Men's Health

SAN DIEGO – More than 16% of emergency department sepsis patients are not admitted to the hospital, preliminary results from a large retrospective cohort study found.

Doug Brunk/MDedge News

“Nothing is really known about this topic,” lead study author Ithan D. Peltan, MD, said in an interview at an international conference of the American Thoracic Society. “In previous research, we’ve been focused on patients with sepsis who are admitted to the hospital. We have never thoroughly recognized that a fair number of patients who meet clinical criteria for sepsis in the emergency department are actually triaged to outpatient management. We don’t really know anything about these patients. What are their clinical characteristics and what are their outcomes like? And what are the factors that are leading them to be discharged from the ED rather than be admitted to the hospital?”

To find out, he and his associates retrospectively reviewed the medical records of 12,002 adult ED patients who met criteria for sepsis at two tertiary hospitals and two community hospitals in Utah between July 2013 and December 2016. They excluded trauma patients, those who left the ED against medical advice, those who were discharged to hospice or who died in the ED, and eligible patients’ repeat ED encounters. Patients transferred to another acute care facility were considered admitted, while transfers to non-acute care such as skilled nursing or psychiatric facilities were classified as discharges. Next, Dr. Peltan and his associates employed inverse probability weights using a propensity score for ED discharge based on age, sex, Charlson score, ED acuity score, initial ED vital signs, white blood cell count, lactate, sequential organ failure assessment (SOFA)score, busyness of the ED, and study hospital to compare 30-day mortality between patients admitted to the hospital versus those discharged from the ED.

Of the 12,002 patients included in the analysis, 10,032 (83.6%) were admitted, while 1,970 (16.4%) were discharged. Compared with admitted patients, discharged patients were younger (a mean of 53 vs. 60 years, respectively; P less than .001); more likely to be female (65% vs. 55%; P less than .001); more likely to be nonwhite or Hispanic (21% vs 17%; P less than .001), and had fewer comorbidities and physiologic derangements. In addition, crude mortality at 30 days was lower in discharged versus admitted patients (1.0% vs. 6.2%, respectively; P less than .001). After the propensity-adjusted analysis, there was no significant difference in 30-day mortality for discharged vs. admitted sepsis patients (adjusted odds ratio 1.0).

“We were worried that discharged ED sepsis patients were being mismanaged and weren’t going to do well as similar patients who were admitted to the hospital,” Dr. Peltan said. “This analysis is still a work in progress, but with that caveat, our findings so far suggest that physicians are making pretty good decisions overall.”

The researchers also found that, among 89 ED physicians who cared for 20 or more eligible patients, some did not discharge any of their sepsis patients, while others discharged 39% of their sepsis patients. “That was surprising,” Dr. Peltan said. “This could mean that some hospital sepsis admissions depend on physician practice style more than the patient’s condition or treatment needs.”

[email protected]

SOURCE: Peltan ID et al. ATS 2018, Abstract A5994/702.

SAN DIEGO – More than 16% of emergency department sepsis patients are not admitted to the hospital, preliminary results from a large retrospective cohort study found.

Doug Brunk/MDedge News

“Nothing is really known about this topic,” lead study author Ithan D. Peltan, MD, said in an interview at an international conference of the American Thoracic Society. “In previous research, we’ve been focused on patients with sepsis who are admitted to the hospital. We have never thoroughly recognized that a fair number of patients who meet clinical criteria for sepsis in the emergency department are actually triaged to outpatient management. We don’t really know anything about these patients. What are their clinical characteristics and what are their outcomes like? And what are the factors that are leading them to be discharged from the ED rather than be admitted to the hospital?”

To find out, he and his associates retrospectively reviewed the medical records of 12,002 adult ED patients who met criteria for sepsis at two tertiary hospitals and two community hospitals in Utah between July 2013 and December 2016. They excluded trauma patients, those who left the ED against medical advice, those who were discharged to hospice or who died in the ED, and eligible patients’ repeat ED encounters. Patients transferred to another acute care facility were considered admitted, while transfers to non-acute care such as skilled nursing or psychiatric facilities were classified as discharges. Next, Dr. Peltan and his associates employed inverse probability weights using a propensity score for ED discharge based on age, sex, Charlson score, ED acuity score, initial ED vital signs, white blood cell count, lactate, sequential organ failure assessment (SOFA)score, busyness of the ED, and study hospital to compare 30-day mortality between patients admitted to the hospital versus those discharged from the ED.

Of the 12,002 patients included in the analysis, 10,032 (83.6%) were admitted, while 1,970 (16.4%) were discharged. Compared with admitted patients, discharged patients were younger (a mean of 53 vs. 60 years, respectively; P less than .001); more likely to be female (65% vs. 55%; P less than .001); more likely to be nonwhite or Hispanic (21% vs 17%; P less than .001), and had fewer comorbidities and physiologic derangements. In addition, crude mortality at 30 days was lower in discharged versus admitted patients (1.0% vs. 6.2%, respectively; P less than .001). After the propensity-adjusted analysis, there was no significant difference in 30-day mortality for discharged vs. admitted sepsis patients (adjusted odds ratio 1.0).

“We were worried that discharged ED sepsis patients were being mismanaged and weren’t going to do well as similar patients who were admitted to the hospital,” Dr. Peltan said. “This analysis is still a work in progress, but with that caveat, our findings so far suggest that physicians are making pretty good decisions overall.”

The researchers also found that, among 89 ED physicians who cared for 20 or more eligible patients, some did not discharge any of their sepsis patients, while others discharged 39% of their sepsis patients. “That was surprising,” Dr. Peltan said. “This could mean that some hospital sepsis admissions depend on physician practice style more than the patient’s condition or treatment needs.”

[email protected]

SOURCE: Peltan ID et al. ATS 2018, Abstract A5994/702.

SAN DIEGO – More than 16% of emergency department sepsis patients are not admitted to the hospital, preliminary results from a large retrospective cohort study found.

Doug Brunk/MDedge News

“Nothing is really known about this topic,” lead study author Ithan D. Peltan, MD, said in an interview at an international conference of the American Thoracic Society. “In previous research, we’ve been focused on patients with sepsis who are admitted to the hospital. We have never thoroughly recognized that a fair number of patients who meet clinical criteria for sepsis in the emergency department are actually triaged to outpatient management. We don’t really know anything about these patients. What are their clinical characteristics and what are their outcomes like? And what are the factors that are leading them to be discharged from the ED rather than be admitted to the hospital?”

To find out, he and his associates retrospectively reviewed the medical records of 12,002 adult ED patients who met criteria for sepsis at two tertiary hospitals and two community hospitals in Utah between July 2013 and December 2016. They excluded trauma patients, those who left the ED against medical advice, those who were discharged to hospice or who died in the ED, and eligible patients’ repeat ED encounters. Patients transferred to another acute care facility were considered admitted, while transfers to non-acute care such as skilled nursing or psychiatric facilities were classified as discharges. Next, Dr. Peltan and his associates employed inverse probability weights using a propensity score for ED discharge based on age, sex, Charlson score, ED acuity score, initial ED vital signs, white blood cell count, lactate, sequential organ failure assessment (SOFA)score, busyness of the ED, and study hospital to compare 30-day mortality between patients admitted to the hospital versus those discharged from the ED.

Of the 12,002 patients included in the analysis, 10,032 (83.6%) were admitted, while 1,970 (16.4%) were discharged. Compared with admitted patients, discharged patients were younger (a mean of 53 vs. 60 years, respectively; P less than .001); more likely to be female (65% vs. 55%; P less than .001); more likely to be nonwhite or Hispanic (21% vs 17%; P less than .001), and had fewer comorbidities and physiologic derangements. In addition, crude mortality at 30 days was lower in discharged versus admitted patients (1.0% vs. 6.2%, respectively; P less than .001). After the propensity-adjusted analysis, there was no significant difference in 30-day mortality for discharged vs. admitted sepsis patients (adjusted odds ratio 1.0).

“We were worried that discharged ED sepsis patients were being mismanaged and weren’t going to do well as similar patients who were admitted to the hospital,” Dr. Peltan said. “This analysis is still a work in progress, but with that caveat, our findings so far suggest that physicians are making pretty good decisions overall.”

The researchers also found that, among 89 ED physicians who cared for 20 or more eligible patients, some did not discharge any of their sepsis patients, while others discharged 39% of their sepsis patients. “That was surprising,” Dr. Peltan said. “This could mean that some hospital sepsis admissions depend on physician practice style more than the patient’s condition or treatment needs.”

[email protected]

SOURCE: Peltan ID et al. ATS 2018, Abstract A5994/702.

Hard work may be its own reward, but there may be an added, but unwelcome, bonus lurking for women who work more than 40 hours a week: diabetes.

Men have a higher risk overall for developing diabetes, 12.2%, compared with 7.5% for women, but the risk for women increases as they work more hours per week, which is not the case for men, according to the results of a 12-year Canadian study that included over 7,000 workers.

Among the 3,502 women in the study, those who worked 45 or more hours per week had a cumulative diabetes incidence of 8.5% over the median 11.7 years of follow-up. Diabetes incidence was 7.2% for women who worked 41-44 hours a week, 6.8% for those who worked 35-40 hours, and 7.9% among women who worked 15-34 hours weekly, Mahée Gilbert-Ouimet, PhD, of the Institute for Work & Health, Toronto, and her associates reported in BMJ Open Diabetes Research & Care.

For the 3,563 men included in the study, diabetes incidence was 9.5% for those who worked at least 45 hours a week versus 12% for those who worked 41-44 hours, 14.6% for men working 35-40 hours weekly, and 17.6% among those who put in 15-34 hours, the investigators wrote.

Hazard ratios for working 45 or more hours, compared with 35-40 hours, were 1.63 for women and 0.81 for men after adjustment for age, level of education, working conditions, and other factors, although the effect was significant only for women, they noted.

“Considering the rapid and substantial increase of diabetes prevalence in Canada and worldwide, identifying modifiable risk factors, such as long work hours, is of major importance to improve prevention and orient policy making as it could prevent numerous cases of diabetes and diabetes-related chronic diseases,” Dr. Gilbert-Ouimet and her associates wrote.

The study was supported by the Canadian Institutes of Health Research and by the Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. None of the investigators declared any conflicts of interest.

[email protected]

SOURCE: Gilbert-Ouimet M et al. BMJ Open Diab Res Care. 2018. doi: 10.1136/bmjdrc-2017-000496.

Hard work may be its own reward, but there may be an added, but unwelcome, bonus lurking for women who work more than 40 hours a week: diabetes.

Men have a higher risk overall for developing diabetes, 12.2%, compared with 7.5% for women, but the risk for women increases as they work more hours per week, which is not the case for men, according to the results of a 12-year Canadian study that included over 7,000 workers.

Among the 3,502 women in the study, those who worked 45 or more hours per week had a cumulative diabetes incidence of 8.5% over the median 11.7 years of follow-up. Diabetes incidence was 7.2% for women who worked 41-44 hours a week, 6.8% for those who worked 35-40 hours, and 7.9% among women who worked 15-34 hours weekly, Mahée Gilbert-Ouimet, PhD, of the Institute for Work & Health, Toronto, and her associates reported in BMJ Open Diabetes Research & Care.

For the 3,563 men included in the study, diabetes incidence was 9.5% for those who worked at least 45 hours a week versus 12% for those who worked 41-44 hours, 14.6% for men working 35-40 hours weekly, and 17.6% among those who put in 15-34 hours, the investigators wrote.

Hazard ratios for working 45 or more hours, compared with 35-40 hours, were 1.63 for women and 0.81 for men after adjustment for age, level of education, working conditions, and other factors, although the effect was significant only for women, they noted.

“Considering the rapid and substantial increase of diabetes prevalence in Canada and worldwide, identifying modifiable risk factors, such as long work hours, is of major importance to improve prevention and orient policy making as it could prevent numerous cases of diabetes and diabetes-related chronic diseases,” Dr. Gilbert-Ouimet and her associates wrote.

The study was supported by the Canadian Institutes of Health Research and by the Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. None of the investigators declared any conflicts of interest.

[email protected]

SOURCE: Gilbert-Ouimet M et al. BMJ Open Diab Res Care. 2018. doi: 10.1136/bmjdrc-2017-000496.

Hard work may be its own reward, but there may be an added, but unwelcome, bonus lurking for women who work more than 40 hours a week: diabetes.

Men have a higher risk overall for developing diabetes, 12.2%, compared with 7.5% for women, but the risk for women increases as they work more hours per week, which is not the case for men, according to the results of a 12-year Canadian study that included over 7,000 workers.

Among the 3,502 women in the study, those who worked 45 or more hours per week had a cumulative diabetes incidence of 8.5% over the median 11.7 years of follow-up. Diabetes incidence was 7.2% for women who worked 41-44 hours a week, 6.8% for those who worked 35-40 hours, and 7.9% among women who worked 15-34 hours weekly, Mahée Gilbert-Ouimet, PhD, of the Institute for Work & Health, Toronto, and her associates reported in BMJ Open Diabetes Research & Care.

For the 3,563 men included in the study, diabetes incidence was 9.5% for those who worked at least 45 hours a week versus 12% for those who worked 41-44 hours, 14.6% for men working 35-40 hours weekly, and 17.6% among those who put in 15-34 hours, the investigators wrote.

Hazard ratios for working 45 or more hours, compared with 35-40 hours, were 1.63 for women and 0.81 for men after adjustment for age, level of education, working conditions, and other factors, although the effect was significant only for women, they noted.

“Considering the rapid and substantial increase of diabetes prevalence in Canada and worldwide, identifying modifiable risk factors, such as long work hours, is of major importance to improve prevention and orient policy making as it could prevent numerous cases of diabetes and diabetes-related chronic diseases,” Dr. Gilbert-Ouimet and her associates wrote.

The study was supported by the Canadian Institutes of Health Research and by the Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. None of the investigators declared any conflicts of interest.

[email protected]

SOURCE: Gilbert-Ouimet M et al. BMJ Open Diab Res Care. 2018. doi: 10.1136/bmjdrc-2017-000496.

Researchers have highlighted the need for contraception counseling for transgender men, after a study found around half of transgender men had not been asked by their health care providers about their fertility desires.

Writing in Contraception, researchers reported the results of an anonymous, online survey of 197 female-to-male transgender men, 86% of whom were taking masculinizing hormones.

Overall, 17% of respondents had experienced a pregnancy, with 60 pregnancies reported in total. While participants who had never taken hormones had a nearly 200% higher incidence of pregnancy, compared with those who had taken testosterone, one pregnancy occurred while the subject was taking testosterone, and five of seven reported abortions were in participants who had used testosterone prior to conception.

A total of 30 participants (16.4%) believed testosterone was a contraceptive method, and 10 said that a health care provider had advised them to use testosterone for contraception. However, nearly half of all participants did report using condoms for contraception, making it the most common method. IUDs were the second most common method of contraception currently used.

Nearly one-third of participants said they had used some type of contraceptive pill at some point, 17 said they had tried more than one type of pill, and 36 had used combination pills. However, of those who had used combination pills, nearly half stopped using them because of side effects or because of concern about extra feminine hormones.

The authors noted that most study participants expressed a desire to become a parent. Around one-quarter wanted to bear a child while the majority said they would consider adoption.

One-quarter of respondents had fears about not achieving a desired pregnancy, and for some, those fears began after initiating hormone treatments. Just over half the respondents said their health care provider had not asked about their fertility desires.

“Transgender men have unintended pregnancy as well as future fertility desires, and yet, there is a paucity of reproductive health care best practices research for this unique population,” wrote Alexis Light, MD, MPH, of MedStar Washington Hospital Center, and her coauthors. “This survey confirms earlier studies: Transgender men do become pregnant, both intentionally and unintentionally, and some transgender men engage in behaviors that can lead to unintended pregnancy.”

The study authors called for doctors to be more equipped and prepared to counsel transgender men on contraception and discuss other reproductive health concerns.

The study was supported by MedStar Washington Hospital Center. No conflicts of interest were declared.

SOURCE: Light A et al. Contraception. 2018 Jun 23. doi: 10.1016/j.contraception.2018.06.006.

Researchers have highlighted the need for contraception counseling for transgender men, after a study found around half of transgender men had not been asked by their health care providers about their fertility desires.

Writing in Contraception, researchers reported the results of an anonymous, online survey of 197 female-to-male transgender men, 86% of whom were taking masculinizing hormones.

Overall, 17% of respondents had experienced a pregnancy, with 60 pregnancies reported in total. While participants who had never taken hormones had a nearly 200% higher incidence of pregnancy, compared with those who had taken testosterone, one pregnancy occurred while the subject was taking testosterone, and five of seven reported abortions were in participants who had used testosterone prior to conception.

A total of 30 participants (16.4%) believed testosterone was a contraceptive method, and 10 said that a health care provider had advised them to use testosterone for contraception. However, nearly half of all participants did report using condoms for contraception, making it the most common method. IUDs were the second most common method of contraception currently used.

Nearly one-third of participants said they had used some type of contraceptive pill at some point, 17 said they had tried more than one type of pill, and 36 had used combination pills. However, of those who had used combination pills, nearly half stopped using them because of side effects or because of concern about extra feminine hormones.

The authors noted that most study participants expressed a desire to become a parent. Around one-quarter wanted to bear a child while the majority said they would consider adoption.

One-quarter of respondents had fears about not achieving a desired pregnancy, and for some, those fears began after initiating hormone treatments. Just over half the respondents said their health care provider had not asked about their fertility desires.

“Transgender men have unintended pregnancy as well as future fertility desires, and yet, there is a paucity of reproductive health care best practices research for this unique population,” wrote Alexis Light, MD, MPH, of MedStar Washington Hospital Center, and her coauthors. “This survey confirms earlier studies: Transgender men do become pregnant, both intentionally and unintentionally, and some transgender men engage in behaviors that can lead to unintended pregnancy.”

The study authors called for doctors to be more equipped and prepared to counsel transgender men on contraception and discuss other reproductive health concerns.

The study was supported by MedStar Washington Hospital Center. No conflicts of interest were declared.

SOURCE: Light A et al. Contraception. 2018 Jun 23. doi: 10.1016/j.contraception.2018.06.006.

Researchers have highlighted the need for contraception counseling for transgender men, after a study found around half of transgender men had not been asked by their health care providers about their fertility desires.

Writing in Contraception, researchers reported the results of an anonymous, online survey of 197 female-to-male transgender men, 86% of whom were taking masculinizing hormones.

Overall, 17% of respondents had experienced a pregnancy, with 60 pregnancies reported in total. While participants who had never taken hormones had a nearly 200% higher incidence of pregnancy, compared with those who had taken testosterone, one pregnancy occurred while the subject was taking testosterone, and five of seven reported abortions were in participants who had used testosterone prior to conception.

A total of 30 participants (16.4%) believed testosterone was a contraceptive method, and 10 said that a health care provider had advised them to use testosterone for contraception. However, nearly half of all participants did report using condoms for contraception, making it the most common method. IUDs were the second most common method of contraception currently used.

Nearly one-third of participants said they had used some type of contraceptive pill at some point, 17 said they had tried more than one type of pill, and 36 had used combination pills. However, of those who had used combination pills, nearly half stopped using them because of side effects or because of concern about extra feminine hormones.

The authors noted that most study participants expressed a desire to become a parent. Around one-quarter wanted to bear a child while the majority said they would consider adoption.

One-quarter of respondents had fears about not achieving a desired pregnancy, and for some, those fears began after initiating hormone treatments. Just over half the respondents said their health care provider had not asked about their fertility desires.

“Transgender men have unintended pregnancy as well as future fertility desires, and yet, there is a paucity of reproductive health care best practices research for this unique population,” wrote Alexis Light, MD, MPH, of MedStar Washington Hospital Center, and her coauthors. “This survey confirms earlier studies: Transgender men do become pregnant, both intentionally and unintentionally, and some transgender men engage in behaviors that can lead to unintended pregnancy.”

The study authors called for doctors to be more equipped and prepared to counsel transgender men on contraception and discuss other reproductive health concerns.

The study was supported by MedStar Washington Hospital Center. No conflicts of interest were declared.

SOURCE: Light A et al. Contraception. 2018 Jun 23. doi: 10.1016/j.contraception.2018.06.006.

Patients with localized prostate cancer who were smokers at the time of local therapy had a higher risk of experiencing adverse outcomes and death related to the disease, a systematic review and meta-analysis has shown.

Current smokers in the study had a higher risk of biochemical recurrence, metastasis, and cancer-specific mortality after undergoing primary radical prostatectomy or radiotherapy.

Brett Mulcahy/ThinkStock

Future studies need to more closely examine the link between smoking cessation and longer-term oncologic outcomes, as well as a more precise assessment of smoking exposure, the researchers concluded.

In the current study, results were inconclusive as to whether former smoking and time to cessation had any relationship to outcomes after radical prostatectomy or radiotherapy.

“Available data were sparse and heterogenous,” they noted.

Dr. Foerster is supported by the Scholarship Foundation of Swiss Urology. One coauthor reported disclosures related to Astellas, Cepheid, Ipsen, Jansen, Lilly, Olympus, Pfizer, Pierre Fabre, Sanochemia, Sanofi, and Wolff.

SOURCE: Foerster B et al. JAMA Oncol. 2018 May 24. doi: 10.1001/jamaoncol.2018.1071.

Patients with localized prostate cancer who were smokers at the time of local therapy had a higher risk of experiencing adverse outcomes and death related to the disease, a systematic review and meta-analysis has shown.

Current smokers in the study had a higher risk of biochemical recurrence, metastasis, and cancer-specific mortality after undergoing primary radical prostatectomy or radiotherapy.

Brett Mulcahy/ThinkStock

Future studies need to more closely examine the link between smoking cessation and longer-term oncologic outcomes, as well as a more precise assessment of smoking exposure, the researchers concluded.

In the current study, results were inconclusive as to whether former smoking and time to cessation had any relationship to outcomes after radical prostatectomy or radiotherapy.

“Available data were sparse and heterogenous,” they noted.

Dr. Foerster is supported by the Scholarship Foundation of Swiss Urology. One coauthor reported disclosures related to Astellas, Cepheid, Ipsen, Jansen, Lilly, Olympus, Pfizer, Pierre Fabre, Sanochemia, Sanofi, and Wolff.

SOURCE: Foerster B et al. JAMA Oncol. 2018 May 24. doi: 10.1001/jamaoncol.2018.1071.

Patients with localized prostate cancer who were smokers at the time of local therapy had a higher risk of experiencing adverse outcomes and death related to the disease, a systematic review and meta-analysis has shown.

Current smokers in the study had a higher risk of biochemical recurrence, metastasis, and cancer-specific mortality after undergoing primary radical prostatectomy or radiotherapy.

Brett Mulcahy/ThinkStock

Future studies need to more closely examine the link between smoking cessation and longer-term oncologic outcomes, as well as a more precise assessment of smoking exposure, the researchers concluded.

In the current study, results were inconclusive as to whether former smoking and time to cessation had any relationship to outcomes after radical prostatectomy or radiotherapy.

“Available data were sparse and heterogenous,” they noted.

Dr. Foerster is supported by the Scholarship Foundation of Swiss Urology. One coauthor reported disclosures related to Astellas, Cepheid, Ipsen, Jansen, Lilly, Olympus, Pfizer, Pierre Fabre, Sanochemia, Sanofi, and Wolff.

SOURCE: Foerster B et al. JAMA Oncol. 2018 May 24. doi: 10.1001/jamaoncol.2018.1071.

SAN FRANCISCO – Long-term use of statins may protect against lethal forms of prostate cancer by altering the inflammatory profile of the tumor microenvironment, according to the results of a new genetic analysis of prostate cancers in men in the Health Professionals Follow Up Study.

A previous analysis from the Health Professionals Follow Up Study published in 2015 showed no difference in the risk of lethal prostate cancer for those who began using statins after diagnosis of their tumors.

Jim Kling/MDedge News

There was no association between lethality and ERG-positive or ERG-negative status. Those who used statins for more than 5 years were less likely to have a PTEN-null tumor (hazard ratio, 0.42; 95% confidence interval, 0.20-0.90) but not more likely to have a PTEN-positive tumor (HR, 1.18; 95% CI, 0.95-1.46).

Compared with never users, long-term statin users also were less likely to have advanced prostate cancer (multivariate analysis, HR, 0.62; 95% CI, 0.45-0.85) as well as lethal prostate cancer (HR, 0.52; 95% CI, 0.35-0.78).

The researchers conducted a gene set enrichment analysis in statin users and found an enrichment of T-cell, B-cell, and PI3K signaling in tumor-adjacent normal prostate tissue, as well as other changes. “We think maybe there’s a microenvironment inflammation component to the mechanism through which statins are associated with lower risk of lethal prostate cancer,” said Dr. Allott.

The molecular data could identify patient subgroups that could benefit from statins. Dr. Allott said that is the goal, but it will take time. “That’s more obviously translatable to the clinic, but we don’t yet have enough data in this cohort to look at that.”

SOURCE: Allott E et al. AUA 2018, Abstract MP21-01.

SAN FRANCISCO – Long-term use of statins may protect against lethal forms of prostate cancer by altering the inflammatory profile of the tumor microenvironment, according to the results of a new genetic analysis of prostate cancers in men in the Health Professionals Follow Up Study.

A previous analysis from the Health Professionals Follow Up Study published in 2015 showed no difference in the risk of lethal prostate cancer for those who began using statins after diagnosis of their tumors.

Jim Kling/MDedge News

There was no association between lethality and ERG-positive or ERG-negative status. Those who used statins for more than 5 years were less likely to have a PTEN-null tumor (hazard ratio, 0.42; 95% confidence interval, 0.20-0.90) but not more likely to have a PTEN-positive tumor (HR, 1.18; 95% CI, 0.95-1.46).

Compared with never users, long-term statin users also were less likely to have advanced prostate cancer (multivariate analysis, HR, 0.62; 95% CI, 0.45-0.85) as well as lethal prostate cancer (HR, 0.52; 95% CI, 0.35-0.78).

The researchers conducted a gene set enrichment analysis in statin users and found an enrichment of T-cell, B-cell, and PI3K signaling in tumor-adjacent normal prostate tissue, as well as other changes. “We think maybe there’s a microenvironment inflammation component to the mechanism through which statins are associated with lower risk of lethal prostate cancer,” said Dr. Allott.

The molecular data could identify patient subgroups that could benefit from statins. Dr. Allott said that is the goal, but it will take time. “That’s more obviously translatable to the clinic, but we don’t yet have enough data in this cohort to look at that.”

SOURCE: Allott E et al. AUA 2018, Abstract MP21-01.

SAN FRANCISCO – Long-term use of statins may protect against lethal forms of prostate cancer by altering the inflammatory profile of the tumor microenvironment, according to the results of a new genetic analysis of prostate cancers in men in the Health Professionals Follow Up Study.

A previous analysis from the Health Professionals Follow Up Study published in 2015 showed no difference in the risk of lethal prostate cancer for those who began using statins after diagnosis of their tumors.

Jim Kling/MDedge News

There was no association between lethality and ERG-positive or ERG-negative status. Those who used statins for more than 5 years were less likely to have a PTEN-null tumor (hazard ratio, 0.42; 95% confidence interval, 0.20-0.90) but not more likely to have a PTEN-positive tumor (HR, 1.18; 95% CI, 0.95-1.46).

Compared with never users, long-term statin users also were less likely to have advanced prostate cancer (multivariate analysis, HR, 0.62; 95% CI, 0.45-0.85) as well as lethal prostate cancer (HR, 0.52; 95% CI, 0.35-0.78).

The researchers conducted a gene set enrichment analysis in statin users and found an enrichment of T-cell, B-cell, and PI3K signaling in tumor-adjacent normal prostate tissue, as well as other changes. “We think maybe there’s a microenvironment inflammation component to the mechanism through which statins are associated with lower risk of lethal prostate cancer,” said Dr. Allott.

The molecular data could identify patient subgroups that could benefit from statins. Dr. Allott said that is the goal, but it will take time. “That’s more obviously translatable to the clinic, but we don’t yet have enough data in this cohort to look at that.”

SOURCE: Allott E et al. AUA 2018, Abstract MP21-01.

SAN FRANCISCO – Among men aged younger than 55 years undergoing prostate biopsies, black men were more likely to have a diagnosis of prostate cancer, according to a new study that drew subjects aged 40-54 years from three public and two private hospitals in the Chicago area.

Black race, rather than socioeconomic or clinical factors, appeared to be the strongest nonmodifiable predictor of prostate cancer risk in that age group, the researchers concluded, based on multivariate analyses that examined the association between prostate cancer risk and clinical setting, race, genetically determined West African ancestry, and clinical and socioeconomic risk factors.

For patients of all ages, biopsies were positive in 63.1% of black men, compared with 41.5% of nonblack men (P less than .001). Cancers were also more advanced in black men: 47.5% were Gleason 3+4 in black men, compared with 40% in nonblack men (P less than .001), and 14.4% were Gleason 4+4 in black men, compared with 9.6% in nonblack men (P = .02).

After researchers controlled for other risk factors, black race was associated with heightened risk of prostate cancer diagnosis (OR, 5.66; P = .02), as was family history (OR, 4.98; P = .01).

There was no association between West African ancestry and prostate cancer risk either as a continuous variable or in quartiles.

Limitations of the study include the fact that race was self-reported and that this was a referred population.

The study received funding from the National Institutes of Health and the U.S. Department of Veterans Affairs. Dr. Nettey reported having no financial disclosures.

SOURCE: Nettey OS et al. AUA Annual Meeting. Abstract MP 21-17.

SAN FRANCISCO – Among men aged younger than 55 years undergoing prostate biopsies, black men were more likely to have a diagnosis of prostate cancer, according to a new study that drew subjects aged 40-54 years from three public and two private hospitals in the Chicago area.

Black race, rather than socioeconomic or clinical factors, appeared to be the strongest nonmodifiable predictor of prostate cancer risk in that age group, the researchers concluded, based on multivariate analyses that examined the association between prostate cancer risk and clinical setting, race, genetically determined West African ancestry, and clinical and socioeconomic risk factors.

For patients of all ages, biopsies were positive in 63.1% of black men, compared with 41.5% of nonblack men (P less than .001). Cancers were also more advanced in black men: 47.5% were Gleason 3+4 in black men, compared with 40% in nonblack men (P less than .001), and 14.4% were Gleason 4+4 in black men, compared with 9.6% in nonblack men (P = .02).

After researchers controlled for other risk factors, black race was associated with heightened risk of prostate cancer diagnosis (OR, 5.66; P = .02), as was family history (OR, 4.98; P = .01).

There was no association between West African ancestry and prostate cancer risk either as a continuous variable or in quartiles.

Limitations of the study include the fact that race was self-reported and that this was a referred population.

The study received funding from the National Institutes of Health and the U.S. Department of Veterans Affairs. Dr. Nettey reported having no financial disclosures.

SOURCE: Nettey OS et al. AUA Annual Meeting. Abstract MP 21-17.

SAN FRANCISCO – Among men aged younger than 55 years undergoing prostate biopsies, black men were more likely to have a diagnosis of prostate cancer, according to a new study that drew subjects aged 40-54 years from three public and two private hospitals in the Chicago area.

Black race, rather than socioeconomic or clinical factors, appeared to be the strongest nonmodifiable predictor of prostate cancer risk in that age group, the researchers concluded, based on multivariate analyses that examined the association between prostate cancer risk and clinical setting, race, genetically determined West African ancestry, and clinical and socioeconomic risk factors.

For patients of all ages, biopsies were positive in 63.1% of black men, compared with 41.5% of nonblack men (P less than .001). Cancers were also more advanced in black men: 47.5% were Gleason 3+4 in black men, compared with 40% in nonblack men (P less than .001), and 14.4% were Gleason 4+4 in black men, compared with 9.6% in nonblack men (P = .02).

After researchers controlled for other risk factors, black race was associated with heightened risk of prostate cancer diagnosis (OR, 5.66; P = .02), as was family history (OR, 4.98; P = .01).

There was no association between West African ancestry and prostate cancer risk either as a continuous variable or in quartiles.

Limitations of the study include the fact that race was self-reported and that this was a referred population.

The study received funding from the National Institutes of Health and the U.S. Department of Veterans Affairs. Dr. Nettey reported having no financial disclosures.

SOURCE: Nettey OS et al. AUA Annual Meeting. Abstract MP 21-17.

SAN FRANCISCO – Primary hyperparathyroidism was detected in 7% of 742 patients with recurrent kidney stones at a single tertiary care clinic, and the patients’ primary care physicians may have missed the diagnosis because several affected patients’ calcium levels were in the high normal range.

Of the 53 patients diagnosed with primary hyperparathyroidism (hPTH), 72% had high normal serum calcium levels. After examining the charts of those patients, researchers found that 11 of the 53 patients (21%) had been tested for parathyroid hormone and serum calcium levels and could have been identified by their primary care physicians.

SOURCE: Boyd C et al. AUA 2018, Abstract MP13-03.

SAN FRANCISCO – Primary hyperparathyroidism was detected in 7% of 742 patients with recurrent kidney stones at a single tertiary care clinic, and the patients’ primary care physicians may have missed the diagnosis because several affected patients’ calcium levels were in the high normal range.

Of the 53 patients diagnosed with primary hyperparathyroidism (hPTH), 72% had high normal serum calcium levels. After examining the charts of those patients, researchers found that 11 of the 53 patients (21%) had been tested for parathyroid hormone and serum calcium levels and could have been identified by their primary care physicians.

SOURCE: Boyd C et al. AUA 2018, Abstract MP13-03.

SAN FRANCISCO – Primary hyperparathyroidism was detected in 7% of 742 patients with recurrent kidney stones at a single tertiary care clinic, and the patients’ primary care physicians may have missed the diagnosis because several affected patients’ calcium levels were in the high normal range.

Of the 53 patients diagnosed with primary hyperparathyroidism (hPTH), 72% had high normal serum calcium levels. After examining the charts of those patients, researchers found that 11 of the 53 patients (21%) had been tested for parathyroid hormone and serum calcium levels and could have been identified by their primary care physicians.

SOURCE: Boyd C et al. AUA 2018, Abstract MP13-03.

SAN FRANCISCO – In men with low-risk prostate cancer, vascular-targeted phototherapy (VTP) led to a significant reduction in subsequent conversions to radiation therapy or prostatectomy, compared with patients who underwent active surveillance. The latest results come at 4 years of follow-up, and confirm a reduction of risk seen in the original study at 2 years post treatment.

The new analysis was presented by Inderbir Gill, MD, in a late-breaking abstract session at the annual meeting of the American Urological Association.

SAN FRANCISCO – In men with low-risk prostate cancer, vascular-targeted phototherapy (VTP) led to a significant reduction in subsequent conversions to radiation therapy or prostatectomy, compared with patients who underwent active surveillance. The latest results come at 4 years of follow-up, and confirm a reduction of risk seen in the original study at 2 years post treatment.

The new analysis was presented by Inderbir Gill, MD, in a late-breaking abstract session at the annual meeting of the American Urological Association.

SAN FRANCISCO – In men with low-risk prostate cancer, vascular-targeted phototherapy (VTP) led to a significant reduction in subsequent conversions to radiation therapy or prostatectomy, compared with patients who underwent active surveillance. The latest results come at 4 years of follow-up, and confirm a reduction of risk seen in the original study at 2 years post treatment.

The new analysis was presented by Inderbir Gill, MD, in a late-breaking abstract session at the annual meeting of the American Urological Association.

Resources

US Preventive Services Task Force. Screening for prostate cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319:1901-1913.

Carter HB. Prostate-specific antigen (PSA) screening for prostate cancer: revisiting the evidence. JAMA. 2018;319:1866-1868.

US Preventive Services Task Force. Prostate cancer screening final recommendation. Available at: https://screeningforprostatecancer.org/. Accessed May 18, 2018.

US Preventive Services Task Force. Prostate cancer: screening, 2008. Available at:  https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prostate-cancer-screening-2008. Accessed May 15, 2018.

US Preventive Services Task Force. Prostate cancer: screening. May 2012. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/prostate-cancer-screening. Accessed May 15, 2018.

Resources

US Preventive Services Task Force. Screening for prostate cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319:1901-1913.

Carter HB. Prostate-specific antigen (PSA) screening for prostate cancer: revisiting the evidence. JAMA. 2018;319:1866-1868.

US Preventive Services Task Force. Prostate cancer screening final recommendation. Available at: https://screeningforprostatecancer.org/. Accessed May 18, 2018.

US Preventive Services Task Force. Prostate cancer: screening, 2008. Available at:  https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prostate-cancer-screening-2008. Accessed May 15, 2018.

US Preventive Services Task Force. Prostate cancer: screening. May 2012. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/prostate-cancer-screening. Accessed May 15, 2018.

Resources

US Preventive Services Task Force. Screening for prostate cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319:1901-1913.

Carter HB. Prostate-specific antigen (PSA) screening for prostate cancer: revisiting the evidence. JAMA. 2018;319:1866-1868.

US Preventive Services Task Force. Prostate cancer screening final recommendation. Available at: https://screeningforprostatecancer.org/. Accessed May 18, 2018.

US Preventive Services Task Force. Prostate cancer: screening, 2008. Available at:  https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prostate-cancer-screening-2008. Accessed May 15, 2018.

US Preventive Services Task Force. Prostate cancer: screening. May 2012. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/prostate-cancer-screening. Accessed May 15, 2018.

A 38-year-old man presented to our emergency department with a 2-day history of fever, general malaise, and a painless genital ulcer. He denied having any abdominal pain, myalgias, arthralgias, or other rashes. He had been treated about a month earlier on an outpatient basis with penicillin for a presumed diagnosis of syphilis, but his symptoms did not resolve. His medical history included well-controlled human immunodeficiency virus (HIV), hepatitis B, hypertension, anxiety, and fibromyalgia for which he took lisinopril, emtricitabine/tenofovir, metoprolol, and darunavir/cobicistat. He smoked a half-pack of cigarettes a day and had unprotected sex with men.

On physical examination, the patient was febrile (103.1^° F) with otherwise normal vital signs. A genital examination revealed a nontender, irregularly shaped 8-mm ulcer at the base of the glans penis (FIGURE). Tender unilateral inguinal lymphadenopathy was noted on the right side.

A chart review showed a normal CD4 count (obtained 2 months earlier). We were unable to access the results of his outpatient rapid plasma reagin test for syphilis. Due to the patient’s degree of pain from his lymphadenopathy, fever, and general malaise, he was admitted to the hospital for overnight observation.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Based on the patient’s history and clinical presentation, we suspected lymphogranuloma venereum (LGV). A positive nucleic acid amplification test (NAAT) for Chlamydia trachomatis confirmed the diagnosis.

LGV is an infection caused by C trachomatis—specifically serovars L1, L2, and L3—that is transmitted through unprotected sex.^1-3 During intercourse, the serovars cross the epithelial cells through breaks in the skin and enter the lymphatic system, often resulting in painful lymphadenopathy. LGV is more commonly reported in men (primarily men who have sex with men [MSM]), but can occur in either gender.⁴ The true incidence and prevalence of LGV are difficult to ascertain as the disease primarily occurs in tropical areas, but outbreaks in the United States occur predominantly in patients infected with HIV.

The 3 stages of infection

Following an incubation period of 3 to 30 days, LGV progresses through 3 stages. The first stage involves a small, painless lesion at the inoculation site—usually the prepuce or glans of the penis or the vulva or vaginal wall. The lesion typically heals in about one week.^1,2,4

Lymphogranuloma venereum is more commonly reported in men—primarily men who have sex with men.

Two to 6 weeks later, LGV enters the second phase, characterized by painful unilateral inguinal or femoral lymphadenopathy or proctitis. Inguinal and femoral lymphadenopathy is more common in men.^1,4 The “groove sign”—lymphadenopathy occurring above and below the inguinal ligament—is seen in 10% to 20% of men with LGV.^1,3 In women, lymphatic drainage occurs in the retroperitoneal or intra-abdominal nodes and may result in abdominal or back pain.^1,4 Proctitis is reported primarily in women and in MSM.^1,4

Tertiary LGV (aka genitoanorectal syndrome) is also more common in women and MSM, due to the location of the involved lymphatics. In this stage, chronic inflammation causes scarring and destruction of tissue.^1,4 Left untreated, LGV can lead to lymphatic obstruction, deep tissue abscesses, chronic pain, strictures, or fistulas.^1,3,4

Continue to: Other genital ulcers can mimic LGV

LGV can be confused with other causes of genital ulcers (such as syphilis, chancroid, herpes simplex virus, and Behçet’s disease). Identification of the causal bacteria is often needed to make a definitive diagnosis.

Syphilis, caused by the spirochete Treponema pallidum, initially manifests as a chancre (a single, well-demarcated, painless ulcer). It is less commonly associated with inguinal lymphadenopathy and can be diagnosed via serologic testing.^5,6

Chancroid is caused by Haemophilus ducreyi and manifests as a painful ulcer with a friable base covered with a necrotic exudate. It can be associated with tender unilateral inguinal lymphadenopathy.⁵ Due to the widespread availability of culture media to test for H ducreyi, the diagnosis of chancroid is based on the clinical exam plus a handful of clinical criteria: painful genital ulcers, no evidence of T pallidum infection, and negative culture or polymerase chain reaction testing (PCR) for herpes simplex virus (HSV).

HSV, the most common cause of genital ulcers in the United States,⁵ typically manifests with multiple vesicular painful lesions, with or without lymphadenopathy. Constitutional symptoms, including fever, headache, malaise, and myalgias, occur in 66% of females and 40% of males.^5,7 Identification of HSV on culture or PCR can confirm the diagnosis.⁵

Behçet’s disease is a noninfectious syndrome associated with intermittent arthritis, recurrent painful oral and genital ulcers, uveitis, and skin lesions. While most symptoms of Behçet’s are self-limited, recurrent uveitis can result in blindness. A biopsy may be warranted to diagnose Behçet’s disease; the results may show diffuse arteritis with venulitis.^5,8

Continue to: NAAT is recommended to confirm the diagnosis

In the outpatient setting, diagnosis of LGV relies on physical exam, clinical presentation, confirmation of infection, and exclusion of other causes of genital ulcer, lymphadenopathy, and proctitis.³ Diagnostic tests include culture identification of C trachomatis, visualization of inclusion bodies on immunofluorescence of bubo aspirate, and positive serology for C trachomatis.^1-3 (Serology to differentiate LGV from non-LGV C trachomatis serovars is difficult and not widely available.)

Recommendations regarding lab studies have shifted away from serologic testing and toward the use of NAAT. NAAT via PCR has a sensitivity and specificity comparable to invasive testing methods: 83% and 99.5% with urine samples and 86% and 99.6% with cervical samples, respectively.⁹ NAAT has a sensitivity and specificity that is superior to culture for detecting chlamydia in rectal specimens¹⁰ and is preferred by patients because it doesn’t require a pelvic exam or a urethral swab.

Treat with antibiotics

Oral antibiotics are the treatment of choice for LGV. Standard treatment includes doxycycline 100 mg bid for 21 days. Women who are pregnant or lactating may alternatively be treated with macrolides (eg, erythromycin).^1,2,4 Buboes may be aspirated for pain relief and to prevent the development of ulcerations or fistulas.^3,4

Our patient was started on oral doxycycline, which resolved his fever and reduced the size of his ulcer. He was discharged on oral doxycycline and continued on the full 21-day course. Two weeks later, the ulcer and lymphadenopathy had completely resolved. On follow-up in our office, the resident physician who treated the patient in the hospital discussed future use of safe sexual practices.

CORRESPONDENCE
Jeffrey Walden, MD, Cone Health Family Medicine Residency, 1125 North Church Street, Greensboro, NC 27401; [email protected].

A 38-year-old man presented to our emergency department with a 2-day history of fever, general malaise, and a painless genital ulcer. He denied having any abdominal pain, myalgias, arthralgias, or other rashes. He had been treated about a month earlier on an outpatient basis with penicillin for a presumed diagnosis of syphilis, but his symptoms did not resolve. His medical history included well-controlled human immunodeficiency virus (HIV), hepatitis B, hypertension, anxiety, and fibromyalgia for which he took lisinopril, emtricitabine/tenofovir, metoprolol, and darunavir/cobicistat. He smoked a half-pack of cigarettes a day and had unprotected sex with men.

On physical examination, the patient was febrile (103.1^° F) with otherwise normal vital signs. A genital examination revealed a nontender, irregularly shaped 8-mm ulcer at the base of the glans penis (FIGURE). Tender unilateral inguinal lymphadenopathy was noted on the right side.

A chart review showed a normal CD4 count (obtained 2 months earlier). We were unable to access the results of his outpatient rapid plasma reagin test for syphilis. Due to the patient’s degree of pain from his lymphadenopathy, fever, and general malaise, he was admitted to the hospital for overnight observation.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Based on the patient’s history and clinical presentation, we suspected lymphogranuloma venereum (LGV). A positive nucleic acid amplification test (NAAT) for Chlamydia trachomatis confirmed the diagnosis.

LGV is an infection caused by C trachomatis—specifically serovars L1, L2, and L3—that is transmitted through unprotected sex.^1-3 During intercourse, the serovars cross the epithelial cells through breaks in the skin and enter the lymphatic system, often resulting in painful lymphadenopathy. LGV is more commonly reported in men (primarily men who have sex with men [MSM]), but can occur in either gender.⁴ The true incidence and prevalence of LGV are difficult to ascertain as the disease primarily occurs in tropical areas, but outbreaks in the United States occur predominantly in patients infected with HIV.

The 3 stages of infection

Following an incubation period of 3 to 30 days, LGV progresses through 3 stages. The first stage involves a small, painless lesion at the inoculation site—usually the prepuce or glans of the penis or the vulva or vaginal wall. The lesion typically heals in about one week.^1,2,4

Lymphogranuloma venereum is more commonly reported in men—primarily men who have sex with men.

Two to 6 weeks later, LGV enters the second phase, characterized by painful unilateral inguinal or femoral lymphadenopathy or proctitis. Inguinal and femoral lymphadenopathy is more common in men.^1,4 The “groove sign”—lymphadenopathy occurring above and below the inguinal ligament—is seen in 10% to 20% of men with LGV.^1,3 In women, lymphatic drainage occurs in the retroperitoneal or intra-abdominal nodes and may result in abdominal or back pain.^1,4 Proctitis is reported primarily in women and in MSM.^1,4

Tertiary LGV (aka genitoanorectal syndrome) is also more common in women and MSM, due to the location of the involved lymphatics. In this stage, chronic inflammation causes scarring and destruction of tissue.^1,4 Left untreated, LGV can lead to lymphatic obstruction, deep tissue abscesses, chronic pain, strictures, or fistulas.^1,3,4

Continue to: Other genital ulcers can mimic LGV

LGV can be confused with other causes of genital ulcers (such as syphilis, chancroid, herpes simplex virus, and Behçet’s disease). Identification of the causal bacteria is often needed to make a definitive diagnosis.

Syphilis, caused by the spirochete Treponema pallidum, initially manifests as a chancre (a single, well-demarcated, painless ulcer). It is less commonly associated with inguinal lymphadenopathy and can be diagnosed via serologic testing.^5,6

Chancroid is caused by Haemophilus ducreyi and manifests as a painful ulcer with a friable base covered with a necrotic exudate. It can be associated with tender unilateral inguinal lymphadenopathy.⁵ Due to the widespread availability of culture media to test for H ducreyi, the diagnosis of chancroid is based on the clinical exam plus a handful of clinical criteria: painful genital ulcers, no evidence of T pallidum infection, and negative culture or polymerase chain reaction testing (PCR) for herpes simplex virus (HSV).

HSV, the most common cause of genital ulcers in the United States,⁵ typically manifests with multiple vesicular painful lesions, with or without lymphadenopathy. Constitutional symptoms, including fever, headache, malaise, and myalgias, occur in 66% of females and 40% of males.^5,7 Identification of HSV on culture or PCR can confirm the diagnosis.⁵

Behçet’s disease is a noninfectious syndrome associated with intermittent arthritis, recurrent painful oral and genital ulcers, uveitis, and skin lesions. While most symptoms of Behçet’s are self-limited, recurrent uveitis can result in blindness. A biopsy may be warranted to diagnose Behçet’s disease; the results may show diffuse arteritis with venulitis.^5,8

Continue to: NAAT is recommended to confirm the diagnosis

In the outpatient setting, diagnosis of LGV relies on physical exam, clinical presentation, confirmation of infection, and exclusion of other causes of genital ulcer, lymphadenopathy, and proctitis.³ Diagnostic tests include culture identification of C trachomatis, visualization of inclusion bodies on immunofluorescence of bubo aspirate, and positive serology for C trachomatis.^1-3 (Serology to differentiate LGV from non-LGV C trachomatis serovars is difficult and not widely available.)

Recommendations regarding lab studies have shifted away from serologic testing and toward the use of NAAT. NAAT via PCR has a sensitivity and specificity comparable to invasive testing methods: 83% and 99.5% with urine samples and 86% and 99.6% with cervical samples, respectively.⁹ NAAT has a sensitivity and specificity that is superior to culture for detecting chlamydia in rectal specimens¹⁰ and is preferred by patients because it doesn’t require a pelvic exam or a urethral swab.

Treat with antibiotics

Oral antibiotics are the treatment of choice for LGV. Standard treatment includes doxycycline 100 mg bid for 21 days. Women who are pregnant or lactating may alternatively be treated with macrolides (eg, erythromycin).^1,2,4 Buboes may be aspirated for pain relief and to prevent the development of ulcerations or fistulas.^3,4

Our patient was started on oral doxycycline, which resolved his fever and reduced the size of his ulcer. He was discharged on oral doxycycline and continued on the full 21-day course. Two weeks later, the ulcer and lymphadenopathy had completely resolved. On follow-up in our office, the resident physician who treated the patient in the hospital discussed future use of safe sexual practices.

CORRESPONDENCE
Jeffrey Walden, MD, Cone Health Family Medicine Residency, 1125 North Church Street, Greensboro, NC 27401; [email protected].

A 38-year-old man presented to our emergency department with a 2-day history of fever, general malaise, and a painless genital ulcer. He denied having any abdominal pain, myalgias, arthralgias, or other rashes. He had been treated about a month earlier on an outpatient basis with penicillin for a presumed diagnosis of syphilis, but his symptoms did not resolve. His medical history included well-controlled human immunodeficiency virus (HIV), hepatitis B, hypertension, anxiety, and fibromyalgia for which he took lisinopril, emtricitabine/tenofovir, metoprolol, and darunavir/cobicistat. He smoked a half-pack of cigarettes a day and had unprotected sex with men.

On physical examination, the patient was febrile (103.1^° F) with otherwise normal vital signs. A genital examination revealed a nontender, irregularly shaped 8-mm ulcer at the base of the glans penis (FIGURE). Tender unilateral inguinal lymphadenopathy was noted on the right side.

A chart review showed a normal CD4 count (obtained 2 months earlier). We were unable to access the results of his outpatient rapid plasma reagin test for syphilis. Due to the patient’s degree of pain from his lymphadenopathy, fever, and general malaise, he was admitted to the hospital for overnight observation.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Based on the patient’s history and clinical presentation, we suspected lymphogranuloma venereum (LGV). A positive nucleic acid amplification test (NAAT) for Chlamydia trachomatis confirmed the diagnosis.

LGV is an infection caused by C trachomatis—specifically serovars L1, L2, and L3—that is transmitted through unprotected sex.^1-3 During intercourse, the serovars cross the epithelial cells through breaks in the skin and enter the lymphatic system, often resulting in painful lymphadenopathy. LGV is more commonly reported in men (primarily men who have sex with men [MSM]), but can occur in either gender.⁴ The true incidence and prevalence of LGV are difficult to ascertain as the disease primarily occurs in tropical areas, but outbreaks in the United States occur predominantly in patients infected with HIV.

The 3 stages of infection

Following an incubation period of 3 to 30 days, LGV progresses through 3 stages. The first stage involves a small, painless lesion at the inoculation site—usually the prepuce or glans of the penis or the vulva or vaginal wall. The lesion typically heals in about one week.^1,2,4

Lymphogranuloma venereum is more commonly reported in men—primarily men who have sex with men.

Two to 6 weeks later, LGV enters the second phase, characterized by painful unilateral inguinal or femoral lymphadenopathy or proctitis. Inguinal and femoral lymphadenopathy is more common in men.^1,4 The “groove sign”—lymphadenopathy occurring above and below the inguinal ligament—is seen in 10% to 20% of men with LGV.^1,3 In women, lymphatic drainage occurs in the retroperitoneal or intra-abdominal nodes and may result in abdominal or back pain.^1,4 Proctitis is reported primarily in women and in MSM.^1,4

Tertiary LGV (aka genitoanorectal syndrome) is also more common in women and MSM, due to the location of the involved lymphatics. In this stage, chronic inflammation causes scarring and destruction of tissue.^1,4 Left untreated, LGV can lead to lymphatic obstruction, deep tissue abscesses, chronic pain, strictures, or fistulas.^1,3,4

Continue to: Other genital ulcers can mimic LGV

LGV can be confused with other causes of genital ulcers (such as syphilis, chancroid, herpes simplex virus, and Behçet’s disease). Identification of the causal bacteria is often needed to make a definitive diagnosis.

Syphilis, caused by the spirochete Treponema pallidum, initially manifests as a chancre (a single, well-demarcated, painless ulcer). It is less commonly associated with inguinal lymphadenopathy and can be diagnosed via serologic testing.^5,6

Chancroid is caused by Haemophilus ducreyi and manifests as a painful ulcer with a friable base covered with a necrotic exudate. It can be associated with tender unilateral inguinal lymphadenopathy.⁵ Due to the widespread availability of culture media to test for H ducreyi, the diagnosis of chancroid is based on the clinical exam plus a handful of clinical criteria: painful genital ulcers, no evidence of T pallidum infection, and negative culture or polymerase chain reaction testing (PCR) for herpes simplex virus (HSV).

HSV, the most common cause of genital ulcers in the United States,⁵ typically manifests with multiple vesicular painful lesions, with or without lymphadenopathy. Constitutional symptoms, including fever, headache, malaise, and myalgias, occur in 66% of females and 40% of males.^5,7 Identification of HSV on culture or PCR can confirm the diagnosis.⁵

Behçet’s disease is a noninfectious syndrome associated with intermittent arthritis, recurrent painful oral and genital ulcers, uveitis, and skin lesions. While most symptoms of Behçet’s are self-limited, recurrent uveitis can result in blindness. A biopsy may be warranted to diagnose Behçet’s disease; the results may show diffuse arteritis with venulitis.^5,8

Continue to: NAAT is recommended to confirm the diagnosis

In the outpatient setting, diagnosis of LGV relies on physical exam, clinical presentation, confirmation of infection, and exclusion of other causes of genital ulcer, lymphadenopathy, and proctitis.³ Diagnostic tests include culture identification of C trachomatis, visualization of inclusion bodies on immunofluorescence of bubo aspirate, and positive serology for C trachomatis.^1-3 (Serology to differentiate LGV from non-LGV C trachomatis serovars is difficult and not widely available.)

Recommendations regarding lab studies have shifted away from serologic testing and toward the use of NAAT. NAAT via PCR has a sensitivity and specificity comparable to invasive testing methods: 83% and 99.5% with urine samples and 86% and 99.6% with cervical samples, respectively.⁹ NAAT has a sensitivity and specificity that is superior to culture for detecting chlamydia in rectal specimens¹⁰ and is preferred by patients because it doesn’t require a pelvic exam or a urethral swab.

Treat with antibiotics

Oral antibiotics are the treatment of choice for LGV. Standard treatment includes doxycycline 100 mg bid for 21 days. Women who are pregnant or lactating may alternatively be treated with macrolides (eg, erythromycin).^1,2,4 Buboes may be aspirated for pain relief and to prevent the development of ulcerations or fistulas.^3,4

Our patient was started on oral doxycycline, which resolved his fever and reduced the size of his ulcer. He was discharged on oral doxycycline and continued on the full 21-day course. Two weeks later, the ulcer and lymphadenopathy had completely resolved. On follow-up in our office, the resident physician who treated the patient in the hospital discussed future use of safe sexual practices.

CORRESPONDENCE
Jeffrey Walden, MD, Cone Health Family Medicine Residency, 1125 North Church Street, Greensboro, NC 27401; [email protected].