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Granuloma Venereum of Cervix Uteri
GRANULOMA VENEREUM OF CERVIX UTERI A STATIS'riCAL STUDY EDGAR
R.
PuND,
V.
M.D.,
GEORGIA BRAWNER
A. GoTCHER,
M.D.,
Hum,
AND
AuGUSTA, GA.
(From the Department of Pathology, University of Georgia School of Medicine)
HE cervix uteri is now recognized as a site for the lesion of granuloma venereum (inguinale), either with or without ulcerations elsewhere.1 This exuberant granulomatous ulceration of the cervix simulates carcinoma so closely that the diagnosis is usually made only after histologic study of a biopsy. The frequency of this specific condition has never been determined, yet granulomas of the cervix have been described since 1928. Gardner 2 suggested that such granulomas may possibly be related to granuloma inguinale (venereum). In 1934 McGee 3 reported eight cases of cervical granuloma, in none of which was he able to demonstrate Donovan bodies. He classified these lesions as a nonspecific granuloma but observed that five of his patients responded favorably to treatment with tartar emetic. It is interesting to note that his patients were negroes, from 19 to 60 years of age, and in each a tentative clinical diagnosis of carcinoma was made. Granuloma venereum (inguinale) of the cervix was not established as a definite entity until 1937 1 and it was then observed that the Donovan bodies had an affinity £or silver. This observation £ollowed a previous description 4 of a specific histology £or granuloma venereum and a pathognomonic cell was discerned. In regard to grl').nuloma venereum o£ the cervix, questions now arise as to its numerical, racial and age incidence; symptomatology; its association with ulcerations elsewhere. We have reviewed all sections of cervices which have been examined in our laboratory :for the past ten years. The criteria :for the diagnosis were based upon the observations made in a former article. 4 In all cases that were accepted as positive, the pathognomonic cell was observed. This is a large cell which contains intracytoplasmic cysts; and the round or rodlike Donovan bodies are grouped peripherally within the cysts. Prom our previous studies on venereal diseases we have recognized histologic characteristics which frequently enable us to diagnose, in addition to granuloma venereum, lymphogranuloma venereum and chancroid.5 In lymphogranuloma venereum there is pronounced peritubular infiltration with plasma cells and lymphocytes, accompanied by fibroblastic activity, dilated lymphatics, and in some cases with giant cells of the foreign body type. Occasionally foci o£ suppuration are noted, similar to that type o£ reaction seen in buboes, necrotic centers surrounded by macrophages. The chancroid is characterized by superficial necrosis infiltrated with polymorphonuclear leucocytes. In the surrounding area plasma cells, lymphocytes, and endothelial leucocytes are also present. There is an acute peri- and endovasculitis with pronounced swelling o£ the endothelium, frequently blocking the lumen of the capil-
T
477
478
AlVIEHICA K SOURNM, OF OB~TETRICS AXIJ cn:XJ>}COJ~OGY
]aries and leading 1o net·I·osis. Tht· ntt-
\Ve
'Were
unahh; to find
simdc·
n
r·
of granulolllil
\'HWI't'Hlll
of llw
eervix in the fih•s pl'ior to l!l:H. Ho\\'f'Wl', ~inN' 19:1-l nine t•ast>s wcr(• obsened. This eontil·ms tlw imJH'Pssion shan·d h~· mn· r-olleagncs tlwt n:nereal gnmulollHI is on the inereasc. 'l'Jw !) easps Wt>n• fouw1 in llw H:30 hiopsh·s of the t•t•J·vix whil'h wr•rt• rwrfonnc·c1 heh\'t•vn ,Jan. 1. Hl:l.t and J\'Iareh :n. IH:ifo:. This is 1.1 pter ('Pllt of Hll 1·c·nic•es thut wnc< hiopsit'd. Of ilwse ~:m patients. (i9.f \Wl't• whitl' and in non(• was the diagnosis of granuloma nneremn made. ( )f th1: hiopsi1•s fl'om the 1:5fi negro patiPnt:-;, 9 WNl' positivt! for gTannloma venerNtm, an ineidmwe of 6.6 per cent. 1f iht> 6!l ear·cinomas 1m• elimimtted from this group, We find that ]8.4 per 1'('111 of tlw l'Pmaining 1)7 lH'g'l'O pnti{•lli.S who POTnp]ained of c·0rvicaJ lesions. snffre0d from granuloma n•rwrt'nm. No espe<'ial age ineidcnee e
I.
SY~!P'l'O::.IA'I'OLclGY
*Reported previous!~· by Pund and Greenblatt. tReporte
SYMPTOMA'l'OLOGY
The tluration of romplaints, from \l'hirh the patients Rought relief, varied from two months to two years, with an average of eight months. Eight patients complained of vaginal dil'eharge ani! in :J of tht-~
PUND E'f AIJ.:
GRANULOMA VENERimM OF CERVIX UTERI
479
'l'hree suffered some pain in the lower abdomen, 1 complained of backache, and 1 had lost weight. The 6 hospitalized patients exhihiteil a varying degree of anemia. It is interesting to note that these symptoms suggest carcinoma, and in 5 this was the presumptive clinical diagnosis. A presumptive diagnosis of granuloma venereum was made in four in~tances. These 4 patients were seen in the past two years while a group study of the venereal diseases was being conducted at the University of Georgia School of Medieine. ·Five of the patients had borne children, and 1 of the remaining 4 wa8 pregnant. Four }Jatients were tested with Frei and chancroid bacillary antigens. Two of these had positive chancroid te~ts and in one of these the histologic lesion suggested ehaneroid as well as venereal granuloma. The other 2 patients reacted positively both to the chancroid and Frei antigens, and in both of these the histology sug· gPsted chancroid. One patient, a diabetic, was tested with Frei antigen and did not rt>art. She, however, luvl a hit~tory of a pnwious bubo. Four patients were not tested for venereal lymphogranuloma or chancroid. The hlstologie lesion of one suggested lymphogranuloma venereum and the ulcerations were accompanied by elephantiasis of vulva. One hacl a history of gonorrheal infection; one had previ· ou~ly been operated upon for pelvic inflammatory disea,;e; and in the section from the fourth patient, the histology suggested granuloma venereum complicated with clumeroirl. In our experience, multiple infections" are so common that we believe that granuloma venereum usually oreur,.; superimposed upon other conditions. The histories, phy,;ieal findings, and histology suggest that. this disease in most of these patients was superimposed upon gonorrheal ceniciti~, rhaneroidal in:feetion or lesions of lymphogranuloma. The lesion was limited to the eenix or cervix and vagina in 5 ra;;es, and in 3 to the eervix alone. In the other 4 <'ases, uleerations were also present on the Yuh·a, and ·in only 1 was an inguinal ulreration present. SUM:i\1ARY
From a study of 830 biopsies of diseased cervices of the uterus, the lesion was due to granuloma venereum in 9 eases, an incidence of 1.1 per cent. In biopsies from negro patients the incidence was 6.6 per cent. In biopsies from negro patients without carcinoma of the cervix, the incidence was 13.4 per cent. \Ve have never observed granuloma venereum of the cervix in a biopsy from a white patient. Nine cases of granuloma venereum of the cervix have been found since 1!}34. No cases were ohserved six years prior to 1934. The cervix uteri may be the primary site of granuloma venereum, and is often a complication of other venereal diseases. The symptoms suggest carcinoma.
(1) Pund, Edga·r R., and Greenblatt, R. B.: J. A. M.A. 108: 1401, 1937. (2) Ga.nlner, G. H.: Gynecology, by Howard A. Kelly and collaborators, New York, l!J28, D. Appleton & Co. (3) McGee, W. B.: AM . .T. 0BS'r. & GYKEC. 28: 244, 1934. (•t) Pund, Edgar R., and Greenblatt, R. B.: Arch. Path. 23: 224, 1937. (5) Pund, Edgar R., Greenblatt, R. B., ancl Huie, Georgia B.: Am .•T. Syrh., Gonor., & Ven. Dis. 22: 495, 1938.
R.
PuND,
V.
M.D.,
GEORGIA BRAWNER
A. GoTCHER,
M.D.,
Hum,
AND
AuGUSTA, GA.
(From the Department of Pathology, University of Georgia School of Medicine)
HE cervix uteri is now recognized as a site for the lesion of granuloma venereum (inguinale), either with or without ulcerations elsewhere.1 This exuberant granulomatous ulceration of the cervix simulates carcinoma so closely that the diagnosis is usually made only after histologic study of a biopsy. The frequency of this specific condition has never been determined, yet granulomas of the cervix have been described since 1928. Gardner 2 suggested that such granulomas may possibly be related to granuloma inguinale (venereum). In 1934 McGee 3 reported eight cases of cervical granuloma, in none of which was he able to demonstrate Donovan bodies. He classified these lesions as a nonspecific granuloma but observed that five of his patients responded favorably to treatment with tartar emetic. It is interesting to note that his patients were negroes, from 19 to 60 years of age, and in each a tentative clinical diagnosis of carcinoma was made. Granuloma venereum (inguinale) of the cervix was not established as a definite entity until 1937 1 and it was then observed that the Donovan bodies had an affinity £or silver. This observation £ollowed a previous description 4 of a specific histology £or granuloma venereum and a pathognomonic cell was discerned. In regard to grl').nuloma venereum o£ the cervix, questions now arise as to its numerical, racial and age incidence; symptomatology; its association with ulcerations elsewhere. We have reviewed all sections of cervices which have been examined in our laboratory :for the past ten years. The criteria :for the diagnosis were based upon the observations made in a former article. 4 In all cases that were accepted as positive, the pathognomonic cell was observed. This is a large cell which contains intracytoplasmic cysts; and the round or rodlike Donovan bodies are grouped peripherally within the cysts. Prom our previous studies on venereal diseases we have recognized histologic characteristics which frequently enable us to diagnose, in addition to granuloma venereum, lymphogranuloma venereum and chancroid.5 In lymphogranuloma venereum there is pronounced peritubular infiltration with plasma cells and lymphocytes, accompanied by fibroblastic activity, dilated lymphatics, and in some cases with giant cells of the foreign body type. Occasionally foci o£ suppuration are noted, similar to that type o£ reaction seen in buboes, necrotic centers surrounded by macrophages. The chancroid is characterized by superficial necrosis infiltrated with polymorphonuclear leucocytes. In the surrounding area plasma cells, lymphocytes, and endothelial leucocytes are also present. There is an acute peri- and endovasculitis with pronounced swelling o£ the endothelium, frequently blocking the lumen of the capil-
T
477
478
AlVIEHICA K SOURNM, OF OB~TETRICS AXIJ cn:XJ>}COJ~OGY
]aries and leading 1o net·I·osis. Tht· ntt-
\Ve
'Were
unahh; to find
simdc·
n
r·
of granulolllil
\'HWI't'Hlll
of llw
eervix in the fih•s pl'ior to l!l:H. Ho\\'f'Wl', ~inN' 19:1-l nine t•ast>s wcr(• obsened. This eontil·ms tlw imJH'Pssion shan·d h~· mn· r-olleagncs tlwt n:nereal gnmulollHI is on the inereasc. 'l'Jw !) easps Wt>n• fouw1 in llw H:30 hiopsh·s of the t•t•J·vix whil'h wr•rt• rwrfonnc·c1 heh\'t•vn ,Jan. 1. Hl:l.t and J\'Iareh :n. IH:ifo:. This is 1.1 pter ('Pllt of Hll 1·c·nic•es thut wnc< hiopsit'd. Of ilwse ~:m patients. (i9.f \Wl't• whitl' and in non(• was the diagnosis of granuloma nneremn made. ( )f th1: hiopsi1•s fl'om the 1:5fi negro patiPnt:-;, 9 WNl' positivt! for gTannloma venerNtm, an ineidmwe of 6.6 per cent. 1f iht> 6!l ear·cinomas 1m• elimimtted from this group, We find that ]8.4 per 1'('111 of tlw l'Pmaining 1)7 lH'g'l'O pnti{•lli.S who POTnp]ained of c·0rvicaJ lesions. snffre0d from granuloma n•rwrt'nm. No espe<'ial age ineidcnee e
I.
SY~!P'l'O::.IA'I'OLclGY
*Reported previous!~· by Pund and Greenblatt. tReporte
SYMPTOMA'l'OLOGY
The tluration of romplaints, from \l'hirh the patients Rought relief, varied from two months to two years, with an average of eight months. Eight patients complained of vaginal dil'eharge ani! in :J of tht-~
PUND E'f AIJ.:
GRANULOMA VENERimM OF CERVIX UTERI
479
'l'hree suffered some pain in the lower abdomen, 1 complained of backache, and 1 had lost weight. The 6 hospitalized patients exhihiteil a varying degree of anemia. It is interesting to note that these symptoms suggest carcinoma, and in 5 this was the presumptive clinical diagnosis. A presumptive diagnosis of granuloma venereum was made in four in~tances. These 4 patients were seen in the past two years while a group study of the venereal diseases was being conducted at the University of Georgia School of Medieine. ·Five of the patients had borne children, and 1 of the remaining 4 wa8 pregnant. Four }Jatients were tested with Frei and chancroid bacillary antigens. Two of these had positive chancroid te~ts and in one of these the histologic lesion suggested ehaneroid as well as venereal granuloma. The other 2 patients reacted positively both to the chancroid and Frei antigens, and in both of these the histology sug· gPsted chancroid. One patient, a diabetic, was tested with Frei antigen and did not rt>art. She, however, luvl a hit~tory of a pnwious bubo. Four patients were not tested for venereal lymphogranuloma or chancroid. The hlstologie lesion of one suggested lymphogranuloma venereum and the ulcerations were accompanied by elephantiasis of vulva. One hacl a history of gonorrheal infection; one had previ· ou~ly been operated upon for pelvic inflammatory disea,;e; and in the section from the fourth patient, the histology suggested granuloma venereum complicated with clumeroirl. In our experience, multiple infections" are so common that we believe that granuloma venereum usually oreur,.; superimposed upon other conditions. The histories, phy,;ieal findings, and histology suggest that. this disease in most of these patients was superimposed upon gonorrheal ceniciti~, rhaneroidal in:feetion or lesions of lymphogranuloma. The lesion was limited to the eenix or cervix and vagina in 5 ra;;es, and in 3 to the eervix alone. In the other 4 <'ases, uleerations were also present on the Yuh·a, and ·in only 1 was an inguinal ulreration present. SUM:i\1ARY
From a study of 830 biopsies of diseased cervices of the uterus, the lesion was due to granuloma venereum in 9 eases, an incidence of 1.1 per cent. In biopsies from negro patients the incidence was 6.6 per cent. In biopsies from negro patients without carcinoma of the cervix, the incidence was 13.4 per cent. \Ve have never observed granuloma venereum of the cervix in a biopsy from a white patient. Nine cases of granuloma venereum of the cervix have been found since 1!}34. No cases were ohserved six years prior to 1934. The cervix uteri may be the primary site of granuloma venereum, and is often a complication of other venereal diseases. The symptoms suggest carcinoma.
(1) Pund, Edga·r R., and Greenblatt, R. B.: J. A. M.A. 108: 1401, 1937. (2) Ga.nlner, G. H.: Gynecology, by Howard A. Kelly and collaborators, New York, l!J28, D. Appleton & Co. (3) McGee, W. B.: AM . .T. 0BS'r. & GYKEC. 28: 244, 1934. (•t) Pund, Edgar R., and Greenblatt, R. B.: Arch. Path. 23: 224, 1937. (5) Pund, Edgar R., Greenblatt, R. B., ancl Huie, Georgia B.: Am .•T. Syrh., Gonor., & Ven. Dis. 22: 495, 1938.