Increase in Lymphogranuloma Venereum Cases in South Florida

Introduction

Lymphogranuloma venereum (LGV) is an invasive, systemic reemerging sexually transmitted infection (STI) in the Western world, and if not treated early, LGV proctocolitis can lead to chronic, colorectal fistulas and strictures. ^1,2 Endemic in Africa, the Caribbean, and many parts of Asia, prior to 2003, LGV was considered rare in industrialized countries, where most cases were considered imported. ³ In 2003, a cluster of LGV cases of a new strain, L2b, was detected in Rotterdam, the Netherlands, among men who have sex with men (MSM), presenting mainly as proctitits. ⁴ Since then, there have been reports of similar outbreaks in large cities of Western Europe, United States, Canada, and Australia. ^5–9 In the United States, the true incidence is unknown because national reporting of LGV ended in 1995 after a steady decline in the rates of LGV, since 1972. However, between November 2004 and January 2006, US Centers for Disease Control and Prevention (CDC) began offering assistance to test for LGV in the United States. The majority of individuals in these outbreaks are MSM, coinfected with HIV, and presenting with anorectal symptoms.

Treatment cures infection and prevents ongoing tissue damage, although tissue reaction to the infection can result in scarring. Buboes might require aspiration through intact skin or incision and drainage to prevent the formation of inguinal/femoral ulcerations. Doxycycline for at least 3 weeks is the preferred treatment. ²

The Miami-Dade Health Department (MDHD) sexually transmitted disease (STD) clinic performs routine Chlamydia trachomatis (CT) screening using anorectal swabs on individuals reporting receptive anal intercourse. Following the initial reports of LGV outbreaks in 2005, the MDHD in collaboration with the State of Florida, Bureau of Laboratories, Jacksonville (BOL-Jax), and CDC have conducted surveillance for LGV in all rectal samples found positive for Chlamydia trachomatis. The objective of this report is to describe the clinical and epidemiological characteristics of individuals diagnosed with LGV infection identified in South Florida, since 2007.

Methods

Patients who attend the MDHD STD clinic and report anal intercourse are offered a rectal swab for screening with nucleic acid amplification testing for CT/Neiseria gonorrhea (GC) regardless of their symptoms. Rectal swab samples are collected and placed in the collection container and shipped to the BOL-Jax for testing for CT and/or GC. All specimens positive for Ctrachomatis are then sent to the Chlamydia Reference Testing Laboratory of the Division of STD Prevention of the CDC for LGV DNA detection by nucleic acid amplification/ompA gene sequencing. Laboratory reports from the CDC and BOL-Jax are sent to the clinic for patient identification, contact tracing, and treatment. Since LGV testing is done primarily for clinical surveillance, results were usually received months after the samples were collected.

A retrospective chart review was conducted of individuals with reactive LVG testing in the MDHD STD clinic from 2007 to 2010. Pertinent medical and epidemiological information of all identified cases were entered into an Excel database for analysis. Approval from the University of Miami and International Review Board of Florida Department of Health was obtained prior to any study-related activities.

Results

During the study period, from 2007 to 2010, a total of 2596 rectal swabs were collected according to clinic protocol (men and women who reported receptive anal intercourse). Prevalence of rectal CT among tested individuals has been relatively stable during the study period as shown in Table 1. Eight cases of LGV were identified during the study period, 1 in 2009 and 7 in 2010. All individuals who tested positive for LGV were reported to Miami-Dade County Disease Intervention Specialists who advised them to return to the clinic for treatment and contact tracing. Treated individuals were advised for a  retest after 3 months.

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Table 1.

Prevalence of Rectal Chlamydia (CT) by Year

Year	Total Rectal Tests	Positive Rectal CT	Prevalence Rectal CT, %	95% CI
2007	428	64	15	12-19
2008	689	104	15	13-18
2009	603	74	12	10-15
2010	876	123	14	12-17

Abbreviation: CI, confidence interval.

Characteristics of Individuals with Positive Rectal LGV Results

Demographic characteristics, HIV status, and clinical presentation from individuals with positive rectal LVG testing are shown in Table 2.

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Table 2.

Characteristics of Patients with LGV in the MDHD STD Clinic (2007-2010)

Sex	MSM	HIV	Year	Race	Concurrent STIs	Anal Symptoms
M	Yes	Positive	2009	White		Yes
M	Yes	Negative	2010	Black	Syphilis	No
M	Yes	Positive	2010	White	Gonorrhea	Yes
M	Yes	Positive	2010	Black		N/A
M	Yes	Positive	2010	White		N/A
M	Yes	Positive	2010	Black	Gonorrhea, syphilis	Yes
M	Yes	Negative	2010	N/A	Gonorrhea	Yes
M	Yes	Negative	2010	White	Syphilis	N/A

Abbreviations: LGV, lymphogranuloma venereum; MDHD, Miami-Dade Health Department; STI, sexually transmitted infection; MSM, men who have sex with men; STD, sexually transmitted disease.

All individuals positive for LGV testing were male and 63% (5 of 8) of them were coinfected with HIV. Their ages ranged from 22 to 56 years. All men were MSM, although 1 individual also had sex with women. Most of them presented with anal symptoms or had abnormal physical findings in the anorectal area (4 of the 5 who had the information), and the majority had a concurrent STI. The LGV test results were usually received months after patients were evaluated in the clinic.

Discussion

This study reports the prevalence of rectal CT and LGV in individuals reporting receptive anal intercourse in the MDHD STD clinic. The first case of LGV in South Florida was confirmed in 2005. This review suggests a rapid increase in the number of cases in the last 2 years. In all, 87% (7 of 8) of the identified cases occurred in 2010, despite similar screening volume and testing methods prior to this time. All individuals diagnosed with LGV were men and the majority of them were HIV coinfected. Most of the cases presented with anal symptoms. Similar to Europe, where LGV has emerged as an important STI in MSM coinfected with HIV, all of the individuals in our sample were MSM and 63% (5 of 8) of them were coinfected with HIV. Recognition of LGV infection is extremely important because if left untreated it can lead to chronic scarring and deformities requiring surgery. ¹⁰

Similar to other genital ulcerative diseases, LGV may increase transmissibility and susceptibility of HIV. ¹¹ This is especially concerning in a community like South Florida that has one of the highest HIV rates in the country. (South Florida ranks second in the country in the rate of AIDS diagnoses, 2010 and cumulative, and persons living with an AIDS diagnosis by the end of  2009, in the metropolitan statistical area of residence in the United States and Puerto Rico.) ¹²

Results from this clinic-base surveillance system represent only a small sample and do not fully encompass the potential impact of this disease in the community. In addition, since there is no commercial test available for LGV detection, surveillance is limited to individuals presenting to our center. Regarding treatment, and in the absence of specific LGV diagnostic testing, CDC recommends that patients with a clinical syndrome consistent with LGV, including proctocolitis or genital ulcer disease with lymphadenopathy, should be treated for LGV; and as described in this report, in particular, individuals who are HIV positive with the history of receptive anal intercourse have anorectal complaints and have a positive CT rectal test. Also, given the occurrence of LGV in HIV-positive sexual networks, individuals who test positive for LGV should also be tested for HIV, and the individuals who tested negative should receive additional counseling.

Conclusions

This is the first report of LGV cases in South Florida and shows a rapid increase in the number of cases. Practitioners in the community should be alerted about the emergence of this STI and empiric treatment should be considered in selected cases, given the lack of commercial testing.