Increase in LGV cases in gay men reported in the UK

Simon Collins, HIV i-Base

The first ever late breaker presentation for a BHIVA meeting was included to report a rapid increase in the number of cases of Lymphogranuloma venereum (LGV) reported to the Health Protection Agency (HPA) over winter 2009/10.

Diagnoses were 91% higher for November 2009 to January 2010 than in the previous three months (88 vs 46 cases), and 115% higher than that seen in the same period in 2008/09 (41 cases).

Since 2004, outbreaks amongst MSM have occurred in major cities in Europe, with 1,070 cases in the UK, mainly in London and to a lesser extent in Brighton and Manchester. LGV, which is caused by the L serovars of Chlamydia trachomatis, is endemic to areas of Africa, Asia, South America and the Caribbean.

The understanding of the epidemiology and mode of transmission of LGV remains poor, with only a small number of asymptomatic cases detected. Urethral infection is uncommon and, whilst infected individuals have high risk sexual behaviour and links to sex toys and sex parties have been described, no definitive associations have emerged.

Unlike other forms of C. trachomatis, LGV is invasive. Most cases seen in the UK have presented with proctitis but symptoms vary according to the site of infection and may include ulcers and inflamed and swollen lymph nodes in the groin (inguinal syndrome). If left untreated symptoms can become more severe and cause lasting damage to health. Treatment with three weeks of doxycycline BD 100 mg is recommended by BASHH.

Information posted to the HPA website, includes the following recommendations for limiting further spread.

Testing for LGV should be offered during routine clinical care to HIV positive MSM who have symptoms of LGV infection and have a positive test for C. trachomatis;
MSM should have a full sexual health screen annually. This should include testing for HIV where it is not already diagnosed;
Behavioural modification is a key component of control strategies. Campaigns that increase awareness and knowledge of STIs and promote safer sex need to be intensified.

Several posters at the conference related to LGV.

Pallawela and colleagues from five clinics in London and Brighton presented results from a six-month pilot screening programme in 98 men who were newly diagnosed with HIV, HCV or syphilis and who were routinely offered testing for urethral and, if indicated, rectal Chlamydia. [2]

Of the 82 men (84%) who were screened within 4 weeks, 40 (49%) were newly diagnosed with HIV, 36 (44%) with syphylis and 8 (10%) with hepatitis C. Rectal Chlamydia was diagnosed in 13/82 (16%), of whom one also had urethral Chlamydia, and two with urethral Chlamydia only. No cases of LGV were found.

Dosekun and colleagues from St Thomas Hospital, London, which was also one of the five centres reported above, included a case report of pharyngeal LGV in a 26-year old HIV-positive gay man. [3]

He presented in April 2009 with rectal discharge and constipation, but reported no symptoms of urethritis or sore throat. Sexual history included recent protected anal and unprotected oral receptive and insertive sex with casual male partners. He was on antiretroviral therapy with a CD4 count of 627 cells/mm3 and undetectable viral load (<40copies/mL).

On examination he had ?orid proctitis with haemopurulent exudate. A rectal swab was positive for Chlamydia trachomatis (CT) and pharyngeal swab showed an equivocal CT result. Both specimens had LGV-speci?c DNA detected in laboratory analysis.

He was treated for proctitis with ce?xime 400mg stat and a 21-day course of doxycycline 100mg bd. His rectal symptoms resolved with treatment and a pharyngeal CT test of cure at 6 weeks was negative.

Although most cases have been rectal, the authors reported this as the ?rst documented case of LGV- associated CT DNA detected from the pharynx in the current UK outbreak. Reported risk factors for LGV acquisition suggest that transmission is predominantly rectal-to-rectal via intermediate carriage on hands or fomites. This case highlights possible transmission via orogenital contact.

References:

1. Substantial increase in cases of Lymphogranuloma venereum (LGV) in UK. Oral late breaker.