Br J Vener Dis 1984;60:45-7

The histopathological diagnosis of donovanosisV N SEHGAL,* A L SHYAMPRASAD,* AND P C BEOHARtFrom the *Department of Dermatology and Venereology and the tDepartment of Pathology, MaulanaAzad Medical College and Associated LNJPN and GB Pant Hospitals, New Delhi, India

SUMMARY The role of histopathology in the diagnosis of donovanosis was assessed in 42patients. There was heavy infiltration of the dermis with plasma and mononuclear cells but withfew lymphocytes and neutrophils. The epidermis contained focal collections of polymorpho-neuclear leucocytes. Endothelial proliferation and dilatation of dermal blood vessels was striking.Intracellular and extracellular Donovan bodies were shown in Giemsa stained sections from 40patients. Pseudoepitheliomatous hyperplasia was found in biopsy specimens from a few patients.

Introduction #W,

Donovanosis, a sexually transmitted disease causedby Calymmatobacterium granulomatis, is predomin-antly a disease of the tropics. It was first described byMcLeod in 1882 in Madras. The diagnosis of dono-vanosis is largely made on the clinical features of thecondition, which have been well documented. 1-3Diagnosis is helped by finding Donovan bodies intissue smears, although the usefulness of this test islimited by lack of sensitivity on microscopy ofstained smears. We therefore decided to assess therole of histopathology in the diagnosis of dono-vanosis.

I4

Patients and methods FIG I Tissue smear showing intracellular Donovanbodies (Giemsa x 1000).

All patients with genital ulcers who attended thesexually transmitted diseases (STD) clinic of ourhospital were studied. A detailed history was takenfrom each patient and, after clinical examination,material from each ulcer was taken for microbio-logical investigations. These included dark groundmicroscopy for Treponema pallidum, examination ofa Gram stained smear for Haemophilus ducreyi, andof a tissue smear for Donovan bodies (fig 1). Thelatter test was performed by removing a piece oftissue from a granulating area or the edge of the ulcerwith a pair of forceps. This was pressed between twoglass slides, so as to get tissue impressions on boththe slides. After air drying the smears were fixed withmethanol, stained with Giemsa stain, and examinedmicroscopically. Serological tests for syphilis,

Address for reprints: Dr V N Sehgal, A/6 Panchwati, Delhi-i 10033,India

Accepted for publication 18 July 1983

Venereal Diseases Research Laboratory (VDRL) andTreponema pallidum haemagglutination (TPHA)tests, were performed at the time of the first examin-ation. The VDRL test was repeated every month forthree months in each case. All patients showingpositive tissue smears for Donovan bodies, as well asthose clinically suggestive of donovanosis but withnegative tissue smears, underwent biopsy of thelesions. The biopsy specimen was taken from themargin of the ulcer or from an area exhibitingluxuriant granulation tissue. A wedge of tissue wasremoved by a Bard-Parker knife, after localinfiltration with 1% lignocaine at the base of theulcer. Bleeding was arrested by pressure with a pieceof gauze.

After being processed in the usual manner, tissuesections were stained with haematoxylin and eosinand Giemsa stains. A final diagnosis of donovanosiswas based on clinical examination and the presence

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of Donovan bodies in tissue smears, histopatholo-gical sections or both.

Results

Of the 42 cases of donovanosis diagnosed, 34 wereulcerative or ulcerogranulomatous, seven hyper-trophic, and one necrotic. Donovan bodies wereshown in histopathological sections. In two othercases Donovan bodies were seen in tissue smears butthese micro-organisms were not detected in histo-pathological sections.

HISTOPATHOLOGYThe histopathological changes were rather strikingand affected the dermis as well as the epidermis.

Dermal changesThe dermal changes were primarily inflammatoryand consisted of a dense infiltrate which waspredominantly formed of large numbers of plasmaand mononuclear cells throughout the dermis (fig 2).In addition, histiocytes were seen in varying numbers.A few large cells containing cystic spaces, often withnuclei pushed to one side, and darkly staininginclusions (cells of Greenblatt) were conspicuous.The number of neutrophils and lymphocytes wasinsignificant in most sections. Intracellular and extra-cellular Donovan bodies (fig 3) were shown in 40 outof 42 tissue sections. They had different morpho-logical features: coccoid, coccobacillary, or bacillary.Mature forms surrounded by a capsule were seen insome sections. Donovan bodies were easily identifiedin Giemsa stained tissue sections but difficult toidentify in haematoxylin and eosin stained sections.Vascular changes (dilatation, proliferation, or both)

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FIG 2 Tissue section showing massive inflammatoryinfiltrate comprising plasma and mononuclear cells.Vascular dilatation showing endothelial proliferation(H & E x 400).

VN Sehgal, A L Shyamprasad, and P C Beohar

FIG 3 Tissue section showing collection of Donovanbodies (Giemsa x 1000).

were predominant in 6207 of cases. Endothelialproliferation was a common feature, and prolifer-ation of the tunica media was seen in some cases.

Epidermal changesOf the tissue sections 34 showed discontinuity in theepidermis, with ulcerations varying from mild tosevere. Proliferation of the stratum spinosum(acanthosis), in the form of elongation of rete ridges(fig 4), was a constant feature of the hypertrophicvariety, but was observed only in 19 cases of theulcerative type of donovanosis. Pseudo-epithelio-matous hyperplasia was seen in only four tissuesections of the hyperplastic variety. There was noclear cut evidence of malignancy in the form of hornpearls, atypia of individual cells, or numerousmitotic figures, however, in these sections. Neutro-philic sprinkling of both the upper dermis, and theepidermis was seen in 18 sections. In only three caseswas there a collection of neutrophils forming micro-abscesses in the epidermis (fig 5). The adnexae, fat,and muscle were conspicuously spared. In foursections, fibrosis of the lower dermis was alsorecorded.

Discussion

The diagnosis of donovanosis in our series was basedon the clinical features and tissue smear microscopy.The limitations of the tissue smear are obvious insome varieties of donovanosis; in our study it wasdifficult to demonstrate Donovan bodies in earlydonovanosis, in two chronic cases, or with thenecrotic variety of ulcer. Rajam and Rangiah haveexpressed similar views.' In addition, cases whichclinically suggest malignancy necessitate a biopsy.4Histopathological sections are of great value in thediagnosis of each of the clinical varieties of dono-

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The histopathological diagnosis of donovanosis

FIG 4 Epidermal changes in the form of elongation ofthe rete ridges, with intense inflammatory infiltrate

primarily of mononuclear cells (H & E x 160).

vanosis. In three of our cases which were clinicallydiagnosed as donovanosis, Donovan bodies were notfound in repeated tissue smear examinations but wereclearly shown in histopathological sections. Pundand Greenblatt described five essential histopatho-logical features for the diagnosis of donovanosis.5Their main emphasis was on the massive cellularinfiltrate formed predominantly by plasma cells, apaucity of lymphocytes, diffuse sprinkling of poly-morphonuclear leucocytes with focal collections,pronounced epithelial proliferation at the margins,and the presence of large, mononuclear cells in theinfiltrate which were considered to be pathognomic.All these features were observed in our study. Intra-cellular and extracellular Donovan bodies of varyingmorphology and vascular proliferation and dilatationwere also prominent in the lower dermis. The vas-cular proliferation was especially marked in theulcerogranulomatous variety of donovanosis. Dono-van bodies were easily identifiable in Giemsa stainedtissue sections, and were easier to locate than in tissuesmears. The characteristic cellular infiltrate ofplasma and mononuclear cells and the extensiveulceration with acanthosis and rete ridge elongationat the margins were other characteristics whichfeatured in our cases. Pseudo-epitheliomatous hyper-

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FIG 5 Ulcer with micro-abscess formation(H & E x 400).

plasia was observed in only four tissue sections, noneof which showed features of malignancy. Beermanand Sonck emphasised the prominence of thisfeature.6 According to them, mitotic figures were notso numerous and 'pearl' formation not so prominentin epitheliomas compared with pseudo-epithelio-matous hyperplasia. Neutrophilic micro-abscesses inthe epidermis and localised collections of neutrophilsin the upper dermis were features seen in our study.Such findings were reported earlier by Rajam andRangiah' and Nayar et al.4

References

1. Rajam RV, Rangiah PN. Donovanosis (granuloma inguinale,granuloma venereum) WHO Series Mdnograph No 24.Geneva: World Health Organisation, 1954.

2. US Public Health Service. Management of chancroid, granu-loma inguinale, lymphogranuloma venereum in generalpractice. Atlanta, Georgia: US Department of Health,Education and Welfare, Communicable Disease Centre,Venereal Diseases Branch, 1964.

3. Sehgal VN. A textbook of venereal diseases. 1st ed. New Delhi:Vikas Publishing House, 1978.

4. Nayar M, Chanclra M, Saxena HMK, Bhargava NC, SehgalVN. Donovanosis-a histopathological study. Indian J PatholMicrobiol 1981;24:71-6.

5. Pund ER, Greenblatt RB. Specific histology of granulomainguinale. Arch Pathol Lab Med 1937; 23:224-30.

6. Beerman H, Sonck CE. The epithelial changes in granulomainguinale. American Journal of Syphilis, Gonorrhea, andVenereal Disease 1952; 36:501-10.

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