Volume 25, Number 3—March 2019
Rectal Lymphogranuloma Venereum, Buenos Aires, Argentina
Among 34 men with proctitis in Buenos Aires, Argentina, 16 (47%) had Chlamydia trachomatis infection, 11 (68.8%) of which were biovar lymphogranuloma venereum. The outbreak was probably local, as in Europe. In Argentina, lymphogranuloma venereum should be a suspected cause of proctitis in HIV-infected men who have had unprotected anal sex with men.
Lymphogranuloma venereum (LGV) is a sexually transmitted infection caused by Chlamydia trachomatis serovars L1, L2, or L3 and their variants. LGV has been considered endemic to Asia, Africa, and the tropical region of South America. Over the past 2 decades, case reports of LGV in Argentina have been sporadic and regarding only patients who acquired the infection abroad.
In the Netherlands in 2003, an outbreak of rectal LGV among men who have sex with men (MSM), mainly HIV infected, was reported (1). This report was followed by many other reports from other developed countries (2,3).
LGV has been traditionally described as causing inflammation and swelling of the inguinal lymph nodes and also involving the rectum, causing acute proctitis, particularly among HIV-infected MSM (4). Since 2015, some clinicians in Argentina have suspected LGV in certain patients with proctitis (regardless of association with inflammatory tumors) in which C. trachomatis has been detected but not genotyped. Thus, we conducted a prospective study to assess the C. trachomatis genotypes as the causative agent of infectious proctitis in Buenos Aires, Argentina. Our study was conducted in a private practice and a public hospital, under a protocol previously approved by the hospital’s ethics committee (no. 201723).
From September 1, 2017, through February 1, 2018, we included in our study every man who visited either the private or public study site and who had rectal signs or symptoms of proctitis and had not taken antimicrobial drugs in the previous month. None of the included patients was referred by a previously included patient. Each participant signed an informed consent form.
Over the first 5 months, we obtained a rectal swab sample from 34 men on their first visit. To detect C. trachomatis, we extracted DNA from the samples by using real-time PCR targeting a cryptic plasmid fragment (Alert PCR; ELITech Molecular Diagnostics, https://www.elitechgroup.com). Positive samples were genotyped by ompA-based PCR restricted fragment length polymorphism (5).
Of the 34 samples analyzed, 16 were positive for C. trachomatis; 11 were identified as genotype L2 and 5 as genotypes D, F, or J. All participants reported having engaged in unprotected receptive anal sex in Argentina, except for 1 who had had receptive anal sex while in Mexico. None declared having traveled to an LGV-endemic area. Mean age was 31.63 years (range 22–43 years). All but 1 were HIV positive, and 5 had another sexually transmitted infection (1 had gonorrhea, 1 had syphilis and gonorrhea, 1 had syphilis only, and 2 had viral condylomas). The signs and symptoms of proctitis included rectal pain; tenesmus; and a discharge that was mucous, crystalline, hematic, or purulent. Endoscopic appearances of proctitis were variable, from mild to severe. Three patients had perianal lesions, 1 had a fistula, and 2 had ulcers. One patient had severe proctitis with rectal stenosis and was suspected of having had inflammatory bowel disease (IBD) for 1 year at the time of the first interview.
All patients were prescribed doxycycline for 3 weeks as recommended (4), resulting in complete resolution of proctitis and perianal ulcers. Two patients with chronic complications required additional treatments (surgical resolution of fistula and endoscopic dilatation of stenosis), resulting in complete resolution.
We observed a high prevalence (47%) of chlamydial infection within the studied group (16/34); the most frequent biovar was LGV (68.8% of the Chlamydia-infected patients). The cases included in this series were detected within a short period, which suggests a local outbreak. As in the series in Europe, the patients in Argentina were MSM, almost all HIV infected, who reported having had unprotected anal sex (6,7).
Signs and symptoms from most patients did not suggest LGV: 7 of the 11 with genotype L2 had mild or moderate proctitis similar to non-LGV infection. In 1 patient, severe proctitis mimicked an inflammatory tumor; in another, IBD. Proctitis is a nonspecific manifestation with diverse origins, for which clinical or endoscopic findings are insufficient to determine etiology, as observed in this case series. Also, because in about one quarter of patients with LGV infections the symptoms are mild or absent, diagnosis can be missed or late (8,9). Thus, given this evidence and the similarities between LGV and IBD, gastroenterologists should consider LGV as a differential diagnosis for patients with proctitis, especially HIV-infected MSM. Because the clinical assessment is not specific and quite inconclusive on which to base a diagnosis with certainty, genotyping is needed to indicate the proper patient care, management, and treatment. Including C. trachomatis typing as a routine diagnostic step also helps avoid chronic complications, stop the transmission chain (3,4,10), and provide useful information for epidemiologic surveillance. We conclude that in Buenos Aires, Argentina, as well as in countries in Europe, rectal LGV should be suspected as a cause of proctitis in HIV-infected MSM with a history of unprotected anal sex.
Dr. Svidler López is a surgeon who specializes in colon and rectum surgery in Buenos Aires, Argentina, and works at a public institution. She is also an associate professor at the School of Medicine of the University of Buenos Aires. Her main research interest is sexually transmitted infections.
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Original Publication Date: 1/31/2019