A clinical and investigational study of donovanosis

Introduction

Donovanosis is an acquired chronic, progressive, sexually transmitted disease characterized by granulomatous ulcers of the genitalia and neighbouring sites, caused by a gram negative bacillus Calymmatobacterium.[1] Though its descriptions were given century back, it is often neglected because of its few specific geographic locations and low incidence. Initial description of this disease was given by McLeod in 1882.[2]

Although Danovanosis is known as a clinical entity since 1882, its pathogenesis and epidemiology is not yet completely understood and needs further study. Difficulties in culturing the organism have led to considerable debate about the causative agent. The present study was undertaken to consolidate its current status with those of previous works and to study the epidemiological, clinical and investigational aspects of this disease.

Materials and Methods

The study material comprised of Donovanosis, diagnosed in the STD clinic, Medical College Hospital, Bellary from November 1992 to September 1994. The patients irrespective of the age, sex and socio economic status were included in the study.

A detailed history was taken with reference to age, sex, occupation, sexual exposure, socio- economic status, marital status, duration of the disease, initial site, progression and treatment taken. Local examination of the ulcer was done in detail. All the cases clinically diagnosed were investigated by tissue smear examination, routine blood test and urinalysis, VDRL and HIV tests. Female patients who had vaginal discharge were tested for candidiasis and Trichomonas vaginalis. Biopsy of the ulcer was done in 8 patients with pseudo elephantiasis and also were screened for filarial infection.

Results

Total number of 1,630 cases attended the STD clinic during this 22 months pe-riod. Total of 25 cases of Donovasnosis were diag-nosed giving an average of 1.53% of all STDs. Analy-sis of different STD′s are given in [Table - 1].

Among 1,630 STD cases, 841 case: presented with GUD, incidence of Donovanosi: among GUD being 2.9%.

Other minor STD′s included genital warts balanoposthitis, genital scabies, molluscun contagiosum, vulvovaginitis and pediculosis Maximum incidence was seen in 21-30 years o age group (44%). In this study males out numberec females. Out of 25 cases 17 (68%) were male and 8(32%) were females. M:F ration was 2.12:1 Out of 25 cases 14(56%) were unmarried, married and 4 divorced, out of 5 marital partner examined 1 was found to have conjugal donovanosis.

Incidence of the disease was highesi 11 manual laborers 44%. The disease was more common in patients with lower socio economic status (64%).

Majority of patients presented with painless genital ulcer. Duration the disease varied from 7 days to 2 years. Among the 4 described types of ulcers of Donovanosis only 3 types were encountered in the present study [Table - 2].

MI of the patients presented with ul-cer situ-ated over the external genitalia (80%). Two patients presented with extragenital ulcers, one with a oral another with perianal ulcers. Both perianal and oral le-sions were found in homosexuals.

Among 25 cases, 13 patients (52%) presented with single ulcer. Out of the 25 cases 9 patients (36%) had regional lymphadenopathy.

Associated STDs

Among the associated STDs syphilis was present in 3 patients, genital warts, scabies and HIV in one each.

Ten patients presented with local complica-tions. 8 had pseudo elephan-tiasis, one had micro-stomia, and one deve-loped squa-mous cell carcinoma of the vulva.

Tissue smear examination demonstrated Donovan bodies in 22 cases. VDRL test was reactive in 4 cases (16%). HIV antibodies were present in 1 patient. Biopsy was done in 8 patients (32%). All specimens showed granulomatous infiltration of the dermis with plasma cells and histiocytes. Various histological changes seen are given in [Table - 4].

Discussion

The incidence of Donovanosis varies from 0.3% to 23.6% across India.[3] The present study showed an incidence of 1.53%, which is well comparable with studies by Rajam and Rangaiah (1.5%). Anandam (1.6%), and Iyangar (1.5%). The low incidence can be explained by long incubation period, low infective nature of the disease and easy availability of antibiotics. Bellary is a dry and hot place with extremes of temperature. C. granulomatis prefers hot and humid climate.

In the present study the highest incidence was seen in the age group of 21-31 years similar to previous studies.[1],[3],[4]

The males out numbered females. Other studies conducted also reported male predominance[1],[3] Unmarried males were commonly affected which can be explained by their sexual promiscuity and low morality. Studies on conjugal Donovanosis has shown wide variation. Majority of patients were from rural area which is due to low living standards, illiteracy and unawareness. Prostitution had always been blamed for the spread of Donovanosis.[2] In the present study 60% contracted the disease from the prostitutes.

Many workers have questioned the venereal origin of the disease.[10] Several points observed in the present study are in favour of venereal origin of the disease.

• Majority had history of sexual contact
• 92% had lesions on genitalia
• History of promiscuity was present in majority of cases
• Association with other STD′s

Donovanosis mainly involves genitalia and secondarily spread to neighbouring area.[1] In the present study 92% of patients presented with ulcers over genitalia and neighbouring areas. 2(8%) patients had primary extragenital lesion over perianal and oral region. Both gave history of sodomy and oral sex respectively. Extra genital lesion occupies 6% of cases.[1] Several workers have reported extra genital Donovanosis.[5],[6]

Among local complications pseudo elephantiasis was commonest. This complication had also been reported by various workers.[2],[3],[7] There was also a case of squamous cell carcinoma of the vulva developing after long standing Donovanosis. Greenblat in 1984 reported that 6.8% of Donovanosis developed malignancy.

Donovan bodies can be detected in 90--95% of cases and is considered gold standard for diagnosis of Donovanosis.[2] In the present study 22 cases showed Donovan bodies. In the remaining 2, ulcer was of short duration (7 days) and showed some atypical extracellular bodies. In one case of sclerotic type of ulcer, histopathology showed evidence of Donovanosis.

The main histopathological features present in 8 cases were plasma cell and histio-cytic infiltration in the dermis and presence of pathognomonic cells containing Donovan bodies. Irregular ocanthosis, hyperkeratosis, pseudo-epitheliomatous hyperplaiso were also present in few cases. Though several of the above said features are nonspecific, the presence of pathognomonic cells and plasma cell infiltration are enough to point towards the diagnosis. Also biopsy helps to rule out malignancy.[2]

All the 25 cases responded well to standard antibiotics, mainly streptomycin, tetracyclin, sulfonamides and minocyclin. Recent studies reported azithromycin and quinolones and ceftriaxone very effective and well tolerated.[1],[8] Surgical correction of pseudoelephantiasis was done in 3 cases.

In the present study syphilis was the common associated STD which is also observed in other studies.[1] One patient with associated HIV infection did not show any unusual clinical or therapeutic response. In few reports of HIV +ve patients with Donovanosis had high failure rate to first-line antibiotic therapy.[9] In conclusion the epidemiological features of the disease found in the present study was well correlated with earlier studies. Prostitutes were the major source of infection. Veneral origin of the disease is well supported in the present study. The fleshy exuberant type was the commonest clinical type of ulcer found. 2 extra genital lesions of perional and perioral were also encountered. Shorter the duration the more difficult it was to demonstrate Donovan bodies in tissue smear.

Histopathological changes though non specific will help in distinguishing between malignancy and Donovanosis. Pseudoelephantiasis was the common complication found. This was common in females.