Sixty-seven confirmed cases of the previously rare sexually transmitted infection, LGV (lymphogranuloma venereum), have now been confirmed in gay men in the UK, the vast majority of whom are chronically infected with HIV, according to the Health Protection Agency. HPA presented details of its enhanced surveilliance programme at the Eleventh Annual Conference of the British HIV Association with the British Association for Sexual Health and HIV in Dublin last month.
Professor Catherine Ison presented geographic distribution data for 65 of the confirmed cases so far. Although the majority (47, or 75%) were diagnosed in London, and six were in Brighton, one or two confirmed cases of LGV have now been in diagnosed in Birmingham, Chichester, Edinburgh, Glasgow, Gloucester, Liverpool, Manchester, Norwich and Oxford.
A personal communication to aidsmap from Neil MacDonald, an epidemiologist at the HPA’s Communicable Disease Surveillance Centre (CDSC), updated the confirmed number of cases to 67, and provided enhanced surveillance reports for 45 of these. However, eight of these were retrospective, and did not include details of symptoms.
Of the remaining 37, all but one had anorectal symptoms, with rectal discharge, rectal pain and bloody stools reported as the most common symptoms. Of these 37, seven also experienced painful or swollen lymph nodes. One individual had pain when urinating and another had penile discharge. The most common systematic symptoms were general malaise, fever and muscular pain.
Thirty of 37 (79%) were also HIV-positive, of whom two were diagnosed whilst symptomatic for LGV. Seven were HCV-positive, although no details were provided regarding HIV/HCV co-infection, or whether the hepatitis C was newly-diagnosed or a chronic infection.
“The behavioural data is on the whole poorly reported (and probably beyond the remit of enhanced surveillance) but where it is known, it does implicate risky sex and risky networks,” Mr MacDonald tells aidsmap. In a previous report, the HPA wrote that the most common sex practices associated with acquiring LGV include “unprotected anal intercourse, oral contact, fisting, use of sex toys and ‘heavy’ sex (use of urine or faeces).”
In a second presentation in Dublin, Matthew Hamill from the Mortimer Market Centre characterised the spread of LGV as “a real and current problem that we’re facing.”
Of the 21 cases confirmed at this central London HIV/GUM centre, all were in gay men with an average age of 35 (range 27-50). Twenty of the men were also HIV-positive, and four were infected with hepatitis C. The most common reported sex practices included unprotected anal intercourse, fisting, and the use of sex toys.
Dr Hamill highlighted two unusual case reports. One patient developed LGV symptoms twelve months after his last reported (high risk) sexual intercourse, which suggests either that LGV transmission occurred more recently through other means (e.g. oral sex or fingering), or that in some individuals symptoms can take several months to appear.
A second case was reported by a 37 year-old gay man who suffered for six weeks with weight loss, fever and diarrhoea. He was first diagnosed with ulcerative proctitis, but after testing positive for both HIV and hepatitis C, was then found to have LGV.
The third case, a poster presentation from the Chelsea and Westminster Hospital in London, describes seven chronically-infected HIV-positive men presenting to their clinics between October 2004 and March 2005. The average age was 39 (range 35-42) and two were also hepatitis C co-infected. On average the men had been diagnosed HIV-positive for ten years (range 3-15). Four were antiretroviral-naive, and three were on HAART with ‘undetectable’ viral loads. The mean CD4 count was 584 cells/mm3.
Six cases were successfully treated with doxycycline, and one with azithromycin. Three cases had concurrent rectal gonorrhoea and were treated with ceftriaxone. Six men reported unprotected anal intercourse, but only one reported fisting and the use of sex toys. Four of the men were thought to have acquired their LGV infection outside of the UK, in Italy, Germany, Madeira and Gran Canaria.
Ison CA et al. Enhanced surveillance for lymphogranuloma venereum (LGV) in England. Eleventh Annual Conference of the British HIV Association with the British Association for Sexual Health and HIV, Dublin, abstract O37, 2005.
Hamill M et al. An outbreak of lymphogranuloma venereum in London in 2004. Eleventh Annual Conference of the British HIV Association with the British Association for Sexual Health and HIV, Dublin, abstract O38, 2005.
Annan NT et al. Lymphogranuloma venereum in HIV-positive homosexual men: is an outbreak emerging in London? Eleventh Annual Conference of the British HIV Association with the British Association for Sexual Health and HIV, Dublin, abstract P85, 2005.