Granuloma inguinale in Northern Queensland

Donovanosis of the oral cavity. Case report

Donovanosis (Granuloma inguinale) is an infectious disease, the effects of which are usually confined to the genital region. Various extragenital manifestations of the disease have been described. This report describes a case where the condition represented in the oral cavity some time after the apparently successful treatment of the genital lesion. Members of both the medical and dental profession serving the northern parts of Australia and adjacent tropical regions should be aware of the possibility of encountering this disease. Delay in its diagnosis may result in extensive tissue destruction and a potentially fatal outcome. Intensive antibiotic therapy followed by long-term follow-up is usually curative.

Ceftriaxone in the treatment of chronic donovanosis in central Australia

OBJECTIVES

To determine the effectiveness of intramuscular (IM) ceftriaxone sodium in the treatment of chronic donovanosis, and the acceptability to patients and staff of supervised outpatient treatment in rural clinics.

METHODS

We collected demographic and sexual health data from participants using a standard questionnaire, and recorded their donovanosis lesions at baseline using genital diagrams. Treatment consisted of a single daily IM injection of 1 g ceftriaxone diluted in 2 ml of 1% lignocaine. Clinic staff followed patients for between three and 12 months, enabling the detection of late recurrences.

SETTING

Rural Aboriginal communities in central Australia.

PARTICIPANTS

The study describes eight women and four men with chronic donovanosis in detail, and summarises the outcome in 12 additional cases. All cases presented with advanced lesions which had failed to heal on the standard oral antibiotic regimens used in the region.

RESULTS

The mean duration of infection was 3.0 years (SD 1.9 years), and between four and ten courses of antibiotics had been prescribed for six of the 12 patients. Patients received between 7-26g of ceftriaxone sodium. Clinical improvement was dramatic in most lesions, and four patients healed completely without recurrence after a total 7-10g of ceftriaxone. Mild recurrences responded to further ceftriaxone or short courses of oral antibiotics. Treatment was well tolerated, and both patient and staff compliance high.

CONCLUSION

Donovanosis is an important cause of chronic genital ulceration in central Australia, and is potentially an important risk factor for HIV transmission in Aboriginal communities. The pharmacokinetics and safety profile of ceftriaxone make it a useful and cost-effective agent in the ambulatory management of donovanosis, especially in remote communities. Supervised multidrug regimens of two or more long-acting agents may provide the best answer in donovanosis, administered through the existing health care infrastructure.

The diagnosis and treatment of donovanosis (granuloma inguinale)

Donovanosis is a predominantly tropical cause of genital ulcer occurring chiefly in small endemic foci in all continents except Europe. Diagnosis requires the careful collection, staining and examination of smears or biopsies of characteristic genital and, occasionally, extragenital lesions for demonstration of the pathognomonic Donovan bodies (Calymmatobacterium granulomatis) within histiocytes. Successful isolation of C. granulomatis has rarely proved feasible, the last report being in 1962. Donovanosis has a characteristic histopathological picture which occasionally simulates epithelioma. The antibiotics reported as showing good activity in donovanosis are those with good activity against gram negative bacilli and whose lipid solubility ensures good intracellular penetration. They include streptomycin, chloramphenicol, erythromycin, lincomycin, cotrimoxazole and the tetracyclines. More recently, good results have been reported with norfloxacin and thiamphenicol. The treatment of donovanosis in pregnant women and patients with AIDS poses special problems. Complications of donovanosis such as elephantiasis, stricture and pelvic abscess may require surgery. Contacts should be traced for examination but only treated if lesions are found.

Extragenital granuloma inguinale in North Queensland

Two cases of extragenital granuloma inguinale are presented. A 41-year-old female presented with fever, a swollen knee joint and osteolytic lesions involving distal bones, and a 49-year-old male had multiple faecal fistulae in the lower abdomen with extensive involvement of pelvic organs. The diagnostic difficulties presented by such cases and the various types of extragenital pathology that have been described in this disease are discussed.