Lymphogranuloma Verereum (LGV) and proctitis

For a comprehensive guide to the assessment and management of proctitis and sexually transmitted enteric infection in MSM see Chapter 3 of the UK national guideline on the sexual healthcare of MSM, filed along with this chapter of the Borders protocol.  The full guideline is at:

http://journals.sagepub.com/doi/abs/10.1177/0956462417746897

LGV

• Caused by invasive serovars of Chlamydia trachomatis – L1,L2 or L3
• LGV is now hyperendemic among MSM in the UK following outbreaks in Europe from 2003.
• The proportion of cases which were asymptomatic increased from 6% in 2006 to 22% in 2012
• Many are also HIV positive (78% of all LGV cases diagnosed 2004-2011)
• Many have concomitant STIs, including Hepatitis C in 14% of cases. There is an association with “rough” sex, fisting, use of sex toys and sex parties.
• Most MSM patients present with proctitis rather than “classical” LGV in heterosexuals causing inguinal lymphadenopathy.

 Other sexually acquired causes of proctitis

• Neisseria gonorrhoea
• Chlamydia trachomatis serovars A-K
• Treponema pallidum
• Herpes Simplex Virus
• Possibly Mycoplasma genitalium

Clinical features

Symptoms

• Anal discharge
• Bleeding PR
• Constipation
• Sensation of rectal fullness
• Tenesmus
• + diarrhoea and abdominal pain if colon involved

Signs

• Mucopurulent anal discharge
• Anorectal Bleeding
• + lower abdominal tenderness if colon involved

Proctoscopic findings (proctoscopy recommended if tolerated by patient)

• Mucopus in lumen of rectum
• Mucosal oedema
• Contact bleeding
• +/- ulceration
• +/- inflammatory mass

Investigation of proctitis

Gram stain of mucopus obtained via proctiscopy – poor correlation between PMNL alone and STI

If intracellular GNDC seen – presumptive diagnosis rectal gonorrhea

Swab of mucopus for GC NAAT and GC culture

Swab of rectal wall for CT NAAT
If LGV is suspected write “If Chlamydia positive - LGV specific PCR” and remember to specify which sample to be tested if more than one eg MSM

LGV specific tests can take up to 10 days – further delays will be avoided by requesting PCR on initial sample form.

Swab of any ulcers in red-topped viral transport medium for HSV and T.pallidum PCR

Syphilis serology

Urine and pharyngeal NAAT for GC/CT

If diarrhoea

• stool x3 for ova, cysts and parasites (OCP)
• stool for C.difficile toxin if recent antibiotics
• stool for culture of Shigella spp, Salmonella spp and Campylobacter spp.

If inguinal lymphadenopathy - send a first pass urine/urethral NAAT for chlamydia and ask “if Chlamydia positive - LGV specific PCR”.

In MSM – HIV and Hepatitis C testing should be carried out (and repeated after appropriate window periods)

Management of proctitis in clinic

If GNDC seen and presumptive diagnosis rectal gonorrhoea – see section 2.

If non-LGV chlamydial infection – see section 3.

The following are suggested with a review at 1-2 weeks

Moderate/severe proctitis:

Ceftriaxone 1g im stat
GC most likely cause (even if microscopy negative - rectal smears poor sensitivity)

Plus

Doxycycline 100mg oral twice daily for 1 week
If LGV serovars positive extend to 3 week course
Alternative if allergic, Azithromycin 1g + 500mg OD for 2 days

And consider
Aciclovir 400mg TDS 5 Days
If potential HSV lesions present

Management of confirmed LGV

Doxycycline 100mg oral twice daily for 3 weeks

Alternative
Erythromycin 500mg oral four times a day for 21 days
OR
Azithromycin 1g weekly for 3 weeks

HIV positive patients – same regimens as above.  There are few significant drug-drug interactions (DDIs) between doxycycline and commonly used antiretrovirals.  If in doubt, check with doctor/pharmacist.

Partner notification

Look back 4 weeks if symptomatic (3 months if asymptomatic).

Treatment of contacts of LGV

If >14 days since contact with index, and asymptomatic - offer testing prior to treatment.

If treating presumptively give doxycycline 100mg bd for 3 weeks.

Patient information

• LGV is an invasive bacterial STI that can be cured with antibiotics.
• Untreated infection can have serious and permanent adverse effects on the rectum/bowel.
• Symptoms should resolve within 1-2 weeks of starting antibiotic therapy
• Importance of avoidance of sexual intercourse until they and their partners have completed treatment and follow up.

Follow up

• Test of cure is not required for non-LGV Chlamydial proctitis if symptoms resolve
• Test of cure is not required for LGV proctitis if symptoms resolve – unless treatment course not completed
• Test of cure for Gonococcal proctitis would be advised at 3 weeks – see section C

Differential diagnosis of proctocolitis/enteritis

• E. histolytica
• Shigella spp
• Campylobacter spp.
• Cryptosporidium

Inflammatory bowel disease                      Coeliac disease

Medication side-effects                               Trauma