Chlamydia%20-%20uncomplicated%20anogenital%20infection Diagnosis
Diagnosis
- Clinical signs and symptoms as described above
- Bubo aspiration
- Milky fluid in aspirate
- May require sterile saline injection for aspiration
-
Direct detection by NAAT, culture, or direct immunofluorescence
- Genital lesion swab, rectal swab or bubo aspirate may be used
- Culture is the most specific test but may not be widely available
-
Serology
- High antibody titers are suggestive of LGV in a patient with symptoms consistent with LGV, but low titers do not rule out the diagnosis
- Complement fixation titer of ≥1:64 in the relevant clinical setting is consistent with LGV
- Exclusion of other causes of inguinal lymphadenopathy
- Non-sexually transmitted local and systemic infections (eg those of the lower limb or TB lymphadenopathy) can also cause inflammation of the inguinal lymph nodes
- Because definite diagnostic testing is lacking, patients with symptoms consistent with LGV (ie proctocolitis or genital ulcer with lymphadenopathy) should receive treatment for LGV
- Lymphogranuloma venereum (LGV) is a systemic disease caused by L1, L2, L3 serovars of C trachomatis
Clinical Manifestation of LGV
Primary LGV
- Incubation period of 3-30 days
- Painless papule (1-6 mm) at inoculation sites (eg vulva, vagina, penis, rectum, oral cavity, cervix)
- These papules may ulcerate but are self-limited
- Genital ulcer may occur at the site of inoculation but is usually healed by the time patients are seen in the clinic
Secondary LGV
- Occurs 2-6 weeks from appearance of primary lesion
- Accompanying symptoms may be present (eg fever, chills, malaise, myalgia, arthralgia, arthritis, pneumonitis or hepatitis)
- Cardiac symptoms, meningitis and ocular inflammation may also be present
- Abscesses and draining sinuses occur in <1/3 of patients
- Lymph node, anus and/or rectum may be involved
- Lymphadenopathy is characterized by a “groove sign” (ie swollen inguinal nodes above and femoral nodes below the level of the inguinal ligament)
- Anorectal involvement is characterized by acute hemorrhagic proctitis/proctocolitis
Tertiary/Chronic LGV
- More common in females
- Lymphatic obstruction may cause genital elephantiasis
- Genital and rectal strictures and fistula may occur at this stage
- Clinical signs and symptoms as described above
- Bubo aspiration
- Milky fluid in aspirate
- May require sterile saline injection for aspiration
- Direct detection by NAAT, culture, or direct immunofluorescence
- Genital lesion swab, rectal swab or bubo aspirate may be used
- Culture is the most specific test but may not be widely available
- Serology
- High antibody titers are suggestive of LGV in a patient with symptoms consistent with LGV, but low titers do not rule out the diagnosis
- Complement fixation titer of ≥1:64 in the relevant clinical setting is consistent with LGV
- Exclusion of other causes of inguinal lymphadenopathy
- Non-sexually transmitted local and systemic infections (eg those of the lower limb or TB lymphadenopathy) can also cause inflammation of the inguinal lymph nodes
- Because definite diagnostic testing is lacking, patients with symptoms consistent with LGV (ie proctocolitis or genital ulcer with lymphadenopathy) should receive treatment for LGV
Physical Examination
- Perform general assessment and look for signs of sexually transmitted infection (STI)
- Examine mucocutaneous regions including the pharynx
- External genitalia should be inspected for anatomical irregularities, cutaneous lesions, inflammation, and urethral discharge
- Perianal inspection
- Digital rectal exam and anoscopy should be considered if patient has practiced receptive anal intercourse or has rectal symptoms
- Inguinal lymph nodes should be palpated
Illuminated Speculum Exam
- Visualize cervix and vaginal walls
- Evaluate vaginal and endocervical discharges
- Observe for cervical mucopus, ectropion, friability
- If resources are available, obtain specimens
- Cervical swab may be sent for Chlamydia test, gonorrhea culture
- Vaginal swab may be sent for Chlamydia test, for Gram stain and Trichomonas slide
Bimanual Pelvic Exam
- Detect uterine or adnexal masses, tenderness or cervical motion tenderness
Assessment
Risk Assessment
- In some settings, certain demographic and behavioral risk factors have been frequently associated with cervical infection (the following should be adjusted for local, social, behavioral and epidemiological situations)
- Women at risk for cervicitis have a higher likelihood of cervical infection than those who are risk-negative
- Women with vaginal discharge and positive risk assessment should, therefore, be offered treatment for gonococcal and chlamydial cervicitis
- Annual screening of Chlamydia infection is advised for all sexually active nonpregnant women ages ≤24 years and older nonpregnant women with risk factors
- Pregnant women at risk should be screened at 1st prenatal visit and at 3rd trimester if she continues to be at high risk
Women at Higher Risk for Infection
- Age ≤24 years (>5x higher risk than age 30 years)
- Sexual contact with known case of STI
- IV drug users
- Street involvement (youth on the streets, sex workers)
- New or ≥2 sex partners in the past year
- Previous STI
- Lack of barrier contraception
Evaluation
- Finding of lower abdominal tenderness or cervical motion tenderness should prompt the attending physician to evaluate the patient for salpingitis and/or endometritis which are part of PID
- Treat patient accordingly (See Pelvic Inflammatory Disease Management Chart for details)
- Differential diagnoses may also include other surgical or gynecological conditions
Laboratory Tests
- If resources permit, lab tests to screen women with vaginal discharge should be considered
- In patients who undergo a speculum exam, endocervical or vaginal swabs may be sent for testing
- If a speculum exam is not done, consider sending self-obtained low vaginal swab or 1st-void urine for testing
- Urine or rectal swab specimen may also be used, if appropriate
- Test utilized will depend on available resources
- Diagnosis is confirmed if C trachomatis is isolated by culture or demonstrated in a specimen through antigen or nucleic acid detection
Lab Exams for C trachomatis
- Nucleic acid amplification tests (NAAT)
- Recommended test for detection of chlamydial infection of genital tract
- Most sensitive (90-95%) and specific
- Test of choice for cervical, urethral, 1st-void urine specimens
- Recommended specimen from women is a self- or physician-obtained vaginal swab
- Cell culture
- Recommended for throat and rectal specimens
- May be used when blood and mucus interfere with NAAT result
- Though highly specific, high cost and low sensitivity (60-80%) preclude routine use
- Routine use of the following lab tests is not recommended:
- Direct fluorescent antibody test: Not to be used for routine testing of specimen from the genital tract
- Nucleic acid hybridization or probe test: Assays are not widely available
- Enzyme immunoassays: False-positive results may occur due to cross-reactivity among chlamydial species
- Serological test: Not to be used for screening since prior chlamydial infection may or may not generate a systemic antibody response