Concomitant Malacoplakia and Granuloma Inguinale of the Cervix in Acquired Immune Deficiency Syndrome

Abstract

We describe concomitant granuloma inguinale (GI) and malacoplakia of the cervix in 2 acquired immune deficiency syndrome (AIDS) patients aged 27 and 36 years. Both patients presented with a bloody foul-smelling vaginal discharge. Speculum examination confirmed cervical ulceration, prompting the diagnosis of cervical carcinoma in both patients. Cervical punch biopsies confirmed the characteristic features of GI; granulation tissue containing a dense plasma cell infiltrate, aggregates of neutrophils, and vacuolated enlarged histiocytes containing Donovan bodies were noted. Many of these histiocytes and sheets of von Hansemann cells contained intracytoplasmic Michaelis-Gutmann bodies, confirming concomitant malacoplakia. Michaelis-Gutmann bodies were also present in extracellular locations. Ultrastructural examination confirmed these histopathologic findings. One patient died of disseminated tuberculosis before treatment was initiated. The other patient did not return for a follow-up visit of her cervical lesion. Concomitant GI and malacoplakia is unreported in genital and extragenital sites; Klebsiella granulomatis must therefore be added to the list of bacteria associated with malacoplakia. Malacoplakia of the female genital tract is documented rarely and remains unreported, to date, in AIDS patients. Similar to the pathogenetic mechanisms described for AIDS-associated malacoplakia in extragenital sites, it is hypothesized that, in addition to abnormal macrophage functioning and an inability to degrade bacteria, special constituents of K. granulomatis are undigestable by lysosomal enzymes in human immunodeficiency virus-infected patients.

A novel cause of postmenopausal bleeding in an immunosuppressed patient

“…Abnormal macrophage activity has been attributed to inadequate intracellular eradiation of phagocytosed bacteria, leading to accumulation of calcium and iron on bacterial glycolipid within cellular phagolysosomes 5. The formation of Michaelis-Gutmann bodies has been thought to be the result of fusion and then calcification of the phagolysosomes within macrophages.…”

“…Malakoplakia of the female genital tract is most commonly described in older patients with a mean age of 70 at diagnosis 3. Clinical investigations and examinations are often non-diagnostic, and this in combination with the rarity of the disease poses challenges for the diagnosis of malakoplakia in the female genital tract 5. The clinical significance of this case being significant disease burden without reliable detection on MRI, pelvic US and CT.…”

“…The treatment of malakoplakia involves long-term antibiotic treatment, surgical excision or a combination of both 5. Appropriate antibiotic selection and duration are important to ensure eradication of malakoplakia.…”

Cytomorphology of unusual infectious entities in the Pap test

“…The differential diagnosis includes follicular cervicitis, granulation tissue, and other granulomatous diseases, including malakoplakia. [5–7] In follicular cervicitis, tingible-body macrophages may have cytoplasmic inclusions with cellular debris. In addition, the accompanying inflammatory infiltrate with follicular cervicitis is lymphoid predominant and not neutrophilic.…”

Donovanosis: An incidental finding on Pap test

“…The differential diagnosis includes follicular cervicitis, granulation tissue, and other granulomatous diseases, including malakoplakia. [5] In follicular cervicitis, lymphoid cell infiltrate is seen instead of neutrophils along with tingible-body macrophages with cellular debris. In malakoplakia, cytoplasmic inclusions called Michaelis-Gutmann bodies are more dense, laminated and round, compared to Donovan bodies.…”