Anus and perianal area
Inflammatory diseases
Granuloma inguinale

Author: Arvind Rishi, M.D. (see Authors page)
Editor: Toby Cornish, M.D.

Revised: 28 September 2017, last major update June 2014

Copyright: (c) 2002-2017, PathologyOutlines.com, Inc.

PubMed Search: Granuloma inguinale [title] "loattrfree full text"[sb]

Cite this page: Rishi, A. Granuloma inguinale. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/anusgranulomainguinale.html. Accessed November 23rd, 2017.
Definition / general
  • Synonym "donovanosis"
  • Causative organism was previously classified as Calymmatobacterium granulomatosis; subsequent molecular characterization reclassified the causative organism as Klebsiella granulomatis
  • Gram negative, nonmotile and encapsulated organism
  • May extend to perianal region
Epidemiology
  • Most common in tropical regions, no gender preference
  • Bacterial infection associated with sexually transmitted disease or via childbirth with infected genital tract
  • Development of lesion requires repeated exposure because of low pathogenicity of organism
  • Fewer than 100 cases reported annually in United States
  • Untreated lesions may have superadded infections, progression to extensive fibrosis, obstruction of lymphatic vessels and massive lymphedema
Sites
  • Penile ulcers (sulcocoronal and balanopreputial)
  • Labia minora
  • Fourchette
  • Cervix (uncommon)
Clinical features
  • Median incubation period is ~50 days but exact incubation period is unknown
  • There are four predominant types of clinical presentations:
    1. Nodular
    2. Ulcerovegetative
    3. Cicatricial
    4. Verrucous
  • The lesion starts as an elevated nodular or papular area which then progresses to anulcerated lesion with communicating satellite nodules and ulcerations
  • Anal involvement is more common in men
  • Extragenital involvement occurs in minority of cases (6%) and results from direct or local spread
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, Toluidine blue and Leishman stain
  • 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
Case reports
Treatment
  • Either trimethoprim / sulfamethoxazole or tetracyclines (doxycycline) for at least 3 weeks (choice is based on allergies, pregnancy or other clinical conditions)
  • Resistant lesions are treated longer
Clinical images

Images hosted on other servers:

Perianal ulcerations

Diffuse ulceration

Auto-amputation

Missing Image

Ulcerous and ulcerovegetative forms

Gross description
  • Varies based on age of lesion and immunosuppression
  • Ulceration with ragged beefy red edges and indurated base
  • Ulcer size ranges from 0.5 cm to 5 cm
  • Usually multiple ulcers
Microscopic (histologic) description
  • Marked reactive changes in surface epithelium secondary to inflammation and ulceration; marked pseudoepitheliomatous hyperplasia adjacent to ulcer
  • Numerous histiocytes and plasma cells, with fewer neutrophils and lymphocytes
  • Granulomatous inflammation, neutrophilic microabscesses (particularly in ulcer bed)
  • Large vacuolated / foamy macrophages / histiocytes with multiple intracytoplasmic organisms (bacteria are called Donovan bodies, not the histiocytes; have bacillary or coccobacillary appearance); Donovan bodies may be extracellular
  • Acute and chronic granulation tissue, fibrosis (dermal and subcutaneous cicatricial) in late stages
  • Prominent lymphatic channels
Microscopic (histologic) images

Images hosted on other servers:

Safety pin shaped structures

Epithelioid histiocytes

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Biopsy and smear

Positive stains
Differential diagnosis
  • Squamous cell carcinoma: may grossly as well as clinically resemble the ulcerative and verrucous type of granulomas inguinale lesions