Lymphogranuloma Venereum (LGV)

Lymphogranuloma venereum (LGV) is a sexually transmitted infection caused by Chlamydia trachomatis serovars L1, L2 (most common globally), and L3, which differ from non-invasive serovars (D-K) causing standard urogenital chlamydia in their ability to invade lymphatic tissue and cause systemic disease. Historically endemic in tropical and subtropical regions (Africa, Southeast Asia, Caribbean, Latin America), since 2003 a new epidemic has emerged in industrialized countries, predominantly affecting HIV-positive men who have sex with men (MSM), often presenting as severe proctitis rather than classical inguinal disease.

Classical clinical presentation occurs in three stages: Primary stage (3-30 days post-exposure) — small painless papule, vesicle, or shallow ulcer at site of inoculation (penis, vagina, cervix, rectum, oral), often missed; Secondary stage (1-6 weeks) — painful unilateral or bilateral inguinal lymphadenopathy with characteristic 'groove sign' (lymphadenopathy above and below inguinal ligament separated by it), buboes that may rupture and form sinus tracts, with systemic symptoms (fever, malaise, arthralgia); Tertiary stage (chronic) — anogenital fibrotic scarring, lymphatic obstruction with elephantiasis (esthiomene in women), rectal strictures, fistulas, and perianal disease.

Modern epidemic LGV in MSM presents predominantly as severe hemorrhagic proctitis with anorectal pain, mucopurulent or bloody discharge, tenesmus, constipation, and systemic symptoms; coinfection with HIV (50-80%), hepatitis C, and other STIs is common. Diagnosis requires NAAT for C. trachomatis (positive) followed by molecular typing for L1-L3 serovars; rectal NAAT is essential in MSM with proctitis. Treatment is doxycycline 100 mg twice daily for 21 days (longer than standard chlamydia 7 days) — the extended duration is critical; alternative is azithromycin 1g weekly for 3 weeks. Sexual partner notification and treatment, screening for other STIs (HIV, syphilis, hepatitis), and follow-up testing are essential.