International Journal of srD & AIDS 1991; 2: 447-448
CASE REPORT
Donovanosis (granuloma inguinale) • In pregnancy N O'Farrell MRCP Ngwelezana Hospital, Empangeni, Natal, South Africa Keywords: Donovanosis, pregnancy, sexually transmitted diseases
Donovanosis is generally regarded as a slowly Treatmer:t was commenced with erythromycin progressive sexually transmitted disease (STD) 500 mg twice a day for 2 weeks. When caeserian causing genital ulceration. Since the advent of section was performed 3 weeks later at 39 weeks antibiotics the incidence world-wide has decreased gestation for cephalopelvic disproportion, both but significant prevalences are still reported from lesions had healed. India, Papua New Guinea, parts of southem Africa and the West Indies. Four well-differentiated clinical DISCUSSION variants of donovanosis are described: ulcerogranulomatous, hypertrophic, necrotic and cicatricial. The hypertrophic variant of donovanosis is characterA combination of these variants in anyone individual ized by a slowly growing elevated ulcer above a is not recorded. A case of donovanosis developing warty granulomatous base. A dry verruciform lesion rapidly during the third trimester of pregnancy with is reported! but is unusual and a combination of hypertrophic and ulcero-granulomatous lesions is dry and ulcerative lesions as in this patient has not reported. been described. The severity of disease in donovanosis may increase during pregnancy--' and response to treatment CASE REPORT A 20-year-old married Zulu female 36 weeks pregnant presented with vaginal ulceration and a swelling in the inguinal region for 10 and 6 weeks respectively (Figures 1 and 2). Noticeable enlargement had occurred in the previous 2 weeks. Her husband was asymptomatic and she denied other contacts. Examination of the vulva revealed an ulcerogr.anulomatous lesion at the introitus with slightly r~d edges 2 em in diameter. A dry solid verruciform lesIo~ with a keloidal appearance 2 x 4 cm, attached ~o skin but without ulceration was present in the mguinal region. A Giemsa-stained tissue smear from the ulcer site Was negative for Donovan bodies. The inguinal lesion was excised under local anaesthesia and a p':lnch biopsy of the vulval lesion performed. H~stological examination of both specimens showed mildly acanthotic surface squamous epithelium with underlying granulation tissue containing plasma cells, a few lymphocytes, pockets of neutrophils and sca~tered histiocytic cells. Donovan bodies with the tYpIcal safety pin appearance were demonstrated by GIemsa staining. TPHA and RPR serological tests ~or syphilis were negative. Antibodies to human Immunodeficiency virus type 1 (ELISA) were not detected.
Figure 1. Genital and inguinal lesions of donovanosis
------------------Correspondence to: Dr N O'Farrell, Lydia Clinic, St Thomas' HOSpital, London SE1 ?RH, UK
Figure 2. Close urI of inguinal hypertrophic lesion of donovanosis
448
International Journal of SID & AIDS Volume 2 November/December 1991
is less rapids. In one review of patients with donovanosis complicated by dissemination to bone, a history of antecedent pregnancy was not uncommons. Locally, in a study of 100 women with genital ulcer disease, lesions of donovanosis were diagnosed in 4 of 8 pregnant women". Altered maternal immunocompetence during pregnancy may affect the natural history of infections possibly by depression of lymphocyte proliferative responses in the third trimester and account for both the unusual manifestation of donovanosis in this case and worsening of disease during pregnancy". This report may alert clinicians examining pregnant women with atypical genital ulcers to the possibility of infection with donovanosis.
Acknowledgements: The assistance of Mr Les Allen, Consultant in Obstetrics and Gynaecology, Ngwelezana Hospital, and Dr A Bramdev and Dr A Hoosen, University of Natal Medical School is gratefully acknowledged.
References 1 Sehgal VN, Shyam Prasad AL. A clinical profile of donovanosis in a non-endemic area. Dermatologica 1984;168: 273-8
2 Wilson LA. Pregnancy and labour complicated by granuloma inguinale. lAMA 1930;95:1093-5 3 Nair VG, Pandalay NG. Granuloma genito-inguinale. Indian Med Gazette 1934;69:361-71 4 Latif AS, Mason PR, Paraiwa E. The treatment of donovanosis (granuloma inguinale). Sex Transm Dis 1988;15:27-9 5 Kirkpatrick DJ. Donovanosis (granuloma inguinale): a rare cause of osteolytic lone lesions. Clin RRdioI1970;21:101-5 6 O'Farrell N, Hoosen AA, Coetzee KD, van den Ende J. Genital ulcer disease in women in Durban, South Africa. Genitourin Med 1991;67:322-6 7 Gehrz RC, Christianson WR, Linner KM, etal. A longitudinal analysisof lymphocyte proliferativeresponses to mitogens and antigens during human pregnancy. Am J Obstet Gynecol 1981;140:665-70
(Accepted 11 March 1991)
CASE REPORT
Donovanosis (granuloma inguinale) • In pregnancy N O'Farrell MRCP Ngwelezana Hospital, Empangeni, Natal, South Africa Keywords: Donovanosis, pregnancy, sexually transmitted diseases
Donovanosis is generally regarded as a slowly Treatmer:t was commenced with erythromycin progressive sexually transmitted disease (STD) 500 mg twice a day for 2 weeks. When caeserian causing genital ulceration. Since the advent of section was performed 3 weeks later at 39 weeks antibiotics the incidence world-wide has decreased gestation for cephalopelvic disproportion, both but significant prevalences are still reported from lesions had healed. India, Papua New Guinea, parts of southem Africa and the West Indies. Four well-differentiated clinical DISCUSSION variants of donovanosis are described: ulcerogranulomatous, hypertrophic, necrotic and cicatricial. The hypertrophic variant of donovanosis is characterA combination of these variants in anyone individual ized by a slowly growing elevated ulcer above a is not recorded. A case of donovanosis developing warty granulomatous base. A dry verruciform lesion rapidly during the third trimester of pregnancy with is reported! but is unusual and a combination of hypertrophic and ulcero-granulomatous lesions is dry and ulcerative lesions as in this patient has not reported. been described. The severity of disease in donovanosis may increase during pregnancy--' and response to treatment CASE REPORT A 20-year-old married Zulu female 36 weeks pregnant presented with vaginal ulceration and a swelling in the inguinal region for 10 and 6 weeks respectively (Figures 1 and 2). Noticeable enlargement had occurred in the previous 2 weeks. Her husband was asymptomatic and she denied other contacts. Examination of the vulva revealed an ulcerogr.anulomatous lesion at the introitus with slightly r~d edges 2 em in diameter. A dry solid verruciform lesIo~ with a keloidal appearance 2 x 4 cm, attached ~o skin but without ulceration was present in the mguinal region. A Giemsa-stained tissue smear from the ulcer site Was negative for Donovan bodies. The inguinal lesion was excised under local anaesthesia and a p':lnch biopsy of the vulval lesion performed. H~stological examination of both specimens showed mildly acanthotic surface squamous epithelium with underlying granulation tissue containing plasma cells, a few lymphocytes, pockets of neutrophils and sca~tered histiocytic cells. Donovan bodies with the tYpIcal safety pin appearance were demonstrated by GIemsa staining. TPHA and RPR serological tests ~or syphilis were negative. Antibodies to human Immunodeficiency virus type 1 (ELISA) were not detected.
Figure 1. Genital and inguinal lesions of donovanosis
------------------Correspondence to: Dr N O'Farrell, Lydia Clinic, St Thomas' HOSpital, London SE1 ?RH, UK
Figure 2. Close urI of inguinal hypertrophic lesion of donovanosis
448
International Journal of SID & AIDS Volume 2 November/December 1991
is less rapids. In one review of patients with donovanosis complicated by dissemination to bone, a history of antecedent pregnancy was not uncommons. Locally, in a study of 100 women with genital ulcer disease, lesions of donovanosis were diagnosed in 4 of 8 pregnant women". Altered maternal immunocompetence during pregnancy may affect the natural history of infections possibly by depression of lymphocyte proliferative responses in the third trimester and account for both the unusual manifestation of donovanosis in this case and worsening of disease during pregnancy". This report may alert clinicians examining pregnant women with atypical genital ulcers to the possibility of infection with donovanosis.
Acknowledgements: The assistance of Mr Les Allen, Consultant in Obstetrics and Gynaecology, Ngwelezana Hospital, and Dr A Bramdev and Dr A Hoosen, University of Natal Medical School is gratefully acknowledged.
References 1 Sehgal VN, Shyam Prasad AL. A clinical profile of donovanosis in a non-endemic area. Dermatologica 1984;168: 273-8
2 Wilson LA. Pregnancy and labour complicated by granuloma inguinale. lAMA 1930;95:1093-5 3 Nair VG, Pandalay NG. Granuloma genito-inguinale. Indian Med Gazette 1934;69:361-71 4 Latif AS, Mason PR, Paraiwa E. The treatment of donovanosis (granuloma inguinale). Sex Transm Dis 1988;15:27-9 5 Kirkpatrick DJ. Donovanosis (granuloma inguinale): a rare cause of osteolytic lone lesions. Clin RRdioI1970;21:101-5 6 O'Farrell N, Hoosen AA, Coetzee KD, van den Ende J. Genital ulcer disease in women in Durban, South Africa. Genitourin Med 1991;67:322-6 7 Gehrz RC, Christianson WR, Linner KM, etal. A longitudinal analysisof lymphocyte proliferativeresponses to mitogens and antigens during human pregnancy. Am J Obstet Gynecol 1981;140:665-70
(Accepted 11 March 1991)
