Guidelines 2016 – Lymphogranuloma Verereum
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
LGV is an STI characterized by a transitory primary lesion followed by sup- purative lymphangitis and serious local complications.
II. ETIOLOGY
A. Causative agent > C. trachomatis, serotypes L1, L2, and L3
B. Incubation period: 3 to 12 days up to 3 weeks
C. Found mainly in tropical climates (Asia, Africa, South America); rare in the United States
III. HISTORY
A. What the patient may present with
1. “Sore” in genital area, mouth, anus, penis (of short duration, may go unnoticed); usually single and painless vesicle or nonindurated
a. Fever
b. Malaise
c. Headaches
d. Joint pain
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e. Anorexia
f. Vomiting
g. Unilateral tender enlargement of inguinal lymph node; stiff- ness, aching of groin
h. Abscess in groin after 2 to 3 weeks
i. Sinuses, scars in lower vagina or around introitus, or (in males) on penis
j. Rectal discharge; perirectal/perianal fistulas and strictures
k. Vaginal discharge
B. Additional information to be considered
1. Sexual preference; sexual practices
2. Last sexual contact; new partner
3. Known contact
4. History of STI or PID
5. Last menstrual period
6. Method of birth control; other medications (antibiotics may mask symptoms)
7. History of chronic infections
8. Recent trip out of the country or new immigrant from a country where LGV is common
9. Duration of lesion
IV. PHYSICAL EXAMINATION
A. Vital signs
1. Blood pressure
2. Pulse
3. Respiration
4. Temperature
B. Inguinal nodes
1. First symptom is unilateral tender enlargement of nodes.
2. Disease progresses for 2 to 3 weeks to form a large, tender, fluctuant mass that adheres to deep tissues and has overlying reddened skin (bubo).
3. Multiple sinuses develop with purulent or serosanguinous discharge.
4. Healing occurs with scar formation, but sinuses persist or recur.
5. Chronic inflammation causes blockage of the lymphatic vessels, leading to edema, ulceration, and fistula formation.
C. Vaginal examination (speculum)
1. Vaginal walls: Initial lesion may be on upper vaginal wall, resulting in enlargement and suppuration of perirectal and pelvic lymphatic vessels.
2. Cervix: Initial lesion could be on the cervix.
D. Bimanual examination: tenderness in groin, vulva
E. Rectovaginal examination: Rectal wall may be involved, resulting in ulcerative proctitis with serosanguinous rectal discharge.
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V. LABORATORY EXAMINATION AND DIAGNOSIS
A. Genital and lymph node swabs of lesion or bubo aspirate can be tested by culture, immunofluorescence, or nucleic acid detection.
B. Chlamydia serology complement fixation test: Fourfold rise or single titer of greater than 1:64 can support diagnosis.
C. Serology test for syphilis, gonorrhea culture
D. Biopsy of chronic anorectal lesions and lymph nodes to rule out carcinoma
E. Diagnosis made on clinical suspicion, epidemiologic information, and exclusion of other etiologies along with C. trachomatis testing
VI. DIFFERENTIAL DIAGNOSIS
A. Syphilis
B. Herpes simplex
C. Carcinoma
D. Chancroid
E. Granuloma inguinale
F. Chlamydia infection
G. Hodgkin’s disease
H. Proctocolitis
I. Inguinal lymphadenopathy
J. Genital or rectal ulcers
VII. TREATMENT
A. Medications
1. Doxycycline 100 mg orally twice a day for 21 days
2. Alternative regimens: erythromycin base 500 mg orally four times a day for 21 days
B. Medications in pregnancy and lactation
1. Erythromycin base 500 mg orally twice a day for 21 days
C. General measures
1. Sitz bath
2. Stress the importance of completing the course of medication.
3. All sexual partners should be treated if contact within 30 days before onset of symptoms; examine and test for Chlamydia/ gonorrhea in urethra, cervix
4. Comfort measures
a. Take tepid water sitz baths; dry carefully with cool air hair dryer making sure to hold dryer sufficiently away from body
b. Avoid tight, restricting clothing
c. Expose perineum to airflow as much as possible (wear a skirt or robe without underpants at home)
d. Recommend peri-irrigation set
5. Patient education
a. Explain disease process and route of transmission
b. Stress the importance of checking sexual partner(s) for urethral or cervical Chlamydia infection within 60 days of onset of symptoms.
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VIII. COMPLICATIONS
A. Scar formation
B. Sinuses causing blockage of the lymphatic vessels, which leads to edema
C. Fistula formation: rectovaginal, vulvar, other
D. Suppuration of perirectal and lymphatic vessels
E. Rectal stricture
F. Systemic: phlebitis, hepatomegaly, nephropathy
IX. CONSULTATION/REFERRAL
A. Consult with physician prior to treatment if infection is suspected
B. If no response to treatment as outlined previously
C. If any of the aforementioned complications occur
X. FOLLOW-UP
A. Reevaluate 3 to 5 days after treatment
B. Then evaluate every 1 to 2 weeks until healing is complete
See Bibliographies.
Website: www.cdc.gov/mmwr/pdf/rr/rr5912.pdf