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CORRESPONDENCE |
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| Year : 2022 | Volume
: 67
| Issue : 6 | Page : 807-810 |
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| Donovanosis or squamous cell carcinoma of penis: Can dermoscopy solve this Enigma? |
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Preema Sinha1, Afreen Ayub1, Manoj Gopal Madakshira2, Lanka Praveen3, Saikat Bhattacharjee4, Kumar Alok1
1 From the Department of Dermatology, Base Hospital, Lucknow, Uttar Pradesh, India
2 Department of Pathology, Command Hospital Lucknow, Uttar Pradesh, India
3 Department of Urology, Command Hospital Lucknow, Uttar Pradesh, India
4 Department of Radiodiagnosis and Imaging, Command Hospital Lucknow, Uttar Pradesh, India
| Date of Web Publication | 23-Feb-2023 |
Correspondence Address:
Preema Sinha
Department of Dermatology, Base Hospital, Lucknow, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijd.ijd_293_22
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How to cite this article:
Sinha P, Ayub A, Madakshira MG, Praveen L, Bhattacharjee S, Alok K. Donovanosis or squamous cell carcinoma of penis: Can dermoscopy solve this Enigma?. Indian J Dermatol 2022;67:807-10 |
How to cite this URL:
Sinha P, Ayub A, Madakshira MG, Praveen L, Bhattacharjee S, Alok K. Donovanosis or squamous cell carcinoma of penis: Can dermoscopy solve this Enigma?. Indian J Dermatol [serial online] 2022 [cited 2023 Mar 29];67:807-10. Available from: https://www.e-ijd.org/text.asp?2022/67/6/807/370286 |
Sir,
Donovanosis or granuloma inguinale is a sexually transmitted, chronic indolent bacterial disease caused by Gram-negative bacilli (Calymmatobacterium granulomatis) which manifest as granulomatous ulceration of genito-inguinal region with little tendency to heal.[1] Increased awareness about safe sex practices, use of condoms, and syndromic management by broad spectrum antibiotics in recent years, has decreased the incidence of donovanosis to a few sporadic cases.[2] Squamous cell carcinoma (SCC) occurs either as a complication of or a sequel to long-standing donovanosis and in itself is a rare occurrence.[3] We hereby report a case of this rare disease, where despite adequate therapy after confirmation of diagnosis, persistence of symptoms led us to the diagnosis of SCC.
A 45-year-old married, uncircumcised male, presented with a single-large non-healing ulcer on the penis of six months duration. The lesion initially started as a pea-sized, skin coloured, painless nodule over the glans penis that subsequently broke down to leave behind a raw painless area which gradually increased in size over a period of four months to involve the whole glans, coronal sulcus and anterior part of penile shaft. There was history of bleeding from the lesion after coitus and minor trauma, however, the ulcer in general was asymptomatic. There was history of unprotected sexual contact outside marriage three months prior to the onset of lesion, but there was no history of urethral discharge, difficulty in micturition, or any other genital complaints in the past. He also developed progressive difficulty in retracting the prepucial skin, over the last one month.
Venereological examination revealed a solitary well-defined ulcer with wavy margin involving the complete glans, coronal sulcus, and the distal end of penile shaft. The floor of the ulcer was covered with granulation tissue [Figure 1]. Scrotum and perianal examination were normal. Palpation revealed multiple firm, non-matted, non-mobile bilateral inguinal lymph nodes measuring 2–3 cm in size. Rest of the cutaneous and systemic examination revealed no abnormality. Genital examination of the spouse did not reveal any abnormality.
Crush tissue smear from the edge of the ulcer did not reveal any positive findings. A biopsy from the ulcer revealed the presence of both extracellular and intracellular basophilic Donovan bodies [Figure 2]. Venereal Disease Research Laboratory (VDRL) and Human immunodeficiency virus (HIV) serologies were non-reactive. He was started on oral antibiotic therapy of doxycycline100 mg twice a day for a period of 21 days. However, seeing only mild improvement in the disease, in spite of good compliance the same therapy was continued for a period of three months. | Figure 1: A solitary well defined ulcer with wavy margin with granulation tissue involving the complete glans, coronal sulcus and the distal end of penile shaft
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 | Figure 2: (H & E 1,000×) Photomicrograph showing donovan bodies. Arrow points at the macrophage with the Donovan bodies
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Failure to respond adequately to medical therapy, pushed us to look for other causes. Dermoscopy at this stage revealed red structureless areas with polymorphic vascularization comprising of dotted, linear vessels, hairpin, corkscrew vessels of varying size in patchy distribution surrounded by white structureless areas and white clods [Figure 3] and [Figure 4]. Suspecting penile carcinoma, we referred the case to urologist who after complete evaluation planned for a deeper biopsy that revealed infiltrative tumour arranged in pattern less sheets, having broad infiltrative edges. The tumour cells were large with distinct borders, moderate nuclear pleomorphism and open chromatin, prominent nucleoli, and dense eosinophilic cytoplasm. Keratin pearl and individual cell keratinisation was also seen. Histopathology of the resected specimen confirmed SCC [Figure 5]a and [Figure 5]b. On the basis of above report, he was diagnosed histopathologically as a case of moderately differentiated SCC with tumour invading till corpora spongiosum and no lympho-vascular or perineural invasion. Contrast enhanced computed tomography of chest and abdomen revealed conglomerate of multiple, enlarged, discrete, and matted inguinal lymph nodes involving both horizontal and vertical groups suggestive of metastatic inguinal lymphadenopathy. A final diagnosis of penile SCC with bilateral inguinal lymph node metastases (T1aN2M0, stage IIIb) was made. The patient was managed with distal penectomy with inguinal lymph node dissection. | Figure 3: Dermoscopy (3Gen Dermlite DL4 Polarized Dermoscope) shows dotted vessels (green star), linear vessels (maroon arrow), hairpin vessels (yellow cross), corkscrew vessels (black star), and serpentine vessels (blue star)
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 | Figure 4: Dermoscopy (3Gen Dermlite DL4 Polarized Dermoscope) White clods (grey square) and white structureless areas (grey circle) can be seen
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 | Figure 5: (H & E (a) 100×, (b) 400×) shows infiltrating islands of tumor with keratin pearls features suggestive of SCC of the penis
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Amongst the many names used to describe this chronic and progressive genital ulcer disease, Donovanosis or Granuloma Inguinale is the most commonly used. First described in India, “Granuloma” means granulation tissue, and “inguinale” indicates involvement of the groin region while the term donovanosis was named after Donovan who described the characteristic Donovan bodies.[1],[2],[3],[4] The causative organism is a gram-negative, non-motile, encapsulated, facultative aerobe bacillus initially named as Calymmatobacterium granulomatosis which was later changed in 1999 to Klebsiella granulomatis due to its phylogenetic similarity to the Klebsiella species.[5]
The incubation period of gastrointestinal (GI) is variable ranging from 07 to 360 days and this wide range can be contributed to either late presentation, denial, or nonsexual transmission like faecal contamination and autoinoculation.[6]
The characteristic presentation of the disease is a sharply defined painless ulcers that bleeds readily to touch although it can present in varying forms like classic ulcero-granulomatous, hypertrophic or verrucous, necrotic and sclerotic or cicatricial. Diagnosis is mainly clinical and is confirmed by the demonstration of intracellular Donovan bodies in mononuclear cells obtained in tissue specimens. Histologically changes are generally non-specific but the presence of pathognomonic donovan bodies and plasma cell infiltration point towards the diagnosis.[2],[3]
In donovanosis, there is generally absence of lymphadenopathy and if present other causes of lymphadenopathy like concomitant sexually transmitted infection and malignancy need exclusion.
Penile cancer in itself is a rare entity accounting for less than 1% of all male cancer among which SCC is the most common variant. Although pseudo elephantiasis is the commonest local complication in a known case of donovanosis, there have been cases which reported development of carcinoma in donovanosis. Greenblat in 1984 reported that 6.8% of donovanosis developed malignancy while Rajam and Rangaiah reported carcinoma in 0.25% of 2000 cases of donovanosis.[3] SCC of the penis may present as ulcerative, exophytic, papillary or fungating mass with foul smelling discharge along with inguinal lymphadenopathy. Phimosis, most common complication may mask the lesion resulting in delay in seeking medical consultation.[7],[8]
Donovanosis and SCC of penis are close mimickers and develop in similar populations who are unkept, marginalised, and impoverished with limited access to health facilities, their stand with relation to each other is still under debate. Sometimes, it is even difficult to histologically distinguish these two diseases.[2] SCC of genitalia has been reported in conjunction with active donovanosis, superimposing on long-standing cases and may even develop at sites of healed lesions while donovanosis has rarely occurred as a superimposed infection in cases of carcinoma.[7],[8]
Dermoscopy is one such tool which can be explored to differentiate between these two conditions to prevent either hastily performing mutilating surgeries misdiagnosing the lesion as cancer or mistreating with antibiotics further delaying the detection of malignancy. There are very few case reports which focus on this imaging modality in SCC of genital region and even fewer for donovanosis. Dermoscopy of a diagnosed SCC of penis showed erosion with a polymorphic vascularization made up of point vessels, linear, hairpin surrounded by whitish halo and rosettes.[9] In a report by Neema et al.,[10] dermoscopy of ulceroproliferative moderately differentiated SCC over the glans penis showed white structureless area, white clods, blood spots, erosion, and polymorphic vessels which is similar to our case. Dermoscopy of a diagnosed case of nodular ulcero-granulomatous donovanosis revealed polymorphous vessels (linear, hairpin, and glomerular) separated by white linear area and multiples white shiny structures arranged as a four-leaf clover (rosettes). There is marked vascular proliferation in the ulcerogranulomatous variety of donovanosis which can explain the polymorphous vascular structures seen in dermoscopy, although it is a common finding in SCC too.[11] Rosettes (four white points, arranged as a four-leaf clover or four-clod dots) which represent the keratin-filled adnexal openings at infundibular level should be absent in a case of donovanosis, however, their absence does not rule out SCC as it may not be visible at places where hair follicles are absent, such as the glans.[12] Larger rosettes or clods represent keratin pearls or concentric perifollicular fibrosis while, white shiny streaks or lines correspond to fibrotic changes in the dermis. Pseudo-epitheliomatous hyperplasia, a known sequelae in long standing donovanosis may show white clods which corelate with large keratin pearls and keratin cyst.
Our case highlights the diagnostic struggle that dermatologist can face due to similar features of genital malignancy and STDs. Our patient was a middle-aged man with high-risk sexual behaviour, who presented with a painless non-healing ulcer and inguinal lymphadenopathy. Even after confirmation of diagnosis of venereal disease, lack of response to therapy should make the clinician suspicion to further evaluate for other causes of non-healing ulcer of genitalia. Phimosis, a known complication of both malignancy and venereal disease can further complicate the picture. Dermoscopy if included in the bedside investigation can help in reaching the diagnosis earlier, thus saving time and unnecessary invasive procedures which in most of the cases are cumbersome for the patient.
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.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
 References | |  |
| 1. | McLeod K. Precis of operations performed in the wards of the first surgeon, Medical College Hospital, during the year 1881. Indian Med Gaz 1882;111:113-23.  |
| 2. | O'Farrell N. Donovanosis. In: Gupta S, Kumar B, editors. Sexually Transmitted Infections. 2 nd ed. India: Elsevier; 2012. |
| 3. | Rajam RV, Rangaiah PN. Donovanosis. Monogr Ser World Health Organ 1954;24:1-72. |
| 4. | Stary A. Sexually transmitted infections. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. 2 nd ed. Spain: Mosby Elsevier Lmtd; 2008. p. 1271. |
| 5. | Donovan C. Medical cases from Madras general hospital. Indian Med Gaz 1905;40:411-4. |
| 6. | Goldberg J. Studies on Granuloma inguinale V. Isolation of a bacterium resembling Donovania granulomatis from the faeces of a patient with granuloma inguinale. Br J Vener Dis 1962;38:99-102. |
| 7. | Pow-Sang MR, Ferreira U, Pow-Sang JM, Nardi AC, Destefano V. Epidemiology and natural history of penile cancer. Urology 2010;76(Suppl 1):S2-6. |
| 8. | Arora AK, Kumaran MS, Narang T, Saikia UN, Handa S. Donovanosis and squamous cell carcinoma: The relationship conundrum! Int J STD AIDS 2017;28:411-4. |
| 9. | Ibtissam AL, Douhi Z, Boukhari KH, Elloudi S, Baybay H, Mernissi FZ. Clinical and dermoscopy of squamous cell carcinoma of the penis. Int J Clin Med Imaging 2020;7:693. |
| 10. | Neema S, Radhakrishnan S, Kinra P, Sandhu S. Two cases of squamous cell carcinoma of the penis—A dermoscopic view. Dermatol Pract Concept 2021;11:e2020097. |
| 11. | Saad S, Youssef M, Idoudi S, Hadhri R, Soua Y, Toumi A, et al. Donovanosis in a Tunisian man: Atypical presentation and dermoscopic findings. Indian J Dermatol Venereol Leprol 2021;87:393-5. |
| 12. | Haspeslagh M, Noë M, De Wispelaere I, Degryse N, Vossaert K, Lanssens S, et al. Rosettes and other white shiny structures in polarized dermoscopy: Histological correlate and optical explanation. J Eur Acad Dermatol Venereol 2016;30:311-3. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5] |
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