CDC sounds doctor alert about rare STD

Loren Crown, MD, remembers the 33-year-old woman who appeared in his office in Covington, Tenn., complaining of a painful lump on her groin. But it was not a hernia, as first suspected. Instead, it turned out to be a rare case of infection with lymphogranuloma venereum, one of the more vicious members of the Chlamydia trachomatis family.

"There's no quick test, so it's difficult to diagnose," said Dr. Crown, a family physician and clinical professor of medicine at the University of Tennessee Health Science Center College of Medicine. He published a report on this case in the July 1997 issue of Tennessee Medicine. "But I'd be happy to see another case, because it's easy to treat."

He could get the opportunity.

A series of outbreaks in Europe and a handful of confirmed cases in the United States has led Centers for Disease Control and Prevention officials to alert physicians to be on the lookout for this sexually transmitted disease, report patients suspected of being infected to local health departments and submit specimens to the CDC's Chlamydia laboratory.

"LGV is present in the United States, and it's extremely important for physicians to be aware of that, to watch for symptoms and make sure patients are getting treated," said Catherine McLean, MD, a medical epidemiologist with the CDC's Division of STD Prevention and the agency's point person on the bacteria.

In the past year, European public health officials have noted dozens of cases among gay and bisexual men. U.S. officials have been keeping a watchful eye. One case reported in Houston in October 2004 was linked to travel to Paris. The more recently discovered cases -- including at least two in New York, three in San Francisco and one in Atlanta -- had no association with European travel. Many U.S. experts now believe it has found footing here.

"This could reach epidemic proportions," said Tri Do, MD, MPH, president of the Gay and Lesbian Medical Assn. "And it's possible that it could become endemic."

AMA policy encourages physicians to participate in strategies for prevention and control of Chlamydia and urges doctors to familiarize themselves with STDs, but the CDC's request is a challenging one.

This disease might be easy to treat, but it's also easy to miss. The symptoms could be confused with other gastrointestinal ills, and there is no commercially available test to distinguish easily and quickly LGV from more common variants of Chlamydia. This could have significant implications for treatment that could lead to further spread. LGV requires three weeks of antibiotics, while its milder cousins require only one week or less.

"This is not the standard Chlamydia," said James Allen, MD, MPH, president of the American Social Health Assn.

It is also low on many physicians' radar screens. The bacteria is common in lesser-developed countries but has been so rare in this one that it has not been nationally reportable since 1994. Just over 200 cases were reported during that year -- a far cry from its high of nearly 3,000 cases in 1944. In the past 10 years, it has appeared in scientific literature only in the occasional case study, such as Dr. Crown's.

"[Doctors] don't recognize the symptoms, and a lot of labs don't do this testing," said Kenneth Haller, MD, a St. Louis pediatrician and immediate past president of the Gay and Lesbian Medical Assn. "But until now, it hasn't been needed much."

There are also more questions about these outbreaks than answers. Many of those diagnosed with LGV are also infected with HIV, and it's unclear whether the new spread of this disease is a result of unsafe behavior or a compromised immune system. Many experts also are concerned that it could have an asymptomatic latency period that might make for easier spread.

"There are a lot of questions that we are investigating along with our colleagues in state and local health departments," Dr. McLean said.

The true size of this outbreak is also unclear, although most experts believe that these six patients confirmed at press time are the surface of a long, simmering epidemic.

"This is probably just the tip of the iceberg," said Jeffrey Klausner, MD, MPH, deputy health officer and director of STD Prevention and Control Services at the San Francisco Dept. of Public Health. "But we have no idea what the true burden of cases is."