Six cases of lymphogranuloma venereum are described in White South Africans. All initially presented diagnostic problems. This sexually transmitted disease is uncommon in South Africa, and 5 of. the 6 patients presented with inguinallymphadenopathy without a primary lesion. The value of serological tests in the diagnosis of this disease is emphasized

Ballard, R.C.

Koornhoff, H. J.

Mauff, A.C.

English

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2. Shaw EC, Arbegasr NR, Schmalhorst WR, Commer TP. Splenic artery aneu-rysms. Arch SlIrg 1973; 106: 660-662.3. Culver GJ, Pirson HS. Splenic arrery aneurysms. Radiology 1957; 68: 217-222.4. Boijsen E, Efsing HO. Aneurysm of the splenic artery. ACla Radiol (Diagn)(Slockh) 1969; 8: 29-41.5. Probst P, Castaneda-Zuniga WR, Gomes .AS, Yonehiro EG, Delaney JP,Amplatz K. Ton-surgical treatment of splenic artery aneurysms. Radiology1978; 128: 619-623.6. Babb RR. Aneurysm of the splenic arrery. Arch SlIrg 1976; 111: 924-925.7. Jones EL, Finney GG. Splenic artery aneurysms: a reappraisal. Arch Surg1968; 97: 640-647.8. Mac Farlane JR, Thorbjarnarson B. Rupture ofsplenic aneursym during preg-nancy. AmJ Ob,teI GyencoI1966; 95: 1025-1037.SA MEDI ESE TYDSKRIF DEEL 63 8 JANUARIE 1983 559. Nathanson SO, Levin CH, Bremner CG. Ruptured splenic artery aneurysm. SrlfrMedJ 1974;48: 917-918.10. Lawaetz 0, Beck Hansen J, Folke K. Ruptured arteriosclerotic aneur)·sm of (hesplenic arrery. Acta Chir Scand 1976; 142: 335-337.11. Baum 5, Greensrein RH', Nusbaum t\1J Blakemore S. Diagnosis of rupturednon-ealcified splenic artery aneurysm by selective coeliac arteriography_ A rthSlIrg 1965; 91: 1026-1028.12. Carlisle BB, Lawler MR. Aneurysm of the splenic artery: report of <en cases.rlm J SlIrg 1967; 114: 443-447.13. Schug J, Rankin RP. Rupture ofa splenic artery aneurysm in pregnancy. ObSletGvneco11965; 25: 717-723.14. Sianley JC, Fry WJ. Pathogenesis and clinical significance of splenic arteryaneurysms. SlIrgerv 1974; 76: 898-909.Problems in the diagnosis oflymphogranuloma venereumA review of 6 casesA. C. MAUFF, R. C. BALLARD, H. J. KOORNHOFSummarySix cases of lymphogranuloma venereum are de-scribed in White South Africans. All initially pre-sented diagnostic problems. This sexually transmit-ted disease is uncommon in South Africa, and 5 of.the 6 patients presented with inguinallymphadeno-pathy without a primary lesion. The value of serolo-gical tests in the diagnosis of this disease is empha-sized.S Atr Med J 1983: 63: 55-56.Lymphogranuloma venereum (LGV) is a sexually transmitteddisease caused by Chlamydia crachomacis serotypes L I, L2 andL3. These serotypes differ biologically from other members ofthe species, being more invasive than those serotypes responsiblefor trachoma and other oculogenital infections.' LGV has aworld-wide distribution but is most prevalent in tropical andsubtropical countries. In recent years the incidence of the diseaseappears to have declined considerably, a finding which has beenattributed to improved standards of living.2The disease is classically described as an infection of theregionallymphatics draining the genitalia, and the most commonpresentation is therefore significant inguinal lymphadenopathy,MRC Emergent Pathogen Research Unit, School of Patho-logy, University of the Witwatersrand and South AfricanInstitute for Medical Research, JohannesburgA. C. MAUFF, M.B. B.CH., F.F.PATH.R. C. BALLARD., Ml. BIOL.H. J. KOORNHOF, M.B. B.CH, F.RC.PATH.Dale received: 23 February 1982.frequently without an obvious primary lesion. The infection ismore commonly diagnosed in men than in women, who probablyact as asymptomatic carriers. The only previous report of LGVin South Africa is that of Ulman,' who described a series of 16cases in Black women seen at Baragwanath Hospital, Johannes-burg. In his series all cases were diagnosed on clinical groundswith additional evidence provided by positive Frei skin tests. Allthe patients evaluated ~ere admitted to hospital with erroneousdiagnoses, and he felt that the correct diagnosis was ultimatelymade only because he was. actively seeking cases of the disease.In this report we describe 6 cases of LGV in White men. Ineach case there were initial diagnostic problems. The diagnosis ofLGV was only subsequently made on clinical grounds and sup-ported by serological evidence of infection. In 2 cases the resultsof histological investigations further supported the diagnosis.Case reportsCase 1. A young man presented with a I-month history ofprogressive enlargement of the inguinal lymph nodes on theright side. There was no preceding urethral discharge or penileulceration. A diagnosis of Hodgkin's disease was considered, butbefore referring the patient for a biopsy a number of otherlaboratory tests were performed. These included a chlamydialcomplement fixation test, which was positive at a titre of 1:64,and rapid plasma reagin (RPR) and fluorescent treponemalantibody-absorption (FTA-Abs) tests, which were negative. Thepatient was treated with tetracycline 250 mg 4 times daily for 3weeks with complete resolution of the lymphadenopathy. Hishistory suggests that the infection had probably been acquired inSWa2iland.Case 2. The patient presented with bilateral inguinal Iym-ph'ldenopathy with no previous history of genital ulceration orurethral discharge. No definite diagnosis was made, and he wasgiven short courses of amoxycillin and erythromycin withoutclinical response. A few days later the left inguinal nodes suppu-rated and drained. A biopsy was taken which showed nonspecific56 SA MEDICAL JOURNAL VOLUME 63 8 JANUARY 1983infection. One week later the nodes on the right suppurated andanother biopsy was taken. Histological examination showed cen-tral suppuration with surrounding epithelioid histiocytes. Thepossibility of LG V or cat-scratch disease was suggested. At thispoint a chlamydial complement fixation test was performed,which was strongly positive at a titre of 1:2048. The RPR andFTA-Abs tests were negative. As a result the patient was given a4-week course of tetracycline with a good clinical response.Case 3. This patient presented with a 2-week history of right-sided inguinal lymphadenopathy following a visit to Swaziland.There was no history of genital ulceration or urethral discharge.At this time a chlamydial complement fixation test and RPR andFTA-Abs tests all proved negative. A lymph node biopsy wasperformed and revealed absce ses consisting of aggregates ofhistiocytes, lymphocytes and plasma cells with breakdown in thecentral areas. Cat-scratch disease or LGV was considered as apossible diagnosis. The patient was given a 4-week course oftetracycline and the lymphadenopathy resolved completely. Achlamydial complement fixation test performed 4 weeks afterbiopsy was positive at a titre of I: 128.Case 4. This patient had previously been treated for primarysyphilis which had been confirmed serologically. Nine monthslater he developed right-sided inguinal lymphadenopathy whichhad not been preceded by any genital ulceration or urethraldischarge. At this time a chlamydial complement fixation testwas positive at a titre of 1:4096; the RPR test was negative andthe FTA-Abs test positive (presumably as a re ult of previoussyphilis). A diagnosis of LGV was made, and the patient wasgiven tetracycline 250 mg 4 times a day for 4 weeks. Despitetherapy the lymph nodes showed no improvement and even-tually became fluctuant. Approximately 8 011 of pus was aspi-rated. He was given a further course of tetracycline with a goodclinical response.Case 5. A small painless penile ulcer of3-4 days' duration wasthe presenting feature in this patient. This was followed bybilateral tender lymphadenopathy. Culture of material from thebase of the ulcer was negative for Haemophi/lIs dllcreYl~ andserological tests for syphilis were negative. A chlamydial com-plement fixation test was positive at a titre of I :256. The patientwas given tetracycline, which resulted in complete resolution ofhis lymphadenopathy. Three·weeks later his wife was seen byanother practitioner for a swelling in the right groin. She wasreferred to a surgeon with a diagnosis of a femoral hernia. At thispoint, because of the diagnosis of LGV in her husband, a chla-mydial complement fixation test was done. This was positive at atitre of 1:64. She was also successfully treated with tetracycline.Case 6. The final patient in this series presented with unila-teral inguinal and femoral ?wellings initially thought to be ahernia (Fig. 1). The onset of these signs had been immediatelyFig. 1. The classic groove sign, due to enlarged inguinal andfemoral nodes, may be seen.preceded by transient urethral discharge with burning on mictu-rition. On examination there was no evidence of urethritis orulceration, but both the inguinal and femoral lymph nodes wereenlarged and tender. Both the RPR and FTA-Abs tests werenegative but the chlamydial immunofluorescence test was posi-tive at a titre of 1:4096. The patient was treated with tetracycline500 mg 6-hourly for 3 weeks with complete resolution of thedisease. His most recent sexual contact had been in Swaziland,approximately 2 weeks before the onset of symptoms.DiscussionAll 6 patients in this series presented with the classic clinicalfeatures of LGV as exemplified by significant and painful ingpi-nallymphadenopathy with little or no genital ulceration. In eachcase the diagnosis was confirmed by positive serological tests forLGV and all the patients responded to treatment with tetracy-cline. However, in none of these patients was LGV the initialdiagnosis. Three patients were initially thought to have a lym-phoma. Biopsies were subsequently performed on 2 of thesepatients for a histological diagnosis. One patient was originallysuspected of having an inguinal hernia and the other 2 werediagnosed as having syphilis.Difficulty in making a diagnosis of LGV in a patient withsignificant inguinal lymphadenopathy arises as a result of theabsence of a primary genital lesion in most cases and the fact thatLGV has been considered a rare disease in South Africa. It isprobably significant that 3 of our patients acquired their infec-tions in Swaziland, where a high incidence of the disease hasrecently been reported· In this series only I of the 6 patientspresented with a primary lesion. This is a similar proportion ofcases to that described by Alergant 5 and Sigel6 who found prim-ary lesions in only 24% and 26% of cases respectively. LGV isth~refore the most likely cause ofsignificant inguinallymphade-nopathy in the absence ofgenital ulceration. In contrast, patientswith significant genital ulceration and associated lymphadeno-pathy are more likely to have chancroid. The laboratory isolationof the causative organism H. dllcreyi has been greatly improvedby inoculating material from the base of the ulcer directly onto awell-defined culture medium.' Although in classic descriptionsthe discrete rubbery, painless lymph nodes of syphilis differfrom the matted lymph nodes of LGV, the former must alwaysbe excluded by appropriate laboratory tests. For LGV, agentisolation is the only laboratory proofavailable. Since facilities forthe isolation of Ch/alii. lracholllUlis are available only in a fewcentres in South Africa, serological methods (either complementfixation or micro-immunofluorescence tests) remain the bestaids in the diagnosis of the disease. 2We wish to thank Dr R. Skudowitz for his assistance with thehistological investigations in 2 of the cases.REFERE 'CESI. Kuo C-C, Wang S·P, Grayson JT. Oifferenriarion of TRIC and LGV orga-nisms based on enhancement of infecri\'iry by OEAE-dexrran In cellculrure.JInjeer Dis 1972; 125: 313-317.2. Schachrer j, Oawson CR. HUll/un Clzlul11yJiullnjeerions. Li,,!eron, Mass.: PSGPublishing Company, 1978. .3. Ulman H. Lymphoparhia venereum in rhe Sourh Afncan Banru female. S AjrMed J 1955; 29: 273-278. . ..4. Meheus A, Ballard R, Olamini ,\-t el al. Epidemiology and ae[lologyof urerhnHsin Swaziland. 1nl J Epidemiol 1980; 9: 239-245.5. A!erganr CO. Lymphogranuloma inguinale in rhe male in Li\'erpool, England,1947-1954. Br J Verzer Dis 1957; 33: 45-51. . . . .6. Sigell\11\-1.Lymphogramdoma Venereum: l?pidemiolo~lcal, Clzmcal, Surgical andTherapeuric Aspew Based on a SllIdy In rhe Caribbean. Coral Gables, Fla:Universirv of Miami Press, 1962.7. Hammond GW, Lian CL WilrJCerul. Comparisonofspecimen~ollecrionandlaboratory techniques for isolation of Haemophllu5 Jucreyl. J (hn /\t11croblOl1978; 7: 39-43.

Problems in the diagnosis of lymphogranuloma venereum - A review of 6 cases

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Problems in the diagnosis of lymphogranuloma venereum - A review of 6 cases

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