Ulcero-granulomatous donovanosis in a HIV positive male

Abstract

We report the case of a 29-year-old HIV-positive male on antiretroviral therapy who presented with multiple pinhead-sized papules that progressed into varying-sized ulcers over the penile shaft and glans penis. The patient had a history of both protected and unprotected sexual encounters. Recent contact tracing led to the treatment of some partners, although several could not be traced due to residing in distant areas. The patient had a history of recurrent herpes genitalis for the past 4–5 years, with frequent outbreaks. Laboratory findings revealed a CD4 count of 677 cells/mm³ and the patient tested negative for hepatitis B, hepatitis C, VDRL, and TPHA. Diagnosis of donovanosis was confirmed by Giemsa staining, which revealed Donovan bodies. This case highlights the importance of early diagnosis, partner tracing, and comprehensive treatment strategies in managing donovanosis in HIV-positive individuals.

Introduction

Donovanosis, also known as granuloma inguinale, is a bacterial infection of the genital region caused by Klebsiella granulomatis.[1] It is prone to occur globally with typical regions including tropical and subtropical climates such as New Guinea, Southern India, Southeast Asia, Brazil, Indonesia, Argentina, and the Caribbean region. The WHO has expressed concern over resurgence of sexually transmitted infections (STI’s) which has become uncommon in last two decades. In India, donovanosis is endemic in states along the east coast, such as Odisha, Tamil Nadu, and Andhra Pradesh.[2] The disease is rare in North India, with an incidence of less than 0.5%.[3] Recently, new cases of donovanosis have been reported, particularly among HIV-positive individuals.[4] However, data on the impact of HIV on the clinical presentation and progression of donovanosis remain limited.

Case Description

We report a case of an uncommon STI in a 29-year-old HIV-positive male on antiretroviral therapy (ART). He presented with multiple pinhead-sized papules progressing into varying-sized ulcers over the penile shaft and glans penis. The patient had a history of multiple protected and unprotected sexual encounters with known partners. Recent contact tracing was conducted, and whereas some partners were successfully treated, a few could not be traced due to their distant locations. Investigations and treatment were recommended for all partners. The patient also had a history of recurrent herpes genitalis over the last 4–5 years, with outbreaks occurring every 2–3 months. These outbreaks were moderate to severe, lasting around 10–14 days. Each episode was managed with acyclovir, but the patient experienced frequent relapses, particularly during periods of stress or when coinfections were present.

On examination, multiple nontender, erythematous, indurated, and discrete ulcers with everted edges of size ranging from 1.5 cm × 2.5 cm to 2.2 cm × 2.5 cm were present over the penile shaft and glans penis. Slight bleeding was present on manipulation [Figure 1a and b]. Bilateral discrete, firm, and tender inguinal lymph nodes of size approximately 1.5 × 2–2.2 cm × 2.5 cm were present. Other cutaneous examinations were within normal limits. Based on the patient’s history and examination, clinical differentials of atypical herpes genitalis, donovanosis, and histoplasmosis were considered. The patient was given initial treatment for herpes genitalis but lesions failed to show any improvement. Blood tests, including complete blood count, liver, and kidney function tests, were normal. The patient was HIV positive with a CD4 count of 677 cells/cm. Hepatitis B, C, VDRL, and TPHA were negative. Tzanck smear showed no multinucleated giant cells but immunoglobulin (Ig) G herpes simplex virus (HSV) serology was positive. Giemsa stain revealed Donovan bodies in tissue smear [Figure 2]. Periodic acid-Schiff (PAS) and Grocott’s methenamine silver (GMS) were negative for fungus. A Final diagnosis of donovanosis was made on the basis of clinical features and investigations. The patient was treated with oral doxycycline for 8 weeks after which 90% of ulcers healed in 3 weeks; doxycycline was continued for 8 weeks until all lesions resolved. Biweekly follow-up showed no recurrence up to 2 months posttreatment.

Figure 1.

(a) Multiple nontender, erythematous, indurated, discrete ulcers with everted edges of size ranging from 1.2 cm × 1.5 cm to 2.2 cm × 2.5 cm over penile shaft. (b) Multiple nontender, erythematous, indurated, discrete ulcers with everted edges of size ranging from 0.5 cm × 1.2 cm to 2.2 cm × 2.5 cm over penile shaft and glans penis

Figure 2.

Multiple large Gram-negative intractytoplasmic cyst filled with deeply staining bodies (Donovan bodies) on Giemsa smear (black arrows) (×100)

Discussion

Donovanosis, a chronic ulcerative disease, can lead to significant complications if left untreated. In this patient, prompt diagnosis using Giemsa staining, which revealed Donovan bodies, allowed for the initiation of appropriate antimicrobial therapy.[1] Early diagnosis is critical, particularly in immunocompromised patients, to prevent severe outcomes such as hematogenous spread or neoplastic changes.[2] The patient’s history of recurrent herpes genitalis further complicated his clinical picture. In immunocompromised individuals, HSV can present with atypical, severe, and persistent lesions that are less responsive to standard antiviral therapy.[3] However, in this case, the Tzanck smear was negative for multinucleated giant cells, ruling out an active herpes infection. The failure of herpes treatment and the identification of Donovan bodies on Giemsa stain confirmed the diagnosis of donovanosis. The rapid response to doxycycline further supported this diagnosis. A similar case reported by Kumari et al. described a HIV-positive female with donovanosis who required an extended treatment course of doxycycline and azithromycin over 12 weeks.[4] Frequent relapses, despite antiviral therapy, suggest the need for long-term suppressive antiviral therapy in HIV-positive individuals.[5] Effective contact tracing plays a crucial role in controlling the spread of STIs, including donovanosis. In this case, while some partners were traced and treated, others were unreachable due to geographical distance. This highlights the limitations in STI management when contact tracing is incomplete, as untreated partners may continue to spread the infection. The patient’s CD4 count of 677 cells/mm³ was within the expected range for a patient on ART. Monitoring the CD4 count is essential in understanding the patient’s immune status and its impact on the progression of both herpes genitalis and donovanosis. Immunocompromised individuals with lower CD4 counts may require longer and more intensive antibiotic therapy for infections like donovanosis, as the immune response is altered.[5]

Other possible causes of genital ulceration, such as histoplasmosis, were considered. PAS and GMS stains were negative for fungal elements, ruling out fungal infections.

Donovanosis was once considered nearly eradicated in India, but recent cases, particularly in HIV-positive individuals, raise public health concerns. It is essential to re-emphasize awareness of rare and re-emerging STIs among healthcare providers. Early recognition and effective public health interventions, including partner tracing, are key to controlling such infections in high-risk populations.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.