Severe proctitis due to lymphogranuloma venereum (Chlamydia trachomatis)

ARTICLE

Auteur(s) : Ricardo Coelho¹, Candida Fernandes², Joao Machado³, Fernanda Correia³, Teresa Martins³, Fernando Maltez³, Jorge Cardoso²

¹Faro Hospital Dermatology Department, Hospital Central de Faro, Rua Leão, Penedo 8000 Faro, Portugal
²Dermatovenereology Department, Lisbon, Portugal
³Infectious Disease Department, Lisbon, Portugal

In June 2007, a 54-year-old HIV1 positive man from Lisbon presented with a 3-month history of rectal pain, mucopurulent rectal discharge, rectal bleeding, tenesmus, weight loss (8 kg) and generalized weakness. He was on antiretroviral therapy (Combivir^® + Telzir^® + Norvir^®) with a CD4 count of 1158 cell/mm³ and a viral load of < 50 copies/mL. He had several stool cultures that showed no enteric pathogens. A sigmoidoscopy and later, a colonoscopy (figure 1), showed multiple rectal ulcers; histological examination revealed ulceration with mixed acute and chronic inflammatory cells and a lymphoid infiltrate. He was treated with metronidazol (several courses) but his symptoms failed to resolve. He was then referred to our dermatovenereology department for screening of enteric sexually transmitted diseases.

The patient had had at least 4 anonymous sex partners in the previous 6 months and regular anal-receptive intercourse without condoms. VDRL, TPHA, VHB and VHC serology were performed. Serology for Chlamydia trachomatis showed a titer of 1:1024 (IgG), IgM < 16 and IgA 1:32. VDRL was reactive (1/32) and TPHA was positive. We performed a rectal swab that was tested for Neisseria gonorrhoeae, Chlamydia trachomatis, herpes simplex virus 1 and 2 and Treponema pallidum, through commercial nucleic acid amplification tests (Cobas-Amplicor and Sacace), performed according to manufacturers’ instructions. Chlamydia trachomatis and Treponema pallidum were both detected and further molecular biological studies of the Chlamydia trachomatis isolate (ompA genotyping) confirmed the infection with a new lymphogranuloma venereum (LGV) variant (different from all the described to date) associated with recent syphilis. In the C. trachomatis ompA gene, our strain presents 3 nucleotide changes to L₂-434 (which is the L₂ prototype strain), 1 nucleotide change to L_2b-144276 and 2 nucleotide changes to the recently described L_2c. Treatment with 100 mg oral doxycycline twice daily for 3 weeks and a single dose of benzatinic penicillin (2.400.000 U) was effective. Test of cure was performed 5 weeks after treatment and was negative. LGV is caused by the L1, L2 and L3 serovars of Chlamydia trachomatis and was previously confined to endemic areas in tropical regions. However, since 2003, a cluster of LGV cases presenting with anorectal symptoms in MSM has been reported in Rotterdam. This was followed by a series of case reports in various cities in Western Europe and the United States. Most of these patients presented with rectal symptoms and only a few with inguinal lesions. The majority of patients were co-infected with HIV, and high levels of co-infection with sexually transmitted bacterial infections and hepatitis C were also reported [1-3]. The majority reported large numbers of sexual partners and unprotected anal intercourse. Therefore, as in our patient, contact tracing has been of limited use so far. This is the first rectal LGV case reported in Portugal; Chlamydia trachomatis (L2 serovar) has previously been isolated from urogenital samples in another 5 patients.

As in the case of our patient, a diagnostic delay has been common as many doctors are unfamiliar with this condition. Endoscopic features are non-specific, with a wide range of differential diagnoses including Crohn’s disease, anorectal carcinoma and other non-sexually and sexually transmitted infections. Most guidelines [4, 5] have suggested that first-line treatment is doxycycline 100 mg twice daily for 21 days (erythromycin 500 mg, 4 times daily, 21 days is an alternative). We treated our patient first with penicillin and introduced doxycycline when we received nucleic acid amplification tests.

A diagnostic delay is common in this condition and LGV cases may easily be missed if LGV is not considered during diagnosis or if appropriate diagnostic tools are not available. This condition is an important sentinel event with serious implications for the patient and for public health. For these reasons, it is important to consider this diagnosis when seeing MSM with bowel symptoms.

Acknowledgements

References

2 Van der Bij AK, Spaargaren J, Morre SA, et al. Diagnostic and clinical implications of anorectal lymphogranuloma venereum in men who have sex with men: a retrospective case-control study. Clin Infect Dis 2006; 42: 186-94.

3 Ranki A. HIV infection. Eur J Dermatol 2008; 18: 217-9.

4 CDC guidelines for LGV (www.cdc.gov/STD/treatment/).

5 McMillan A, van Voorst Vader PC, de Vries HJ. The 2007 European guideline (IUSTI/WHO) on the management of proctitis, proctocolitis and enteritis caused by sexually transmissible pathogens. Int J STD AIDS 2007; 18: 514-20.