Chlamydia%20-%20uncomplicated%20anogenital%20infection 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

• 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

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

• 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

• 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