Journal Club: Risk factors and clinical predictors of rectal lymphogranuloma venereum (LGV) infection

Articles reviewed

1. N. Macdonald, A.K. Sullivan, P. French, J.A. White, G. Dean, A. Smith, A.J. Winter, S. Alexander, C. Ison and H. Ward. Risk factors for rectal lymphogranuloma venereum in gay men: results of a multicentre case-control study in the UK. Sex Transm Infect 2014;90:262–268.
2. S.N.S. Pallawela, A.K. Sullivan, N. Macdonald, P. French, J. White, G. Dean, A. Smith, A.J. Winter, S. Mandalia, S. Alexander, C. Ison and H. Ward. Clinical predictors of rectal lymphogranuloma venereum infection: results from a multicentre case–control study in the UK. Sex Transm Infect 2014;90:269–274.

Purpose of the study

Lymphogranuloma venereum (LGV) is a sexually transmitted infection (STI) caused by Chlamydia trachomatis serovars L1, L2, and L3. Depending on the site of inoculation, LGV can manifest either as an inguinal syndrome with a unilateral painful inguinal lymphadenopathy (buboes) or as an anorectal syndrome with haemorrhagic proctocolitis.

Until recently, LGV was considered an STI confined mainly to tropical areas of Africa, Asia and the Caribbean. However, in 2003, outbreaks of LGV proctitis in HIV positive men having sex with men (MSM) were reported in several European countries and later in North America.

In order to better understand the epidemiology, risk factors and presenting clinical features, a large, multicenter case-control study (LGV-net) was conducted in the United Kingdom (UK).  The aim of LGV-net was to provide a detailed clinical and epidemiological description of the LGV in the UK to improve clinical diagnosis, treatment and control.

Methods

A prospective, multicenter case-control study was conducted between August 2008 and December 2010 at different clinics in London, Brighton and Glasgow.

Cases were defined as MSM with laboratory-confirmed rectal LGV (rLGV). Controls were symptomatic and/or asymptomatic MSM seen in the same clinic on the same day/week and confirmed rLGV negative.

Clinical examination, including proctoscopy and routine STI screening, was performed according to clinic protocol. All study subjects were assigned a study number and asked to complete a computer-assisted self-interview. Information related to socio-demographics, STI history, detailed sexual behaviours and substance/alcohol use in the previous 3 months was collected. Details on the possible LGV exposure event were also collected.

Clinical data including symptoms, details of physical exam, prescribed treatment and STI/HIV testing history was reported by clinicians through an online form.

Results

Questionnaire responses from 96 rLGV cases were compared with 74 asymptomatic and 69 symptomatic patients.

When cases were compared with asymptomatic controls, anonymous contacts, rectal douching, sex under influence of drugs, unprotected receptive anal intercourse and fisting were identified as significant risk factors for rLGV infection. However, when cases were compared with symptomatic controls, unprotected insertive anal intercourse and rectal douching were identified as significant risk factors for rLGV infection.

Common factors contributing to potential LGV acquisition were recreational drug and alcohol use.

Symptoms including tenesmus, constipation and exudate on proctoscopy were found to have the best balance of sensitivity and specificity in clinical prediction model.

The majority of cases received recommended treatment of Doxycycline (100mg twice daily for 21 days).

Implications for practice

LGV emerged in Canada in 2003, concurrent with a rise in cases among MSM in Europe and the USA. Since then, it has been reported increasingly in MSM, especially those co-infected with HIV.

The findings from this multicenter study may be applicable in Canadian settings, as LGV has become established among MSM populations. Clinicians should include LGV in the differential diagnosis of all MSM presenting with rectal symptoms. In addition, men at risk of LGV should be targeted for frequent STI screening.

For more information

Links to PubMed articles:

• http://www.ncbi.nlm.nih.gov/pubmed/24493859
• http://www.ncbi.nlm.nih.gov/pubmed/24687130

References

1. Van der Bij A.K., Spaargaren J., Morré S.A., Fennema H.S.A., Mindel A., Coutinho R.A., et al. Diagnostic and clinical implications of anorectal Lymphogranuloma venereum in men who have sex with men: A retrospective case-control study. Clinical Infectious Diseases. 2006;42(2):186-94.
2. Hamill M., Benn P., Carder C., Copas A., Ward H., Ison C., et al. The clinical manifestations of anorectal infection with Lymphogranuloma venereum (LGV) versus non-LGV strains of Chlamydia trachomatis: A case-control study in homosexual men. Int J STD AIDS. 2007;18(7):472-5.
3. de Vrieze N.H.N., van Rooijen M., Schim van der Loeff, Maarten F, de Vries H.J.C. Anorectal and inguinal Lymphogranuloma venereum among men who have sex with men in Amsterdam, the Netherlands: Trends over time, symptomatology and concurrent infections. Sex Transm Infect. 2013;89(7):548.
4. Public Health Agency of Canada. Lymphogranuloma venereum, LGV, in Canada : Recommendations for diagnosis and treatment and protocol for national enhanced surveillance. Ottawa: Public Health Agency of Canada; 2005.
5. Murray T. LGV cases on the rise. Medical Post [Internet]. 2005 [cited 2014 Nov 30];41(22):5.
6. Tinmouth J., Gilmour M.W., Kovacs C., Kropp R., Mitterni L., Rachlis A., et al. Is there a reservoir of sub-clinical Lymphogranuloma venereum and non-LGV Chlamydia trachomatis infection in men who have sex with men? Int J STD AIDS. 2008;19(12):805-9.