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Case report: cobblestone
Recently, the quinolone class of antibiotics has been used successfully in a few patients with granuloma inguinale.1–3 We report a case of chronic granuloma inguinale, failing repeated antibiotic treatment over 15 years, which responded to a 2 month course of trovofloxacin.
A 33 year old white woman developed granuloma inguinale involving the vulva, left labia, and vaginal canal since about 1982. Over the years, she was treated with doxycycline, ampicillin, erythromycin, trimethoprim/sulfamethoxazole, intramuscular injection of ceftriaxone, and then intravenous gentamicin or chloramphenicol for several weeks. The patient has had improvement and often short term healing of the ulcers, but has never had resolution of the lesions. She was seen in January 1997 for two recurrent, tender labial ulcers, measuring 1.5 cm × 2 cm each, after failing treatment of 2 months of doxycycline and 3 weeks of ciprofloxacin. Re-biopsy of the ulcer confirmed the diagnosis of chronic granuloma inguinale. Bacterial and viral cultures of ulcer drainage were negative; administration of aciclovir did not result in any improvement. HIV antibody was negative, immunoglobulin level and lymphocytes were unremarkable. Prolonged administration of ofloxacin and azithromycin, followed by intravenous ceftriaxone and oral metronidazole, resulted in initial improvement but ulcers relapsed with increasing necrosis 2 weeks after discontinuation of antibiotics. In October 1998, the patient was given trovofloxacin 200 mg each night. The pain and swelling decreased by day 3 and the ulcer size was reduced by 75% at the end of 1 week of therapy. The patient had mild dizziness while on therapy but completed a total of 2 months of treatment. She has not had recurrence of lesions for over 20 months.
Antibiotic treatment for donovanosis has largely been based on clinical experience. There have been conflicting reports on the efficacy of several regimens, and treatment failures have been reported with all regimens.1 Our patient has been treated with all of the antibiotic regimens for a prolonged period of time but repeatedly relapsed after discontinuation of antibiotics. After failing treatment with ciprofloxacin and ofloxacin, administration of trovofloxacin cured this recalcitrant infection. In this patient, the recurrence of painful ulceration was usually associated with rapid tissue necrosis and some purulent drainage, a variant form described by Hart.1 A synergistic infection involving both C granulomatis and anaerobes could account for the rapid necrosis and difficulty in eradicating this infection. Thus, trovofloxacin may have been effective because of its broad spectrum antimicrobial activity and excellent intracellular penetration. Monitoring of liver function is mandatory since prolonged use of trovofloxacin has been associated with increased incidence of serious liver toxicity. Other newer quinolones with similar antimicrobial activity may prove to be even better and safer agents for the treatment of recalcitrant cases of donovanosis.
Case report: cobblestone
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