A 34 year old, HIV-infected Puerto Rican male inmate presents at intake with a complaint of a swollen right inguinal lymph node. He states that 2 months ago he noticed a swelling in the right groin which gradually increased in size from that of a pea to a tender, mobile mass the size of an almond. He denies fever, chills, night sweats or other constitutional symptoms. Further, he denies dysuria, penile/rectal ulceration or discharge.
He has 18 months remaining in his sentence. He has sex only with men and has a history of urethral gonorrhea times two and rectal warts. In 2003 he developed a mononucleosis syndrome with generalized lymphadenopathy, fevers and malaise, which was later diagnosed as HIV. On the outside, he was sexually active, with approximately 50 sex partners, many of whom were anonymous, during the previous 2 months. He only practices insertive anal intercourse and uses condoms most of the time. He was regularly using crystal methamphetamines and occasionally used marijuana. He is ARV-naive with a CD4 count of 350 cells/mL and a viral load varying between 30,000-40,000 cells/mL. He has had no history of opportunistic infections. He reports an allergy to penicillin, which manifested as a rash.
Q: What are the differential diagnoses for unilateral tender inguinal lymph node enlargement in a sexually active HIV-infected male from Puerto Rico?
A: The differential diagnoses include HIV with generalized lymphadenopathy, lymphoma, tuberculosis, chronic fungal infections, kaposi's sarcoma, cat-scratch disease (bacillary angiomatosis) and a reaction to a local viral/bacterial infection (e.g. HSV, chancroid, syphilis, lymphogranuloma venereum [LGV] or Staphylococcus aureus).
Q: What tests would you order on the initial evaluation?
A: The Rapid Plasma Reagin (RPR) test was negative and cultures of the throat and rectum were negative for gonococcus and chlamydia. DNA amplification test was positive for Chlamydia trachomatis and negative for Neisseria gonorrhoeae from a urine sample.
Although not conclusive of LGV, the clinical presentation in this patient is suggestive of an inguinal bubo with the initial site of infection being the penis or urethra.
Q: What measures, if any, should be taken to evaluate and treat all sexual contacts over the last 2 months?
A: This sexually transmitted infection (STI) is reportable, and therefore, the public health department should be contacted. Depending on the particular county/state and available resources, ideally an officer from the health department would visit the prison and interview the inmate as well as all potential sexual contacts. All exposed contacts within the preceeding 2 months would not only need to be cultured for chlamydia but also screened for HIV and other STIs, such as syphilis. Because this inmate was diagnosed at intake, all sexual contacts were likely those in the community from which he came. However, any potential inmate contacts who may have been exposed to this inmate (the index case) since he has been in custody should still be explored.
LGV is an STI caused by serovars of Chlamydia trachomatis and is endemic to parts of Africa, India, Southeast Asia, South America and the Caribbean. The disease process has several stages based upon the duration of infection. A primary lesion in the genital region characterizes the first stage. The lesion is a shallow ulcer or papule, which is minimally symptomatic and rapidly heals without scarring. The second stage involves the swelling of locally draining lymph nodes, which forms into an inflammatory mass with loculations of pus (bubo). Progressive fibrosis leads to strictures in the rectum, draining buboes, and disfigurement of the external genitalia. The second and late stages may have associated constitutional signs and/or symptoms.
The diagnosis of LGV may be difficult. Perhaps the most definitive test is culture of an aspirate from the bubo; however, this is only about 50% sensitive. Other tests available include direct immunofluorescence or enzyme immunoassay of the bubo aspirate, but may be less sensitive or not available. A 4-fold rise in antibody titers is suggestive of LGV, but not specific as there may be cross reactions produced as a result of infections with other forms of chlamydial infections.1
The patient was treated with doxycycline 100 mg twice daily for 21 days with resolution of the bubo and no further recurrence of disease. The CDC recommendations for treatment of LGV are 21 days of doxycycline. Other agents which are active include co-trimoxazole, erythromycin, minocycline and tetracycline. Also, azithromycin as a 1-gram dose has been successful in HIV-infected patients with LGV, though most of the literature recommends antibiotic treatment for 21 days.1,2 Patients with LGV should be followed weekly for at least 4 weeks or until signs and symptoms have resolved.
A recent report from the Netherlands has shown a dramatic increase in LGV among men who have sex with men and have unprotected anal intercourse. These presentations may be markedly atypical in that most of the men infected with LGV developed gastrointestinal bleeding and inflammation of the rectum and colon.3 These atypical presentations should be distinguished from inflammatory bowel diseases. Proper diagnosis and treatment of LGV may also decrease the transmission of HIV since it has been shown that other ulcerative diseases, such as herpes and syphilis, increase risk of HIV acquisition.
For FREE continuing education opportunities related to STIs, visit the following web site at www.stdhivtraining.org/nnptc/about.cfm.
Steven Scheibel, M.D., is Regional Medical Director at Prison Health Services. Disclosures: Speaker's Bureau: GlaxoSmithKline, Bristol Myers Squibb, Boehringer Ingelheim, and Gilead Sciences.
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