Granuloma inguinale in a mentally retarded girl.

Sir,

Bacterial sexually transmitted infections are at dearth situation in many of the institutions. Especially chancroid, lymphogranuloma, and granuloma inguinale are almost not reported for the past two decades. Complications of past infections such as lymphogranuloma and granuloma inguinale can be expected, but a new case of granuloma inguinale is worth to be presented. Granuloma inguinale is caused by a fastidious organism called Klebsiella granulomatis, formerly called Calymmatobacterium granulomatis, which was first demonstrated by Major Charles Donovan in 1905 at Chennai who was a co-discoverer also for organisms causing leishmaniasis.[1] Granuloma inguinale was common in the coromandel coast in previous years, i.e., from Odisha, Andhra Pradesh, and Tamil Nadu, India.[2]

A 31-year-old mentally retarded female patient was brought by her mother for a sore genital of less than 1-month duration to her knowledge. The patient was left in a mentally retarded home, from where the mother was informed that she was admitted in a hospital for bleeding per vagina. Only when she was taken home after discharge after the control of bleeding per vagina, the mother noticed the sore while she gave her a bath. According to her mother's report, she was normal when she saw her back a month ago. History of exposure was not able to be elicited as the girl was mentally retarded and was not able to understand and reply relevantly to the questions.

On examination, a large beefy red ulcer was present on the inner aspect of the left labium majus and labium minus extending up to the introitus of the vagina 4–6 cm size with a depth of 1–2 cm. The ulcer was slightly tender, not indurated with irregular edges. The floor was clean and verrucous in nature [Figure 1].

Figure 1

On the 1st day of admission

The inguinal glands were just palpable on both sides, not tender. Blood tests for syphilis and HIV were nonreactive, and herpes simplex virus (HSV) 1 and 2 immunoglobulin G antibodies were strongly positive. Other routine blood and urine investigations were within normal limits. Tissue smear was stained with Leishman's stain and was showed intracellular bacteria [Figures 2 and 3].

Figure 2

Intracellular bacilli

Figure 3

Another field

However, this was not very much typical inside a vacuole of a mononuclear cell. Biopsy report came as squamous papilloma with chronic inflammatory cells.

The patient was initiated with injection streptomycin 0.75 g twice daily after test dose along with tablet acyclovir 400 mg three times daily as her HSV antibodies were positive. However, after 5 days, acyclovir was discontinued and injection streptomycin alone was continued [Figures 4-6].

Figure 4

5th day after treatment

Figure 6

Day 15th of treatment

On day 13 during treatment

Injection streptomycin 0.75 g twice daily was continued for 15 days.

The patient was discharged on day 15, after her admission, and was asked to continue capsule doxycyclin 100 mg twice daily for another 7 days. Then, the patient was not brought for review.

DISCUSSION

Originally, this patient was admitted for bleeding per vagina to a gynecologist. Bleeding per vagina as the primary symptom of granuloma inguinale has already been reported.[3] In that case, a bright pinkish ulcer over the vulva in a girl during her sexually active age was present for an unknown duration. The ulcer was slightly tender on palpation. The patient was not reactive for syphilis and HIV. Biopsy report ruled out the possibility of tuberculosis and malignancy. Tissue smear stained with Leishman's stain revealed intracellular bacilli. The patient reported that antibodies to herpes simplex infection supported some sort of sexual activity. The patient responded well to treatment with injection streptomycin 0.75 g twice daily for 15 days. The response to treatment as per the recommendation of olden text book[4] for the management of Granuloma Inguinale in this case was a granuloma inguinale caused by Klebsiella granulomatis. As no specific blood test or culture facilities are available for the confirmation of the diagnosis of granuloma inguinale, the diagnosis is established on the basis of clinical appearance, tissue smear examination, the response to treatment, and ruling out other ulcerative causes, malignancy, and tuberculosis by histopathological examination. Even though most of the institutions have not reported the incidence of granuloma inguinale, sporadic cases of granuloma inguinale have been reported,[5678] then and there from various parts of the world. Hence, nobody can ignore granuloma inguinale as a differential diagnosis in cases of genital ulcer, and it must be a routine to go for a tissue smear and look for Klebsiella granulomatis either to confirm or rule out the diagnosis. Sometimes, treatable conditions such as genital tuberculosis and granuloma inguinale were misdiagnosed as carcinoma of genitals and unnecessary extensive surgery had been advocated.[9] In the present case, after discharge, the patient did not turn up for follow-up.

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Conflicts of interest

There are no conflicts of interest.