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Recent outbreaks of lymphogranuloma venereum (LGV) proctitis among men who have sex with men (MSM) have occurred in several European countries, however, there have been only a few cases reported in Eastern Europe.1 ,2 A primary anogenital lesion and the secondary lymphadenopathy may mimic other sexually transmitted infections (STIs), therefore an early laboratory diagnosis is essential for adequate therapy.
Between November 2012 and February 2014 four HIV-positive, Hungarian men were diagnosed with LGV. The patients’ lifestyle (unsafe sexual contact with multiple casual partners while visiting abroad) suggests that they are presumably linked to the recent Western-European epidemic of LGV among MSM. Neither of them developed a classical proctocolitis, which could have served as a telltale sign for clinicians. Three of the patients were affected by severe inguinal lymphadenopathy but none of them had been suspected having LGV before the classical bubonic form developed and became their leading symptom. The fourth patient suffered from a perianal ulcer that resembled a syphilitic chancre but proved negative by a Treponema pallidum PCR.
Purulent aspiration samples of the inguinal lymph nodes and urethral/anal samples were positive for Chlamydia trachomatis L serovar tested by a LGV real-time PCR. Genotyping by a PCR-restriction fragment length polymorphism method and sequencing confirmed the aetiological role of L2 in the first two cases and L2b serovars in the other ones.3 ,4 To our best knowledge these sporadic cases are the first confirmed LGV infections among MSM in Hungary.
Modern diagnostic approaches focus on the detection of LGV biovar specific DNA, while alternative serological assays may provide a presumptive diagnosis in this invasive type of chlamydial infection.5 Immunoblot assays performed with species-specific chlamydial antigens are reported highly sensitive and specific therefore may serve as a reliable tool for the presumptive diagnosis of LGV.6 We chose a commercially available immunoblot test (GenID Gmbh, Strassberg, Germany) for the separate detection of antichlamydia IgA and IgG antibodies. As expected, strong positive IgA and IgG antibodies were detected in all the four patients’ samples.
In the absence of the characteristic inguinal buboes clinicians may face a differential diagnostic problem and screening for other concomitant STI infections is also needed.7 We suggest that C. trachomatis serology should also be selectively added to the STI screening if the patients’ clinical signs and anamnestic background may raise the possibility of a LGV infection. Immunoblot results may serve as a good predictor of LGV until the nucleic acid amplification test tests provide more definitive information. Our preliminary data strongly suggest the diagnostic utility of immunoblotting in this condition, however, it should be controlled on a larger population to get more representative results.
EB and FP are joint first authors and contributed equally to this work
Contributors EB: coordinated the study, evaluated the immunoblot results, wrote the manuscript; FP: adapted real time PCR and PCR restriction fragment length polymorphism for LGV, analysed data, revised and approved the paper; TM: performed laboratory testing, commented on and approved the paper; ABal: performed laboratory testing, commented on and approved the paper; TE: performed sequence alignment, commented on and approved the paper; KE: provided clinical samples and anamnestic data of Case 1, was involved with establishing clinical diagnosis of Case 1, commented on and approved the paper ABán: provided clinical samples and anamnestic data of Case 2, was involved with establishing clinical diagnosis of Case 2, commented on and approved the paper; MM: provided clinical samples and anamnestic data of Case 3 and Case 4, was involved with establishing clinical diagnosis of Case 3 and Case 4, commented on and approved the paper.
Competing interests None.
Ethics approval All the four patients have agreed to work on with their clinical samples during medical examination.
Provenance and peer review Not commissioned; internally peer reviewed.
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