Penile Ulcer - Acute LGV

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HISTORY

  • 41 year old HIV positive MSM
  • Presented with painful penile ulcer
  • Denied any sexual contacts during preceding 3 months
  • He thought that this lesion was traumatic in origin. He may have cut the area while shaving, and had been using a penile enlargement pump

EXAMINATION

Shallow tender ulcer, surrounded by induration, and associated with right imguinal lymphadenitis

 

INITIAL INVESTIGATION:

  • Dark ground microscopy: No spirochaetes detected
  • Gram stain: mixed bacteria; +1 polymorphs

 

INITIAL DIAGNOSIS:

  • Uncertain – possible HSV with secondarily infected traumatic lesion
  • Other STI unlikely in view of lack of sexual contacts

 

PROGRESS:

Another attempt was made at clarifying his sexual history, and he then admitted to having had 2 sexual partners within the preceding month

Declined treatment with benzathine penicillin, but accepted oral treatment with famvir and amoxicillin/clavulanate

 

RESULTS:

  • Syphilis serology negative
  • Multiplex PCR negative for HSV and VZV DNA
  • Treponema pallidum PCR negative
  • Chlamydia trachomatis DNA detected by SDA
  • Lymphogranuloma venereum (LGV) genotype confirmed positive
  • Chlamydia trachomatis serology: IgG 4.29

 

FINAL DIAGNOSIS

Penile acute LGV ulcer 

Clinical Course

He was reviewed one week after the initial consultation and given azithromycin 1 gram orally (genotyping was not available at this time).  He was seen again 2 weeks later (when the strain had been confirmed as an LGV genotype) at which time the ulcer had almost resolved.  He was given 3 weeks of doxycycline.  He has not attended for further follow-up.

The lesson:

Acute LGV ulceration is said to be classically fleeting and painless.  Symptomatic anorectal LGV infection in MSM has been reported in increasing rates internationally and in Australia over the past few years but there have been few (if any) reports of acute ulcerative LGV.  By inference there must be penile LGV lesions which are being missed.

  • Think of the possibility of LGV in genital ulcers in MSM.
  • Swab for Chlamydia in genital ulcers in MSM
  • Remember that acute LGV ulcers can be painful

Dated June, 2008