by M.P. Vora
(An All-India Monthly Journal of Medicine & Surgery)
Regd. No. P 46 of April, 1964.
Page No. 42 to 44.
Granuloma inguinale is a chronic infectious granulomatous disease of the skin of the genitalia and the neighbouring tissues caused by bacillus Donovania Granulomatis. It shows no tendency to heal spontaneously. Its actual mode of transmission is not known. Widespread metastatic lesions in the bones and joints have been noted.
Donovan (1905) was first to detect ovoid bodies in the microphages in the smear made from the ulcer. The organism has protozoon character akin to Leishmania tropica and L. Donovani of Kala-azar. These ovoid bodies are called Donovan bodies. The disease is mainly confined to the tropical and subtropical areas. The incubation period varies from a few days to three months. The initial lesion is a small nodule which is usually noticed on the skin of the genitalia. From the original lesion, the disease spreads slowly but steadily and peripherally along the warm moist folds and creases of the skin in the perineal region. The nodules become eroded on account of friction and present a bright red granulomatous surface which bleeds easily on touch.
There are four clinical types:
The Nodular Type- Pale, red, soft, elevated nodules appear, increase slowly in size and become eroded and present bright red granulomatous surface. The lesion is surrounded by healthy skin. The new lesions develop at the margin and undergo similar changes. Peripheral extension and sharply defined margins or borders are evident. When the lesions are fairly well advanced the borders appear heaped up, rolled out and bright red full of soft granulations. The mass is raised well above the level of the surrounding healthy skin and often overlaps the surrounding skin. The edges are never undermined. The central granulations are somewhat finer than those at the margin. Fetid blood- tinged discharge, giving foul smell is common. The most striking feature is the absence of neighbouring lymph node involvement. Granuloma inguinale is primarily the disease of the skin and mucous membrane not a disease of the lymphatics as in case of lymphogranuloma venereum. Buboformation is not common.
The Ulcerovegetative Type- It develops from the nodular variety. Secondary infection is not uncommon and results in a serpiginous ulceration.
The Hypertrophic Type- This is not so common as the first two types. Here the poliferative reaction predominates giving rise to large vegetations and pseudo-elephantiasis of the affected region.
The Cicatrical Type- This is characterised by scar formation. The scar is usually hypertrophic and dispigmented. Donovan bodies can be found in the tissue section and smears. There may not be any visible previous lesion.
Systemic manifestations such as fever, pain in joints, headache etc are usually not met with as in the case of Lymphogranuloma venereum.
This is based on:
Smear- Making a smear from the suspected ulcer for the Donovan bodies is the most simple and accurate procedure for the diagnosis of G.I. Soft friable reddish nodules are richest in organisms. A small bit is punched out and it is then rolled in between two slides to make two smears. The smear is then treated with either with Wright or Leishmann’s stain. Organisms appear as diplo-coccoid with or without safety-pin appearance or straight or slightly curved rods. The capsule takes pink colour and surrounds the blue-stained centre. Finding of intramonocytic Donovan bodies is pathognomonic.
In a very old and chronic lesion; microscopic examination of the tissue has double advantage. It not only helps to confirm the histologic picture of G.I. but also serves to exclude malignancy.
Other methods include dark field microscopy for treponema pallidum, serologic test for syphilis, smears for Ducrey’s bacillus if chancroid is suspected. One must always bear in mind the possibility of acquiring more than one disease at one contact. Clinical observations especially in an advanced case are very useful. Chronic, indolent and spreading at the periphery, granulomats nodular ulcer, healthy surrounding skin, absence of the involvement of neighbouring lymph nodes, mass elevated well above the level of the surrounding skin, rolled over margins and absence of systemic manifestations- all these go to strengthen the suspicion.
Until late the treatment of G.I. was extremely unsatisfactory. Antimony preparations were chiefly employed. Tartar emetic 1% intravenously 1 to 10 cc, Anthiomaline (M&B), Fantorin (Glaxo Lab), and Fuadin (Bayer) 3 to 5 cc intramuscularly has to be given for weeks and even then relapses were common. Local treatment has little curative effect. It is mainly directed towards cleanliness and prevention of secondary infection. Dressing with potassium permanganate solution 1 in 8000 is quite satisfactory. Development of new broad- spectrum antibiotics in the recent years, has revolutionised some old treatment procedures. Penicillin and sulpha drugs have no effect on G.I. however; they may be of use where secondary infection is present. Streptomycin, I.M. or chloromycitin or Terramycin or Tetracyclin orally are quite effective but must be used for prolonged time for a success.
Streptomycin gms 20 to 30 I.M. in 10 to 15 days.
Chloromycetin gms 20 to 40 in 10 to 20 days orally.
Terramycin gms 20 to 30 in 10 to 15 days orally.
However in old cases treatment may have to be prolonged till satisfactory results are obtained.
Follow-up- It is essential to carry out subsequent check-up for a few months. Such a precaution will remove any possibility of developing syphilis and to prevent relapse of G.I. which is so common.