Friday, December 11, 2015

painless penile ulcerations

painless penile ulcerations

A 24-year-old man seeks evaluation for painless penile ulcerations. He noted the first lesion about 2 weeks ago, and since that time, two adjacent areas have also developed ulceration. He states that there has been blood staining his underwear from slight oozing of the ulcers.

He has no past medical history and takes no medication.

He returned 5 weeks ago from a vacation in Mumbai , where he did have unprotected sexual intercourse with a local woman. He denies other high-risk sexual behaviors and has never had sex with prostitutes. He was last tested for HIV 2 years ago. He has never had a chlamydial or gonococcal
infection. On examination, there are three welldefined red, friable lesions measuring 5 mm or less on
the penile shaft. They bleed easily with any manipulation.
painless penile ulcer which shows bleeding on touch 

There is no pain with palpation. There is shotty inguinal lymphadenopathy. On biopsy of one lesion, there is a prominent intracytoplasmic inclusion of bipolar organisms in an enlarged mononuclear cell. Additionally, there is epithelial cell proliferation with an increased number of plasma cells and few neutrophils.

A rapid plasma reagin test result is negative. Cultures grow no organisms.

What is the most likely causative organism?

A. Calymmatobacterium granulomatis (donovanosis)
B. Chlamydia trachomatis (lymphogranuloma venereum)
C. Haemophilus ducreyi (chancroid)
D. Leishmania amazonensis (cutaneous leishmaniasis)
E. Treponema pallidum (secondary syphilis)

The answer is A.  Donovanosis is caused by the intracellular organism Calymmatobacterium
granulomatis and most often presents as a painless erythematous genital
ulceration after a 1- to 4-week incubation period.

However, incubation periods can be as long as 1 year. The infection is predominantly sexually transmitted, and autoinoculation can lead to formation of new lesions by contact with adjacent infected skin.

Typically, the lesion is painless but bleeds easily. Complications include phimosis in men and pseudoelephantiasis of the labia in women. If the infection is untreated, it can lead to progressive
destruction of the penis or other organs. Diagnosis is made by demonstration of Donovan
bodies within large mononuclear cells on smears from the lesion. Donovan bodies refers
to the appearance of multiple intracellular organisms within the cytoplasm of mononuclear
cells. These organisms are bipolar and have an appearance similar to a safety pin.
On histologic examination, there is an increase in the number of plasma cells with few
neutrophils; additionally, epithelial hyperplasia is present and can resemble neoplasia.
A variety of antibiotics can be used to treat donovanosis, including macrolides, tetracyclines,
trimethoprim–sulfamethoxazole, and chloramphenicol.

Treatment should be continued until the lesion has healed, often requiring 5 or more weeks of treatment.

All of the choices listed in the question are in the differential diagnosis of penile ulcerations.
Lymphogranuloma venereum is endemic in the Caribbean. The ulcer of primary infection
heals spontaneously, and the second phase of the infection results in markedly enlarged
inguinal lymphadenopathy, which may drain spontaneously.

Haemophilus ducreyi results in painful genital ulcerations, and the organism can be cultured from the lesion. The painless ulcerations of cutaneous leishmaniasis can appear similarly to those of donovanosis but usually occur on exposed skin.

Histologic determination of intracellular parasites can distinguish leishmaniasis definitively from donovanosis. Finally, it is unlikely that the patient has syphilis in the setting of a negative rapid plasma reagin test result, and the histology is inconsistent with this diagnosis.


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