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Lymphographic Studies in Acute Lymphogranuloma Venereum Infection

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Lymphographic Studies in Acute Lymphogranuloma Venereum Infection Brit. J7. vener. Dis. (1976) 52, 399 Br J Vener Dis: first published as 10.1136/sti.52.6.399 on 1 December 1976. Downloaded from Lymphographic studies in acute lymphogranuloma venereum infection A. 0. OSOBA AND C. A. BEETLESTONE From the Special Treatment Clinic and the Departments of Medical Microbology and Radiology, University of Ibadan, Nigeria Summary 1954) described a convenient method of cannulating Lymphography, a radiological method of demon- the lymph vessels and injecting water-soluble strating lymphatic channels and nodes, has been contrastmedium, the procedurehas become extensively used to investigate three cases of acute bubonic used. Lymphography has been used in a variety of lymphogranuloma venereum (LGV). There is conditions in which the pathological process origi- nates in or is associated with lymph nodes (Koehler, general agreement that LGV has a predilection for 1968a, b). In lymphomas, the lymphographic lymphatic channels and lymph nodes. However, appearance can be pathognomonic, hence much very little is known of the extent of lymph node excellent work has been done in this field (Abrams, involvement in the early bubonic stage and whether Takahashi, and Adams, 1968; Lee, 1968; Rosenberg, there is merely a lymphangitis or complete lymph- 1968). However, little work has been done on atic obstruction. inflammatory conditions such as tuberculosis, syphilis The present study was undertaken to determine and lymphogranuloma venereum (LGV), which copyright. the lymphographic appearance in acute bubonic produce lesions in lymph glands. Because lympho- LGV, the extent of lymphatic node involvement in graphy is the only direct method of visualizing the early LGV, and the usefulness of the procedure in lymphatics and lymph nodes, and since it can objectively evaluate the inaccessible pelvic and the management of LGV patients. retroperitoneal lymph nodes (Koehler, 1968a), it The buboes were not outlined by this procedure. was thought worthwhile to study some cases of The vessel phase of the lymphogram appeared LGV by this procedure. normal, while the nodal phase showed a gradient of LGV has a predilection for the lymphatic channels http://sti.bmj.com/ pathological involvement from the inguinal region and lymph nodes, but very little is known of the lessening towards the lumbar nodes. The main extent of lymph node involvement in the early drawbacks of lymphography in LGV are the bubonic stage and it is uncertain whether the difficulty ofvisualizing the lymphatics in the negroid condition is merely a lymphangitis or causes a skin and the lack ofdiagnostic criteria for inflamma- complete lymphatic obstruction. This paper reports the results of a study of the tory diseases of the lymphatic system. The on September 28, 2021 by guest. Protected lympho- lymphographic appearances in acute bubonic LGV, graphic findings in LGV as described here may be the extent of lymphatic and lymph node involve- regarded as typical of LGV but cannot be accepted ment in early LGV, and the usefulness of the pro- as specific for LGV with a high degree ofconfidence. cedure in the management of patients with LGV. It is suggested that the procedure could be used for monitoring patients with the severe and late sequelae of LGV infection. Material The investigation was carried out on eight patients with Introduction acute classical bubonic LGV who had fluctuant un- ruptured buboes and had received no antibiotic therapy. Lymphography is the radiographic study oflymphatic The clinical diagnosis of LGV was confirmed by the vessels and lymph nodes. Since Kinmonth (1952, results Frei test and/or the LGV complement-fixation test (LGVCFT). Direct lymphography was attempted in all eight Presented at the 14th Annual Conference of Radiologists of West patients but satisfactory lymphograms were obtained in Africa at Abidjan, February 6, 1976 only three. Received for publication March 18, 1976 Address for reprints: Dr A. 0. Osoba, M.D., Department of Medical Syphilis was excluded by the VDRL test and the Microbiology, University of Ibadan, Nigeria FTA-200 test. Journal of Venereal Diseases 400 British Br J Vener Dis: first published as 10.1136/sti.52.6.399 on 1 December 1976. Downloaded from Method (b) of a homogenous reticular appearance with even The procedure of Kinmonth (1952, 1954) was used with distribution of the contrast material; some minor modifications. (c) with well-defined margins with the hilar area well Methylene blue was injected into the web space of the demonstrated by a smooth indentation. great and second toes. This dye was taken up by the Rounded lymph nodes with a structure looser than lymphatics draining the area. normal were considered pathological. These were A suitable vessel was isolated and cannulated. Lipoidal further divided according to their storage pattern. Ultra fluid was injected for a period of approximately and 2 hrs. Dosage never exceeds 1 ml./kg. body weight. Area of various sizes devoid of contrast medium Films were taken during injection of the lymph vessels with an appearance clearly different from the basic and again 24 hrs after the lymph nodes were filled. structure of the lymph node were regarded as filling The four standard positions to demonstrate inguinal defects. and retroperitoneal nodes were used (antero-posterior Lymph glands showing enlargement, a rounded supine, right and left oblique, and left lateral). This shape, and a relatively coarse structure were regarded permits projection of lymphatics free of the vertebral as suggesting acute inflammatory reaction (Wiljasalo, bodies and serves to minimize superimposition of glands. 1965). No complications were encountered by us during these In the present study, anatomical and pathological procedures. interest was focused on the lymph vessels and nodes of the inguinal region, the pelvis, and the retro- Results peritoneal space. Interpretation of radiographs The main lymphographic findings and the clinical The criteria used in the interpretation of the radio- features of each are summarized in the Table. graphs were those accepted by several authors Figs 1 and 2 show the lymphatic 'vessel phases' (Wiljasalo, 1976; Fischer, 1968; Viamonte, 1968; a, b; of Cases 1 and 3. The 'nodal phases' are illustrated Wallace and Jackson, 1968; Wallace, Jackson, and in Figs 3 to 5. Greening, 1962; Forstrom, Hannuksela, and Rauste, There was a gradient of pathology which de- 1973). to lumbar nodes. creased from the inguinal region the copyright. The lymphatic chains were considered to be There were large masses of pathological lymph nodes normal if they were not dilatated, tortuous, displaced, showing evidence of inflammatory involvement in or with evidence of obstruction, and ran a course the inguinal regions in all cases. The buboes clinically paralleling that of the arteries and veins. Lymph demonstrable were not outlined by the lymphograms nodes were normal if they were: and contrast was not taken up by these pathological (a) oval, elongated, or triangular and flattened; nodes and abscesses. TABLE Clinical features and lymphographicfindings in three cases of acute lymphogranuloma venereum http://sti.bmj.com/ Lymphographic findings Highest Case no. Clinical Frei test LGVCFT Vessel phase Nodal phase features titre Inguinal Iliac Lumbar Case 1 Primary penile +ve 1/64 Normal Bilateral oval Bilateral Normal coarse (Figs 1 lesion with left No obstruction enlarged moderately on September 28, 2021 by guest. Protected and 3) inguinal bubo or displacement granular glands enlarged 1 week's Central filling granular glands duration defects No filling Incubation defects period 3 wks Case 2 Primary penile +ve 1/32 Normal Right side Some glands Some glands (Fig. 4) lesion with No obstruction rounded rounded and rounded and right inguinal or displacement enlarged granular granular bubo on right side granular glands Central filling Replacement or 4 days' duration Cannulation Peripheral and defects filling defects Incubation on left side central filling Other normal Other normal period 3 wks unsuccessful defects glands present glands present Case 3 Primary penile + 1/16 Moderate Mass of enlarged Similar to Moderate (Figs 2 lesion with right (Induration obstruction rounded glands inguinal glands enlargement and 5) inguinal bubo in both with dilatation Markedly but only to a and granularity 1 week's control and of lymphatics coarsened lesser degree Filling defects duration test arms) on right side storage pattem Incubation No displace- Some loss of period 3 wks ment of nodes marginal sinus or vessels Filling defects ± =Equivocal venereum 401 Lymphogranuloma Br J Vener Dis: first published as 10.1136/sti.52.6.399 on 1 December 1976. Downloaded from :4 .W. ij ; ?" },.-;u- Case 1. Filling of lymph vessels and nodes FIG. 3 Case 1. Nodal phase, showing oval, enlarged, coarse and granular glands with central filling defects on both sides. Bubo not outlined. copyright. primary and secondary neoplastic involvement of the lymphatic system (Howett and Elmendorf, 1965). However, published data on the lymphographic appearances of inflammatory conditions, such as tuberculosis and LGV, are lacking. A possible explanation may be the lack of suitable clinical material. The main limiting factor in our study has been the relatively small numbers of patients with unruptured buboes and of patients that had not had http://sti.bmj.com/ antibiotics before consultation. Lymphography in this small series of patients has provided the visualization of lymph nodes in the inguinal, iliac, and lumbar regions and an opportunity
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