MORPHOLOGYLGVmaypresentasnonspecificurethritisorpapularorulcerativelesionsinvolvingthelowergenitalia.Subsequently,tenderenlargedmattedinguinaland/orfemorallymphadenopathyensuesthattypicallyisunilateralandisoftenassociatedwithfistuloustracts.Proctocolitisalsocanbeseen.Thelesionscontainamixed granulomatous and neutrophilic inflammatory response. Variablenumbersofchlamydialinclusionsmaybeseeninthecytoplasmofepithelialcellsorinflammatorycellswithspecialstainingmethods.Regionallymphadenopathyiscommon,usuallyappearingwithin30daysofthetimeofinfection.Lymphnodeinvolvementischaracterizedbyagranulomatousinflammatoryreactionassociatedwithirregularlyshapedfociofnecrosisandneutrophilicinfiltration(stellate abscesses). Withtime,theinflammatoryreactiongivesrisetoextensivefibrosisthatcancauselocallymphaticobstructionandstrictures,producinglymphedema.
Within 1 to 2 weeks of exposure, primary infection appears at the site of inoculation in the form of a genital ulcer or a mucosal inflammatory reaction. These primary lesions heal spontaneously, but the organisms at these sites seed draining lymph nodes, triggering a necrotizing lymphadenitis 2 to 6 weeks after the initial exposure. The lymphadenitis is usually unilateral and painful, and may lead to abscess formation. Abscesses sometimes rupture, spreading the inflammatory process into surrounding soft tissues. Rectal infections may progress to proctocolitis, associated with pain, constipation, fever, and bleeding, features that mimic inflammatory bowel disease. If untreated, rectal fissures and strictures may develop secondary to inflammation and fibrosis.
The diagnosis of LGV is difficult because laboratory tests are not standardized and serologic tests have low specificity. As with other chlamydial infections, nucleic acid amplification tests have the highest sensitivity and specific and are becoming more widely available. Culture and serologic tests are less sensitive but are still used, particularly in areas where nucleic acid amplification tests are not available.
Chancroid, sometimes called the “third” venereal disease (after syphilis and gonorrhea), is an acute, ulcerative infection caused by Haemophilus ducreyi, a small, gram-negative coccobacillus. The disease is most common in tropical and subtropical areas and is more prevalent in lower socioeconomic groups, particularly among men who have regular contact with prostitutes. Chancroid is one of the most common causes of genital ulcers in Africa and Southeast Asia, where it serves as an important cofactor in the transmission of HIV infection. Chancroid probably is underdiagnosed in the United States because most STD clinics do not have facilities for isolating H. ducreyi, and PCR-based tests are not widely available.
MORPHOLOGYTheprimarylesionofchanchroidappearsfirstasapapulethatrapidlybreaksdowntoproduceaulcer.Onmicroscopicexamination,theulcerofchancroidcontainsasuperficialzoneofneutrophilicdebrisandfibrin,withanunderlyingzoneofgranulationtissuecontainingareasofnecrosisandthrombosedvessels.Adense,lymphoplasmacyticinflammatoryinfiltrateispresentbeneaththelayerofgranulationtissue.Secondarilyinvolveddraininglymphnodesalsoexhibitnecrotizinginflammationthatfrequentlyprogressestoabscessformation.