LYMPHOGRANULOMA VENEREUM

By M.P.Vora

Indian Medical Record

A monthly journal of Public Health, Tropical Medicine & Surgery etc.

Volume No- LXXXIV, Number. 4 of April 1964

Pages 35-37

This article was solely contributed to Indian Medical Record

Lymphogranuloma Venereum (L.V.) is a specific and systemic infectious disease caused by a filterable virus and is usually acquired and spread by sexual relations. The disease is common in tropical and even in temperate zones and affects both sexes. However, coloured races show greater proclivity to the infection than the whites. The disease is characterised by a transient primary lesion which is often overlooked, and is then followed by a subacute indolent lymphadenitis with suppuration, fistulation and cicatrical healing. It begins incidiously and runs a course extending over months.

The virus of L.V. is immunologically and morphologically very similar to the virus of psittacosis and pneumonitis. Elementary bodies are found in the pus from the lesions. Frei was the first to use human antigen for intradermal test and to prove its specificity. Since then the test for L.V. is known as Frei’s Test.

Clinical diagnosis of the L.V. can be made on the history, location of the primary lesion, duration and intensity of the disease, the resultant complications and over-all clinical picture. However, use of laboratory tests is desirable for confirmation. The area of the lymphatic drainage from the primary lesion is the centre of main pathological changes which vary according to the intensity and duration of the infection.

The primary lesion which appears 10 to 20 days after the contact, is a small, painless, transient erosion which is often overlooked by the patient. It appears before the development of lymphadenopathy for which a patient usually seeks medical advice. The common site for the primary lesion is the prepuce or the glans penis in the male and the vaginal wall or cervix in the female. This variation in the site of primary lesion is responsible for the inguinal adenitis in the male and the pelvi-rectal lymphadenitis in the female, producing two different clinical types of manifestations in two sexes. Hence it is common to meet inguinal adenopathy and genital type of L.V. involving the penis and scrotum in the male and ano-rectal and ano-genital types of L.V. in female.

Inguinal lymphadenitis (or pelvi-rectal lymphadenitis as the case may be) develops in about 15 to 30 days after the appearance of the primary lesion. Lymph nodes are enlarged, discrete, freely movable under the skin and slightly tender. The involvement of the nodes may be on one or both sides. At this stage, the adenopathy resembles very closely to adenitis due to syphilis. However, the overlying skin soon becomes pink, edematous, and purplish in colour indicating adenitis and peri-adenitis. In the course of time, the glands become very much enlarged, firm, matted together and adherent to the overlying skin. The entire mass can be palpated with little pain or discomfort. Sulci or grooves on the surface of the skin, as if dividing the mass are common. Iliac lymph nodes are invariably palpable. Ultimately, lymph glands soften and suppurate but the amount of pus is very small or scanty. Each gland opens separately thus giving rise to multiple foci of suppuration. The duration of adenitis varies considerably and may extend from 3 to 6 months or longer. Systemic changes such as fever, arthritis, headache etc. are pronounced. In short, an incidious beginning, prolonged course, suppuration, fistulation, and scar-formation are evident.

Ano-rectal-genital syndrome may be present together or separately, in the chronic stage. In the genital type of L.V., chronic ulceration and elephantiasis of the penis and the scrotum in the male, and of the vulva in the female, are met with. There is usually an absence of the involvement of rectum. Pedunculated growths are not uncommon. Ano-rectal type of L.V is more common in women than in men. Proctitis, tenesmus and anal pruritis are complained of at the beginning. Soon the rectal granulation is replaced by fibrous tissue giving rise to rectal stricture when obstinate constipation becomes evident. There are three types of rectal strictures: - (1) annular, (2) funnel-shaped and (3) tubular. It is often situated 1-6 cms from the ano-cutaneous junction. It has a soft, fibrous and rubbery consistency on palpation (per rectal examination). The skin around the anus may show, in course of time, ulceration, fistulation and polypoid growth. Peri-rectal abscesses and fistulae may be met with especially in the ano-rectal type of L.V. Systemic changes are not marked as in the case of inguinal adenopathy due to L.V.

Increased E.S.R. and reversal of the albumin globulin ratio i.e. hyperglobulinemia are usual findings.

Complications:-

Arthritis, salpingitis, epididymitis, occular involvement, urethritis, rectal stricture, elephantiasis of the penis and scrotum in male and of the vulva and the perianal area in the female, recto-vaginal or recto-urethral fistulae and finally chronic indolent ulcerative lesions about the genitalia in the female (estheomene) are usual sequelae in late stages.

Diagnosis:-

Although diagnosis of L.V. can be made on clinical impressions in a well advanced case, it is always desirable and even necessary to confirm it by appropriate laboratory tests especially in the early stages of the infection, for the results of treatment are far superior to those obtained when the treatment is begun late. Frei’s intradermal test and Formol-Gel Test can be performed easily as office procedures. Lygranum (Squibb) and Frei’s Antigen (Lederle Lab.) with controls can be had commercially, 0.1 cc of the antigen is injected intradermally on the flexor side of the forearm. If a palpable 5 to 7 mm in diameter reaction develops at the site of injection within 2 to 3 days, the test is considered positive. The control on the other forearm is essential for the proper valuation of the results of the test. In the majority of the cases, the test becomes positive in 2 to 3 weeks after the onset of inguinal adenopathy, and remains so for years. The test is of value when a negative reaction found at the onset of infection, is followed by a positive one when the test is repeated 1 to 2 weeks later. It must be understood that a positive test does not necessary permit a positive diagnosis, but only an indication of a past infection. Formol-Gel test is based on reversal of A/G ratios i.e. increase in sero-globulins with decrease in sero-albumins. Two drops of formalin are added to 2 cc of serum placed in a test tube, 8mm in inside diameter. Readings are made after 2, 6, and 24 hours. When the serum becomes solid and opaque like a jelly, the test is considered positive. Many other diseases besides L.V. may give positive Formol-Gel test. Presence of elementary bodies on the smears of the exudate is an additional evidence to come to a decision of L.V. Microscopic examination of the tissue especially in chronic stages of infection is of great value in confirming the clinical diagnosis of L.V. and at the same time, ruling out any possibility of malignancy. Other tests include serologic test for syphilis, and should be done as a routine in every case to exclude syphilitic infection. At the same time, the possibility of getting a biologically false positivity to S.T.S, in about 20% of L.V. cases should be borne in mind. Such a positivity returns to negativity automatically in the course of 4 to 6 weeks. High titer positivity or persistent positivity with rising titer can alone be taken as an evidence of concomitant syphilis.

Per rectal examination, proctoscopy and x-ray examination following barium enema have to be considered when rectal lesion is present. L.V. must not be confused with granuloma inguinale; for, the latter is a chronic granulomatous ulcerative disease mainly of the skin and the subcutaneous tissues and can be diagnosed by the demonstration of Donovan bodies within large mononuclear phagocytes in the smear made from the ulcer. Involvement of the local lymphatics is rarely a prominent feature.

Treatment:-

Till the production of sulpha drugs and later on broad-spectrum antibiotics, the treatment of L.V. was very unsatisfactory. Bed rest, application of dry heat locally, U.V. rays, vaccines and tartar ematic preparations etc. were used with some success. Incision or surgical removal of suppurating nodes as a method of therapy is not advised, and must not be practiced. If the infection is detected early, sulpha drugs give satisfactory results in the majority of cases. The suggested dose is one gram, orally four or five times a day, for seven or more days depending on the severity of the infection. When the administration of sulpha drugs exceeds a week, appropriate precautions against its toxicity must be taken. A course of 3 to 5 intravenous injections of T.A.B. vaccine starting with 25 million organisms, depending on the individual reaction at two or three day intervals, does help to hasten the resolution of the swelling and to prevent softening of the nodes. Penicillin has no effect on the course of the infection. In long-standing chronic cases, where sulpha drugs do not show satisfactory results, one may have to use one of the broad-spectrum antibiotics. Chloromycitin, Terramycin and Tetracyclin orally are quite effective. Dose suggested is 1 to 2 gms daily for about 20 days. In some cases the period of administration may have to be extended, depending on the severity of the disease.

Follow-up:-

Every case of lymphogranuloma venereum needs to be followed up for a period of 4 months, during which serologic tests for syphilis and physical examination of the patient should be done at regular intervals.