Severe anorectal disease associated with lymphogranuloma venereum ompA -genotype L4 in Malta

Lymphogranuloma venereum (LGV), caused by Chlamydia trachomatis (Ct) ompA-genotypes L1–L3, has increased among men who have sex with men (MSM) in Europe. A novel Ct ompA-genotype L4 was recently described in Argentina, but clinical data remain scarce. We describe the first two cases of LGV caused by Ct ompA-genotype L4 diagnosed in Malta. Both patients were MSM living with HIV, presenting with severe anorectal disease: one with a chronic perianal fistula and the other with acute severe proctitis. Molecular genotyping confirmed ompA-genotype L4, and both patients responded to 21 days of doxycycline with clinical resolution. Neither reported recent travel, suggesting possible local transmission. These findings support the international spread of this emerging LGV lineage and raise concerns about its potential association with severe anorectal inflammation. Molecular surveillance and reporting of well-characterised cases are essential to define the epidemiology, clinical presentation and optimal management of Ct ompA-genotype L4 infection.