Chlamydia trachomatis types 1, 2 and 3 is responsible for this sexually transmitted infection. It is endemic in the tropics, with the highest incidences in Africa, India and South East Asia.
The primary lesion is a painless ulcerating papule on the genitalia and only occurs in one-quarter of the patients. A few days after this heals, regional lymphadenopathy develops. The lymph nodes are painful and fixed and the overlying skin develops a dusky erythematous appearance. Finally, nodes may become fluctuant (buboes) and may rupture. Acute LGV may present as proctitis with perirectal abscesses, the appearances sometimes resembling anorectal Crohn’s disease.
The diagnosis is made on the basis of:
• The characteristic clinical picture
• Isolation of an LGV strain of C. trachomatis (only possible in specialized laboratories)
• Immunofluorescence using specific monoclonal antibodies for identifying organisms in pus from a bubo
• A rising titre in a complement-fixation test
The intradermal Frei test is non-specific and unreliable.
Great care must be taken to exclude syphilis and genital herpes.
Early treatment with oxytetracycline 500 mg four times daily for at least 2 weeks is generally necessary. Chronic infection may result in extensive scarring and abscess and sinus formation. Surgical drainage may be required. Sexual partners should also be treated.
Granuloma inguinale is the least common of all STDs in North America and Europe, but is endemic in the tropics and subtropics, particularly the Caribbean, South-East Asia and South India. Infection is caused by Calymmatobacterium granulomatis, a short, encapsulated Gramnegative bacillus. The infection was also known as Donovanosis, the organism originally being known as Donovan’s body. Although sexual contact appears to be the most important mode of transmission, the infection rates are low, even between sexual partners of many years’ standing.
In the vast majority of patients, the characteristic, heapedup ulcerating lesion with prolific red granulation tissue appears on the external genitalia, perianal skin or the inguinal region within 1-4 weeks of exposure. However, almost any cutaneous or mucous membrane site can be involved, including the mouth and anorectal regions. Extension of the primary infection from the external genitalia to the inguinal regions produces the characteristic lesion, the ‘pseudo-bubo’.
The clinical appearance usually strongly suggests the diagnosis but C. granulomatis (Donovan bodies) may be identified intracellularly in scrapings or biopsies of an ulcer. Culture or serological methods of diagnosis are not available.
Antibiotic treatment should be given for at least 10-14 days. Tetracycline 500 mg four times daily, streptomycin 1 g twice daily i.m. or ampicillin 500 mg four times daily are the three most commonly used drugs. Alternatives include erythromycin and chloramphenicol.
Genital herpes is one of the commonest STDs worldwide – in 1990 in the UK 20 000 new cases were seen in GUM clinics. Transmission occurs during close contact with a person who is shedding virus. Genital contact with oral lesions caused by HSV-1 can produce genital infection. HSV can be divided into types 1 and 2. Both can cause genital infection although type 1 is typically associated with sores on the lips. Susceptible mucous membranes include the genital tract, rectum, mouth and oropharynx. The virus has the ability to establish latency in the dorsal root ganglia by ascending peripheral sensory nerves from the area of inoculation. It is this ability which allows for recurrent attacks.
Asymptomatic infection has been reported but is rare. Primary genital herpes is usually accompanied by systemic symptoms of varying severity including fever, myalgia and headache. Multiple painful shallow ulcers develop which may coalesce. Tender inguinal lymphadenopathy is usual. Over a period of 10-14 days the lesions develop crusts and dry. In women with vulval lesions the cervix is almost always involved. Rectal infection may lead to a florid proctitis. Neurological complications can include aseptic meningitis and/or involvement of the sacral autonomic plexus leading to retention of urine. Recurrent attacks may be expected in a significant proportion of people following the initial episode. Precipitating factors vary amongst individuals as does the frequency of recurrence. Recurrent attacks are usually less severe. A symptom prodrome may be present in some people prior to the appearance of lesions. Systemic symptoms are rare in recurrent attacks.
The clinical manifestations in immunosuppressed patients (including those with HIV) may be more severe and recurrences may occur with greater frequency. Systemic spread has been documented.
Although the history and examination may be highly suggestive of HSV infection a firm diagnosis can only be made on the basis of isolation of virus from lesions. Swabs should be taken and placed in viral transport medium. Virus is most easily isolated from new lesions.
Salt water bathing or sitting in a warm bath is soothing and may allow the patient to pass urine with some degree of comfort. Oral acyclovir (200 mg five times daily initially for 5 days) is useful if patients are seen whilst lesions are still moist. If lesions are already crusting acyclovir will do little to change the clinical course. Secondary bacterial infection may occasionally be present and should be treated. Rest, analgesia and antipyretics should be advised. In rare instances patients may need to be admitted to hospital and acyclovir given intravenously, particularly if HSV encephalitis is suspected.
Recurrent attacks tend to be much less severe and can be managed with simple measures such as salt water bathing. Psychological morbidity may be associated with recurrent genital herpes and frequent recurrences impose strains on relationships; patients need considerable support. Longterm suppressive acyclovir therapy can be given in patients with frequent recurrences. An initial course of 200 mg three to four times daily for 6 months usually reduces the frequency of attacks although there may still be some breakthrough.
If HSV is acquired for the first time during pregnancy transplacental infection of the fetus may occur. For women with previous infection or primary infection at the time of labour concern focuses on the baby acquiring HSV from the birth canal. The risk is very low in recurrent attacks but rather greater in a primary episode.
Obstetric opinion is divided but if the woman has an attack around the time of labour Caesarian section may be performed. Acyclovir is not licensed for use in pregnancy but studies are being carried out to evaluate its use in the last few weeks of pregnancy in women with recurrent HSV.
PREVENTION AND CONTROL
Patients must be advised that they are infectious when lesions are present; sexual intercourse should be avoided during this time or during prodromal stages. Condoms may not be effective as lesions may occur outside the areas covered. Sexual partners should be examined and may need information on avoiding infection.