Lymphogranuloma venereum in the UK in 2003

CASE REPORT

Outbreaks of lymphogranuloma venereum (LGV) have been reported across Europe among men who have sex with men (MSM) ^1,2 of which the largest cohort is in the United Kingdom, ^3,4 with the earliest case diagnosed retrospectively in April 2004. ⁵

In August 2003, a 20-year-old, white English MSM, who was a sex worker, presented with rectal discomfort, pain and bleeding on defaecation. He reported recent unprotected active anal intercourse but no unprotected passive anal intercourse for two years. He reported 40 male casual partners in the previous three months, with lifetime sexual contacts including partners from South Africa, North America and Eastern Europe. He had never tested for HIV and declined to test on this visit, but was known to be infected with hepatitis C (HCV), diagnosed in June 2003. He had for a history of gonorrhoea, syphilis and suspected perianal warts. In November 2003, he returned as a contact of Chlamydia, with persistence of his rectal symptoms and a one-week history of urethral discharge, mild dysuria, lower abdominal pain and diarrhoea but no blood or mucus in the stool. He reported recent unprotected passive anal intercourse, oral sex and rimming with seven different male partners in the previous three months.

The patient attended a further six times (Table 1). In June 2004, he presented with a one-month history of rectal discomfort and contact with gonorrhoea. He reported one regular and four casual male partners in the last three months with whom he was having occasional unprotected anal intercourse. In June 2005, he attended complaining of a rectal discharge for 3–4 weeks and a new perianal skin tag or haemorrhoids and again reported multiple partners and high-risk behaviour. In June and July 2005, he was noted to have a persistent posterior anal fissure and associated skin tag and a new anterior anal fissure. A plan was made to remove the skin tag surgically. In November 2005, he was referred with thrombocytopenia and agreed to an HIV test, which was positive. In February 2006, the patient re-attended with rectal pain and discomfort, similar to his initial presentation in August 2003, and gave a history of unprotected anal sex.

LGV polymerase chain reaction (PCR) ⁶ was positive in June 2005 (Table 1) and on retrospective testing of a sample taken in August 2003, with negative results on two occasions between these dates. This patient showed all the characteristics subsequently associated with individuals infected with LGV, he was MSM, had multiple partners, high-risk behaviour, and infected with other STIs, including HCV. ^3,5 He had contact with partners in Europe and may have acquired his LGV abroad. He was also HIV positive, although his initial refusal to test means that the date of acquisition is unknown. He had persistent rectal problems and surgery was considered which has also been reported for patients with untreated LGV. ⁷ The diagnosis of LGV was made in 2005 following an alert in 2004 to increase awareness and the introduction of diagnostic tests for LGV. We have only been able to detect this early case in 2003 because of a research study comparing different diagnostic tests for the detection of C. trachomatis in rectal specimens. This report raises the question of how long LGV has been circulating among MSM in Europe.