Granuloma inguinale: A case report
1. Loyola Stritch School of Medicine, Chicago, IL 2. Ayza Skin & Research Center, Lalamusa, Pakistan
3. Department of Dermatology, State University of New York Downstate Medical
Granuloma inguinale is common in certain regions of the world, however, it is rarely reported in the United States. It is the result of infection by Calymmatobacterium granulomati, although current literature proposes to re-classify this organism as Klebsiella granulomati. Here we report a case of granuloma inguinale, review the literature, and discuss historical context, treatment options, and differential diagnosis.
Granuloma inguinale, or Donovanosis, is commonly listed on a differential diagnosis of genital ulcers. However, this infectious process is common only in certain regions of the world, and rarely seen in the United States. It is important to be aware of the clinical presentation, diagnostic criteria, and treatment options for granuloma inguinale.
A 48-year-old sexually active, otherwise healthy man presented with 3-month history of a few painless ulcerated lesions on the penis, pubic area, and scrotum. The patient reported painless nodules that slowly evolved to red ulcerated lesions over 1 month. There was a history of unprotected intercourse with a prostitute about 2 months prior to the eruption. Physical examination revealed multiple beefy-red exuberant nontender round ulcers of various sizes on the shaft of the penis, the pubic area, and the scrotum. The ulcers had clean friable granulating bases. Inguinal lymph nodes were not palpable. The man was circumcised but he had a below-average-to-poor standard of hygiene. The rest of the physical examination and routine blood and urinalyses including serotesting for syphilis were unremarkable. A punch biopsy was performed and the crushed granulation tissue was air dried on a glass slide. Microscopic examination of a Giemsa-stained tissue smear revealed numerous rod-shaped encapsulated organisms within the histiocytes.
Granuloma inguinale, was first described and named serpiginous ulcer by McLeod et al. in 1882 . The first use of the term granuloma inguinale is not known, but is believed to be derived from the anatomic description as follows: granuloma indicates a growth of granulation tissue, and inguinale indicates involvement of the groin region . Amongst the numerous nomenclatures suggested for this disease, Donovanosis was proposed by Marmell et al. in 1950 to honor Donovan, who first demonstrated the causative microbe in 1905 [3, 4]. Donovanosis has been the preferred term in modern literature .
Clinical picture and diagnosis
Granuloma inguinale primarily affects the skin and subcutaneous tissue of the genital and perianal region. Upon inoculation, the incubation period ranges from 2 weeks to 6 months . The primary lesion may be noted as a firm papule or subcutaneous nodule. Presentation can be via single or multiple nodules that erode into slow growing ulcerations that easily bleed . The nodules are easily mistaken for lymph nodes, although true lymphadenopathy is rare . Anatomically, less than 10 percent of lesions are extra-genital .
The clinical diagnosis of granuloma inguinale is based on meticulous history and physical, with laboratory confirmation. A biopsy specimen, scrapings from the base of the ulcer, or aspirated exudate can also be used. This allows direct visualization of Donovan bodies after applying Giemsa or Wright stain [7, 9]. Current literature espouses the use of PCR for more accurate, less invasive diagnosis .
The granuloma inguinale lesion is attributed to infection by Calymmatobacterium granulomati (CG), a gram-negative rod. Interestingly, current literature proposes to reclassify this organism as Klebsiella granulomati based on more detailed analysis now available . In macrophages from patient tissue samples Calymmatobacterium granulomati appears as bipolar-staining intracellular inclusions; this organism is a coccobacillus measuring 0.5-1.5 µm wide and 1.0 µm long, with rounded ends . Chromatin condensations at the extremities form safety pins when stained with Giemsa or Wright stains . These bipolar, safety-pin shaped rods in the cytoplasm of macrophages are the Donovan bodies.
Sexual contact is believed to be a central part of transmission [9, 14]. Although, transmission to children is also possible during natural vaginal birth . Although extremely rare in the United States, CG is endemic to certain parts of the world [7, 16].
A variety of lesions can mimic granuloma inguinale. The differential diagnosis includes all lesions that may present as genital ulcerations (see Table 1).
Outcome and treatment
Untreated, granuloma inguinale infection persists and may disseminate or develop abscess formation . Squamous cell carcinoma may arise from the lesion site . Secondary infectious inoculation may occur, as well as more extensive and deep ulcerations with necrosis, fistula formation, and tissue mutilation .
A variety of therapeutic options are available for granuloma inguinale. Conservative pharmacologic approaches should be applied at first. These include gentamicin, tetracycline, ciprofloxacin, doxycycline, and azythromycin [19, 20]. The lesion should be monitored clinically or via serial biopsies to look for Donovan bodies. In advanced disease, with vast tissue obliteration and scarring, surgery may be required . The partner should be examined, although empiric treatment is not recommended . In our case, the diagnosis was confirmed by the identification of the gram negative rods trapped within the histiocytes on examination of a smear. The patient was treated with oral doxycycline for 2 weeks, but was lost to followup.
Physicians must also consider granuloma inguinale lesions as an indication to screen for other sexually transmitted diseases. These lesions may serve to identify high risk patients, and patients susceptible to HIV .
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