Orolabial Lymphogranuloma Venereum, Michigan, USA

Sahrish Ilyas; Deborah Richmond; Gerald Burns; Katherine E. Bowden; Kimberly Workowski; Ellen N. Kersh; Pranatharthi H. Chandrasekar


Emerging Infectious Diseases. 2019;25(11):2112-2114. 

In This Article

The Study

In February 2019, a 25-year-old man with a history of having sex with men with advanced HIV infection sought care at the Wayne State University Physician Group Infectious Diseases Clinic in Detroit, Michigan, USA, for 2 large ulcers over his lower lip. He had noticed the ulcers 2 weeks earlier, associated with pain and purulent discharge, along with a rapidly enlarging, painful swelling over his upper left neck. He reported no history of fever or chills. He also reported having had unprotected insertive and receptive oral and anal sex with >30 male partners during the previous year. He reported that he found anonymous sexual contacts by using "sex apps" and did not trade sex for drugs or money. In 2007, the patient had received a diagnosis of HIV infection and was taking antiretroviral drugs intermittently. His medical history included syphilis, gonorrhea, and genital chlamydia infections.

Physical examination revealed that the patient was afebrile with stable vital signs. His lower lip was markedly swollen and tender, with 2 large, purulent ulcers: 1 deep ulcer on the central lower lip and 1 over the left side near the angle of his mouth. Also, left-sided submandibular adenopathy was present as a large (≈10 cm diameter), tender, nonfluctuant swelling, which was neither warm nor erythematous. His oropharynx, buccal mucosa, and tongue appeared normal. Results of the rest of the examination, including the external genitalia, groin, and perianal region, were unremarkable.

Diagnostic testing of the lip ulcer included nucleic acid amplification testing (NAAT) for herpes simplex viruses (HSVs) 1 and 2 and Chlamydia (Roche LightCycler real-time PCR for HSVs 1 and 2, https://diagnostics.roche.com; BD Viper XTR technology for GC/CT NAAT, https://www.bd.com). We performed NAAT on pharyngeal samples to test for C. trachomatis and Neisseria gonorrhoeae. Additional diagnostics included rapid plasma reagin testing, serologic testing for treponema, HIV viral load measurement, and CD4+ lymphocyte count. Valacyclovir was empirically prescribed; however, the patient did not fill this prescription.

C. trachomatis was identified in samples from the lip and throat; NAAT results for HSVs and N. gonorrheae were negative. The patient's HIV load was 300,000 copies/mL, and CD4+ lymphocyte count was 73/μL. Oral doxycycline (100 mg 2×/d for 3 weeks) was prescribed, and the lip ulcers and cervical adenopathy resolved over the next month. Concomitantly, appropriate antiretroviral therapy was initiated.

Swab samples of the lip ulcers were submitted to the San Francisco Public Health Department, where diagnosis of LGV was confirmed by use of a laboratory-developed, Clinical Laboratory Improvement Amendments–approved test.[1] The lip ulcer samples then underwent LGV genotyping by sequencing the entire ompA gene at the Centers for Disease Control and Prevention (CDC). LGV genotyping confirmed C. trachomatis serovar L2b on the basis of sequence variations compared with serovar L2.[2] Furthermore, the ompA gene, which encodes the chlamydial major outer membrane protein (MOMP), contained a 5' deletion of 1–82 nt in constant domain (CD) 1 and a 3' deletion of 904–1,185 nt, spanning CD4, variable domain (VD) 4, and CD5.