Article Text

Short report
Clinical and epidemiological characterisation of lymphogranuloma venereum in southwest Spain, 2013–2015
  1. Manuel Parra-Sánchez1,
  2. Silvia García-Rey1,
  3. Isabel Pueyo Rodríguez2,
  4. Pompeyo Viciana Fernández3,
  5. María José Torres Sánchez4,
  6. José Carlos Palomares Folía1
  1. 1Unidad Clínica de Enfermedades Infecciosas y Microbiología (UCEIM), Hospital Universitario de Valme, Seville, Spain
  2. 2Centro de Infecciones de Transmisión Sexual de Sevilla (CITS), Seville, Spain
  3. 3Servicio Enfermedades Infecciosas y Microbiología Clínica (UCEIM), Hospital Virgen del Rocío, Seville, Spain
  4. 4Microbiology Department, Universidad de Sevilla, Seville, Spain
  1. Correspondence to Dr Manuel Parra-Sánchez, Unidad Clínica de Enfermedades Infecciosas y Microbiología (UCEIM), Hospital Universitario de Valme, Avenida de Bellavista SN, Seville 41014, Spain; manuel.parra.exts{at}juntadeandalucia.es

Abstract

Objectives Lymphogranuloma venereum (LGV) infections caused by Chlamydia trachomatis L serovars have emerged in 2003 in Europe among HIV-positive men having sex with men (MSM). Our aim was to evaluate LGV prevalence and predictors in a high-risk population attending to two STI clinics in the southwest of Spain between December 2013 and April 2015.

Methods Screening of C. trachomatis using commercial kits was carried out, followed by real-time pmpH-PCR discriminating LGV strains, and finally ompA gene was sequenced for phylogenetic reconstruction.

Results A total of 6398 samples were tested, of which, 594 (9.3%) were C. trachomatis-positive specimens and successfully typed by pmpH PCR. Five hundred and eighty-one samples contained non-LGV and 13 (2.2%; 95% CI 1.3% to 3.7%) samples had LGV. One hundred and sixty-six (27.9%; 95% CI 24.5% to 31.7%) CT-positive results were found in MSM. All C. trachomatis LGV types were found in rectal samples from MSM (13/166, 7.8%; 95% CI 4.5% to 13.0%). Of these, five (38.5%; 95% CI 17.7% to 64.5%) patients were asymptomatic and 11 (84.6%; 95% CI 57.8% to 95.7%; p<0.001) were also HIV positive. Successful treatment of LGV was achieved in all patients including 11/13 (84.6%) who received single-dose azithromycin. All of the L types were confirmed to be genotype L2b with ompA PCR and sequencing.

Conclusions This analysis shows that LGV infections are occurring in MSM in southwest Spain, where no data about LGV have been described before, reinforcing the need for screening and genotyping for LGV. LGV should be taken into account when considering treatment and management of rectal C. trachomatis infections, including in asymptomatic HIV-positive MSM. Larger studies on appropriate treatment for asymptomatic LGV infection are needed.

  • CHLAMYDIA TRACHOMATIS
  • MOLECULAR EPIDEMIOLOGY
  • LYMPHOGRANULOMA VENEREUM
  • HIV
  • TREATMENT

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Introduction

Lymphogranuloma venereum (LGV) is a systemic STI caused by Chlamydia trachomatis serovars L1–L3 that usually causes invasive infections and subsequent severe inflammatory responses. LGV infections had been uncommon in Western countries, until a proctitis outbreak in 2003 due to C. trachomatis LGV serovar L2b was reported in Europe, North America and Australia, mainly among HIV-positive men who have sex with men (MSM).1 ,2

There are limited epidemiological data about LGV internationally as only a few countries have implemented national surveillance.3 In Spain, cities such as Barcelona and Madrid have detected an increase in LGV diagnoses of ∼115% from 2009 to 2011,4 and a recent outbreak, respectively.5 Unfortunately, many laboratories worldwide still do not have genetic tools to detect and identify LGV serovars. There is a need to increase efforts to improve case ascertainment as well as national and international LGV surveillance by identification of LGV genovars based on real-time PCR techniques.

The main aim of the present study was to assess LGV prevalence and phylogenetic characteristics in a population reporting condomless sex and/or other high-risk behaviours attending two STI outpatients clinics in southwest Spain where no data about LGV have been described before. As secondary aim, a retrospective evaluation of the treatment of patients with LGV infection was made.

Methods

Two STI units located in Seville, Spain, were involved in the study. From December 2013 to April 2015, a total of 6398 samples were collected from 4769 patients, who attended voluntarily for an STI check-up following sexual risk behaviour or condomless sex. The criteria for collecting these samples were based on clinical symptoms or reported sexual risk behaviours with or without symptoms. In women, samples were obtained from the cervix, pharynx (in the case of oral sex) or rectum (anal sex), and in men, from the rectum, pharynx and urethra (urine). All samples were analysed for the presence of microorganisms related to STIs, including C. trachomatis, Neisseria gonorrhoeae and Treponema pallidum. HIV detection was also made by RT-PCR (cobas TaqScreen MPX Test V.2.0, Roche Diagnostics, Mannheim, Germany) from blood samples.

The study was approved by the Ethics Committee of Hospital Universitario de Valme (VAL-2013-06UCEIM-ITS).

Screening of C. trachomatis was based on two molecular commercial tests: cobas 4800 CT/NG assay (Roche Diagnostics) was performed in one STI Unit and DX CT/NG/MG assay (Bio-Rad, Marnes-la-Coquette, France) in the second STI Unit, according to the manufacturer’ s instructions. DNA from residual cobas 4800 CT/NG assay was used from the first STI unit; meanwhile, a new DNA extraction was performed using MagNA Pure Compact (Roche Diagnostics) for samples from the second STI unit. A specific real-time PCR to C. trachomatis pmpH gene was performed in all C. trachomatis-positive samples to detect LGV serovars. A reference strain of C. trachomatis ATCC VR-902B (LGC Standards S.L.U, Barcelona, Spain) was used as a positive control for LGV in each real-time PCR assay.

To perform the phylogenetic analyses, amplification and sequencing of an approximately 990-bp fragment of ompA gene was performed by PCR following a protocol described previously.6 The consensus sequences were compared with known C. trachomatis LGV strains by using the BLAST search tool (http://www.ncbi.nlm.nih.gov), including LGV variants previously described in Spain.5 Sequences were edited with Chromas Lite 2.1.1 software and aligned using Clustal Omega by manual editing. Phylogenetic estimations were conducted through MEGA6 by using the neighbour-joining method with bootstrapping (1000 replicates), where the Tamura three-parameter method (using a discrete Gamma distribution) was employed to estimate the evolutionary distances.

Data were analysed using the SPSS statistical software package release V.23.0 (IBM SPSS, Chicago, Illinois, USA).

Results

A total of 4769 patients were included in this study of which 54.6% (95% CI 53.2% to 56.0%) were symptomatic. Median age was 28.5 years (range 15–81); 64.5% (95% CI 63.1% to 65.9%) were men, of whom a 39.0% (95% CI 37.6% to 40.4%) were MSM and 0.12% (95% CI 0.11% to 0.13%) transsexuals. The distribution of samples was as follows: 48.0% urine specimens, 37.8% endocervical, 12.0% rectal, 1.6% pharyngeal and 0.6% urethral swabs.

Five hundred and ninety-four (9.3%) specimens yielded a positive C. trachomatis result, and comprised urine samples (43.4%), and endocervical (32.3%), rectal (20.2%), pharyngeal (3.3%) and urethral (0.8%) swabs. Ninety-eight (16.5%) samples tested positive for both chlamydia and gonorrhoea. Based on the pmpH gene amplification, 13/594 (2.2%; 95% CI 1.3% to 3.7%) (13/166 (7.8%; 95% CI 4.5% to 13.0%) in MSM) were further identified as LGV serovars.

All LGV cases were detected in rectal sites from Spanish MSM reporting condomless sex and with a median age of 31 years (range 19–60), and 84.6% (95% CI 57.8% to 95.7%; p<0.001) were HIV positive. Other STIs, including gonorrhoea (4/13, 30.8%; 95% CI 12.7% to 57.6%) and syphilis (6/13, 46.2%; 95% CI 23.2% to 70.9%), were also detected. Online supplementary table S1 compares the demographic and clinical characteristics of C. trachomatis non-LGV and C. trachomatis LGV-positive groups.

Supplementary table S1

Comparison of the demographic and clinical characteristics of patients diagnosed with diagnosed with Chlamydia trachomatis (CT) by LGV status.

Clinical symptoms were present in 8/13 (61.5%; 95% CI 35.5% to 82.3%) patients (severe proctitis, anal pain, tenesmus and/or anal discharge). No inguinal adenopathy was found. According to the European guideline,7 doxycycline (100 mg/12 hours for 3 weeks) was prescribed in only two patients (14.4%). The criterion for prescription of doxycycline was clinical suspicion of LGV infection (acute symptoms of proctitis) and LGV PCR confirmation. Eleven individuals (retrospectively diagnosed by LGV PCR) deemed not to have clinical symptoms or signs suggestive of LGV (or were asymptomatic) were initially treated with a single dose of azithromycin (1 g). All these patients had C. trachomatis-negative results at post-treatment control (5–6 weeks after treatment and tested with the same methodology). No clinical suspicion of relapse was found in these patients.

Analysis of the ompA gene by BLAST showed a 100% match to the C. trachomatis genotype variant L2b, which has been implicated in the worldwide LGV outbreak. The phylogenetic tree revealed a transmission node constituting three patients: two were HIV-positive without STI coinfection and were aged 25–39 years (figure 1).

Figure 1

Phylogenetic network analysis from 13 lymphogranuloma venereum (LGV) strains identified during the period of study based on ompA/major outer membrane protein.

Discussion

The clinical and epidemiological characterisation of LGV infection in southern Spain has until now been unreported. In this study, we described 13 cases of LGV (2.2% of all C. trachomatis infections detected and 7.8% of those detected in MSM), all with the same variant (L2b) described previously in Europe.4–5 ,8 About 85% were HIV positive higher than previously reported in Spain5 and over a third were asymptomatic similar to a recently published UK study.9

Successful treatment of LGV with a single dose of azithromycin was achieved in 11/13 (84.6%) patients who received it and all were seemingly negative on test of cure. This result suggests that 1 g of azithromycin may be adequate treatment for LGV where there are no clinical symptoms or signs, although larger studies and trials on LGV treatment are needed to improve the evidence base.

The phylogenetic study showed an initial transmission node constituting three LGV strains belonging to the L2b variant in three male patients with a close epidemiological link further verified through molecular typing of the serovars.

The high percentage of LGV co-infection with gonorrhoea or syphilis reflects likely involvement with dense sex networks where contacts meet through the internet, sex parties and clubs.10 This type of sexual behaviour in combination with regular cross-border travel facilitates new outbreaks and continuing spread of LGV infection across Europe. These results reinforce the need for screening and genotyping programmes that provides real-time data for LGV surveillance programmes. In this context, laboratory analysis has a crucial role, but the quest for a reliable and simple method to discriminate LGV from non-LGV CT infections is ongoing.

Indeed, one limitation of this study was that nucleic acid amplification tests (NAATs) have not been Food and Drug Administration approved or CE marked for rectal specimens.

In conclusion, this study presents new information on LGV prevalence and case characteristics in southern Spain. Asymptomatic infections were common and seemed to be successfully treated with a single dose of azithromycin. Our results suggest that, as occurs elsewhere, all rectal samples belonging to MSM complaining of anorectal symptoms, especially if other STIs such as HIV and/or syphilis are identified, should be tested for LGV. Furthermore, these patients could be treated as LGV infection until C. trachomatis molecular genotyping is known. Until more robust evidence of effective treatment for asymptomatic LGV infection is available, it may also be advisable to test asymptomatic HIV-positive MSM with C. trachomatis for LGV.

Acknowledgments

The authors thank Mr Parma for proofreading and translation he did for this work.

References

Supplementary materials

  • Abstract in Spanish

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Handling editor Jackie A Cassell

  • Contributors MP-S and JCPF were involved in the design of the study. IPR and PVF were responsible for patient recruitment and data collection. MP-S and SG-R analysed the data. MJTS was involved in sample sequencing. All authors reviewed the manuscript.

  • Competing interests None declared.

  • Ethics approval The study was conducted with the approval of the Ethics Committee of Hospital Universitario de Valme, Seville, Spain. Ethics committee approval number: VAL-2013-06UCEIM-ITS.

  • Provenance and peer review Not commissioned; externally peer reviewed.