Ward, Michelle J., and Brunott, Nathan (2021) Lymphogranuloma venereum: an uncommon cause of anal ulceration and lymphadenopathy. ANZ Journal of Surgery, 91 (9). E619-E620.

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Abstract

[Extract] A 45-year-old male was referred from the sexual health clinic with 3 weeks of anal ulceration. His background was significant for human immunodeficiency virus with undetectable viral load and normal CD4 count on active antiretroviral therapy, previously treated syphilis, anal human papillomavirus with anal mapping 5 years prior showing hyperplasia without evidence of dysplasia and ischaemic heart disease. He reported some mild perianal discomfort, normal bowel motions and no history of weight loss. On examination, he was noted to have an ulcerated mass at the anal verge from 5 to 7 o'clock with an associated internal mass and blood on glove. He also had a palpable right inguinal lymph node measuring approximately 3 cm. His white cell count was 7.7 × 109/L, C-reactive protein was 10 mg/L and erythrocyte sedimentation rate was 71 mm/h. Punch biopsy was taken from the perianal lesion which showed reactive plasmacytosis without evidence of malignancy. Swabs for herpes simplex virus were negative. Computed tomography imaging showed nodular lesions in the rectum with increased vascularity, abnormal appearance of the mesorectum, periprostatic nodes and enlarged external iliac nodes. Subsequent magnetic resonance imaging revealed a near-circumferential mass of the left mid rectum with a base extending from 2 to 6 o'clock. It showed an ulcerated head with associated inflammation (Fig. 1). Two small abnormal mesorectal nodes were noted as well as bulky and asymmetric right external iliac nodes. The small right anal verge ulcerated mass was also noted. The overall clinical and radiological picture was concerning for a T2-3N1M0 rectal cancer with possible additional anal verge squamous cell carcinoma. The patient proceeded to colonoscopy which showed irregular ulceration throughout the rectum with contact bleeding (Fig. 2). No masses were noted and dry viral swabs were taken. These swabs resulted positive for Chlamydia lymphogranuloma venereum serovar. The patient was treated with 21 days of doxycycline and repeat flexible sigmoidoscopy showed complete resolution of disease (Fig. 3).

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