or redness of the conjunctivae (conjunctivitis) (in neonates)
• Pneumonia (infants less than six months)^{Footnote 17}

Complications of chlamydia infections

If not adequately treated, chlamydia can spread from a local site of inoculation and lead to serious complications and/or sequelae.

Females:

• Pelvic inflammatory disease (PID)
• Ectopic pregnancy
• Infertility
• Chronic pelvic pain
• Reactive arthritis^{Footnote 17}

Males:

• Epididymo-orchitis
• Reactive arthritis^{Footnote 17}

LGV

C. trachomatis LGV genotypes are more invasive than non-LGV genotypes and preferentially affect the lymph tissue.^{Footnote 1} Infection may be accompanied by systemic symptoms, painful lymphadenopathy, inflammation and, if untreated, anogenital scarring. Signs and symptoms of LGV significantly overlap with those of other STBBIs, other infections, non-infectious illnesses (e.g. inflammatory bowel disease), drug reactions and malignancies.

LGV is commonly divided into three stages: primary, secondary and tertiary.^{Footnote 12}

Based on limited data, human immunodeficiency virus (HIV) infection appears to have little effect on clinical presentation, atypical presentations have been rarely reported.^{Footnote 18} However, duration of infection may be prolonged in people with HIV.

LGV signs and symptoms

Primary LGV

The incubation period for primary LGV is three to 30 days. It is usually self-limited and may not be noticed in up to 50% of people.^{Footnote 12} Primary LGV is characterized by painless, small papule(s) (1–6 mm), at the site of inoculation (vulva, vagina, penis, rectum, oral cavity, occasionally cervix) that may ulcerate.

Secondary LGV

Secondary LGV begins within two to six weeks of the primary lesion(s) and involves the lymph nodes and/or anus and rectum.^{Footnote 19} Secondary LGV is often accompanied by significant systemic symptoms, such as low-grade fever, chills, malaise, myalgias, arthralgias. It is occasionally accompanied by arthritis, pneumonitis or hepatitis/perihepatitis and rarely associated with cardiac involvement, aseptic meningitis and ocular inflammatory disease.^{Footnote 19}

In secondary LGV, approximately one-third of women and most men present with recognizable signs and symptoms.^{Footnote 19} Less than one-third of people experience abscesses and draining sinuses.^{Footnote 12}

Secondary LGV causing lymphadenopathy

In LGV-associated lymphadenopathy, the most common involved site is inguinal/femoral: characterized by painful inguinal and/or femoral lymphadenopathy and is referred to as buboes. Lymphadenopathy is unilateral in one-half to two-thirds of cases.

The “Groove sign” (hard, fixed and extremely tender lymph nodes above and below the inguinal ligament, with a groove along the ligament) is pathognomonic of secondary LGV.^{Footnote 12}

Other lymphadenopathies may occur depending on site of inoculation (e.g. cervical lymphadenopathy following inoculation during oral sex).

Secondary LGV causing anorectal symptoms

Secondary LGV may cause anorectal symptoms, characterized by acute hemorrhagic proctitis and/or proctocolitis. Bloody, purulent or mucous discharge from the anus, as well as constipation, are common presentations.^{Footnote 1Footnote 20Footnote 21Footnote 22}

Tertiary LGV (chronic LGV)

Tertiary LGV is more common in females than males. Chronic inflammatory lesions, lymphatic obstruction causing genital elephantiasis^{Footnote 12Footnote 23}, as well as genital and rectal strictures and fistulae, may lead to scarring and extensive destruction of genitalia (esthiomene).^{Footnote 12Footnote 19} Surgery may be required to repair genital/rectal damage of tertiary LGV.

References