Background The lymphogranuloma venereum (LGV) epidemic continues unabated in UK men who have sex with men (MSM). Whatever its presentation, prompt recognition of LGV can be challenging.

Aim We describe a case of LGV inguinal syndrome identified too late to prevent major surgery.

Case report A 46-year-old HIV-positive MSM presented to A&E on a Saturday with a 3-day history of a painful left groin lump. He was stable on Atripla with CD4 count 400 cells/ml. He had a tender left inguinofemoral mass and the surgical team took him to theatre for suspected incarcerated femoral hernia. At operation they found instead a large necrotic lymph node and excised it. The patient self discharged the next day. Two weeks later he presented to the GU clinic as a syphilis contact. He mentioned his recent surgery and review of the histology report from the excised node showed “appearances consistent with LGV or cat scratch disease…also a vigorous periadenitis and syphilis should be considered.” Abdominal examination revealed a 25 cm recent surgical scar in the left iliac region. There was penile oedema with sclerosing lymphangitis. A small round subpreputial ulcer was found; it was non-tender and had a rolled edge. There was no perianal or anal lesion. Dark ground microscopy from the ulcer was negative. Rectal and urethral swabs showed no pus cells. The patient was treated with 21 days doxycycline for suspected LGV as well as to cover early syphilis. Chlamydia trachomatis: RNA was detected from the ulcer, first catch urine and rectal specimens. The ulcer tested negative for herpes simplex and TP DNA. All gonococcal tests were negative. LGV-specific DNA was detected from the ulcer but not the rectal swab. TP antibodies were positive with an RPR titre of 4. TP immunostaining of the node biopsy was negative. All clinical signs had resolved by the end of the 3-week doxycycline course.

Conclusion/Learning points This case highlights that LGV may still evade detection in both A&E and surgical departments. Awareness of LGV remains poor outside of GUM.