From the Guidelines
A gay man with a penile ulcer suspected of having Lymphogranuloma Venereum (LGV) should be diagnosed through nucleic acid amplification testing (NAAT) for Chlamydia trachomatis, specifically serovars L1, L2, or L3, from the ulcer site, as recommended by the most recent guidelines 1. The diagnosis of LGV is crucial to prevent serious complications, and NAAT is the preferred method due to its high sensitivity and specificity.
- The patient's sexual partners within the past 60 days should be evaluated, tested, and treated with the same regimen if infected, as suggested by previous guidelines 1.
- The recommended treatment is doxycycline 100 mg orally twice daily for 21 days, which is necessary due to the deeper tissue invasion of LGV compared to non-LGV chlamydial infections.
- Alternative regimens include erythromycin base 500 mg orally four times daily for 21 days if doxycycline is contraindicated.
- The patient should abstain from sexual activity until treatment is completed and symptoms have resolved, and follow-up testing is recommended 3-6 months after treatment to ensure cure.
- It is essential to note that LGV can present with painful inguinal lymphadenopathy (buboes) that may require drainage, and if left untreated, can lead to serious complications including genital scarring, fistulas, and rectal strictures, particularly in men who have sex with men where anorectal infection is common 1.
From the Research
Diagnosis of LGV in Gay Men with Penis Ulcer
- The diagnosis of Lymphogranuloma Venereum (LGV) is difficult to establish on clinical grounds alone and frequently relies upon either serologic testing, culture, or more recently, nucleic acid amplification testing of direct specimens 2.
- A sample tested Chlamydia trachomatis positive with a commercial nucleic acid amplification test (NAAT) platform should be confirmed with an LGV discriminatory NAAT to diagnose LGV 3.
- The primary stage of LGV may go undetected when only a painless papule, pustule, or ulceration appears, making early and accurate diagnosis essential 2.
Treatment Approach for LGV
- Doxycycline 100 mg twice a day orally for 21 days is the recommended treatment for LGV 3.
- Recent evidence suggests that a shorter antibiotic duration, such as a 7-day course of doxycycline, may be as effective in treating LGV 4.
- Azithromycin 1 g orally once weekly for 3 weeks has also been shown to be an effective alternative treatment option for symptomatic LGV proctitis 5.
- Patient follow-up during treatment and repeated testing for syphilis, hepatitis B and C, and HIV to detect early infection are crucial 2.
Considerations for Gay Men with HIV-1 Infection
- LGV is endemic among men who have sex with men (MSM) in Europe, and a high index of clinical suspicion is necessary for early diagnosis 6.
- Doxycycline has been shown to eradicate Chlamydia trachomatis in HIV patients with LGV 6.
- Azithromycin may be considered as an alternative treatment option for pregnant and lactating women, as well as for patients who cannot tolerate doxycycline 2.