Rare sexually transmitted infection seen in a cluster of HIV-positive men

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A form of the sexually transmitted infection chlamydia rarely seen in Europe and America since antibiotics became available, has been diagnosed in a cluster of gay men in the Netherlands, according to a paper published in the October 1st edition of Clinical Infectious Diseases. The outbreak of rectal infection with Lymphogranuloma venereum (LGV) involved a sexual network of 15 men, 13 of whom were HIV-positive. However, as the men reported sexual contacts across Europe, the investigators warn that LGV may have spread across western Europe.

LGV is caused by a variant of Chlamydia. However, unlike other forms of Chlamydia it is invasive and affects the lymphatic system. Depending on the site of infection, symptoms can include enlarged and tender lymph nodes in the groin with the formation of buboes (swellings of the lymph nodes) or, in instances of rectal infection, proctitis. If the infection is left untreated, it can cause chronic inflammation of the lymphatic system and genital elephantiasis.

Before antibiotics became available, LGV was endemic in Europe and the United States. It is still endemic parts of Africa, India, southeast Asia and the Caribbean, raising the possibility that the infection could be brought back to western countries by travellers. LGV infection is confirmed by polymerase chain reaction testing of chlamydia.


lymphogranuloma venereum (LGV)

A sexually transmitted infection that can have serious consequences if left untreated. Symptoms include genital or rectal ulcers.


The last part of the large intestine just above the anus.


Chlamydia is a common sexually transmitted infection, caused by bacteria called Chlamydia trachomatis. Women can get chlamydia in the cervix, rectum, or throat. Men can get chlamydia in the urethra (inside the penis), rectum, or throat. Chlamydia is treated with antibiotics.

transmission cluster

By comparing the genetic sequence of the virus in different individuals, scientists can identify viruses that are closely related. A transmission cluster is a group of people who have similar strains of the virus, which suggests (but does not prove) HIV transmission between those individuals.


Inflammation of the lining of the rectum. It can cause rectal pain, diarrhoea, bleeding and discharge, as well as the continuous feeling that you need to go to the toilet.

In early 2003 a white bisexual man, who had recently been diagnosed with HIV, attended a sexually transmitted infections clinic in Rotterdam with proctitis caused by early infection with LGV. Shortly after, two HIV-positive gay men attended the clinic with acute proctitis and had infection with LGV confirmed.

Investigators were concerned that there may have been an outbreak of LGV amongst a sexual network of gay men and attempted to trace the sexual contacts of the three men.

A total of 54 men from the sexual network were contacted and of these 15 were investigated. As well as being tested for chlamydia, the men had a wider sexual health screen and provided demographic information, details of their sexual health history, and information on their sexual risk activities.

LGV cluster in sexual network

A total of twelve men tested positive for LGV, with infection thought probable in another patient. All the men had rectal infections. Of the 13 patients in the LGV cluster, eleven (84%) were HIV-positive. One patient was confirmed as HIV-negative, and the other man refused an HIV test.

Infection with other sexually transmitted infections was widespread. Four men (30%) had rectal gonorrhoea, two men (15%) were infected with anogenital herpes, one man had syphilis, a single patient had chronic hepatitis B infection, and a man had been recently infected with hepatitis C virus.

High-risk sexual activity widespread

All the men in the cluster were white, Dutch, and had a median age of 39 years. None had travelled to areas where LGV is present in the six months before the outbreak, but two men reported anonymous sexual encounters with men from Africa and Latin America. The men were highly sexually active, with almost two thirds reporting over ten sexual partners in the previous three months. Both receptive and insertive anal sex was reported by all thirteen men, and over three quarters reported “fisting.”

Condom use was limited, with six men (46%) saying they never used condoms, the other men reporting that they only used them sometimes.

The men in the network met several times a year for sex parties in the Netherlands, Belgium and Germany and reported sexual contacts with men from the Netherlands, Belgium, Germany, France and the United Kingdom.

Symptoms and diagnosis

Twelve of the men had intestinal symptoms of LGV, with the median duration of these symptoms being three months. The most widely reported symptoms included mucous discharge from the rectum, constipation, and bleeding. No cases of enlarged lymph nodes in the groin or urogential deformities were reported.

A proctoscopy was performed on twelve men. In total nine men were found to have a mucous discharge, three had ulcers, and one had a tumorous mass which was biopsied. This revealed ulcerative granulation and severe inflammation and confirmed the presence of Chlamydia.

Commenting on their findings, the investigators emphasise that LGV is very rarely seen in Europe and America and that the symptoms can resemble Crohn's disease. Indeed, data from their patients showed that LGV remained unrecognised in some patients in several medical consultations with Crohn's disease, syphilis, and herpes all considered as possible diagnoses.

“This underscores the unfamiliarity with LGV by Western health care professionals, emphasizing the need for adequate reporting and education”, write the investigators.

The investigators note that all the men had rectal infections with LGV yet none had urethral infections, despite the fact that the men reported both insertive and receptive anal sex without condoms. They speculate that “fisting” may have a role to play in the transmission of LGM, noting that this was a widespread sexual activity in this role.

Treatment for LGM is 100mg doxycycline for 21 days.

“This…outbreak of LGV among men who have sex with men in The Netherlands…[has] implications for other countries in western Europe,” conclude the investigators. They add, “because of high-risk sexual behaviours in the homosexual scene and the ulcerous character of rectal LGV, both the acquisition and transmission of HIV and other STDs are facilitated. Even the sexual transmission of blood-borne disease may be favoured in these patients. Health care professionals who treat patients with acute proctitis should consider LGV."


Nieuwenhuis RF et al. Resurgence of Lymphogranuloma venereum in western Europe: an outbreak of Chlamydia trachomatis serovar L2 proctitis in the Netherlands among men who have sex with men. Clin Infect Dis 39: 996-1003, 2004.