Donovanosis
Illustrated lecture transcript

Slide 1

In a New Guinea study I found that over 50% of patients had lesions for more than 2 months before seeking treatment. This situation is probably replicated in most environments where donovanosis is prevalent. Consequently substantial tissue destruction, including complete erosion of the genitals may result. Extragenital lesions, which can be life threatening when bones and viscera are involved, are rarely diagnosed as donovanosis due to lack of awareness of clinicians and limited laboratory support.

Slide 2

This slide illustrates the origin of the name granuloma inguinale previously used for donovanosis. However inguinal lesions occur in only 10-15% of cases and are usually associated with concurrent genital lesions as in this case.

Slide 3

Inguinal swellings or pseudobuboes are actually subcutaneous granulomata which eventually rupture through the skin producing granulomatous lesions – lymph nodes are rarely involved.

Slide 4

This case demonstrates the typical red beefy granulomatous nature of most donovanosis lesions.

Slide 5

Clinically donovanosis has a wide spectrum of presentations. This necrotic form is frequently misdiagnosed as carcinoma or possibly amebiasis.

Slide 6

This is a case of amebiasis but would probably be diagnosed as donovanosis in an endemic area because of the red granulomatous and erosive nature of the lesion, which has effectively circumcised this man.

Slide 7

Smear demonstrating Entamoeba histolytica. On the right is a trophozoite of irregular shape and with substantial clear hyaline ectoplasm beneath the cell membrance (size 15-30m and a single nucleus) and ingested red blood cells. In the centre are cysts/pre-cysts with 1-4 nuclei, vacuoles and granular cytoplasm.

Slide 8

Carcinoma of penis – diagnosis suggested by lack of red granulation material, but requires biopsy for confirmation. Over 70% of cases of donovanosis of the cervix are misdiagnosed as carcinoma.

Slide 9

Typical beefy red vulval lesions, which demonstrate the potential for spread for autoinoculation or "kissing lesions" which form from direct contact of skin with an adjacent lesion.

Slide 10

Labial swelling is a common local complication of donovanosis, often referred to as pseudo-elephantiasis in more severe cases.

Slide 11

Pudendal lesions of donovanosis are usually red as opposed to pale condylomata lata of secondary syphilis. However, note that some of these lesions are rather pale, and concurrent infection with donovanosis and syphilis cannot be excluded.

Slide 12

Typical pale condylomata lata. However some lesions have a degree of redness and could be donovanosis.

Slide 13

However, note condylomata lata in other areas such as the axilla may not be pale.  This slide shows flesh coloured condylomata lata in the axilla.

Slide 14

Perianal condylomata in a child. Furthermore donovanosis and syphilis may coexist. Syphilis serology is of little help, although low titre VDRL excludes secondary syphilis. Therapeutic trial with penicillin is the most practical solution – condylomata subside within one week, donovanosis lesions are unchanged.

Slide 15

Complete erosion of the penis resulting from delay in seeking treatment. This 30 year old man had penile donovanosis for 3 months before seeking treatment. The suprapubic lesion was produced by autoinoculation from the penis.

Slide 16

The low and variable prevalence of donovanosis among sexual partners is often cited as evidence against sexual transmission. The wide range of infection in conjugal partners (0.4%-52%) can be explained by the long incubation period (up to 1 year), relatively low infectivity of C.granulomatis, variation in exposure of sexual partners, and the diagnostic skills of clinicians. Persuasive evidence of a predominantly sexual route of transmission includes the combined factors of lesions that predominantly affect the genitals, a prevalence that is highest among persons in age groups and socio-economic groups that are most often affected by STDs, and the predictable occurrence of disease in visitors to areas of endemicity following sexual exposure. Extragenital skin lesions can occur by transmission from concurrent genital lesions via fingers or other nonsexual contact. Infants born to infected mothers may acquire infection at birth.

Slide 17

Although some investigators have attached considerable significance to the male-to-female ratio among patients with donovanosis, studies have found a range of ratios from 7:1 in favour of females to 7:1 in favour of males. These ratios probably reflect the diverse selective mechanisms that influence the inclusion of patients in various studies.

Slide 18

Extragenital lesions are estimated to occur in approximately 6% of cases of donovanosis but many more cases probably remain undetected because of diverse non-specific presentations and a low index of suspicion.

Slide 19

Skin lesions may be primary or secondary and will only be diagnosed if there is a high index of suspicion for donovanosis in endemic areas. These lesions probably arise via the patient's fingers. Sometimes genital lesions are only detected after the patient has presented with an extragenital lesion. Genital examination may clarify the diagnosis in these cases.

Slide 20

Oral lesions, probably the most common extragenital lesions, may be red, granular and bleed easily. Loose or missing teeth may indicate invasion of underlying bone. Systemic symptoms are rare.  The affected gums of this 30 year old Aboriginal woman were tender and bled on gentle contact, some teeth were loose, and the radiograph showed erosion of the underlying maxilla. The patient had been treated for genital donovanosis 2 years previously and had residual scarring (but no active lesions) at the primary site.

Slide 21

A further view of the patient in the previous slide. Non-reddened or non-bleeding lumps in the mouth pose a more difficult challenge.

Slide 22

Oral lesions often form fistulae to the external skin, and granular lesions at the angle of the jaw should prompt examination for associated oral lesions.

Slide 23

This slide reviews cases of bone lesions reported in the literature and obviously involves potentially huge unpredictable biases. These reports mostly involve women, most of whom have lesions of the cervix. The tibia is the most common bone involved but mortality is highest with vertebral lesions. Bone lesions are usually associated with systemic symptoms such as fever, night sweats, malaise and weight loss.

Slide 24

Erosion of lower lumbar vertebra by donovanosis, diagnosed post mortem. The patient was treated for tuberculosis and did not have a pelvic examination. Post mortem revealed a large fungating lesion of the cervix.

Slide 25

The preferred method of diagnosis is by a crush impression prepared from the deep surface of excised tissue and stained with Giemsa stain. Histiocytic cells with up to 20 vacuoles containing clusters of organisms in various states of maturity are diagnostic. Immature unencapsulated forms often show bipolar condensation of chromatin, resembling a closed safety pin. Such organisms are shown in this slide.

Slide 26

Donovan bodies demonstrated by a silver stain, showing palisading of the organisms in the periphery of cytoplasmic vacuoles – Warthin-Starry stain, magnification x 400.

Slide 27

Typical histological pattern showing epithelial proliferation - pseudoepitheliomatous hyperplasia.

Slide 28

Heavy inflammatory infiltrate of plasma cells, some neutrophils and few, if any, lymphocytes. However H & E stain is unsatisfactory for demonstrating the pathognomonic donovan bodies.

Slide 29

Differential diagnosis includes condylomata lata, squamous cell carcinoma, amebiasis, tuberculosis, actinomycosis and chancroid. The histological findings must be distinguished from those of rhinoscleroma (large histocyctic cells - 100um-200um) leishmaniasis (nonencapsulated organisms have a distinct nucleus and para nucleus) and histoplasmosis (organisms are in granulomas containing areas of necrosis).

Slide 30

It is essential that antibiotic treatment is continued until lesions are completely healed. Earlier cessation of treatment is frequently followed by complete healing, but recurrence commonly occurs 6-12 months later. Recommended therapies include doxycycline, azithromycin, sulfamethoxazole/trimethoprim and chloramphenicol. Second line therapies produce less consistent results.