Donovanosis – A Case Report with a Review of Literature

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International Journal of Clinical Dermatology
2023; 6(1): 10-13
http://www.sciencepublishinggroup.com/j/ijcd
doi: 10.11648/j.ijcd.20230601.12
Donovanosis – A Case Report with a Review of Literature
Hristo Mangarov
1
, Valentina Broshtilova
2
, Atanas Batashki
3
, Yoanna Velevska
4
, Petar Vatov
5
,
Svetlana Bezhanova
1
, Irina Iungareva
1
, Sonya Marina
1
1
Department of Dermatology and Venereology, Medical Institute of the Ministry of Internal Affairs, Sofia, Bulgaria
2
Department of Dermatology and Venereology, Military Medical Academy, Sofia, Bulgaria
3
Department of Special Surgery, Medical University, Plovdiv, Bulgaria
4
Department of Infectious Diseases, Parasitology and Dermatovenereology, Medical University, Varna, Bulgaria
5
Department of Surgical Diseases, MB Urology, Medical University, Varna, Bulgaria
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To cite this article:
Hristo Mangarov, Valentina Broshtilova, Atanas Batashki, Yoanna Velevska, Petar Vatov, Svetlana Bezhanova, Irina Iungareva, Sonya Marina.
Donovanosis – A Case Report with a Review of Literature. International Journal of Clinical Dermatology. Vol. 6, No. 1, 2023, pp. 10-13.
doi: 10.11648/j.ijcd.20230601.12
Received: June 9, 2023; Accepted: June 28, 2023; Published: July 6, 2023
Abstract:
Donovanosis (Granuloma inguinale) is a sexually transmitted bacterial infection affecting the genital, perineal, and
perianal regions. It is caused by Klebsiella granulomatis, formerly known as Donovania granulomatis and Calymmatobacterium
granulomatis. Without treatment, the infection followed a chronic progressive course with the formation of ulcerations. Upon
chronification, severe tissue destruction occurs and malignant transformation is possible. Healing is complete with timely
diagnosis and treatment. Donovanosis has not been reported in Bulgaria and herein, we present the first clinical case of this
"exotic" for our country sexually transmitted bacterial infection. Our patient was a 38-year-old man of Nigerian origin. The
dermatological status is represented by papular and erosive-ulcerative lesions on the skin of the foreskin, the body of the penis,
the scrotum and the lower abdomen. Upon Giemsa staining of ulcus material, Donovan corpuscles are found in monocytes. The
histopathological examination a lesion demonstrated irregular acanthosis, focal dyskeratosis in the lower epidermal segment,
moderate spongiosis, papillary oedema, edema swollen endothelium obstructing the vessels of small and medium caliber,
abundant granulomatous tuberculoid infiltrate of epithelioid cells and lymphocytes around the blood vessels in the middle dermis
and interstitial. Infectious granulomas are represented by tissue macrophages, epithelioid cells and lymphocytes located around
areas of collagen necrosis. Based on the anamnesis, dermatological status and examinations, the diagnosis of donovanosis was
made. Epithelialization of the ulks occurred after an extended course of systemic treatment with doxycyclin for 20 days, followed
by azax for 7 days. The topical treatment included baths with potassium permanganate and fusidine cream.
Keywords:
Donovanosis, Sexually Transmitted Infection, Genital Ulceration, Diagnosis, Treatment
1. Introduction
Donovanosis (Granuloma inguinale), also known as
phagedenic disease of the genitals infected granuloma,
sclerosing granuloma, infectious granuloma, inguinal
granuloma, venereal and fifth venereal disease, without
treatment, is a chronic and progressive sexually transmitted
bacterial infection (STI). It is known as "carnivorous STIs"
because of the type of red meat on the ulks and their spread in
depth. It is caused by Klebsiella granulomatis, formerly
known as Donovania granulomatis and Calymmatobacterium
granulomatis. It proceeds mainly with painless, genital,
perineal and perianal ulcerations [1, 2]. Upon chronification,
tissue destruction occurs with the risk of malignant
transformation. Superinfections with other STIs, including
syphilis and HIV, have been reported [3]. The disease is rare
in temperate countries, but is common in the tropics and
subtropics [2]. Endemic areas are Papua New Guinea, the
Caribbean, South India, South Africa, Southeast Asia, South
America, Indonesia, Argentina, Australia and Brazil [2, 4].
2. Clinical Case
We represent a 38-year-old man of Nigerian origin. From
about 3 weeks, slightly painful "pimples" appear on the

International Journal of Clinical Dermatology 2023; 6(1): 10-13 11
genitals and lower abdomen, which are sore. He felt a slight
burning and pain. He applied antibiotic and corticosteroid
creams to no avail. The dermatological status is represented by
papular and erosive-ulcerative lesions ranging in size from
0.5-1 cm to 1.5-2.5 cm, with an elevated edge and discrete
serous-purulent secretion with an unpleasant fetor on the skin
of the foreskin, the body of the penis, the scrotum and the
lower abdomen (Figure 1). Conducted paraclinical studies of
CBC, ESR and CRP did not show abnormalities.
Serological tests for syphilis, AIDS, hepatitis B and C and
Chlamydia trachomatis (IgG, IgM) were negative. Upon
Giemsa staining of ulkus material, Donovan corpuscles are
found in monocytes. Microbiological examination of ulkus
secretion also found Streptococcus pyogenes with sensitivity
to amikacin, amoxycillin/clav. acid, cefepime,
cefotaxime/ceftriaxone, ciprofloxacin, co-trimoxazole,
erythromycin, gentamicin and levofloxacin.
The punch biopsy made from a lesion and the subsequent
histopathological examination demonstrated irregular
acanthosis, focal dyskeratosis in the lower epidermal segment,
moderate spongiosis, papillary oedema, edema swollen
endothelium obstructing the vessels of small and medium
caliber, abundant granulomatous tuberculoid infiltrate of
epithelioid cells and lymphocytes around the blood vessels in
the middle dermis and interstitial (Figure 2). Infectious
granulomas (Figure 3) are represented by tissue macrophages,
epithelioid cells and lymphocytes located around areas of
collagen necrosis (Figure 4).
Based on the anamnesis, status and examinations, the
diagnosis of donovanosis was made. We applied an extended
course of treatment. Systemic oral therapy was performed
with doxycyclin 100 mg, 2 times a day 1 tab., 20 days,
followed by azax 500 mg, 1 time per day, 7 days. Local
therapy included 2 times a day baths with KMnO
4
and fucidin
cream. Epithelialization of the ulks with a residual
hypopigmentation occurred (Figure 5).
Figure 1. Erosive-ulcerative lesions on the body of the penis, pubis and
inguinal.
Figure 2. (H&E, x 4) Tuberculoid infectious granuloma in middle dermal
segment.
Figure 3. (H&E, x 100) Interstitial infectious granuloma represented by
collagen necrosis peripherally distinguished by tissue macrophages,
epithelioid cells, lymphocytes and plasmocytes.
Figure 4. (H&E, x 400) Tissue macrophages with amorphous
haematoxylin-positive cytoplasmic oval deposits (donoval corpuscles).
Figure 5. Residual hypopigmentation.
3. Discussion
Donovanosis was first described by K. McLeod in Calcutta,
India, in 1881 [5]. C. Donovan discovered the causative agent
of the disease in 1905 when he was working in a hospital in
Madras [6]. He suggested that intracellular inclusions in
macrophages were protozoa, which were later called Donovan
corpuscles. The term donovanosis was proposed by M.
Marmell and E. Santora in 1950 in honour of C. Donovan [7].
Granuloma inguinale is an STI [1, 2, 7, 8]. The disease
mainly affects sexually active groups (20-40 years), extremely
rarely children or other age groups (9). According to some
authors there is no sexual predisposition, according to others
the ratio of men to women is 2: 1 [2, 7]. In the same patient an
association with HIV, syphilis and other STIs was observed [1,
10]. Infection is predominantly sexually transmitted, rarely by
direct skin-to-skin contact, by autoinoculation or faecal
contamination [7, 8, 11]. Vertical transmission of the infection
from mother to newborn in vaginal birth is also possible [7].
Donovanosis is caused by Klebsiella granulomatis, Gram (-)
intracellular, facultative, aerobic, rod-shaped bacteria,

12 Hristo Mangarov et al.: Donovanosis – A Case Report with a Review of Literature
formerly known as Calymmatobacterium granulomatis [1, 2, 7,
12, 13]. In microscopic examination, microorganisms are
visualized in macrophages in the form of small oval bodies
called Donovan bodies, pathognomonic to infection [1, 2].
They are relatively easy to stain on Giemsa, Leishman or
Wright [1-3, 7, 8]. J. S. Carter et al. based on molecular studies
in 1999 found that C. granulomatis was over 90% similar to K.
pneumoniae and K. rhinoscleromatis [13]. The authors
propose a reclassification of the microorganism as Klebsiella
granulomatis comb. nov., which remains to this day.
The incubation period of the disease ranges from 1 to 365
days, most often 2-3 weeks [1-3, 7, 8, 12, 13]. In 90% of
patients the first lesions are in the genital, perianal or perineal
areas, in 10% are inguinal and in about 6% are extragenital [1,
2, 8, 9, 11, 12]. In men, they are most often on the penis
(foreskin, coronary furrow, frenulum, glans) and anus, and in
women on the labia minora, cervix and upper genital tract. The
lips, oral mucosa, pharynx, larynx, face, scalp, neck, axillae,
chest and abdomen are extragenitally affected.
The onset is slow and gradual, with papule, papulo-vesicle
or subcutaneous nodulus/nodus appearing at the inoculation
site, which may be single or multiple. The latter in the inguinal
region resemble bubon, the so-called. pseudobubon. The
initial lesion progresses to a painless, easily bleeding ulk, with
a soft base and a raised bumpy, serpiginous, slowly growing
periphery. Patients often do not notice it and seek help in
advancing the disease. In skin folds it is possible to occur
autoinoculation and the formation of new "mirror" lesions.
Regional lymphadenitis rarely develops. The general
condition is preserved [1, 2, 8, 12, 14]. In pregnant women, the
disease has a more aggressive course and more slowly
responds to treatment [12].
4 types of lesion have been described [1, 2, 10, 1]:
1. ulcerogranulomatous – most frequent, single or multiple,
soft, easily bleeding, erythemal, painless ulks,
centrifugally growing;
2. hypertrophic or verucosis - the lesions have irregular,
raised edges and a dry surface;
3. necrotic - deep, painful ulcers with an unpleasant fetor
and subsequent tissue destruction;
4. sclerotic or cicatricial - with extensive fibrosis and
formation of cicatrixes.
In the course of the disease, a number of complications may
arise. Syphilis, HIV, or other STIs superinfection often occurs,
with men with donovosis considered "superspreaders" of HIV
[1, 2, 10, 12, 1]. In untreated patients with secondary bacterial
infection, lymphadenitis and sepsis rarely develop [1, 2, 12,
14]. With the cicatricial form, obstruction of the urinary tract
is possible [1, 2, 14]. In women, labial edema and
elephantiasis, profuse vaginal discharge, even bleeding,
strictures of the urethra, vagina or anus, rectovaginal fistulas
and hematuria [1, 2, 14] may be observed. A spinocellular
carcinoma of the vulva after a prolonged course of the disease
has been described [15]. Mental disorders, even suicidal trials,
have been reported [14]. Rarely, hematogenous dissemination
of infection occurs. It is observed in immunocompromised
patients. The spleen, liver, intestines, lungs, uterus, ovaries,
muscles, joints and bones are affected with osteolytic lesions,
primarily of the tibia and vertebrae [12]. The clinical picture
proceeds with a violation of the general condition, fever,
anemia, night sweats, weight loss and sepsis.
In non-endemic areas, diagnosing donovanosis is
challenging and requires thinking about this "exotic" STI [12].
The fastest, most economical and reliable diagnostic method
is direct microscopy with Giemsa, Leishman or Wright
staining [3, 7, 16]. Identification of Donovan corpuscles in the
tissue swab is pathognomic to the disease [1, 2, 12, 16].
Histological examination from an active lesion with Giemza
or silver staining showed chronic inflammation with
infiltration of plasma cells and polymorphonuclear leukocytes
[2, 12]. Other diagnostic options are both PCR testing, which
is not widely available, and serological tests, which are not
accurate enough to confirm the diagnosis [1-3, 12].
Donovanosis should differ in differential diagnostic terms
from syphilis, chancroid, tuberculosis, lymphogranuloma
venereum, ulcus molle, leishmaniasis, carcinoma, chronic
herpetic ulcerations, bipolar aphthosis, Behçe's disease,
pyoderma gangrenosum, amoebiasis, paracoccidioidomycosis
and histiocytosis of Langerhans cells [1, 2, 7, 8, 10, 12].
Treatment of donovanosis was initially carried out with
antimonite used to treat calla-azar as it was supposed to be
caused by a leishmaniasis-like protozoa [2, 8]. In 1913, H. B.
Aragão and G. Vianna introduced intravenous treatment with
antimony potassium tartrate, which was the first effective drug
for donovanosis [2, 7, 8, 10, 12, 17].
Currently, the recommended first-line therapy of
donovanosis is oral azithromycin 1 g per week or 500 mg daily.
Possible alternatives are oral doxycyclin 2 times a day 100 mg,
ciprofloxacin 2 times a day 500 mg or
sulfamethoxazole/trimethoprim 2 times a day 480 mg. In
pregnant women, oral erythromycin is recommended 4 times a
day 500 mg, and in children oral azithromycin 20 mg/kg 1
time daily.
In case of slow response to lesions, gentamicin 1 mg/kg/d 3
times daily was administered parenterally. The duration of
therapy for all regimens is at least 3 weeks or until complete
epithelialization of the lesions [1, 15, 16, 18].
With significant tissue loss and in cicatrix, surgical
interventions are necessary [12, 18].
Relapses were noted after 6-18 months, despite successful
therapy [2, 10].
Both follow-up of patients for 2-3 months for at least 1 year
and a clinical examination of sexual partners from the last 6
months are recommended [1, 12].
It is necessary to disinfect personal and bed linen that has
been in contact with active ulks. since they are the most
contagious [2, 10, 12].
4. Conclusion
Diagnosis of donovanosis in non-endemic areas, such as
Bulgaria, is extremely challenging. Our patient clinically
presented with ulcerogranulomatous lesions and the
differential diagnosis was extremely versatile. The

International Journal of Clinical Dermatology 2023; 6(1): 10-13 13
histolopathological analysis directed towards infectious
etiology, however, verification needed precise
microbiological findings. Direct microscopy forwarded to
donovanosis and prompted an extended systemic antiobiotic
treatment. The complete healing proved timely diagnosis and
demonstrated the first case of granuloma inguinale in our
country.
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