[STDs] Atlas of Donovanosis

These are the images, diagnosis and treatment of the disease caused by Donovanosis. This is a Bacterial Sexually Transmitted Diseases.

Donovanosis

The indolent genital ulcer disease donovanosis, formerly called granuloma inguinale, is one of the five originally defined venereal diseases (with syphilis, gonorrhea, lymphogranuloma venereum, and chancroid). Donovanosis now is rare worldwide, including some areas where it formerly was endemic, such as Papua New Guinea, Australia, and the Indian subcontinent. A specific donovanosis eradication campaign appears to have been successful in aboriginal populations in Australia. The causative organism, Calymmatobacterium granulomatis, is a gram-negative bacillus related to Klebsiella species. The organis was only recently grown in sustained culture, but diagnosis remains dependent largely on clinical and histologic criteria. A polymerase chain reaction (PCR) test has been developed and this or other nucleic acid amplification tests (NAATs) may become available in the future. Sexual transmission is surmis by genital localization and occasional disease in infected persons’ sex partners, but most partners are free of clinical disease. A colonic reservoir and transmission by fecal contamination of abraded skin have been. The disease may progress slowly for several years, with locally destructive outcomes that mimic those of cutaneous cancer. Several antibiotics are believed to be effective, although no wellcontrolled trials are available.

EPIDEMIOLOGY

Incidence and Prevalence

• Rare in the United States and industrialized countries and increasingly rare in developing countries;

largely limited to isolated populations with irregular health care

• No reported cases in the United States since 2000

• Most cases in industrialized countries are imported from endemic areas

Transmission

• Probably by sexual contact, but most sex partners apparently are uninfected

• Some cases may be transmitted by nonsexual routes, perhaps by fecal contact with abraded skin

• Occasional perinatal transmission to newborns

Age

• No known predilection

Sex

• In endemic areas, cases in men typically outnumber those in women, perhaps related to exposure patterns (e.g., commercial sex)

• No known predisposition

• Few cases reported in homosexual men or women, perhaps due in part to reduced recognition of

homosexuality in endemic areas

HISTORY

Incubation Period

• Usually 2–3 weeks, perhaps up to 1 year

Symptoms

• Slowly progressive mucocutaneous ulceration that may become extensive

• Usually painless

• Occasional multiple lesions

• Occasional inguinal swelling

• Rare local symptoms of disseminated osteomyelitis

• Generally no fever or other systemic symptoms

Epidemiologic History

• Residency or sexual exposure in an endemic area

PHYSICAL EXAMINATION

• Four clinical variants:

° Ulcerogranulomatous: hypertrophic red granulation tissue with easily induced bleeding

° Hypertrophic: exuberant exophytic, wart-like (“verruciform”) lesions

° Necrotic: deep ulceration, extensive tissue destruction

° Sclerotic: prominent fibrosis, sometimes with urethral stricture

• Little or no purulent exudate; pus may indicate secondary infection

• Usually involves penis or vulva; sometimes perianal; occasional nongenital sites

• Inguinal mass (“pseudobubo”) may result from subcutaneous extension of inflammatory tissue; usually no true lymphadenopathy

• Extensive ulceration can persist and progress several years, mimicking cancer; penile autoamputation

has been observed

• Rare systemic dissemination, with hepatic or osteolytic lesions

• Cervical lymphadenitis has occurred in young children

LABORATORY DIAGNOSIS

• Histologic identification of organism in vacuoles within macrophages (“Donovan bodies”) using modified Giemsa stain of biopsied tissue or crush preparation

• PCR assay has been described, not yet commercially available

DIAGNOSTIC CRITERIA

• Based primarily on clinical presentation and exclusion of alternate diagnosis

• Biopsy or crush preparation showing characteristic histopathology

• Exposure history in endemic area

TREATMENT

Principles

• Antimicrobial susceptibility uncertain; surmised primarily by clinical response to empirical therapy

• Treat for 3 weeks to 3 months, until healed

• Longer treatment may be required in HIV-infected patients

Recommended Regimen

• Doxycycline 100 mg PO bid for 3 weeks to 3 months

Alternative Regimens

• Azithromycin 1.0 g PO once weekly

• Ciprofloxacin 750 mg PO bid

• Erythromycin base 500 mg PO qid

• Trimethoprim/sulfamethoxazole 800 mg/160 mg PO bid

PREVENTION AND CONTROL

• Identify and offer treatment to sex partners

• Value of treatment for partners without clinically evident infection is unknown

7–1. Donovanosis, ulcerogranulomatous variety. a. Penile lesions.

b. Giemsa stain of crush preparation of tissue

from penile lesion, showing a macrophage with vacuoles

containing bipolar-staining bacilli (Donovan bodies)

CASE 1

Patient Profile Age 47, merchant seaman

History Painless penile sores for 3 weeks; during 2 months prior to onset had unprotected commercial

sex in South Asian seaport cities

Examination Multiple, slightly tender, hypertrophic ulcerative penile lesions; no lymphadenopathy

Differential Diagnosis Donovanosis, primary syphilis, cancer

Laboratory Giemsa stain of crush preparation of biopsy specimen showed large mononuclear cells with Donovan bodies; darkfield examination, lesion cultures for HSV and Haemophilus ducreyi, VDRL, HIV serology (all negative)

Diagnosis Donovanosis

Treatment Doxycycline 100 mg PO bid for 3 weeks

Follow-up Lesions had regressed and were partly reepithelialized after 10 days, after which patient was lost to follow-up.