What is the prevalence of Lymphogranuloma venereum (LGV) in India?

Lymphogranuloma Venereum in India: Prevalence and Epidemiology

Lymphogranuloma venereum (LGV) is rare in India, with no specific prevalence data available indicating it is not a common sexually transmitted infection in the Indian population. 1

Epidemiology and Global Context

• LGV is caused by Chlamydia trachomatis serovars L1, L2, or L3, with L2b and L2 being the predominant strains in recent outbreaks 1, 2
• While the disease is endemic in parts of Africa, Asia, South America, and the Caribbean, specific prevalence data for India is lacking 3
• Recent outbreaks have been primarily reported in Western countries (Europe, Australia, North America) among men who have sex with men (MSM), particularly those who are HIV-positive 4, 2
• The ratio of genital to anorectal LGV infections is approximately 1:15 in these outbreaks, indicating a predominance of anorectal infections 2

Clinical Presentation

• LGV presents in three stages with varying clinical manifestations:
  • Primary stage: A self-limited genital ulcer at the site of inoculation that often goes unnoticed 1
  • Secondary stage: Most common presentation is tender inguinal and/or femoral lymphadenopathy, typically unilateral in heterosexuals 1
  • Tertiary stage: Can lead to lymphatic obstruction, genital elephantiasis, and rectal involvement with strictures and fistulae if left untreated 3
• Among MSM, approximately 25% of anorectal LGV infections are asymptomatic 2
• Women and MSM may develop proctocolitis or inflammatory involvement of perirectal lymphatic tissues 1

Diagnosis

• Diagnosis is challenging and requires a high index of suspicion 3
• Serological testing remains important:
  • Complement fixation titers ≥64 with appropriate clinical presentation suggests LGV (sensitivity 80% at 2 weeks) 1
  • Microimmunofluorescence (MIF) titers ≥256 with appropriate clinical presentation also suggests LGV 1
• Modern diagnosis relies on nucleic acid amplification tests (NAATs):
  • Samples that test positive for C. trachomatis should be confirmed with an LGV discriminatory NAAT 2
  • Standard C. trachomatis NAATs will detect L1-L3 serovars but cannot distinguish them from other serovars 1

Treatment

• The recommended treatment for LGV is doxycycline 100 mg orally twice daily for 21 days 1, 2
• Alternative regimen: Erythromycin base 500 mg orally four times a day for 21 days 1
• Recent evidence suggests azithromycin 1g orally once weekly for 3 weeks may be effective, though this is not yet in guidelines 5, 6
• Pregnant and lactating women should be treated with erythromycin 1, 6
• Therapy should be continued until all lesions have completely healed 1
• Patients with HIV co-infection should receive the same regimen, though they may require prolonged therapy 1

Follow-Up and Contact Management

• Patients should be followed clinically until signs and symptoms have resolved 1
• Sexual contacts within 30 days before symptom onset should be examined, tested for chlamydial infection, and treated 1
• Repeated testing for other STIs (syphilis, hepatitis B and C, HIV) is recommended 6

Clinical Pitfalls and Caveats

• LGV is often misdiagnosed due to lack of awareness and variable clinical presentation 3
• The disease can cause irreversible sequelae if not treated promptly 6
• Buboes may require aspiration through intact skin or incision and drainage to prevent inguinal/femoral ulcerations 1
• The increasing proportion of HIV-negative MSM with LGV in recent years suggests a potential shift toward lower risk populations 4