Vulvar Donovanosis – An Unusual Cause of Genital Ulcer

INTRODUCTION

Donovanosis, also known as granuloma inguinale or granuloma venereum, is a sexually transmitted infection caused by Klebsiella granulomatis (previously known as Calymmatobacterium granulomatis), a Gram-negative bacteria.^[1] It is a chronic progressive granulomatous ulcer affecting labia minora and fourchette in females and prepuce, glans penis and coronal sulcus in males.^[1,2] It was initially described by McLeod in 1882. We are reporting a case of vulvar donovanosis in a 40-year-old female diagnosed with cytopathology.

CASE REPORT

A 40-year-old parous perimenopausal lady presented to the gynaecology department with swelling over the vulva for 5 months duration, which was painless, non-itching, and not associated with any discharge. It started as a small papule and progressed to a present lesion in 5 months. There was no history of trauma, vaginal discharge, itching per vagina or bleeding per vagina. There was no history of human immunodeficiency virus (HIV), tuberculosis and extramarital sexual contact. On clinical examination, she had an ulcerated vulvar mass measuring 4 × 4 cm, which was non-tender, not indurated and was associated with active serosanguinous discharge. There was no inguinal lymphadenopathy. Per vaginal examination was normal. Considering differential diagnoses of infectious and neoplastic causes of vulvar ulcer, smears from serosanguinous discharge and Pap smear were taken. HIV serology was also done which was non-reactive. Pap smear was negative for intraepithelial lesion or malignancy. Cytopathological examination of discharge smear stained with Giemsa stain showed macrophages containing Donovan bodies, which are dark blue safety pin-shaped bipolar Gram-negative bacteria [Figure 1]. Diagnosis of donovanosis was made by the presence of Donovan bodies in the cytoplasm of macrophages. The diagnosis was confirmed by histopathological examination of ulcer edge biopsy, which also ruled out malignancy. The patient was treated with azithromycin 1 g orally weekly once for 4 weeks regimen, and she responded to treatment well.

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Figure 1:

Cytology smear shows intracellular (macrophages) and extracellular Donovan bodies (Giemsa stain, ×100).

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DISCUSSION

The most common route of transmission of the organism causing donovanosis is sexual, followed by faecal contamination and autoinoculation; however, our patient denied sexual promiscuity.^[1] The disease usually starts as a small papule and then progresses to a nodule and ulcerated mass with a beefy red fleshy surface. Based on the appearance, there are four clinical variants-fleshy, sclerotic, hypertrophic and rapidly destructive lesion.^[3] Our case presented with a painless ulcerated vulvar mass similar to the cases described in the literature.^[1,4] Cases with extragenital lesions of donovanosis were also reported involving the oral cavity, vertebra, etc.^[5,6] Since K. granulomatis cannot be cultured, the gold standard method of diagnosing donovanosis is tissue biopsy stained with Giemsa stain showing Donovan bodies in macrophages, as demonstrated in our case, which also screens for the presence of malignancy.^[1,2,4] Donovan bodies are ovoid or bean-shaped bacteria and have a closed safety pin appearance on Giemsa staining due to the presence of blue chromatin inclusions at each pole.

Various treatment regimens are available with azithromycin, doxycycline, cotrimoxazole, ciprofloxacin, and erythromycin, and the regimen should be selected based on the antibiotic sensitivity of the organism for an earlier response.^[7,8] Early diagnosis and appropriate treatment help in preventing complications such as pseudo elephantiasis of the vulva and malignant transformation, which necessitates vulvectomy.^[2,9] Cases of transformation of vulvar donovanosis ulcer into squamous cell carcinoma have been reported, emphasising the importance of earlier consultation and diagnosis of the cause of genital ulcer.^[1,2,4]

CONCLUSION

We diagnosed a case of vulval donovanosis in a 40-year-old patient who presented with an ulcerated vulvar mass by histopathologic examination. A clinician should consider donovanosis as one of the differential diagnoses while treating a patient with a genital ulcer to prevent a fatal malignant transformation of the lesion.