1. Debbie Richmond NP-C ACRN AAHIVS Wayne State University
LGV and HCV Clusters in PLWH: The Nurse’s Role in Identifying and Managing Emerging Issues
Debbie Richmond NP-C ACRN AAHIVS Wayne State University
HIV/AIDS Program
June 1, 2018

2. Our Programs WSUPG Adult Infectious Disease Clinic
~2000 HIV infected patients
Horizons Project: HIV care for youth
~280 HIV infected patients age 14 to 24
As well as youth needing PEP and/or PrEP
Detroit Public Health STD Clinic
Offering STD and HIV testing; PrEP and PEP
MATEC Michigan

3. Nurses Roles in Outbreaks
Severe Acute Respiratory Syndrome-SARS
Swine-origin influenza A
Middle East respiratory syndrome-MERS
Norovirus-camp nurses; school nurses
Ebola
Zika
Measles-school nurse teams
The topic I was asked to speak on was the role of the nurse in outbreaks.
I have been working on 2 outbreaks that happened within our patient population LGV and HCV
So I attempted to do some literature review of nurses in other outbreaks…

4. Closer to home… HIV Hepatitis STDs
Our roles in these outbreaks is more familiar to some of us…

5. Nurses with different roles…
Medical assistants, RN,BSN,MSN,NP,DNP…
public health nurses
non public health
Inpatient
Clinic care nurses
Home care nurses
School nurses

6. How does it affect us…
Minimal literature found on how does identifying and managing an outbreak affect nurses.
Lack of knowledge
Fear
Stress
Preparedness
Resources

7. First Case: Genital Ulcer
Male in late 40’s; MSM and HIV positive for more than 15 years; HIV RNA PCR <20 on HIV meds
Presented with non healing penile ulcer
Tests were negative for Herpes and Syphilis
Developed large right inguinal lymph node
Physician colleague suggested a swab of the ulcer for Ct and the probable diagnosis of LGV
Swab was positive for Ct but we did not have access to confirmatory tests
Symptoms resolved on doxy 100 mg BID for 21 days

8. What did I do about this…
This was a different STD than we usually see
I did some reading and wanted to know if it would fall under health department and partner notification
I called my networks and found that we have an STD epidemiologist and that LGV is reportable and partners are to be notified.

9. Then what happened…
Another patient of mine came in with same symptoms-he reported a partner at another hospital with symptoms of probable proctitis that can happen with LGV
And another patient with a lingering ulcer-that we swabbed and was positive for Ct
Then we were on Michigan alert and conference calls with the CDC

10. Outline CDC 2015 LGV Overview and Guidelines Testing for LGV
Treatment of LGV
LGV Patient Cases Review
Genital syndrome
Proctitis syndrome
Hepatitis C outbreak in MSM / non IVDU

11. Epidemiology LGV prevalence is not known in the U.S.
Not reportable in all states
Literature review includes sources from:
United Kingdom
Netherlands
Spain
Hungary
New Zealand
Canada

12. Eurosurveillance 2003-2015 2003 – 1 case reported
2004 – 28 cases reported
2005 – 220 cases reported…..
2014 – 679 cases reported
Positive chlamydia samples from HIV infected MSM patients in the UK are tested for LGV and they have identified that approximately 25% of them have asymptomatic LGV
Eurosurveillance, Volume 20, Issue 48, 03 December 2015

13. CDC: LGV Genital Symptoms
Lymphogranuloma venereum (LGV) is caused by C. trachomatis (Ct)serovars L1, L2, or L3
self-limited painless genital ulcer or papule
tender inguinal and/or femoral lymphadenopathy that is typically unilateral

14. CDC: LGV Rectal Symptoms
proctitis / proctocolitis
can mimic inflammatory bowel disease
mucoid and/or bloody rectal discharge
anal pain
constipation
tenesmus
fever

15. Untreated and Chronic LGV
If not treated early:
can be an invasive, systemic infection
leading to chronic colorectal fistulas and strictures
reactive arthropathy has also been reported

16. Routine Clinical GC/CT NAAT Testing
Anal swab for GC/Ct
Use the endocervical swab, insert past the sphincter and apply gentle pressure into the crevices of the rectum
Throat swab for GC/Ct
Gentle swabbing of oropharynx, tonsils, uvula and crevices
Urine for GC/Ct
Have patient give first voided 10 cc of urine
*Penile ulcer swab for Ct in suspect case*
GC is Neisseria gonorrhea; Ct is chlamydia trachomatis
NAAT testing is the DNA testing of the organism-not a culture
We use the pink swab from the BD ProbeTec collection kit for endocervical specimens. It may mistake oral Neisseria of other species for Neisseria gonorrhea but this is not relevant to the Chlamydia outbreak

17. CDC LGV Diagnostic PCR Report
There is no licensed LGV test for clinical use
PCR-based DNA sequencing can be used to differentiate LGV from non-LGV C. trachomatis
Currently available at the CDC lab
Results take days
Results are intended for outbreak investigation and for research purposes only

18. Example of CDC LGV PCR test result
“Specimen Process: Qiagen DNA mini kit protocol
Diagnostic Assay: Real-time Multiplex PCR for LGV
Results: The specimen tested positive for LGV C. trachomatis “
For questions regarding specimen collection, transport, storage and lab testing-contact – Dr. Cheng-Yen Chen at
This is what the test result looks like when you get it back from the CDC.

19. Process of LGV Confirmatory Testing
Screening of the patient: risk factors and symptoms
Routine NAAT swab of penile ulcer or anus
If the NAAT is positive for Chlamydia per the clinic or hospital lab:
Fill out 2 page CDC form “CDC Specimen Submission Form”
Have your lab send the “remnant” of the sample along with the CDC form to the CDC via your State lab

20. CDC Guidelines for LGV Treatment
Persons with a clinical syndrome consistent with LGV, including proctocolitis or genital ulcer disease with lymphadenopathy, should be presumptively treated for LGV.
Recommended Regimen
Doxycycline 100 mg orally twice a day for 21 days
Sexually Transmitted Diseases. 44(4): , April 2017
Recent article in April 2017 STD journal confirms this treatment as 97% effective

21. CDC Guidelines for Partners
Management of Sex Partners
Sexual contact with a patient who has LGV within the previous 60 days should tested for urethral, cervical, or rectal chlamydial infection depending on anatomic site of exposure.
Treat presumptively with a Chlamydia regimen (azithromycin 1 g orally single dose or doxycycline 100 mg orally twice a day for 7 days).

22. LGV Case Classification
Confirmed Case
A probable case with laboratory confirmation LGV‐specific PCR
Probable Case
One or more of the following:
1) Patient with one or more signs or symptoms compatible with LGV and other causes of LGV‐like symptoms (e.g. syphilis, gonorrhea, HSV) ruled out AND a positive C. trachomatis from culture or NAAT from a body site associated with symptoms
2) Sexual partner of a probable or confirmed case AND a positive C. trachomatis result by culture or NAAT
Suspect Case
Both of the following:
1) A clinically compatible case as defined by one or more signs or symptoms compatible with LGV
2) A sexual partner of a probable or confirmed case

23. Our LGV Cases as of
32 confirmed cases with positive LGV PCR at CDC
30 with proctitis
1 with penile ulcer.
1 with both penile ulcer and proctitis.
9 probable cases = early in the outbreak
3 with penile ulcers
6 with proctitis
Plus 3 repeat confirmed LGV cases with proctitis
-1 reports not taking his original dose of doxy

24. Asymptomatic Proctitis Case
25 year old sexual contact named by our first case
DIS worker had some difficulty finding and getting him in for care
Asymptomatic- he was seen in the STD clinic and given their standard and complete testing that included HIV testing
Anal swab positive for Ct and confirmed as LGV
Treated with doxycycline
HIV test came back positive and he has been engaged in the HIV clinic

25. Symptomatic LGV Proctitis
Male in late 40’s; MSM and HIV + for many years; HIV RNA undetectable on treatment
Presented in the ER last year with c/o rectal bleeding
Referred to surgeon with c/o pain with bowel movements
Anal ‘Exam Under Anesthesia’ and biopsy
Another surgery clinic appointment
Abd/pelvic Ct scan suggests cancer
Colonoscopy with several biopsies
Follow up visit with surgeon = 15 lb weight loss
Patient comes for routine HIV clinic visit and the doctor evaluates patient for probable LGV diagnosis

26. PrEP Patient
Reported by Detroit Health Dept STD clinic colleague in February 2017
36 year old male presented with anal pain
HIV negative
On PrEP
Reports 15 male partners in the past 2 months
Anal swab positive for Ct
Confirmed positive for LGV by the CDC
Also with anal GC

27. Proctitis Diagnostics
~6 patients had abd/pelvic CT scans
Examples of actual results:
“diffuse thickening of the wall of the rectum with perirectal mildly enlarged lymph nodes suggestive of proctitis”
“Anal rectal cancer with regional and retroperitoneal metastatic involvement; moderate fecal stasis”

28. Colonoscopy and Biopsy
5 patients had a colonoscopy
Ulcerated anal mass
Rectal ulcers
1 patient had sigmoidoscopy
Proctitis
Biopsies
Adenoma
Colonic mucosa
Inflammation

29. Examples of Proctitis Symptoms
54 year old called and came to clinic with report of “hemorrhoids” flaring along with constipation
25 year old reported “worsening” of his chronic anal warts
26 year old reports worsening constipation, anal pressure and feeling like he needs to move his bowels every 30 minutes-making it difficult to work at his job-he was miserable!

30. MMWR Notes from the Field
Cluster of Lymphogranuloma Venereum Cases Among Men Who Have Sex with Men — Michigan, August 2015–April 2016
MMWR Morb Mortal Wkly Rep 2016;65:920–921

31. Additional testing for patients being evaluated for LGV
Other STDs need to be checked
Syphilis serology sequence
GC/Ct NAAT of other exposed sites
Herpes PCR on all ulcers
Hepatitis screening, including annual/PRN Hepatitis C
HIV testing (prefer 4th generation test) and HIV prevention counseling
Always perform if HIV negative or unknown HIV status
Offer PrEP if HIV negative as they may be at high risk
Repeat HIV testing per protocol

32. Concomitant STIs and Connections
New HIV infection
Hepatitis C
Syphilis
Gonorrhea
Herpes
Social media
Jack’d
Grindr

33. Hepatitis C infections in MSM
~5 of our patients with LGV also tested positive for Hepatitis C
We began to notice other new Hepatitis C infections in our MSM/non IVDU patients so we reported these to the state viral hepatitis team
At least 30 cases of HCV in MSM have been reported in the SE Michigan cluster, with 10 of them studied to be linked

34. Poster presented at 2016 STD Prevention Conference
Cluster of Sexually Transmitted Hepatitis C Virus Among the MSM Population in Southeast Michigan Jenny Gubler, MS1, Sandra Johnson, BS2 and Joseph Coyle, MPH1, 1Commumicable Disease Division, Michigan Department of Health and Human Service, Lansing, MI, 2STD Surveillance and Intervention, Michigan Department of Health and Human Service, Detroit, MI The samples are being sent to the CDC for molecular analysis

35. Coinfected LGV and HCV 32 year old MSM patient July 2015:
AST = 304 and ALT = 333
October 2015
AST = 39 and ALT = 49
December 2015:
he came in with symptoms of proctitis
Hepatitis C test was positive
Anal LGV test was positive

36. Interesting HCV Case Routine visit in March 2017
LFTs elevated; AST=368 and ALT=366
RPR elevated up to 1:32
Hepatitis C antibody negative
Last tested HCV negative 8 months earlier
When he came in for syphilis treatment one week later, we ordered hepatitis C as PCR viral load and it was positive at 529,862

37. HCV/HIV/MSM Recent count in our clinic is ~ 32 patients
We are working to treat and cure these patients
My next goal is to review the cases and assess who has been treated
To look at who has achieved 12 week SVR
To look at who is lost to follow up

38. This is the CDC recommended testing sequence for identifying HCV infection;
For persons who might have been exposed or immunocompromised-test for HCV RNA-viral load.

39. Our Roles Student We may be an expert in our current role
But I encourage you to be open to always knowing there is something new to learn everyday.
We need to remain aware of the bigger picture
Our patients are our teachers.

40. Clinician: Using your expertise, training and knowledge base Curiosity
Documentation
And if a signal of outbreak or something happening beyond your patient-be open to seeing the forest, not just the tree

41. Advocate Our patients and their communities need a voice
Sometimes we are the only ones that can speak up for them
If we see something like an outbreak or an issue that is affecting their community we may be the best or the only people that can bring it to light

42. Collaborator: ‘play well with others’
Networking; stepping outside the box! Look where I stepped...health dept, CDC!!
All in an effort to meet the needs of our patients and their community

43. Educator
Here I am again. I have presented this information several times.
Each time someone comes up and may state they have seen a possible LGV case but was not aware of how to make the diagnoses.
But the most rewarding is to hear my patients report that they share this information about health to their peers.
THAT is what it is all about to me. And where I see my main role in these outbreaks

44. Contacts and Thanks! CDC Staff-partially listed in the MMWR article
Michigan Department of Health and Human Services
STD and Hepatitis Divisions
Surveillance
Disease Intervention Specialists
Detroit Public Health STD Clinic
WSU Adult Infectious Disease Clinic and Adolescent HIV Clinic colleagues