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CASE REPORT Unusual transmission route of Lymphogranuloma venereum; following sexual contact with a female donkey Farzin Khorvash MD*, Ammar H Keshteli Servaas A Morre´ PhD§**†† MD†, Hassan Salehi MD*, Levente Szeredi DVM PhD‡ and *Department of Infectious and Tropical Diseases, School of Medicine; †Medical Students’ Research Center, Isfahan University of Medical Sciences, Isfahan, Iran; ‡Central Agricultural Office, Veterinary Diagnostic Directorate, Budapest, Hungary; §Department of Pa
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  CASE REPORT Unusual transmission route of Lymphogranuloma venereum; following sexual contact with a female donkey  Farzin Khorvash  MD * , Ammar H Keshteli  MD † , Hassan Salehi  MD * , Levente Szeredi  DVM PhD ‡ andServaas A Morre´   PhD § ** †† *Department of Infectious and Tropical Diseases, School of Medicine;  † Medical Students’ Research Center, Isfahan University of MedicalSciences, Isfahan, Iran;  ‡ Central Agricultural Office, Veterinary Diagnostic Directorate, Budapest, Hungary;  § Department of Pathology, Laboratoryof Immunogenetics; **Department of Internal Medicine, Section Infectious Diseases, VU University Medical Center, Amsterdam;  †† Department of Medical Microbiology, University Hospital Maasricht, Maastricht, The Netherlands Summary:  Here, we present a 20-year-old man who presented with painful inguinal and femoral masses. He gave a historyof sexual contact with a mare 14 days before his recent illness. He was diagnosed with lymphogranuloma venereum based on thehistopathological findings and a high titre of IgG (1:1400). Keywords:  lymphogranuloma venereum,  Chlamydia trachomatis , transmission route INTRODUCTION Lymphogranuloma venereum (LGV) is a sexually transmitteddisease (STD) caused by  Chlamydia trachomatis  serotypes L1,L2, and L3. 1 LGV is a rare disease in industrialized countries,but it is endemic in parts of Africa, Asia, South America andCaribbean. 2 Recently, LGV infections have been encounteredfrequently in industrialized countries among men having sexwith men. Here, we report another unusual LGV case in an industrialized country. CASE REPORT  A 20-year-old man, working as a shepherd, referred to ourcentre because of painful inguinal and femoral masses. Hewas not suffering from fever, malaise, weakness, rectal pain,tenesmus, urethral discharge but gave a history of smallpapules on his penis 10 days before admission. He was notmarried, and did deny having any sexual contact with anyone but had unprotected vaginal sexual contact with amare 14 days prior to his present illness. At the time of admis-sion, his temperature was 37 8 C and pulse rate was 90 / min.Respiratory rate was 20 / min and blood pressure was 105 / 80 mmHg. Two non-ulcerated, tender, firm, fluctuating andmobile masses were palpated in his right inguinal andfemoral regions. Their sizes were 5  1 and 1  1 cm, respect-ively that caused the characteristic ‘groove sign’. The laboratorytest results were as follows: leukocyte count 11.1  10 9 / L (neu-trophils 67%), platelet count 427  10 9 / L, erythrocyte sedimen-tation rate 35 mm / h. In smear examination from samplesobtained from the swollen area, no intra- or extracellular bac-teria was seen, but there were many polymorphonuclear cells.In the culture of the drained fluid from the lesion, no bacteriagrew after four days. Immunoflourescence testing for C. trachomatis  was positive (IgG [1:1280] and IgA [1:160]). In addition, the patient’s serum was also reactive (IgGBiomerieux MIF, The Netherlands) for the LGV serotype of  C. trachomatis  (1:1400). Histopathological study of the tissueobtained by biopsy was consistent with the diagnosis of LGV(Figure 1). A tissue sample was examined for the presence of  Chlamydiaceae -specific LPS 3 and the result was negative.Realtime polymerase chain reaction (PCR) (TaqMan) wasused to assess the  C. trachomatis  DNA and LGV DNA 4 in theparaffin coupes of the tissue obtained by biopsy. No C. trachomatis  or LGV DNA was detected. With these overallfindings, the patient was diagnosed as having LGV.Doxycycline (2  100 mg / day p.o.) was started. The patientreceived this treatment for 10 days and then he wasdischarged from our centre. He was prescribed the remainingmedication (doxycycline 2  100 mg / day p.o. for 11 days). Atthe time of discharge, patient was not suffering from anypain in the region and the swollen part had decreased in sizesignificantly. DISCUSSION Here, we presented a young man who developed LGV afterreported sexual contact with a mare (a female donkey). Thechlamydial IgG serology was very high (1:1200), a value notfound in normal STD patients with non-LGV  C. trachomatis  ser-ovars (D–K). This has also been described previously in a studyin Amsterdam, emphasizing a very high positive predictivevalue of IgG serology titres for LGV infection. 5 The fact thatneither chlamydial membrane parts could be detected byimmunohistochemistry nor chlamydial DNA could be shown  Correspondence to:  Dr Farzin Khorvash, Infectious andTropical Diseases Research Centre, Seddigheh TaherehResearch Complex, Khorram Street, Isfahan, IranEmail: khorvash@med.mui.ac.ir  DOI: 10.1258 / ijsa.2008.008073.  International Journal of STD & AIDS  2008;  19 : 563–564  by realtime PCR in this case, could be explained by the factthat the initial infectious origin was cleared at the stageof necrotizing granulomatous lymphadenitis. In TheNetherlands in comparable cases among men who had sexwith men also no LGV DNAwas present in the biopsies or aspi-rates of the lymph nodes (personal communication S.A. Morre´).Although there are several studies on the occurrence of  C. psittaci  and  C. pneumoniae  in horses, 6–9 C. trachomatis  hasnot been found in female horses. 6 The situation in donkeyshas not been studied yet, but it might be similar to horses. AsLGV is not a natural pathogen in mares, either LGV has been transmitted through another man to the mare or the reportedacquired route of transmission was reported to hide trans-mission with (homo) sexual contact. However, our patientdenied having sex with a male or female person, and basedon the social and economical status, and sexual and behaviouralvariables in his country, it is highly unlikely that the patient hadacquired this LGV infection through sexual contact with ahuman person, but we cannot exclude this. Unfortunately, itwas impossible to identify the mare and obtain material tofurther substantiate the alleged transmission route.Until now, reports of LGV include patients who had sexualcontact with a human partner, 1 but unlikely and unusual trans-mission of STDs has been described before, for instance thetransmission of   Neisseria gonorrhoeae  through an inflatable doll. 10 We suggest taking a careful history of having sexual relation with animals in LGV patients who deny having sexual contactwith a man or woman in those cultures where having sex with partners while being unmarried is unlikely and / or in cultureswhere zoosexual activities are known to take place.  ACKNOWLEDGEMENT We would like to thank Drs D Taheri and M Mahzad who pro-vided histopathological document. The patient gave informedconsent. REFERENCES 1 Kropp RY, Wong T; Canadian LGV Working Group. Emergence of lymphogranuloma venereum in Canada.  Can Med Assoc J   2005; 172 :1674–62 Mabey D, Peeling RW. Lymphogranuloma venereum.  Sex Transm Infect  2002; 78 :90–23 Szeredi L, Bacsadi A. Detection of   Chlamydophila  ( Chlamydia )  abortus  and Toxoplasma gondii  in smears from cases of ovine and caprine abortion by thestreptavidin-biotin method.  J Comp Pathol  2002; 127  :257–634 Morre SA, Spaargaren J, Fennema JS,  et al.  Realtime polymerase chain reaction to diagnose lymphogranuloma venereum.  Emerg Infect Dis  2005; 11 :1311–25 Spaargaren J, Fennema HS, Morre SA, de Vries HJ, Coutinho RA. Newlymphogranuloma venereum  Chlamydia trachomatis  variant, Amsterdam. Emerg Infect Dis  2005; 11 :1090–26 Szeredi L, Hotzel H, Sachse K. High prevalence of chlamydial(Chlamydophila psittaci) infection in fetal membranes of aborted equinefetuses.  Vet Res Commun.  2005; 29 :37–497 Mair TS, Wills JM.  Chlamydia psittaci  infection in horses: results of a prevalencesurvey and experimental challenge.  Vet Rec  1992; 130 :417–98 Wills JM, Watson G, Lusher M,  et al.  Characterization of   Chlamydia psittaci isolated from a horse.  Vet Microbiol  1990; 24 :11–99 Storey C, Lusher M, Yates P,  et al.  Evidence for  Chlamydia pneumoniae  of non-human srcin.  J Gen Microbiol  1993; 139 :2621–610 Kleist E, Moi H. Transmission of gonorrhoea through an inflatable doll. Genitourin Med  1993; 69 :322 (Accepted 20 February 2008) Figure1  Histopathologyofthelymphnode:central,stellatenecro-siswithneutrophils,surroundedbyapalisadingofhistocytes(stel-late abscess) (Haematoxylin and eosin stain   40) ................................................................................................................................................ 564  International Journal of STDs & AIDS Volume 19 August 2008 
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