Be aware of proctitis and lymphogranuloma venereum

ARTICLE

Auteur(s) : Marti Vall-Mayans

STI Unit CAP Drassanes, Catalan Health Institute, Av Drassanes 17-21, 08001 Barcelona, Catalonia (Spain)

Lymphogranuloma venereum (LGV) is a systemic sexually transmitted infectious disease caused by Chlamydia trachomatis serovars L1, L2 and L3, which causes inflammation and drainage of the lymph nodes with destruction and scarring of surrounding tissue [1]. In industrialised countries, classical cases with swollen and painful regional lymph nodes (bubonic form or inguinal syndrome) are incidentally imported from tropical and subtropical areas where the disease is endemic. In 2003, three cases of LGV serovar 2 with acute proctitis were detected in men who had sex with men (MSM) in Rotterdam, Netherlands. The disease being seen was not the typical textbook presentation described, involving genital ulcers and inguinal lymphadenopathy. On the basis of the cases investigated, a possible LGV outbreak was suspected [2]. Since then, a series of similar outbreaks involving around 2000 cases with an anorectal syndrome have been communicated from almost all countries of Western Europe [3], and also from the USA, Canada and Australia. Several papers have appeared describing these unusual cases, including the one from Paris, France published in this Journal in 2006 [4]. Epidemiologically, these outbreaks have in common that they affect homo/bisexual men with multiple and anonymous partners engaging in high-risk sexual practices, such as unprotected anal intercourse or fisting, mainly taking place in sex parties, in leather scene bars or saunas; they are of white ethnicity; and most of them are HIV positive with high levels of concurrent sexually transmitted infections. It has been suspected that the LGV strains causing proctitis represent a new emerging infection spread through international sexual networks of MSM. This is supported by the observed variations in the ompA gene of C. trachomatis, which indicates that these isolates might be a new variant known as L2b [5].

Clinical signs in patients in these outbreaks are mostly gastrointestinal and include an acute proctitis with purulent or mucous anal discharge, and constipation. Early symptoms of LGV proctitis and colitis include anal pruritus and discharge, followed later by fever, rectal pain and tenesmus. Examination using anoscopy shows a hyperaemic, friable and tender mucosa, that bleeds on touching. Also, the rectal mucosa and skin around the anus are frequent sites of fistulas and abscesses. Late complications include obstruction of the lymphatic and venous drainage of the lower rectum and rectal stenosis as grave sequelae [6]. The case from Lisbon, Potugal presented in this issue of the Journal is representative of the clinical and epidemiological picture of patients with this LGV proctitis syndrome [7]. In addition, as the authors point out, it is also representative of the common diagnostic delay, as many doctors – gastroenterologists are often consulted about these patients – are unfamiliar with this condition. It is not uncommon to see patients with an advanced disease being diagnosed and treated for Crohn’s disease or other digestive conditions. Hence, the key message is the following: because of the wide range of differential diagnoses to be considered, nowadays clinical suspicion of LGV is imperative for all doctors – including dermatovenereologists – when seeing MSM with digestive symptoms, to be followed by the use of appropriate diagnostic tests [8].

In light of these current outbreaks there remain several questions regarding routes of transmission, anatomical sites of infection and asymptomatic carriage, for example. That the L2b proctitis strain is a new epidemic isolate that is rapidly spreading worldwide is even questionable. Some experts already consider that this strain, on the contrary, is simply a classical LGV isolate and has been circulating in the human population for a long time [9]. This view has also been supported by studies showing that the genome of the recent isolate is almost identical to that of an old L2 isolate [10]; although the atypical clinical manifestations of the L2b strain are intriguing enough. Moreover, the characterization of strains other than L2b and the identification of LGV cases in a heterosexual couple and in other women as well [11, 12], further justify clinical awareness and attentive surveillance in all at-risk populations for sexually acquired C. trachomatis infections.

Acknowledgments

References

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