Rosen & Barkin's 5-Minute Emergency Medicine Consult (431 page)

• Sexually transmitted disease
  
• Primary stage:
  
  • Painless papule, pustule, or ulcer
    
• Secondary stage:
  
  • Spread to regional lymph nodes
    
  • Fluctuant inguinal lymphadenopathy (buboes)
    
  • Lymphadenopathy may be unilateral or bilateral
    
• Responsive to antibacterial therapy
  
• Tertiary stage:
  
  • If untreated, significant tissue damage and destruction may result
    
• Endemic in Southeast Asia, Latin America, parts of Africa, and the Caribbean
  
• Increasing incidence among men who have sex with men
  
• Also known as:
  
  • Struma
    
  • Tropical bubo
    
  • Nicolas–Favre–Durand disease
    

Chlamydia trachomatis
serotypes L1, L2, and L3

DIAGNOSIS

• Primary genital lesions:
  
  • Incubation: 3–30 days after sexual exposure to
    C. trachomatis
    
  • Painless genital chancre lasts 2–3 days (rarely, a papule or vesicle)
    
  • Often transient and not noticed
    
  • May present as proctitis
    
• Secondary stage:
  
  • Systemic symptoms:
    
    • Fever and malaise
      
    • Myalgias
      
  • Lymphadenopathy; usually inguinal:
    
    • May ulcerate and drain pus
      
  • Proctitis:
    
    • Rectal bleeding
      
    • Tenesmus
      
    • Constipation
      
• Tertiary stage:
  
  • Symptoms mimic inflammatory bowel disease or proctocolitis
    
  • Elephantiasis
    
  • Strictures
    

• Primary stage:
  
  • Painless papule, pustule, or ulcer
    
  • Usually anogenital region
    
• Secondary stage:
  
  • Tender inguinal adenopathy:
    
    • Occurs 1–3 wk after initial inoculation
      
    • Adenopathy is unilateral in 2/3 of cases
      
    • Buboes (large inguinal lymph nodes) form in inguinal and femoral chains
      
    • Groove sign: Scarred or coalescent buboes above and below inguinal ligament give a linear depression parallel to the inguinal ligament (seen in 30%)
      
    • Anal-receptive patients may develop hemorrhagic proctocolitis
      
    • Perirectal lymphatic inflammation causes fistulae and strictures
      
• Tertiary disease (invasive if untreated):
  
  • Chronic proctocolitis:
    
    • Abdominal pain
      
    • Rectal bleeding
      
  • Genital strictures
    
  • Perineal and perianal fistulae
    
  • Elephantiasis of the ipsilateral leg
    

• Standard
  Chlamydia
  DNA probes
  do not
  test for lymphogranuloma venereum (LGV) strain
  
• False-positive VDRL in 20%
  
• Serologic testing and culture are the standard
  
• Complement fixation titers >1:64 are consistent with LGV infection
  

Bubo aspiration—specific but expensive and impractical

• Genital herpes (ulcers usually not seen in LGV)
  
• Syphilis—nodes nontender, longer incubation
  
• Chancroid—multiple ulcers, no systemic symptoms
  
• Granuloma inguinale—lesions painless and bleed easily
  

TREATMENT

No pre-hospital issues

No field or ED stabilization required

If large, buboes may need to be aspirated or drained to avoid or minimize scarring

Doxycycline: 100 mg PO BID for 3 wk

• Azithromycin: 1,000 mg PO weekly for 3 wk
  
• Erythromycin: 500 mg PO QID for 3 wk
  

Erythromycin is the recommended regimen in pregnancy and during lactation

FOLLOW-UP

Hospitalization is rarely needed (i.e., severe systemic symptoms)

Immunocompetent patient without systemic involvement

• Outpatient follow-up is required to confirm diagnosis and cure
  
• Rectal infection may require retreatment
  

• Ensure that sexual partners are tested and treated
  
• Sexual contacts within 60 days should be tested and treated with antichlamydial therapy
  

• Diagnosis is based on clinical suspicion, epidemiologic patterns, and exclusion of other etiologies
  
• Consider this diagnosis in men who have sex with men
  
• Treat to avoid tertiary disease which is not responsive to antibiotic therapy alone
  
• Treatment course is at least 3 wk of antibiotics
  

• Centers for Disease Control and Prevention: 2002 guidelines for treatment of sexually transmitted diseases. Available at:
  http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf#page=28
  .
  
• McLean CA, Stoner BP, Workowski KA. Treatment of lymphogranuloma venereum.
  Clin Infect Dis
  . 2007;44:S147–S152.
  
• White JA. Manifestations and management of lymphogranuloma venereum.
  Curr Opin Infect Dis
  . 2009;22:57–66.
  
• White J, Ison C. Lymphogranuloma venereum: What does the clinician need to know?
  Clin Med
  . 2008;8:327–330.
  

CODES

099.1 Lymphogranuloma venereum

BASICS

• Protozoan infection transmitted through the Anopheles mosquito
  
• Incubation period 8–16 days
  
• Periodicity of the disease is due to the life cycle of the protozoan:
  
  • Exoerythrocytic phase: Immature sporozoites migrate to liver, where they rapidly multiply into mature parasites (merozoites).
    
  • Erythrocytic phase: Mature parasites are released into circulation and invade RBCs.
    
  • Replication within RBCs followed 48–72 hr later by RBC lysis and release of merozoites into circulation, repeating cycle
    
  • Fever corresponds to RBC lysis.
    
• Plasmodium falciparum:
  
  • Cause of most cases and almost all deaths
    
  • Usually presents as an acute, overwhelming infection
    
  • Able to infect red cells of all ages:
    
    • Results in greater degree of hemolysis and anemia
      
  • Causes widespread capillary obstruction:
    
    • Results in end-organ hypoxia and dysfunction
      
  • More moderate infection in people who are on or who have recently stopped prophylaxis with an agent to which the P. falciparum is resistant
    
  • Post-traumatic immunosuppression may cause relapse of malaria in patients who have lived in endemic areas.
    
• Plasmodium vivax and Plasmodium ovale:
  
  • May present with an acute febrile illness
    
  • Dormant liver stages (hypnozoites) that may cause relapse 6–11 mo after initial infection
    
• Plasmodium malariae:
  
  • May persist in the bloodstream at low levels up to 30 yr
    

• Transmission usually occurs from the bite of infected female Anopheles mosquito.
  
• North American transmission possible:
  
  • Anopheles mosquitoes on east and west coasts of US.
    
  • Transmission may also occur through infected blood products and shared needles.
    

• Sickle cell trait protective
  
• Cerebral malaria more common in children
  
• In highly endemic areas with minimal lab capability, all children presenting with febrile illness may be treated.