Donovanosis

Bacterial and venereal skin disease also known as Granuloma inguinale

1. DONOVANOSIS (Granuloma inguinale) Chamika Wickramavansa 4 th Year 2 nd Semester Group No.5 Department of Dermatology & Venereology Kursk State Medical University

2. The Definition Donovanosis ( Granuloma inguinale ) is a sexually transmitted (Venereal), bacterial infection that affects skin and mucous membranes of anal and genital areas. Its name is derived from  granuloma , a medical term for a mass or growth of granulation tissue, and inguinale , a Latin word that means located in the groin.  Granulation tissue is tissue formed during wound healing that is rich in blood capillaries and has a rough lumpy surface.

3. The Definition Diagnosis is made by microscopic examination and identification of “Safety-Pin” shaped cellular bodies named as “Donovan Bodies” in the cytoplasm of phagocytes (Macrophages) taken from a lesion and dyed with Wright's or Giemsa stain or by histological examination of a biopsy specimen. Therefore it is called Donovanosis

4. The Etiology Donovanosis is caused by Klebsiella granulomatis (formerly called as Calymmatobacterium granulomatis ); small gram-negative rod bacillus. They are non motile and encapsulated organisms There are observed in macrophages cytoplasm as “Donovan Bodies”

5. Donovan Bodies Clusters of blue- or black-staining, bipolar chromatin condensations in large mononuclear cells in granulation tissue infected with Klebsiella (Calymmatobacterium granulomatis).

6. Epidemiology It occurs worldwide but is most common in tropical or subtropical countries, where it is associated with poverty and poor hygiene. As many as 20% of male patients with sexually transmitted diseases (STDs) in tropical countries have granuloma inguinale. All patients who have or are suspected of having granuloma inguinale are also tested for syphilis because concurrent infection is common.

7. Epidemiology Most  patients are  between are between the ages of 20 and 40 years. It occurs more frequently in men than in women and is associated with anal intercourse. Its occurrence in children and sexually inactive adults indicates that it may also be spread by contact with human faeces. Granuloma inguinale is not highly contagious; however, persons with weakened immune systems are at greater risk of infection (HIV/AIDS)

8. Clinical Presentation The bacteria has an incubation period ranging from eight days to twelve weeks, with an average of two weeks to four weeks . This disease has gradual and slow onset, begins with discreet papule or small pustule or lumpy eruption of the skin. In 90% of patients, the initial sign of infection is in the genital region, but a minority of patients will develop the papule in their mouth or anal area if their sexual contact involved those parts of the body.

9. Clinical Presentation Many patients do not notice the sore because it is small and not usually painful. In some women, the first symptom of granuloma inguinale is bleeding from the genitals .

10. The initial papule or pustule is typically followed by three stages of disease; In the first stage , the patient develops a mass of pink or dull red granulation tissue in the area around the anus. In the second stage , the bacteria erode the skin to form shallow, foul-smelling ulcers which spread from the genital and anal areas to the thighs and lower abdomen. The edges of the ulcers are marked by granulation tissue . Clinical Presentation

11. In the third stage , the ulcerated areas form deep masses of keloid or scar tissue that may spread slowly for many years. Patients with long-term infections are at risk for serious complications . The ulcers in second-stage granuloma inguinale often become superinfected with syphilis or other STD organisms. Clinical Presentation

12. Superinfected ulcers become painful to touch, filled with pus and dead tissue, and are much more difficult to treat . There may be sizable areas of tissue destruction in superinfected patients. In addition, the scar tissue produced by third-stage infection can grow until it closes off parts of the patient's urinary tract. Clinical Presentation

13. Major Sites of Lesions Penile ulcers ( sulcocoronal and balanopreputial ) Labia minora Fourchette Cervix (uncommon)

14. Types of Skin Lesions Ulcero-vegetative (most commonly seen) - Painless, beefy red ulcers with clean, friable bases and distinct, raised/rolled margins. Autoinoculation is common. Nodular - Pruritic, soft, red nodules that ulcerate at the site of inoculation. Pseudobubo : nodule appears clinically as a lymph node. Cicatricial - Dry ulcers that progress into scarring plaques. Lymphedema may be present Hypertrophic or verrucous (relatively rare)

15. Ulcero-vegetative type lesion Painless, beefy red ulcers with clean, friable bases and distinct, raised/rolled margins. Autoinoculation is common.

16. Nodular type lesion The initial granuloma inguinale lesion is a papule or nodule that arises at the site of inoculation. The nodule is soft, often pruritic and erythematous, and eventually ulcerates. A nodule may be mistaken for a lymph node [ ie , pseudobubo ]

17. Cicatricial Dry ulcers evolve into cicatricial plaques and may be associated with lymphedema.

18. Diagnosis Made by swabbing the lesion and Giemsa staining of the air dried smear. Other stains that may be used are Warthin-Starry, Gram stain, Toulidine blue and Leishman stain. Smear or biopsy with Wright, Giemsa or Warthin-Starry (silver) stain: Donovan bodies: intracytoplasmic bipolar staining, safety pin–shaped, inclusion bodies seen in histiocytes

19. Diagnosis Recommended to acquire specimen at base or edge of ulceration or by aspirating enlarged regional lymph node Culture of the organism is difficult, and needs specialized methods using human peripheral blood mononuclear cells or Hep-2 cells Polymerase chain reaction and indirect immunofluorescence are available but not commonly used.

20. Diagnosis Histology: acanthosis, dermis with histiocytes and plasma cells, large and vacuolated macrophages with intracellular bacilli (i.e., Donovan bodies ). Granulomatous inflammation, neutrophilic micro abscesses (particularly in ulcer bed ). Acute and chronic granulation tissue, fibrosis (dermal and subcutaneous cicatricial ) in late stages

21. Differential Diagnosis Mycobacterial infection Cutaneous tuberculosis Ovarian cancer: One case report describes a patient with chronic granuloma inguinale (donovanosis) who presented with recurrent abdominal pain. Results of abdominal computed tomography (CT) scanning showed pelvic masses that mimicked ovarian cancer. Carcinoma of the cervix: One report describes cervical donovanosis, which, on an MRI, was indistinguishable from carcinoma of the cervix.

22. Differential Diagnosis Dermatologic Manifestations of Chancroid Dermatologic Manifestations of Herpes Simplex Dermatologic Manifestations of Lymphogranuloma Venereum Pediatric Syphilis

23. Treatment The current first-line drug is azithromycin. Alternative regimens include doxycycline, ciprofloxacin, erythromycin base, and trimethoprim-sulfamethoxazole. All antibiotics should be given for at least a 3-week course and continued until re-epithelialization of the ulcer occurs and all signs of the disease have resolved .

24. If the granuloma inguinale ulcers do not respond within the first days of therapy, add an aminoglycoside ( eg , gentamicin 1 mg/kg IV q8h). Relapse of granuloma inguinale may occur 6-18 months after apparently effective therapy and treatment should be reinitiated at that time. Since there have been past documented reports of tetracycline resistance, it is no longer recommended. Treatment

25. Goal of Treatment The goal of pharmacotherapy for granuloma inguinale is to reduce morbidity and to prevent complications.

26. References Mcgraw-Hill Specialty Board Review Dermatology- Ali, Asra (Textbook) http://www.pathologyoutlines.com/topic/anusgranulomainguinale.html http:// emedicine.medscape.com/article/1052617-overview http:// dxline.info/diseases/granuloma-inguinale#prettyPhoto http://medical-dictionary.thefreedictionary.com/granuloma+inguinale

27. Thank You !!!