Chlamydia and LGV: Risk factors and clinical manifestation

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

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Risk factors

Common risk factors for chlamydia:

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

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):
Females:
Males:
Neonates and infants:

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:
Males:

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 19 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 20 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 20

In secondary LGV, approximately one-third of women and most men present with recognizable signs and symptoms.Footnote 20 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 21Footnote 22Footnote 23

Tertiary LGV (chronic LGV)

Tertiary LGV is more common in females than males. Chronic inflammatory lesions, lymphatic obstruction causing genital elephantiasisFootnote 12Footnote 24, as well as genital and rectal strictures and fistulae, may lead to scarring and extensive destruction of genitalia (esthiomene).Footnote 12Footnote 20 Surgery may be required to repair genital/rectal damage of tertiary LGV.

References

Footnote 1

Nieuwenhuis RF, Ossewaarde JM, Götz HM, Dees J, Thio HB, Thomeer MG, et al. Resurgence of lymphogranuloma venereum in Western Europe: an outbreak of Chlamydia trachomatis serovar l2 proctitis in The Netherlands among men who have sex with men. Clinical infectious diseases 2004;39(7):996-1003.

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Footnote 2

Centers for Disease Control and Prevention (CDC). Lymphogranuloma venereum among men who have sex with men--Netherlands, 2003-2004. MMWR Morb Mortal Wkly Rep 2004 Oct 29;53(42):985-988.

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Footnote 3

Herida M, de Barbeyrac B, Lemarchand N, Scieux C, Sednaoui P, Kreplak G, et al. Émergence de la lymphogranulomatose vénérienne rectale en France, 2004-2005. Bull.Épidémiol.Hebd 2006;25:180-182.

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Footnote 4

Simms I, Macdonald N, Ison C, Alexander S, Lowndes C, Fenton K, et al. Enhanced surveillance of lymphogranuloma venereum (LGV) begins in England. Weekly releases (1997–2007) 2004;8(41):2565.

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Footnote 5

ProMED-mail. Lymphogranuloma venereum-USA (California). 2004; Available at: http://www.promedmail.org/post/2207058. Accessed November, 2018, 2018.

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Footnote 6

ProMED-mail. Lymphogranuloma venereum -USA (Texas). 2004; Available at: http://www.promedmail.org/post/2207069. Accessed November, 23, 2018.

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Footnote 7

Boutin CA, Venne S, Fiset M, Fortin C, Murphy D, Severini A, et al. Lymphogranuloma venereum in Quebec: Re-emergence among men who have sex with men. Can Commun Dis Rep 2018 Feb 1;44(2):55-61.

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Footnote 8

Centers for Disease Control and Prevention (CDC). Lymphogranuloma venereum among men who have sex with men--Netherlands, 2003-2004. MMWR Morb Mortal Wkly Rep 2004 Oct 29;53(42):985-988.

Return to footnote 8 referrer

Footnote 9

Lafferty WE, Hughes JP, Handsfield HH. Sexually transmitted diseases in men who have sex with men: acquisition of gonorrhea and nongonococcal urethritis by fellatio and implications for STD/HIV prevention. Sex Transm Dis 1997;24(5):272-278.

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Footnote 10

Walter E. Stamm. Chlamydia trachomatis Infections of the Adult. In: King K. Holmes, P.Frederick Sparling, Walter E.Stamm, Peter Piot, Judith N. Wasserheit, Lawrence Corey, Myron S.Cohen, D.Heather Watts, editor. Sexually Transmitted Diseases. 4th Edition ed.; 2008. p. 575-593.

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Footnote 11

Edward W.Hook,III and H. Hunter Handsfield. Gonococcal Infections in the Adult. In: King K. Holmes, P.Frederick Sparling, Walter E.Stamm, Peter Piot, Judith N. Wasserheit, Lawrence Corey, Myron S.Cohen, D.Heather Watts, editor. Sexually Transmitted Diseases. 4th Edition ed.; 2008. p. 627-645.

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Footnote 12

Mabey D PR. Lymphogranuloma venereum. Sex Transm Infect 2002;78:90-92.

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Footnote 13

Moore DL, MacDonald NE. Preventing ophthalmia neonatorum. Canadian Journal of Infectious Diseases and Medical Microbiology 2015;26(3):122-125.

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Footnote 14

Johnson RE, Newhall WJ, Papp JR, Knapp JS, Black CM, Gift TL, et al. Screening tests to detect Chlamydia trachomatis and Neisseria gonorrhoeae infections—2002. MMWR Recomm Rep 2002;51(RR-15):1-38.

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Footnote 15

Schachter J, Grossman M, Sweet RL, Holt J, Jordan C, Bishop E. Prospective study of perinatal transmission of Chlamydia trachomatis. JAMA 1986;255(24):3374-3377.

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Footnote 16

Khattab RA, Abdelfattah MM. Study of the prevalence and association of ocular chlamydial conjunctivitis in women with genital infection by Chlamydia trachomatis, Mycoplasma genitalium and Candida albicans attending outpatient clinic. Int J Ophthalmol 2016 Aug 18;9(8):1176-1186.

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Footnote 17

Navarro C, Jolly A, Nair R, Chen Y. Risk Factors for Genital Chlamydial Infection: A Review. Canadian Journal of Infectious Diseases and Medical Microbiology 2002;13(3):195-207.

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Footnote 18

Korenromp EL, Sudaryo MK, de Vlas SJ, Gray RH, Sewankambo NK, Serwadda D, et al. What proportion of episodes of gonorrhoea and chlamydia becomes symptomatic? Int J STD AIDS 2002 Feb;13(2):91-101.

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Footnote 19

Czelusta A, Yen-Moore A, Van der Straten M, Carrasco D, Tyring SK. An overview of sexually transmitted diseases. Part III. Sexually transmitted diseases in HIV-infected patients. J Am Acad Dermatol 2000;43(3):409-436.

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Footnote 20

Roest R, Van der Meijden W. European guideline for the management of tropical genito-ulcerative diseases. Int J STD AIDS 2001;12(2_suppl):78-83.

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Footnote 21

Kropp RY, Wong T, Canadian LGV Working Group. Emergence of lymphogranuloma venereum in Canada. CMAJ 2005 Jun 21;172(13):1674-1676.

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Footnote 22

Weir E. Lymphogranuloma venereum in the differential diagnosis of proctitis. CMAJ 2005 Jan 18;172(2):185.

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Footnote 23

Goens JL, Schwartz RA, De Wolf K. Mucocutaneous manifestations of chancroid, lymphogranuloma venereum and granuloma inguinale. Am Fam Physician 1994 Feb 1;49(2):415-8, 423-5.

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Footnote 24

Aggarwal K, Jain VK, Gupta S. Bilateral groove sign with penoscrotal elephantiasis. Sex Transm Infect 2002 Dec;78(6):458.

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