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Chapter 145: Lymphogranuloma Venereum

Ronald Berna; Emily Baumrin

LYMPHOGRANULOMA VENEREUM

Therapeutic Approach

Lymphogranuloma venereum is a sexually transmitted infection caused by Chlamydia trachomatis genovars L1, L2, and L3. Clinical progression from a localized ulcer to inguino-femoral lymphadenopathy to proctocolitis occurs over months to years if untreated. Treatment approach should be selection of antibiotics based on expert guidelines, patient factors, and local susceptibility patterns. See Table 145-1.

Table 145-1Lymphogranuloma Venereum Treatment Table
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Table 145-1 Lymphogranuloma Venereum Treatment Table
MEDICATION NAME INDICATION MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORINGd LEVEL OF EVIDENCE (REFERENCE)
Systemic Therapy      
Doxycycline Primary infection (first-line) 4,7 Tetracycline antibiotic, binds to 30S ribosomal subunit and inhibits protein synthesis 100 mg twice daily for 21 da,b Contraindicated in pregnancy and lactation, <8 yo; photosensitivity, GI upset, esophagitis, headache None IIA1,2,3,6
  Asymptomatic sexual contacts Tetracycline antibiotic, binds to 30S ribosomal subunit and inhibits protein synthesis 100 mg twice daily for 7 dc Contraindicated in pregnancy and lactation, < 8yo; photosensitivity, GI upset, esophagitis, headache None IV4,7
Azithromycin Primary infection (second-line)4,7 Macrolide antibiotic, binds to 50S ribosomal subunit and inhibits protein synthesis 1 g once weekly for 3 wk GI upset, QTc prolongation Test of cure at end of treatment4,5,7 IIA2,4,5,6
  Asymptomatic sexual contacts Macrolide antibiotic, binds to 50S ribosomal subunit and inhibits protein synthesis 1 g as a single dosec GI upset, QTc prolongation None IV4
Erythromycin Primary infection in pregnant and lactating women (second-line)4,7 Macrolide antibiotic, binds to 50S ribosomal subunit and inhibits protein synthesis 500 mg 4 times daily for 21 d GI upset, QTc prolongation, hepatic dysfunction, medication interactions Cyp450 inhibitor8 Test of cure at end of treatment4,5 IV4,7
Minocycline Failure of other therapies Tetracycline antibiotic, binds to 30S ribosomal subunit and inhibits protein synthesis 300 mg loading, followed by 200 mg twice daily for 21 d Contraindicated in pregnancy, <8 yo; headache, lupus, skin/teeth pigmentation Test of cure at end of treatment4 IV4
Rifampicin Failure of other therapies Inhibits bacteria DNA-dependent RNA synthesis 600 mg daily for 21 d GI upset, orange discoloration of body fluids, medication interactions Cyp450 inducer8 Test of cure at end of treatment4 IV4
Moxifloxacin Failure of other therapies Anti-inflammatory, antimicrobial 400 mg daily for 21 d GI upset, tendonitis, tendon rupture Test of cure at end of treatment4 IV4
Procedural Therapy      
Needle aspiration Presence of fluctuant buboes Mechanical   Infection, bleeding None IV4,7
Surgical repair Residual fibrotic lesions or fistulae Mechanical   Infection, bleeding None IV4

aFDA-approved therapy.

bCourses shorter than 21 days have been observed efficacious in a retrospective study3 and ...

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