To the Editor: Lymphogranuloma venereum (LGV) is an uncommon sexually transmitted infection caused by Chlamydia trachomatis serovars L1–3. LGV is not endemic in Australia, and rare Australian cases of LGV have been seen in patients who have either acquired the infection while travelling overseas in an endemic area, or have had local contact with an imported case. Currently, there is an outbreak of LGV in western Europe (in particular, The Netherlands) and the United States.1-4 A case of LGV in an Australian man with no history of overseas travel was managed recently.

A 42-year-old bisexual man with previously treated early syphilis and hepatitis C infection presented to a Melbourne hospital in August 2004 complaining of 3 months of tender right inguinal lymphadenopathy. An excisional biopsy showed the formation of necrotising granuloma indicative of LGV. He had no history of penile ulceration, urethritis or proctitis. The surgical wound healed normally. The patient gave a history of attending sex-on-venue premises (“gay saunas”) and “beats”. He reported having oral sex with men, and recently having non-insertive sex involving masturbation with an unknown casual male contact who was apparently an overseas visitor. The patient had a female sexual partner with whom he had irregular, unprotected vaginal intercourse.

The diagnosis of LGV was confirmed by polymerase chain reaction (PCR), which detected C. trachomatis, identified as serovar L2 by nucleotide sequencing, from the excised lymph gland. IgG and IgA antibodies to C. trachomatis were demonstrated by enzyme-immunoassay. Tests for other active sexually transmitted infections were negative. The patient was treated with doxycycline (100 mg twice daily for 3 weeks). His asymptomatic female partner was also treated.

LGV is endemic in developing countries in our region, but occurs only sporadically in industrialised countries. The first stage of disease consists of a papule or ulcer that may occur on the penis, urethra or cervix. Proctocolitis may also be present, mimicking inflammatory bowel disease. Regional lymphadenopathy develops in the secondary stage of disease when there may be systemic symptoms. Fistula formation at these sites can be prevented by early recognition and treatment. Late, severe genital ulceration is rarely seen.

Confirmation of a diagnosis of LGV requires showing C. trachomatis serovars L1–3 by serological tests or PCR on genitourinary specimens. Lymph node resection is not favoured because of the possibility of sinus formation. Prolonged treatment with doxycycline or roxithromycin for 3 weeks is required for affected patients. Asymptomatic contacts are treated with doxycycline for 1 week or a single dose of azithromycin.

This case of locally acquired LGV highlights the features of this progressive disease that may now be recognised more frequently in Australian men who have sex with European or North American men.

Histological section of the lymph node showing the thickened node capsule and necrotising granuloma

Image courtesy of Dr Malcolm Buchanan, Department of Anatomical Pathology, Royal Melbourne Hospital.