Lymphogranuloma Venereum, LGV, Strumous Buboe, Durand-Nicolas-Favre disease

1. LYMPHOGRANULOMA
VENEREUM

2. Synonyms
Tropical or Climatic bubo
Durand-Nicholas-Favre disease
Lymphogranuloma inguinale
Poradenitis inguinalis
Strumous bubo

3. History
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Walkee in 1833 first identified
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Caddy 1902 “Climatic bubo” India
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Durand-Nicolas-Favre 1913 “LGI”
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Frei 1925 – Intradermal Test
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1927  Chlamydia Trachomatis causal agent

4. DEFINITION
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Sexually transmitted disease
A disease affecting the Lymphatic System
Caused by Chlamydia Trachomatis Serovars
L1-L2-L3
Regional Suppurative LAN preceded by a
small transient inconspicuous lesion at
Inoculation Site

5. EPIDEMIOLOGY
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6% Prevalence Rate in Clinics
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Endemic to India
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20 - 40 yrs.
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Male : female = 5 :1
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Urban, sexual promiscuity, low socio- economic
status.

6. AETIOLOGY
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Chlamydia Biovar LGV Serovar L1/L2/L3
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Obligate intracellular, Gram negative bacillus with
humans as Natural Hosts by Sexual Transmission /
Perinatal infection
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Intracytoplasmic inclusion bodies
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Controls the organelles of host cells for own growth
and protein synth
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Cell cycle – 48 to 72 hrs

7. 
sss

8. PATHOGENESIS
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Entry into cell as Metabolically inactive
elementary body (Eb) by receptor mediated
endocytosis.
Conversion to Active Reticulate Bodies which
multiply , condense and form Eb  burst out of
host cells
Lymphangitis, perilymphangitis, necrosis of
lymph nodes
PMN stellate abscess- bubo
Healing by fibrosis - esthiomene, adhesions
Dissemination rare

9. 
sas

10. CLINICAL FEATURES
Primary stage
Incubation period : 3-12 days.
Single, painless, evanescent, inconspicuous
Papule / vesicle / Erosion / Ulcer ?herpetiform
Male – coronal sulcus, prepuce, glans,
urethra
Female - endocervix, post vaginal wall
Oral / Rectal localization
NSU
BUBONULUS – Lymphangitic nodules over
dorsal penis  Chord-like swelling

11. PRIMARY LESION

12. BUBONULUS

13. Secondary ‘INGUINAL’ stage
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02-06 wk after primary lesion
Inflammatory swelling of Inguinal nodes in males
perirectal and iliac nodes in females  ‘BUBOES’ 
Fluctuant if untreated  Multilocular Suppuration (70%)
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Unilateral 2/3rd cases
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Constitutional symptoms with bubo
Blue ball sign / Livid colour of overlying skin over
Bubo predicts rupture
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Groove sign of Greenblat (20%)

14. GROOVE’S SIGN

15. ‘BLUE-BALL’ SIGN

16. SECONDARY STAGE
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‘Stage of Diagnosis’
? Women
Dissemination (Rare, hematogenous)
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Arthritis
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Ocular inflammatory disease
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Pneumonitis
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Hepatitis
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EN / EM

17. TERTIARY STAGE
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Develops in 25% of untreated
GENITO-ANO-RECTAL syndrome, more common in
women / MSM
Clinical features
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Hyperplastic Ulcerative lesions
Proctocolitis
• Bloody purulent discharge
• Pruritis Ani
• Tenessemus

18. TERTIARY STAGE
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Lymphatic tissue hyperplasia (LYMPHORROIDS /
PERI-ANAL CONDYLOMAS)
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Chronic Ulceration / Scarring
Fistulae / Strictures
Mechanisms
Peno-Anal Intercourse
Posterior Urethral spread
Direct Spread from Vaginal Secretions
Lymphatic Dissemination by Cx

19. PROCTO-COLITIS

20. COMPLICATIONS
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Genital Elephantiasis
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Ram-rod / Ram-horn / Saxophone Penis

21. COMPLICATIONS
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ESTHIOMENE / Vulval Elephantiasis

22. COMPLICATIONS
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CA RECTUM (2-5%)
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EPIDIDYMO-ORCHITIS
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PROSTATITIS
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SEMINAL VESICULITIS

23. Extragenital manifestations
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Ocular manifestations
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Can occur at any stage
common with L2
Conjunctivitis, Episcleritis, Keratitis, Iritis
Submaxillary, post auricular LN
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Cutaneous manifestations
Id eruptions
Ilio-Psoas Abscess

24. Differential diagnosis
Primary stage
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Genital herpes
Primary syphilis
Chancroid
Traumatic ulcer
NGU
Secondary stage
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Chancroid
Syphilis
Genital herpes
Bubonic Plague
Tuberculosis
Septic LAN

25. Investigations
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Leucocytosis
Raised ESR
Hyperproteinemia with raised globulin
False positive VDRL
Microscopy with giemsa stain
Frei’s test

26. Investigations
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Microscopy / Identification
Gram stain, Giemsa stain, Warthin Starry, Machiavello
Isolation
Culture on McCoy / HeLa Cell Line (Brown Inclusion
bodies)
Histopathology – Stellate Abscesses / Gran Infiltrate
Serological tests: CFT, PCR, NAAT,
IMMUNOFLUORESCENCE
CT / MRI, Lymphography

27. Management
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General measures
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Medical Cap Doxycycline 100 mg bd
Tab Erythromycin 500 mg qid
Tab Azithro 1gm/wk

21days
Erythromycin 7.5- 12.5 mg/kg qid for 2-3wk for
children and pregnant patients

28. 
Surgical
Bubo aspiration preferred over I & D
Sx - elephantiasis, esthiomene, sinus,
fistulae,
stricture dilatation
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Partner management (All contacts in 60
days)
azithromycin 1 gm orally single dose or
doxycycline 100 mg BD X 07 days