The Sexual History is Important, Very Important

Sometimes the ordinary is really the extraordinary

I had two very talented Michigan State University 4^th year medical students rounding with me last month. Each of them expressed an interest in learning more about the outpatient management of HIV. Their request was easy to satisfy, as I have two half-day outpatient clinics each week, with many of the patients having been with me for more than ten years. I sent one of the medical students to see one such patient, a mid-30s gay male, who was very adherent with his antiretroviral regimen. He also was on a stable dose of opioid pain medication to help treat his moderate-to-severe peripheral neuropathy. The medical student reported to me the following information that she had obtained after taking a history and performing a physical examination:

 â–º Complaints of constipation of several weeks’ duration, sometimes associated with bleeding onto the toilet paper and even, occasionally, into the toilet bowl.

 â–º No fever, dysuria, urethral discharge, nausea, vomiting, or abdominal pain.

 â–º A desire to be “checked” for STDs, due to “the condom breaking” 3 weeks earlier.

 â–º An unremarkable physical examination.

The student and I discussed the case. She was appropriately concerned about his complaints of hematochezia, and we discussed options for diagnosis, including colonoscopy. She attributed the recent onset of constipation to his chronic use of opioids, which also seemed reasonable. She could not tell me, however, whose condom it was that broke, nor during which particular sexual activity the incident occurred. I emphasize this latter point mainly because I have found, over many years, that students, interns, residents, and fellows often take an inadequate sexual history. In addition, I have written in this column previously about medical issues and approaches specific to caring for gay men, including the importance of taking a thorough sexual history.¹

The medical student accompanied me into the examination room, where I obtained the following additional information:

 â–º The constipation often was accompanied by perineal discomfort and, occasionally, tenesmus.

 â–º The specific sexual act that was associated with the broken condom was anal intercourse; the condom was worn by my patient’s partner.

 â–º The constipation began shortly after that sexual activity.

To the astonishment of both my patient and the student, I told them that I knew the diagnosis:  lymphogranuloma venereum proctocolitis.

Lymphogranuloma venereum (LGV) proctocolitis is caused by the L1, L2, or L3 serovars of Chlamydia trachomatis (CT).² According to the CDC, symptoms can include any combination of the following: “mucoid and/or hemorrhagic rectal discharge, anal pain, constipation, fever, and/or tenesmus.” If not diagnosed and treated early, LGV proctocolitis can lead to chronic colorectal fistulas and/or strictures. Diagnosis starts with taking a thorough history, followed by obtaining a rectal specimen for chlamydia testing by nucleic acid detection (although nucleic acid detection tests have not been FDA-approved for rectal specimens). Importantly, the testing laboratory must send the specimen, after confirming the presence of chlamydia, to the State Health Department, which will send the specimen to the CDC for confirmation of LGV (by PCR). In Michigan, as is true in most states, LGV (either confirmed or “probable”) is a reportable (to the State) condition, whereas infection with chlamydia is not. Treatment is with oral doxycycline, 100 mg given twice daily for 21 days.

Currently, there is an ongoing investigation of cases of LGV in gay men in southeast Michigan, including Detroit. My patient is the 11^th confirmed case; there have been 8 other “probable” cases (without confirmatory specimens). Many of the cases have presented as proctocolitis; there also have been a few urethral cases presenting with tender inguinal/femoral lymphadenopathy. A nurse practitioner colleague at Wayne State University with whom I used to work, reported the 10 other confirmed cases. She is working actively with the State of Michigan Health Department and the CDC, as well as with the Michigan ID Society, to increase awareness of this disease process.

It is not clear how widespread this “epidemic” is in the United States. In Europe, the UK has the largest reported outbreak of LGV among men who have sex with men (MSM), although that outbreak appears to have originated in the Netherlands in 2003. From 2003 through 2012 in the UK, the 1353 identified cases were categorized as occurring in one of four “phases”:  initial detection; endemic; growth; and hyperendemic.³ Ninety-eight percent of the cases presented with proctitis, and 82% were HIV-infected. Compared to other phases of the epidemic, cases in the growth phase were more likely to meet new contacts at sex parties and to be HIV-infected. A follow-up study in the second half of 2012, conducted at 12 clinics, looked at more than 10,000 Chlamydia trachomatis (CT) specimens. Of 713 men with positive tests for CT, LGV serovars were found in 66 (9%). Most surprisingly, 15 (27%) of the 55 for whom data were available were asymptomatic.

Those of us in primary care, especially those of us who see large numbers of MSM, need to be aware of the substantial likelihood that we will be seeing more cases of LGV proctitis in the near future, regardless of where we practice. It is not clear yet whether we should make CT screening part of routine clinical practice.

References:

• MacArthur RD. Caring for men who have sex with men in primary care. ConsultantLive 14 September 2015. Accessed online at: http://www.consultantlive.com/hiv-aids/caring-men-who-have-sex-men-primary-care
• Centers for Disease Control and Prevention. 2015 sexually transmitted diseases treatment guidelines. Accessed online at:  http://www.cdc.gov/std/tg2015/lgv.htm
• Hughes G, Alexander S, Simms I, et al. Lymphogranuloma venereum diagnoses among men who have sex with men in the U.K.: interpreting a cross-sectional study using an epidemic phase-specific framework. Sex Transm Infect. 2013;89:542-7. http://www.ncbi.nlm.nih.gov/pubmed/23851189
• Centers for Disease Control and Prevention. Emerging Infectious Diseases. January 2016. Accessed online at: http://wwwnc.cdc.gov/eid/article/22/1/14-1867_article