Lymphogranuloma venereum physical examination: Difference between revisions

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{{Lymphogranuloma venereum}}
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==Overview==
==Overview==
The clinical manifestation of LGV depends on the site of entry of the infectious organism (the sex contact site) and the stage of disease progression. Inoculation at the mucous lining of external sex organs (penis and vagina) can lead to the '''inguinal syndrome''' named after the formation of buboes or [[abscess]]es in the groin (inguinal) region where draining lymph nodes are located. The '''rectal syndrome''' arises if the infection takes place via the rectal mucosa (through anal sex) and is mainly characterized by [[proctocolitis]] symptoms. The '''pharyngeal syndrome''' is rare, starts after infection of pharyngeal tissue and buboes in the neck region can occur.
Primary LGV is characterized by a small, nontender [[papule]] or [[ulcer]]. The primary lesion is typically unnoticed so few patients present at this stage. Majority of patients that do present are male. Secondary LGV is characterized by tender, swollen [[lymph nodes]], typically unilateral, known as [[buboes]]. Enlarged [[inguinal]] and/or [[femoral]] lymph nodes occur after primary lesion of anterior genital area. Enlarged [[iliac]] and/or [[perirectal]] lymph nodes occure after primary lesion of posterior genital area. 20% of patients present with "groove sign". [[Buboes]] may be indurated or draining sinuses. Tertiary LGV is characterized by [perirectal]] [[fistulas]] and/or [[strictures]], ulcerative [[proctitis]], and/or [[Elephantiasis]] of gentials. Males may present with "saxophone [[penis]]". Females may present with with ulceration and thickening of the [[vulva]].


==Signs and symptoms==
==Physcial Examination==
===Primary stage===
===Vital Signs===
LGV may begin as a self-limited painless genital [[ulcer]] that occurs at the contact site 3-12 days '''or longer''' in this primary stage.  Rarely do women notice a primary infection, because the initial ulceration where the organism penetrates the mucosal layer are located out of sight in the vaginal wall. Also in men fewer than 1/3 of those infected notice the first signs of LGV.  This primary stage heals in a few days. [[Erythema nodosum]] occurs in 10% of cases.
*[[Fever]] during later stages


===Secondary stage===
===Primary LGV===
The secondary stage occurs from 10-30 days later most often, but has occurred up to 6 months later. The infection is then spread to the lymph nodes through [[lymphatic drainage]] pathways.  The most frequent presenting clinical manifestation of LGV among males whose primary exposure was genital is unilateral, in 2/3 of cases, [[adenitis|lymphadenitis]] and [[lymphangitis]], often tender inguinal and/or femoral lymphadenopathy because of the drainage pathway for their likely infected areas. Lymphangitis of the dorsal penis may also occur and resembles string or cord.  If the route was anal sex the infected person may experience lymphadenitis and lymphangitis noted above or may have proctitis, inflammation limited to the rectum (the distal 10--12 cm) that may be associated with anorectal pain, [[tenesmus]], or rectal discharge, or [[proctocolitis]], inflammation of the colonic [[mucosa]] extending to 12 cm above the anus and is associated with symptoms of [[proctitis]] plus diarrhea or abdominal cramps and or inflammatory involvement of perirectal or perianal [[lymphatic tissue]]s. In females [[cervicitis]], perimetritis, or [[salpingitis]] may occur as well as the [[lymphangitis]] and [[lymphadenitis]] in deeper nodes.  Because of lymphatic drainage pathways, some end up with an abdominal mass which seldom suppurates and only 20-30% end up with inguinal lymphadenopathy. Systemic signs: fever, decreased appetite, and malaise, may occur as well.  Diagnosis is more difficult in women and homosexual men who may not have the inguinal symptoms.
*Patients presenting at first stage of LGV usually have a small, nontender [[papule]] or [[ulcer]].<ref name="pmid25870512">{{cite journal| author=Ceovic R, Gulin SJ| title=Lymphogranuloma venereum: diagnostic and treatment challenges. | journal=Infect Drug Resist | year= 2015 | volume= 8 | issue=  | pages= 39-47 | pmid=25870512 | doi=10.2147/IDR.S57540 | pmc=PMC4381887 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25870512 }} </ref>
*Common locations in males:
:*[[Coronal sulcus]]
:*[[Prepuce]]
:*[[Glans]]
:*[[Scrotum]]
*Common locations in females:
:*Posterior vaginal wall
:*Posterior [[cervix]]
:*[[Fourchette]]
:*[[Vulva]]
*Due to lesion location on each sex, more males present at this stage than females.<ref name="pmid25870512"></ref>


Over the course of the disease, lymph nodes enlarge, enlarged nodes are called buboes, and become painful at first (which may occur in any infection of the same areas as well). The next most common thing is inflammation, thinning and fixation of the overlying skin.  Lastly in the progression are [[necrosis]], fluctuant and suppurative lymph nodes, [[abscess]]es, fistulas, strictures, and sinus tracts all may occur. During the infection and when it subsides and healing takes place, fibrosis may occur.  This can result in varying degrees of lymphatic obstruction, chronic [[edema]], and [[stricture]]s. These late stages characterised by fibrosis and edema are also known as the third stage of LGV and are mainly permanent.
===Secondary LGV===
*Patients present with tender, swollen [[lymph nodes]], typically unilateral, known as [[buboes]].
:*Enlarged [[inguinal]] and/or [[femoral]] lymph nodes occur after primary lesion of anterior genital area (anterior vulva, penis, or urethra).
:*Enlarged [[iliac]] and/or [[perirectal]] lymph nodes occure after primary lesion of posterior genital area (posterior vulva, vagina, or anus).
:*Inguinal inflammation more common in men while anorectal [[lymphadenopathy]] more common in women
*20% of patients develop "groove sign": enlarged inguinal and femoral lymph nodes separated by the inguinal ligament.<ref name="pmid11589803">{{cite journal| author=Roest RW, van der Meijden WI, European Branch of the International Union against Sexually Transmitted Infection and the European Office of the World Health Organization| title=European guideline for the management of tropical genito-ulcerative diseases. | journal=Int J STD AIDS | year= 2001 | volume= 12 Suppl 3 | issue= | pages= 78-83 | pmid=11589803 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11589803  }} </ref>
*Buboes may present as indurated [[abscesses]] or ruptured, draining sinuses.<ref name="Mabey2002">{{cite journal|last1=Mabey|first1=D|title=Lymphogranuloma venereum|journal=Sexually Transmitted Infections|volume=78|issue=2|year=2002|pages=90–92|issn=13684973|doi=10.1136/sti.78.2.90}}</ref>
 
===Tertiary LGV===
*Patients present with [[perirectal]] [[fistulas]] and/or [[strictures]]
*Patients presenting at this stage are predominantly female or homosexual males
*Proctoscopy may reveal ulcerative [[proctitis]]<ref name="pmid10449269">{{cite journal| author=Lynch CM, Felder TL, Schwandt RA, Shashy RG| title=Lymphogranuloma venereum presenting as a rectovaginal fistula. | journal=Infect Dis Obstet Gynecol | year= 1999 | volume= 7 | issue= 4 | pages= 199-201 | pmid=10449269 | doi=10.1155/S1064744999000344 | pmc=PMC1784745 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10449269 }} </ref>
*[[Elephantiasis]] of gentials
*Ulceration and thickening of the [[vulva]] in females
*Penile and scrotal [[edema]] termed "saxophone [[penis]]"<ref name="pmid24339471">{{cite journal| author=Koley S, Mandal RK| title=Saxophone penis after unilateral inguinal bubo of lymphogranuloma venereum. | journal=Indian J Sex Transm Dis | year= 2013 | volume= 34 | issue= 2 | pages= 149-51 | pmid=24339471 | doi=10.4103/0253-7184.120575 | pmc=PMC3841672 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24339471  }} </ref>
 
==Gallery==
<gallery>
Image:Lymphogranuloma venerum - lymph nodes.jpg|Lymphogranuloma venereum: is caused by the invasive serovars L1, L2, or L3 of Chlamydia trachomatis. This young adult experienced the acute onset of tender, enlarged lymph nodes in both groins.
</gallery>


==References==
==References==
{{reflist|2}}
{{reflist|2}}


 
[[Category:Sexually transmitted diseases]]
[[Category:Disease]]
[[Category:Disease]]
[[Category:Gynecology]]
[[Category:Gynecology]]
[[Category:Infectious disease]]


[[Category:Bacterial diseases]]
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Latest revision as of 18:00, 18 September 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Nate Michalak, B.A.

Overview

Primary LGV is characterized by a small, nontender papule or ulcer. The primary lesion is typically unnoticed so few patients present at this stage. Majority of patients that do present are male. Secondary LGV is characterized by tender, swollen lymph nodes, typically unilateral, known as buboes. Enlarged inguinal and/or femoral lymph nodes occur after primary lesion of anterior genital area. Enlarged iliac and/or perirectal lymph nodes occure after primary lesion of posterior genital area. 20% of patients present with "groove sign". Buboes may be indurated or draining sinuses. Tertiary LGV is characterized by [perirectal]] fistulas and/or strictures, ulcerative proctitis, and/or Elephantiasis of gentials. Males may present with "saxophone penis". Females may present with with ulceration and thickening of the vulva.

Physcial Examination

Vital Signs

  • Fever during later stages

Primary LGV

  • Patients presenting at first stage of LGV usually have a small, nontender papule or ulcer.[1]
  • Common locations in males:
  • Common locations in females:
  • Due to lesion location on each sex, more males present at this stage than females.[1]

Secondary LGV

  • Patients present with tender, swollen lymph nodes, typically unilateral, known as buboes.
  • Enlarged inguinal and/or femoral lymph nodes occur after primary lesion of anterior genital area (anterior vulva, penis, or urethra).
  • Enlarged iliac and/or perirectal lymph nodes occure after primary lesion of posterior genital area (posterior vulva, vagina, or anus).
  • Inguinal inflammation more common in men while anorectal lymphadenopathy more common in women
  • 20% of patients develop "groove sign": enlarged inguinal and femoral lymph nodes separated by the inguinal ligament.[2]
  • Buboes may present as indurated abscesses or ruptured, draining sinuses.[3]

Tertiary LGV

Gallery

  • Lymphogranuloma venereum: is caused by the invasive serovars L1, L2, or L3 of Chlamydia trachomatis. This young adult experienced the acute onset of tender, enlarged lymph nodes in both groins.

    Lymphogranuloma venereum: is caused by the invasive serovars L1, L2, or L3 of Chlamydia trachomatis. This young adult experienced the acute onset of tender, enlarged lymph nodes in both groins.

References

  1. ↑ 1.0 1.1 Ceovic R, Gulin SJ (2015). "Lymphogranuloma venereum: diagnostic and treatment challenges". Infect Drug Resist. 8: 39–47. doi:10.2147/IDR.S57540. PMC 4381887. PMID 25870512.
  2. ↑ Roest RW, van der Meijden WI, European Branch of the International Union against Sexually Transmitted Infection and the European Office of the World Health Organization (2001). "European guideline for the management of tropical genito-ulcerative diseases". Int J STD AIDS. 12 Suppl 3: 78–83. PMID 11589803.
  3. ↑ Mabey, D (2002). "Lymphogranuloma venereum". Sexually Transmitted Infections. 78 (2): 90–92. doi:10.1136/sti.78.2.90. ISSN 1368-4973.
  4. ↑ Lynch CM, Felder TL, Schwandt RA, Shashy RG (1999). "Lymphogranuloma venereum presenting as a rectovaginal fistula". Infect Dis Obstet Gynecol. 7 (4): 199–201. doi:10.1155/S1064744999000344. PMC 1784745. PMID 10449269.
  5. ↑ Koley S, Mandal RK (2013). "Saxophone penis after unilateral inguinal bubo of lymphogranuloma venereum". Indian J Sex Transm Dis. 34 (2): 149–51. doi:10.4103/0253-7184.120575. PMC 3841672. PMID 24339471.

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