Donovanosis With Bowen Disease

A 45-year-old farmer presented with ulcers and plaques over his scrotum for the past 4 to 5 years. The condition started as a small lesion on the shaft of the penis, which improved with treatment; however, after 2 to 3 months, papulonodular lesions developed on the scrotum, which increased in size and subsequently broke down to form ulcers. He denied drug abuse but had a history of multiple unprotected sexual exposures. He was prescribed oral antibiotics, which improved the lesions, but he failed to take the antibiotics for more than a week. He also used powders, lotions, and salves (exact nature not known), which did not help and sometimes even burned the skin. After stopping the medicine, he developed new lesions that followed a similar course. Examination revealed nontender ulcers on the scrotum with raised, rolled-out margins and pale red, granulation tissue that bled on touch (Figure 1). In addition, there were nodules with a pinkish red granular surface and scaly erythematous plaques on the scrotum. Regional lymph nodes were not enlarged.

Granuloma inguinale in a 51-year-old man

Granuloma inguinale, or Donovanosis, is a rare, sexually transmitted ulcerative disease primarily affecting the genital area. In this report, we present a case of a 50-year-old man that was diagnosed with granuloma inguinale after a 2-month history of a penile ulcer. Histological analysis demonstrated the presence of Donovan bodies within macrophages, confirming the diagnosis. He was subsequently treated with trimethoprim/sulfamethoxazole with improvement in the ulcer. This case serves as a reminder to clinicians that although granuloma inguinale is rarely encountered in the US, it should still be suspected in patients with non-healing penile ulcers.

Cutaneous metastases of rectal mucinous adenocarcinoma mimicking granuloma inguinale

A 46-year-old man complained of ulcerovegetative lesions in the anogenital region, which he had noted one month prior to presentation. The patient had a history of travel to African countries. Therefore, the ulcerovegetative lesions of the patient were suspected to be granuloma inguinale (GI). Calymmatobacterium granulomatis was not observed in the direct examination of scrapings collected from the base of the ulcerovegetative lesion. Instead, a histological examination revealed cutaneous metastasis of mucinous adenocarcinoma of the rectum. Therefore, a diagnosis of GI was eliminated. As the patient did not report his history of rectal cancer and had travelled to African countries, we had primarily focused on the diagnosis of GI.

Malignant transformation of donovanosis (granuloma inguinale) in a HIV-positive patient

Donovanosis is endemic in various parts of the world. Although donovanosis has been reported to co-exist with the human immunodeficiency virus (HIV) infection, to our knowledge there have been no reports of co-existent squamous cell carcinoma (SCC) in an HIV positive patient. In our case the patient did not respond to treatment for donovanosis and on biopsy we realized that the patient had coexistent SCC, which is hitherto unreported with granuloma inguinale.

Oral donovanosis

A 23-year-old male presented with oral ulcers. Tissue smear showed Donovan bodies. The patient was treated with oral tetracycline.

Disseminated donovanosis (granuloma inguinale) with osteomyelitis of both wrists

Donovanosis is a sexually transmitted infection which presents with genital ulceration and inguinal lymphadenopathy. Rarely, it presents with extra-genital manifestations. We present a case of disseminated donovanosis with cervical ulceration, massive pelvic lymphadenopathy, osteomyelitis of the wrists and septic arthritis of the knees and right elbow. A 23-year-old gravida two presented with wasting, oedema, ascites, bilateral iliac lymphadenopathy, anaemia and a large ulcer of the cervix uteri. Two months later in the outpatient clinic, she was much improved but still had post-coital bleeding and a hyperaemic cervix, suggestive of persistent infection. The course of antibiotics was therefore repeated. Histopathological examination of a specimen from colposcopic biopsy of the cervix uteri revealed granuloma inguinale. She improved after several courses of antibiotics, blood transfusion, surgical débridement and aspiration of affected joints.

An uncommon cause of a destructive vulval lesion

We present a case of a 39-year-old woman with a vulval lesion, which macroscopically looked consistent with a fungating squamous cell carcinoma of the vulva. However, further investigations demonstrated a less common cause for this presentation.

Transepithelial elimination of cutaneous vulval granuloma inguinale

BACKGROUND

Transepithelial elimination (TEE), a distinct and well-known entity, is a process during which the skin eradicates undesirable or irritative dermal substances through intact epidermis or follicular epithelium by passive or active means. Although TEE is being described in an increasing number and range of pathological processes, to date, TEE of granuloma inguinale (GI) remains unrecorded in the English-language literature. The aims of this study were: 1) To appraise the light microscopic and ultrastructural morphological epidermal changes that are associated with TEE of cutaneous vulval GI; and 2) To determine the role of intra-epidermal leucocytes and histiocytes in the pathogenesis of TEE of vulval GI.

METHODS

This is a retrospective 9-year histopathological review of all cases diagnosed and coded as vulval granuloma inguinale in the Department of Anatomical Pathology, Nelson R. Mandela School of Medicine, University of Natal, Durban, South Africa. Ultrastructural evaluation was performed on selected cases using a Jeol transmission electron microscope.

RESULTS

Of 53 skin biopsies from 47 patients with vulval GI, 43 were suitable for the study. The age range of patients was 15-40 years (mean age=22 years). There were eleven papular, twelve nodular, seven verrucous and thirteen ulcerative lesions. Donovan bodies within macrophages, free-lying Donovan bodies and dense aggregates of neutrophils and plasma cells were seen in the dermis of all biopsies. There was consistent overlying pseudoepitheliomatous hyperplasia. The dermal inflammatory infiltrate hugged the dermo-epidermal junction and appeared entrapped between elongated and acanthotic epidermal rete ridges and pegs. Transepidermal neutrophil microabscesses, histiocytes containing Donovan bodies and neutrophilic and histiocytic fragmentation were present. A variable number of free-lying and intra-histiocytic Donovan bodies and neutrophils were present on the surface of the epidermis. On ultrastructural investigation epidermal spongiosis, intracellular oedema, free-lying, intra-neutrophilic and intra-histiocytic Donovan bodies, and intact and degenerating neutrophils and histiocytes were evident between keratinocytes. The degenerative histiocytes demonstrated marked vacuolation, mitochondrial swelling and bacilli within phagolysosomal vacuoles, bound by intact or disrupted limiting membranes.

CONCLUSION

The inflammatory infiltrate at the epitheliomesenchymal interface, pseudoepitheliomatous hyperplasia, intra-epidermal accumulation and disintegration of neutrophils and histiocytes, and the associated release of lytic enzymes, play important contributory roles in TEE of GI. TEE of infectious agents is a poorly recognised mechanism of spread of infectious diseases and represents a public health hazard. In cutaneous vulval GI, TEE is highlighted as a hitherto unrecognised, potential method of spread of Calymmatobacterium granulomatis.

Granuloma inguinale (donovanosis) presenting as a neck mass in an infant

A case of granuloma inguinale (GI) presenting as a lateral neck mass in a 4-month-old, HIV-positive infant is described. The histological features of the mass were typical of GI, with numerous macrophages containing intracellular organisms with a "closed-safety-pin" appearance. This is a rare occurrence, and the mode of transmission of infection is discussed. An awareness of GI in infants by both clinicians and pathologists is important to prevent morbidity and allow for prompt institution of appropriate treatment.

Ultrastructure of Calymmatobacterium granulomatis: comparison of culture with tissue biopsy specimens

The ultrastructural features of cells of Calymmatobacterium granulomatis from monocyte co-cultures and tissue biopsy specimens were compared. In cultures the bacteria were mainly extracellular, i.e., not within membrane-bound vacuoles. The bacterial body was surrounded by a uniformly extensive homogeneous layer with a relatively high electron density. This layer varied considerably in tissue biopsy specimens, having either homogeneously electron-dense or delicate web-like structures with varying density and thickness. In tissue specimens the bacteria were located predominantly within vacuoles of varying sizes in the cytoplasm of the macrophages and, occasionally, extracellularly within the intercellular spaces of the stroma. The bacterial cytoplasm contained ribosomes scattered throughout with electron-dense granules located peripherally. The trilaminar cell-wall structure was typical of a gram-negative organism, comprising an outer membrane, a middle electron-opaque layer and an inner plasma membrane. Surface structures such as fimbriae, flagella and bacteriophages were not identified in specimens from either source.

Disseminated donovanosis (granuloma inguinale) causing spinal cord compression: case report and review of donovanosis involving bone

Donovanosis is a genital ulcer disease that occasionally has extragenital manifestations. This report describes a case of disseminated donovanosis in a 54-year-old woman from northern Australia who had subsequent thoracic vertebral osteomyelitis and spinal cord compression. Malignancy and vertebral tuberculosis were the major differential diagnoses. The patient had no genital lesions at the time of diagnosis of extragenital donovanosis but had undergone a hysterectomy, thus raising the possibility of prior disease of the uterine cervix (most previous cases have been associated with primary cervical disease). Despite treatment with doxycycline, she had no significant neurological improvement. Donovanosis disseminated to bone has been reported in 18 cases in the last 55 years. Awareness of donovanosis in the differential diagnosis of osteomyelitis and prompt pelvic examinations enabling early diagnosis of occult cervical disease are the most important measures in preventing morbidity and mortality due to disseminated donovanosis.

Culture of the causative organism of donovanosis (Calymmatobacterium granulomatis) in HEp-2 cells

We report successful culture of Calymmatobacterium granulomatis by standard cell culture methods. Swabs were obtained from lesions in three patients with a clinical diagnosis of donovanosis. For two patients, there was histological confirmation of the disease (i.e., the presence of Donovan bodies in Giemsa-stained smears). Specimens were inoculated onto cycloheximide-treated HEp-2 cell monolayers in RPMI 1640 medium (supplemented with fetal calf serum, NaHCO3, vancomycin hydrochloride, and benzylpenicillin). At 48 h, organisms resembling Donovan bodies were identified in monolayer cultures from all three specimens. The organisms appeared as pleomorphic bacilli with characteristic bipolar staining and "safety pin" appearance. Using a PCR designed to differentiate C. granulomatis from the Klebsiella species (which have a high degree of molecular homology), we were able to demonstrate that the cultured organisms produced a PCR product identical to that obtained from the original swab specimens. It is now possible to test in vitro susceptibility of C. granulomatis to antibiotics and to provide a ready source of DNA and antigenic material to enable the development of serological tests and, possibly in the future, a vaccine.

Granuloma inguinale (donovanosis): an unusual cause of otitis media and mastoiditis in children

Granuloma inguinale (donovanosis) is seen predominantly in adults (it rarely occurs in children) and mainly affects genital skin and mucosa. Infection occurs at other skin and mucosal sites, and hematogenous dissemination to bone also has been described. The infection responds dramatically to appropriate antibiotic treatment. We present two cases of granuloma inguinale occurring in children (8 months and 5 months of age) causing mastoiditis and external ear discharges. A temporal lobe abscess also developed in the 8-month-old child. Subsequent computed tomography scans showed marked improvement in the brain lesion after treatment. The second child had a polypoid mass in the middle ear that on biopsy showed the features of granuloma inguinale. The mother of this child had biopsy-proven granuloma inguinale of the uterine cervix. These cases indicate that granuloma inguinale can be transmitted during vaginal delivery, and careful cleansing of neonates born to infected mothers is recommended.

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.

Granuloma inguinale: three cases diagnosed in Toronto, Canada

Granuloma inguinale (GI) is a sexually transmitted disease seldom seen in the United States and Canada. We are reporting three cases recently seen in Toronto, Ontario, two in immigrants, and one in a native born Canadian who had an intimate relationship with a foreign visitor. The basic features of the disease are discussed.

Sexually transmitted diseases of the vulva

Sexually transmitted disorders may present on the vulva as ulcers, rashes, edema, adenopathy, or pruritus. Clinical and laboratory skills are needed to distinguish one from another so that the proper treatment is selected and further venereal spread is prevented.

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.

Tissue level lymphocyte subpopulations in donovanosis

Total T-, B-, T4-, and T8-lymphocyte populations were estimated in tissue sections of ulcers from 22 donovanosis patients, comprising 17 ulcerogranulomatous, four hypertrophic, and one sclerotic variants, using monoclonal antibodies and immunohistochemical technique (PAP). T- and B-lymphocytic infiltrations in the tissues were almost identical, without any significant difference in ulcerogranulomatous and hypertrophic variants. The T4:T8 ratio in ulcerogranulomatous variants, however, was 1.41, which was significantly higher than that of hypertrophic variants (1.28), indicating a greater cell-mediated immune response in the former than in the latter. This is substantiated by the documentation of a paucity of Donovan bodies, both in the tissue smear and slow (overnight) Giemsa-stained tissue sections, in the ulcerogranulomatous variant.

Granuloma inguinale of the cervix: a carcinoma look-alike

Granuloma inguinale of the cervix presents as a proliferative growth and may mimic carcinoma. Over a 3 year period 18 patients with cervical granuloma inguinale were detected. Nine (50%) had a clinical diagnosis of carcinoma of the cervix on admission, five of whom had extensive investigations to exclude a malignancy. In communities where these two conditions are commonly seen it is recommended that granuloma inguinale be considered in young women with granulomatous lesions of the cervix, so as to avoid extensive and financially costly investigations, and unnecessary psychological stress for patients.

Granuloma gluteale infantum: case report and review of the literature

Granuloma gluteale infantum, a benign granulomatous eruption involving the gluteal region, histologically shows a nonspecific dermal inflammatory infiltrate composed of neutrophils, lymphocytes, histiocytes, plasma cells, and eosinophils. It is important to recognize this condition, as it may clinically simulate a neoplastic process. It arises as a complication of primary irritant diaper dermatitis, however, and typically resolves without treatment.

Diagnosis of an unusual abdominal presentation of granuloma inguinale by fine needle aspiration cytology

A 63-year-old Hispanic man from Peru who recently had immigrated to the United States presented with progressive weakness, weight loss, recurrent abdominal pain and passing bright red blood per rectum. Rectal carcinoma was suspected. Biopsies of two lesions in the sigmoid colon showed granuloma inguinale (donovanosis). A computed tomographic scan of the abdomen revealed a large presacral mass. A radiographically guided fine needle aspiration (FNA) of the presacral mass showed findings characteristic of granuloma inguinale. FNA thus proved to be a useful adjuvant in the diagnosis of an unusual case of granuloma inguinale (donovanosis) presenting with a presacral mass that had the radiologic characteristics of a malignant tumor.

Extragenital granuloma inguinale mimicking a soft-tissue neoplasm: a case report and review of the literature

Granuloma inguinale has been reported to mimic squamous cell carcinoma, as well as sexually transmitted diseases. We describe a rare case of extragenital granuloma inguinale that mimicked a soft tissue neoplasm in an 18-year-old pregnant woman who presented with cervical and labial ulcers. An elective cesarean section was performed, at which time a retroperitoneal mass that involved the right ureter was found. At frozen section, the mass had a xanthogranulomatous appearance consistent with a soft-tissue neoplasm. Special stains of the permanent sections revealed the pathognomic features of granuloma inguinale.

Pseudoelephantiasis of the penis following donovanosis

Pseudoelephantiasis of the penis, an unusual sequel of longstanding donovanosis with otherwise characteristics clinical expression, is reported in a young man. The diagnosis was confirmed by the demonstration of Donovan bodies in Giemsa stained tissue smears and tissue sections.

Perianal abscess and sinuses caused by granuloma inguinale. Case report

An atypical case of the venereal disease granuloma inguinale, which is very rare in Scandinavia, is reported. The patient presented with recurrent perianal abscess and sinuses, and the diagnosis was not made until histologic examination of an extirpated subcutaneous nodule showed cells containing the pathognomonic Donovan bodies.

Utility of semithin sections in the diagnosis of donovanosis

The relative merits of tissue smears, paraffin sections and semithin plastic embedded sections in the diagnosis of donovanosis were assessed. In three cases reported negative or doubtful for the organisms by the former two methods, semithin plastic sections provided definite diagnosis. The latter method revealed in addition the organisms in epidermis and perivascular locations. From amongst the three stains: toluidine blue, Leishman's and thionine azure II basic fuchsin, the last mentioned was found to be the method of choice for demonstrating the organisms differently from the host cells.

An ultrastructural study of donovanosis

In an ultrastructural study undertaken on donovanosis, the inflammatory response was studied along with the fine structure of causative organisms, Calymmatobacterium granulomatis. Macrophages were seen to be activated and showed presence of numerous filopodia and increase in the number of lysosomes and rough endoplasmic reticulum. Many cells showed vacuoles of varying size in the cytoplasm some of which contained the organisms. Other cells seen included plasma cells, polymorphonuclear cells and sparse lymphocytes. In one case few multinucleated giant cells and dendritic cells with long cytoplasmic processes making cell-cell contact with other inflammatory cells were seen. Such cells have not been described in donovanosis so far. The organisms showed surface structures like pili and vesicles, the role of which is yet to be clearly understood.

Granuloma inguinale of cervical lymph nodes simulating tuberculous lymphadenitis: two case reports and review of published reports

Granuloma inguinale (donovanosis) is commonly thought to be a superficial disease, which spreads by continuity and does not affect the regional lymph nodes. Two patients with the disease affecting lymph nodes in the neck are reported from a series of 108 seen in a continuing study of granuloma inguinale. An immunofluorescent antibody test is described that showed antigenic relatedness between the intracellular organisms in these patients and in patients with typical genital granuloma inguinale. Lymphadenitis associated with granuloma inguinale appears to be a stage in the pathogenesis of the pseudobubo, an uncommon feature of this disease.

Granuloma inguinale (donovanosis) in women

A ten-year review (1973-1983) revealed 13 cases of documented granuloma inguinale at Grady Memorial Hospital, Atlanta. The patients' ages ranged from 17 to 77, with the majority in their early 20s. The initial presentation of granuloma inguinale included large, fungating labial ulcers, labial swelling, vaginal discharge, rectovaginal fistulae and hematuria. Common presumptive diagnoses included carcinoma, herpes, syphilis and granuloma inguinale. The final diagnosis was made with cytology and/or tissue examination with the help of special stains to demonstrate the causative organism, Calymmatobacterium granulomatis. Granuloma inguinale is rare and difficult to diagnose, but with physician awareness, cytology and biopsy, it should not be missed.

The treatment of donovanosis (granuloma inguinale)

Over a two-year period, 37 patients with genital ulcer disease attending a clinic for sexually transmitted diseases in Harare were found to have donovanosis. Of the 37 patients, 25 were male, and 12 were female; all presented with painless, indurated, granulating ulcers without lymph-node involvement. The lesions were more extensive in pregnant women. All patients responded well to either a combination of intramuscular streptomycin plus oral tetracycline given over 14 days, or a 14-day course of oral co-trimoxazole (trimethoprim-sulfamethoxazole). No metastatic lesions were found.

Histological aspects of sexually transmitted genital lesions

Occasional biopsies of genital lesions due to chancroid, secondary syphilis (the condyloma latum) and granuloma inguinale are encountered in routine histopathological practice. These lesions have specific microscopical appearances enabling a confident, or at least a presumptive, diagnosis to be made in most cases, yet the value of biopsy in the diagnosis of these diseases is not generally appreciated. The ulcer of chancroid shows three zones--a narrow superficial zone of degenerate leucocytes and fibrin, a broader middle zone with characteristic vascular changes, and a deep zone in which there is a plasma cell and lymphocyte infiltrate. The condyloma latum shows hyperplasia of the epidermis which is infiltrated with polymorphonuclear leucocytes in addition to the mononuclear infiltration of the dermis. Large numbers of spirochaetes are found in the area of the polymorph exocytosis of the epidermis. The inflammatory infiltrate of granuloma inguinale consists of a neutrophil and plasma cell infiltrate with moderate numbers of large mononuclear cells in which there are one or more vacuoles containing Donovan bodies.

Cytologic detection of cervical granuloma inguinale

Two cases of granuloma inguinale detected cytologically on routine Papanicolaou-stained cervical smears are presented; the cytologic and histologic features are described in detail, and the electron microscopic appearances are shown. The suitability of the Papanicolaou stain in the detection of granuloma inguinale is discussed, with emphasis on possible differential diagnoses to be considered. It is concluded that a definitive diagnosis of granuloma inguinale can be made on routine Papanicolaou-stained smears showing the following spectrum of changes: intact capillaries indicative of epithelial and stromal ulceration; a marked inflammatory cell infiltrate consisting predominantly of neutrophils; epithelioid histiocytes representing granuloma formation; and Donovan bodies located in characteristic single or multiple intracytoplasmic vacuoles within large histiocytes. Recognition of this cytologic picture may enable early diagnosis, even in nonendemic areas, of a potentially disfiguring venereal disease.

Granuloma inguinale. Report of the first case in Qatar

The first known case of granuloma inguinale in the State of Qatar was observed in an Indian expatriate who contracted the disease in India. The patient had the ulcero-vegetative clinical variant of the disease, which was suspected from the history, lack of spontaneous healing for five months, and the typical clinical picture. The diagnosis was confirmed by the finding of intracellular Donovan bodies in a crushed-tissue smear stained with Wright's stain. The patient was treated by tetracycline hydrochloride (2 g daily for 20 days). The ulcer was healed completely within ten days. The diagnosis of more cases of granuloma inguinale in Qatar is anticipated because of the recent improvement of health care, medical records, and attraction of medical attention to the disease.