The changing epidemiology of genital ulcer disease in South Africa: has donovanosis been eliminated?

OBJECTIVES: We used an in-house molecular assay for the detection of Klebsiella granulomatis in ulcer specimens collected over a 12-year surveillance period in order to determine whether a diagnosis of donovanosis could be ascribed to genital ulcer disease (GUD) of unknown aetiology in our setting. METHODS: Between 2007 and 2018, a total of 974 genital ulcer specimens with no previously identified sexually transmitted (STI) pathogens were selected from STI aetiological surveys conducted in all nine provinces of South Africa. Giemsa-stained ulcer smears from the same participants had previously been routinely analysed for the presence of typical Donovan bodies within large mononuclear cells. A Klebsiella screening assay targeting the phoE (phosphate porin) gene was used in combination with restriction digest analysis and sequencing to confirm the presence of K. granulomatis. RESULTS: The Klebsiella screening assay tested positive in 19/974 (2.0%) genital ulcer specimens. Restriction digest analysis and nucleotide sequencing of the phoE gene confirmed that none of these specimens was positive for K. granulomatis DNA. Similarly, Donovan bodies were not identified in the Giemsa stained ulcer smears of these specimens. CONCLUSIONS: This is the first study to assess K. granulomatis as a cause of genital ulceration in South Africa over a 12-year surveillance period using molecular methods. The results demonstrate that K. granulomatis is no longer a prevalent cause of GUD in our population.

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.

[A case of donovanosis acquired in France]. / Donovanose contractée en France.

INTRODUCTION: Donovanosis (granuloma inguinale) is a bacterial infection caused by Klebsiella granulomatis that occurs mainly in the genital area and is primarily sexually transmitted; it is seen predominantly in the tropics. Herein, we report a case of the disease contracted in metropolitan France. PATIENTS AND METHODS: A 47-year-old man presented with painless ulceration of the glans, present for one month, with progressive extension; there was no history of any recent trip abroad. Skin biopsy with Whartin-Starry and Giemsa staining revealed Donovan bodies in the cytoplasm of macrophages. Based on these findings, further questioning of the patient revealed unprotected sexual contact two months earlier in France. Treatment was initiated with azithromycin 1g on the first day followed by 500mg per day for three weeks. The clinical outcome was spectacular, with almost complete regression of the ulcer at 7 days. DISCUSSION: This case demonstrates that donovanosis can occur in metropolitan France.

Donovanosis.

Donovanosis is a chronic, progressive, and indolent bacterial disease that affects the skin and mucous membranes of the genital and perigenital regions, often associated with sexual transmission, and with low infectivity. The malignant transformation of donovanosis lesions occurs exceptionally, as is usually seen in long-term ulcerations.

Donovanosis presenting as a pelvic mass mimicking ovarian cancer.

A 29-year-old female presented with chronic postpartum abdominal pain. Computerized tomography scan was consistent with ovarian carcinoma, and biopsy yielded macrophages laden with eosinophilic bodies. Cultures, histoplasma serologies, and taxoplasma serologies were negative. A diagnosis of pelvic donovanosis was reached; the patient was treated with azithromycin resulting in clinical and radiographic resolution.

Sexually Transmitted Diseases in the Emergency Department.

Sexually transmitted diseases (STDs) continue to be underrecognized leading to devastating health and economic consequences. Emergency clinicians play an important role in diagnosing and managing STDs and in improving health care outcomes for both the patient and their partners. In addition, antibiotic resistance and emerging infections continue to challenge providers in clinical practice. This review focuses on the cause, history, physical examination, diagnostic studies, and treatment strategies for bacterial vaginosis, chlamydia, genital herpes, gonorrhea, human papillomavirus, granuloma inguinale, Lymphogranuloma Venereum, Mycoplasma genitalium, syphilis, and trichomoniasis.

Concomitant malacoplakia and granuloma inguinale of the cervix in acquired immune deficiency syndrome.

We describe concomitant granuloma inguinale (GI) and malacoplakia of the cervix in 2 acquired immune deficiency syndrome (AIDS) patients aged 27 and 36 years. Both patients presented with a bloody foul-smelling vaginal discharge. Speculum examination confirmed cervical ulceration, prompting the diagnosis of cervical carcinoma in both patients. Cervical punch biopsies confirmed the characteristic features of GI; granulation tissue containing a dense plasma cell infiltrate, aggregates of neutrophils, and vacuolated enlarged histiocytes containing Donovan bodies were noted. Many of these histiocytes and sheets of von Hansemann cells contained intracytoplasmic Michaelis-Gutmann bodies, confirming concomitant malacoplakia. Michaelis-Gutmann bodies were also present in extracellular locations. Ultrastructural examination confirmed these histopathologic findings. One patient died of disseminated tuberculosis before treatment was initiated. The other patient did not return for a follow-up visit of her cervical lesion. Concomitant GI and malacoplakia is unreported in genital and extragenital sites; Klebsiella granulomatis must therefore be added to the list of bacteria associated with malacoplakia. Malacoplakia of the female genital tract is documented rarely and remains unreported, to date, in AIDS patients. Similar to the pathogenetic mechanisms described for AIDS-associated malacoplakia in extragenital sites, it is hypothesized that, in addition to abnormal macrophage functioning and an inability to degrade bacteria, special constituents of K. granulomatis are undigestable by lysosomal enzymes in human immunodeficiency virus-infected patients.

2018 UK national guideline for the management of donovanosis.

The objective of this guideline is to provide guidance for the diagnosis and management of donovanosis, a now rare sexually transmitted infection. This guidance is primarily for professionals working in UK Sexual Health services (although others may find it useful) and refers to the management of individuals presenting with possible symptoms of donovanosis who are over the age of 16. An updated literature review since the last Clinical Effectiveness Group (CEG) guideline produced for this condition in 2011 has shown few new developments. Most reports in the literature relate to cases of unusual presentations of the condition.

Donovanosis in a child victim of sexual abuse: response to doxycycline treatment.

Donovanosis is a chronic infectious disease caused by the Gram-negative bacteria Klebsiella granulomatis, which mainly affects the skin and mucous membranes of the genital, perigenital, and inguinal regions. Also known as venereal granuloma or granuloma inguinale, it is endemic in tropical and subtropical regions of the globe and often associated with sexual transmission. We report the case of an 11-year-old female victim of chronic sexual abuse, who was diagnosed with donovanosis and presented a good therapeutic response to doxycycline.

A hat trick of ulcerating pathogens in a single genital lesion.

We report on a patient from a London clinic, (a Jamaican heterosexual man known to have herpes) who has donovanosis and syphilis in a single genital ulcer. The case highlights the importance of careful clinical examination of genital ulcers.

Donovanosis and squamous cell carcinoma: The relationship conundrum!

Donovanosis is a rare, chronic and indolent sexually transmitted infection caused by Klebsiella granulomatis. The ulcers in donovanosis rarely undergo malignant transformation, which is usually seen in longstanding ulcers. We present a case of a 32-year-old male who presented with a two-month history of rapidly progressive, large, foul-smelling ulcers over the groin, distal penile shaft and scrotum. Crushed tissue smears from ulcers revealed basophilic intracellular and extracellular Donovan bodies. Fine needle aspiration cytology from inguinal lymph nodes and biopsy from the ulcers revealed well-differentiated squamous cell carcinoma. The current case aims to alert clinicians that donovanosis is a rare but possible cause of cutaneous malignancy. Nonetheless, the pathogenesis of malignant transformation in donovanosis needs further research.

Genital elephantiasis and sexually transmitted infections - revisited.

Genital elephantiasis is an important medical problem in the tropics. It usually affects young and productive age group, and is associated with physical disability and extreme mental anguish. The majority of cases are due to filariasis; however, a small but significant proportion of patients develop genital elephantiasis due to bacterial sexually transmitted infections (STIs), mainly lymphogranuloma venereum (LGV) and donovanosis. STI-related genital elephantiasis should be differentiated from elephantiasis due to other causes, including filariasis, tuberculosis, haematological malignancies, iatrogenic, or dermatological diseases. Laboratory investigations like microscopy of tissue smear and nucleic acid amplification test for donovanosis, and serology and polymerase chain reaction for LGV may help in the diagnosis, but in endemic areas, in the absence of laboratory facilities, diagnosis largely depends on clinical characteristics. The causative agent of LGV, Chlamydia trachomatis serovar L1-L3, is a lymphotropic organism which leads to the development of thrombolymphangitis and perilymphangitis, and lymphadenitis. Long-standing oedema, fibrosis and lymphogranulomatous infiltration result in the final picture of elephantiasis. Elephantiasis in donovanosis is mainly due to constriction of the lymphatics which are trapped in the chronic granulomatous inflammatory response generated by the causative agent, Calymmatobacterium (Klebsiella) granulomatis. The LGV-associated genital elephantiasis should be treated with a prolonged course of doxycycline given orally, while donovanosis should be treated with azithromycin or trimethoprim-sulphamethoxazole combination given for a minimum of three weeks. Genital elephantiasis is not completely reversible with medical therapy alone and often needs to be reduced surgically.

Granuloma inguinale: a case report.

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.