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Practice Lesson of the week

Ulcerative proctitis in men who have sex with men: an emerging outbreak

BMJ 2006; 332 doi: (Published 12 January 2006) Cite this as: BMJ 2006;332:99
  1. Deborah Williams, consultant physician1,
  2. Duncan Churchill, consultant physician (
  1. Department of Genitourinary Medicine, Royal Sussex County Hospital, Brighton BN2 5BE
  1. Correspondence to: D Churchill

    Lymphogranuloma venereum (LGV) is a sexually transmitted infection that is caused by Chlamydia trachomatis types L1, L2, and L3.1 Although endemic in some tropical countries, lymphogranuloma venereum is usually uncommon in the United Kingdom.1 The classical presentation of LGV is with genital ulceration (which may be asymptomatic or transient) and associated painful inguinal lymphadenopathy (or bubo), but it may also present with proctitis, extragenital lymphadenopathy, and systemic symptoms, including fever.1 Response to treatment of early infection is usually excellent. Untreated infection, however, can result in lymphatic obstruction and fibrosis, leading to genital elephantiasis, or, if involving the rectum, the formation of strictures and fistulas.

    In January 2004, genitourinary doctors in Europe were alerted to the existence of a cluster of cases of lymphogranuloma venereum presenting as a rectal syndrome in men who have sex with men with HIV infection.2 We describe three cases of LGV for which diagnosis was considerably delayed because the possibility of this infection was not considered.

    Case reports

    Case 1

    A 33 year old HIV positive man who has sex with men presented to his general practitioner in May 2003 with a short history of perianal pain accompanied by discomfort on sitting. His HIV disease was well controlled with antiretroviral therapy, and his CD4 lymphocyte count was 799 × 109/l. His symptoms persisted and he developed rectal bleeding accompanied by the passage of mucus, with alternating diarrhoea and …

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