Fine Needle Aspiration Cytology as an Aid to Diagnose Lymphogranuloma Venereum in a Resource-Poor Setting – A Case Report

Sir, Lymphogranuloma venereum (LGV) is a sexually transmitted disease caused by L1, L2, and L3 serovars of Chlamydia trachomatis.[1] The diagnosis of LGV is difficult to establish on clinical grounds alone and needs various diagnostic choices. A 25-year-old sexually active married female presented with 2 months duration of mild painful right inguinal ulcerated swelling along with watery discharge per vagina for 1 month. There was no history of genital ulceration, dysuria, urethral discharge, proctitis, rectal discharge, fever, chills, night sweats, weight loss, and chronic diarrhoea. Family history was unremarkable except for history of pulmonary tuberculosis in a family member. On examination, there was a swelling at the right inguinal area of size 5 × 6 cm with ulceration at the centre of size 2 × 3 cm with minimal purulent deposit and perilesional erythema [Figure 1]. On palpation, mild, tender, matted lymph nodes were palpated below the swelling. Gynaecological examination revealed an ulcer of size 0.5 × 0.5 cm ulcer in the cervix.Figure 1: Ulcerated inguinal bubo over the right inguinal areaBased on history of high-risk sexual behaviour of the husband, who is a truck driver by profession, family history of pulmonary tuberculosis, painful inguinal lymphadenopathy, and ulcer on the cervix with vaginal discharge, differential diagnosis of LGV and scrofuloderma were considered. Mantoux test, Ziehl–Nielsen stain, cartridge-based nucleic acid amplification test, and culture for tuberculosis from the pus sample were negative. Gram’s and Giemsa staining showed plenty of polymorphonuclear cells without any organisms. FNAC of the right inguinal lymph node revealed plenty of histiocytes with coarse eosinophilic granules and a few giant cells [Figure 2]. Chlamydial culture, serology, and NAAT could not be done due to non-availability of resources. Viral markers and Venereal Disease Research Laboratory test and routine investigations were normal. Based on clinical and FNAC findings, the patient was suspected to be having LGV with chlamydial cervicitis and was treated with a grey kit containing a single dose of azithromycin 1 g and cefixime 400 mg, along with oral doxycycline 100 mg twice a day for 21 days. There was complete healing of the inguinal bubo and ulcer with a linear scar after 2 weeks of starting of treatment [Figure 3]. Partner treatment could not be done due to poor compliance of the husband.Figure 2: Histiocytes with coarse eosinophilic granules (black arrow) and a few giant cells (H and E, X100)Figure 3: Healing of the inguinal bubo and ulcer with a linear scarThe diagnosis of LGV is difficult to establish on clinical grounds alone and is frequently relied upon serology, culture, or, more recently, nucleic acid amplification testing (NAAT). Isolation of Chlamydia trachomatis in cell culture (highly specific with a detection rate of 60–80%), NAAT (gold standard), and chlamydial serology tests are available only in research laboratories.[2] Histopathology of lymph node is non-specific (necrotic foci infiltrated by neutrophil, epithelioid cells, Langhan’s giant cells).[3] Therefore, laboratory confirmation of LGV in developing countries remains a challenge. Laboratory diagnosis of LGV can be carried out by cytology with Giemsa (sensitivity 45% and specificity 95%) or Papanicolaou (sensitivity 62%, specificity 96%) staining with observation of inclusion bodies.[4] Inclusion bodies in LGV are elementary, intra-cytoplasmic microcolonies of Chlamydia trachomatis, known as Miyagawa bodies/corpuscles.[5] In our case, haematoxylin and eosin-stained FNAC aspirate from inguinal bubo revealed multiple giant cells and histiocytes containing intra-cytoplasmic, eosinophilic, coarse granules that correspond to microcolonies of Chlamydia trachomatis (inclusion bodies). Hence, we report FNAC of the lymph node as a simple, accessible, and easy alternative aid for early diagnosis of LGV presenting as inguinal bubo which can prevent LGV complications like ulceration of lymph nodes, anogenital fibrosis, and fistulae. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.