CASE REPORT D. Govender á G. P. Hadley á R. Donnellan Granuloma inguinale (donovanosis) presenting as a neck mass in an infant Accepted: 24 March 1998 Abstract A case of granuloma in- guinale (GI) presenting as a lateral neck mass in a 4-month-old, HIV- positive infant is described. The his- tological features of the mass were typical of GI, with numerous mac- rophages containing intracellular organisms with a ``closed-safety- pin'' appearance. This is a rare occurrence, and the mode of transmission of infection is discus- sed. An awareness of GI in infants by both clinicians and pathologists is important to prevent morbidity and allow for prompt institution of ap- propriate treatment. Key words Donovanosis á Granuloma inguinale á Lymph node á Neck á Paediatric Introduction Granuloma inguinale (GI), or donovanosis, caused by Calymmato- bacterium granulomatis, typically presents as genital ulcers in adults, but infection of extragenital sites has also been described. GI in children has been reported rarely [8, 14, 18]. KwaZulu-Natal province in South Africa has emerged as an endemic area for adult GI in recent years [9]. We report the clinical and patho- logical features of GI presenting as a neck mass in an infant. We are not aware of any previous descriptions of GI presenting as cervical lymph- adenopathy in this age group. Case report A 4-month-old infant presented with a left- sided neck mass of 2 months' duration. The skin overlying the mass was intact. Exami- nation of the oral cavity and pharynx did not reveal any pathology. There were no other signi®cant ®ndings on physical ex- amination: especially, there was no evidence of sexual abuse or genital ulceration. Hae- matological and biochemical tests were normal. The patient had positive HIV se- rology. A computed tomography (CT) scan showed a multinodular mass in the neck consistent with several enlarged but distinct lymph nodes (Fig. 1). There was also clini- cal evidence of infection of the left external auditory meatus. The infant was born by normal vaginal delivery and there were no complications during pregnancy or labour. A wedge biopsy of the neck mass was per- formed and tissue was submitted for histo- logical examination. A specimen submitted for culture showed no bacterial growth on conventional culture media. After a diagnosis of GI was made, the patient was commenced on a course of er- ythromycin and amikacin. A reduction in the size of mass following treatment was noted. The mother had a gynaecological examination, which revealed a small cervi- cal lesion that was biopsied. Microscopic examination of this lesion showed multiple small granulomata with refractile foreign material within giant cells. There was no histological evidence of GI. The patient was discharged on treatment, but was subse- quently lost to follow-up. For histological examination, three small biopsies were ®xed in 10% buered formalin, routinely processed, and embed- ded in paran wax. Haematoxylin and eosin, Warthin-Starry, and Giemsa-stained sections were examined. The biopsies con- sisted entirely of granulation tissue with a polymorphous in¯ammatory-cell in®ltrate composed of numerous macrophages and characteristic clusters of neutrophils (Fig. 2). There were few plasma cells and lymphocytes. Warthin-Starry and Giemsa stains revealed intracellular organisms with a ``closed-safety-pin'' morphology typical of Donovan bodies (Fig. 3). Discussion Granuloma inguinale is considered to be sexually transmitted, but transmission by direct skin contact, including autoinoculation, has also been reported [3, 7, 15]. It has been suggested that the natural habitat of Pediatr Surg Int (1999) 15: 129±131 Ó Springer-Verlag 1999 Fig. 1 CT scan showing several enlarged but distinct cervical lymph nodes D. Govender (&) á R. Donnellan Department of Anatomical Pathology, University of Natal Medical School, Private Bag 7, Congella, Durban, 4013, South Africa G.P. Hadley Department of Paediatric Surgery, University of Natal Medical School, Private Bag 7, Congella, Durban, 4013, South Africa