Fig. 20.1 Lymphogranuloma venereum. Primary lesion presenting as an ulcer on the penis. AFIP 218768 (2237).

Fig. 20.2 Lymphogranuloma venereum: large left inguinal bubo in adult black man. (From Ballard and Freinkel, 1995).

 

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Epidemiology and Pathology

LGV is caused by Chlamydia trachomatis. The chlamydia are small gram-negative bacilli, larger than viruses, that appear in tissue in at least two forms - the smaller elementary bodies (200 µm to 300µm) and larger initial bodies (up to 1,000 µm). Intracytoplasmic inclusions formed by clustering of these bodies help in diagnosis and are best visualized by Giemsa stains and immunofluorescence. Chlamydia contain both DNA and RNA and make their own cell walls. They lack the ability to produce ATP and are obligate intracellular pathogens. They are sensitive to a broad range of antibiotics but are resistant to the penicillins. Other serotypes of Chlamydia trachomatis cause a variety of other infections including trachoma, nongonorrheal and postgonorrheal urethritis, inclusion conjunctivitis, proctitis, pharyngitis, cervicitis and arthritis. Another species, Chlamydia psittaci, causes ornithosis.

Chlamydia trachomatis can be recovered from the primary genital lesions, affected lymph nodes, and inflammatory lesions of the rectosigmoid colon and pelvic tissues. The organisms are transmitted almost exclusively by sexual contact and therefore the maximum age incidence is in young and middle-aged adults. However, LGV has occasionally been acquired by accidental laboratory infection, by contact with infected clothing, by bathing patients, and by surgical removal of infected lymph nodes.

The pathological changes in LGV vary with the duration and severity of the infection. The initial lesion, which often goes undetected, develops about 2 weeks after infection and is usually a tiny painless papule, vesicle or ulcer (often disappearing within 7 to 10 days) situated on the penis in the male (Fig. 20.1) and on the vulva, posterior vaginal wall or cervix in the female, where it usually escapes detection. Since the chlamydia is markedly lymphotrophic, the regional lymph nodes are quickly invaded, causing an acute purulent lymphadenitis (bubo formation) 4 to 8 weeks after coitus. The inguinal bubo, which is the commonest site (Fig. 20.2), must be differentiated from swollen nodes of syphilis, chancroid, pyogenic lesions of the lower limbs, and even bubonic plague.

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