Causes and Treatment of Hodgkin’s lymphoma
Sexually transmitted Hodgkin’s lymphoma is a disease with many names, for example, lymphogranuloma inguinale or Nicolas-Favre disease. The pathology is a form of urogenital chlamydiosis but it is enclosed into a separate nosology due to its specific clinical presentation.
The disease is widespread in certain areas as it is usually manifested in the regions with tropical and subtropical climate. The disease occurs very often in many areas in Africa, South America, South Asia and in the ports of Europe and the USA. For other countries, this is an imported infection.
Lymphogranuloma inguinale occurs in men more frequently and is characterized by a stormy clinical picture.
Causes of Hodgkin’s lymphoma
The causative agent is Chlamidia trachomatis, namely, its L-1 – L-3 serotypes which are known by their affinity to the lymphoid tissues.
Chlamydiae are bacterial microorganisms which are known by their similarity to viruses. They can live and propagate only within a cell. Grams staining gives negative results for chlamydiae. Microorganisms are very sensitive to the environment and they quickly die.
The main transmission routes of sexually transmitted Hodgkin’s lymphoma are:
- transplacental (theoretically it is possible but has never been detected);
- domestic (through the contact with affected skin and mucous membranes).
The incubation period of lymphogranuloma inguinale can last from 5 to 30 days.
There are 3 stages of the disease:
- primary affection (does not necessarily occurs);
- secondary period (specific clinical picture);
- third period.
In some cases, lymphogranuloma inguinale in women occurs without any clinical presentation and is diagnosed accidentally in a routine examination.
The first signs of Hodgkin’s lymphoma are not specific and occur not in every patient. The major symptom is a papule or a vesicle on hyperemic base. Further, the rash grows into erosions or ulcers and inflammation develops around it. Indurations are not palpated. In men, the symptoms of Hodgkin’s lymphoma may be similar to balanoposthitis (erythematic or erosive).
Location of rash in men:
- glans penis;
- outer or inner part of the foreskin;
- around the outer part of the urethra.
Location of rash in women:
- labia majora and labia minora;
- vaginal membranes;
- uterine neck (its vaginal part).
The primary affection by sexually transmitted Hodgkin’s lymphoma rapidly disappears and sometimes the patients do not even notice it and fail to visit a doctor.
The symptoms of this period appear in a week or in 2 months after the primary affection. The clinical picture is very characteristic of Nicolas-Favre disease nosology.
The symptoms of Hodgkin’s lymphoma in adults are closely connected with the lymphoid tissues affection. In this period the signs of regional unilateral (bilateral is also possible) lymphadenitis or periadenitis appear. The lymph nodes of inguinal region, thigh or pelvic are affected most often.
The body temperature in Hodgkin’s lymphoma is febrile (38-40 degrees). Lymph nodes are painful and the skin around them is reddened.
Further regression of chlamydial lymphogranuloma is characterized by softening of affected lymph nodes. Later they need to be dissected or fistulized, leaving the scars are left on the skin.
The signs of Hodgkin’s lymphoma relapse have not been detected in any of the studies. However, the pathology may be torpid, it means that it can last for months or even years.
According to the recent data, in the course of chlamydial lymphogranuloma development the following organs can also be affected:
- lymph nodes of the upper extremities and of the neck;
- the spleen (because of a large mass of lymphoid tissue);
- joints (rarely);
- ovaries and epididymis;
- conjunctiva and eye cornea;
- linings of the brain.
This period of sexually transmitted chlamydial lymphogranuloma occurs if the disease is left untreated. The period starts in several months or even years since the onset of the infection. Women have a greater risk for this stage to occur.
Clinical presentation of lymphogranuloma correlates with the genitoanorectal syndrome. It all starts with proctitis when the mucous membrane of the lower rectum is inflamed (it swells and bleeding is also possible) and covered with purulent deposit. The skin of the genitals swells and reddens.
Consequences of Hodgkin’s lymphoma:
- perirectal abscesses;
- anal or rectovaginal fistulas;
- penile and scrotal elephantiasis in men and labial elephantiasis in women;
- labial deformations (in rare cases, clitoral);
- strictures in the rectum, vagina and urethra.
Diagnosis of Hodgkin’s lymphoma
Diagnosis of the disease is complicated by the fact that chlamydiae are obligate intracellular parasites and it is impossible to inoculate them on culture media. Only a few experimental scientific centers are able to use culture media for chlamydiae.
Lymph node scrapping can confirm sexually transmitted Hodgkin’s lymphoma. Among the serological tests in Hodgkin’s lymphoma a blood test is used.
For the most accurate diagnosis, a patient should not take tetracycline group of antibiotics a month before the tests.
- Cytological method
This method implies detection of special inclusions within the cells affected by chlamydiae. However, this method is not very reliable as it detects a very small percent of the inclusions within a cell. Besides, cytology takes a lot of time and should be performed only be an experienced specialist.
- Serological methods:
These tests help to detect antibodies to chlamydial antigens. The most optimal variant is a complement-fixation test with the titer is 1:128 and over which indicates the disease.
- Quick test
“Chlamygen” is the latest innovation of the USA which is an applicator detecting chlamydiae in smears of patients in 10 minutes. The test is performed in the outpatient setting.
Earlier, a Frey test or skin sensitization testing was widely used, but today it is not used anymore because the production of the vaccine was discontinued and also due to some risks it posed for the patients.
Treatment of sexually transmitted Hodgkin’s lymphoma
The treatment of Hodgkin’s lymphoma includes the use of tetracycline antibiotics. The duration of the treatment course is two weeks but it depends on the severity and the stage of the disease. If necessary, the treatment may be prolonged. In case, there are contraindications for tetracycline, erythromycin is used. In some cases, antibiotics are replaced with sulphanilamide but only in exceptional cases as it has a number of negative effects.
Sexually transmitted Hodgkin’s lymphoma in pregnant women
Hodgkin’s lymphoma and pregnancy are compatible conditions. There are no data about fetus infection during pregnancy or delivery.
In a routine sexual health examination, a pregnant woman can be diagnosed Hodgkin’s lymphoma. However, if this is an early diagnosis, the disease will not cause much harm to a woman or a fetus. A woman is not treated as the use of antibiotics (especially, tetracycline) is contraindicated in pregnancy.