Published on 18/03/2015 by admin
Filed under Dermatology
Last modified 18/03/2015
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Jacqueline A. Guidry and Ted Rosen
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Granuloma inguinale, or donovanosis, is an infection causing granulomatous and destructive ulceration of genital, inguinal, and perineal skin. This disorder is extremely rare in Western Europe and the US, but is still endemic or epidemic in India, South Africa, Brazil, Papau New Guinea, and among aborigines in Australia. The causative organism is Klebsiella granulomatis, an intracellular Gram-negative bacillus.
Transmission is frequently, but not exclusively, sexual. The disease presents with a subcutaneous granuloma or nodule that develops into characteristically painless, progressive ulcerative lesions without regional lymphadenopathy. Most often lesions are ulcerogranulomatous, highly vascular (i.e., a beefy red appearance) and friable (bleed easily on contact). Some lesions can be sub-categorized as hypertrophic, necrotic, or sclerotic.
Patients with donovanosis should be treated to prevent the gradual development of the disease leading to genital deformity or (very rarely) life-threatening disseminated infection, to prevent transmission, and to prevent the risk of concomitant transmission of HIV.
In the absence of evidence from randomized placebo-controlled trials, antibiotic treatment of donovanosis is based on the results of local clinical experience and individual case reports, typically involving relatively small numbers of patients.
The US Centers for Disease Control and Prevention (CDC) (2010) recommends doxycycline, with many alternate regimens (e.g., azithromycin, ciprofloxacin, erythromycin, trimethoprim–sulfamethoxazole). Azithromycin is also recommended in the European Guideline on donovanosis (2010). The addition of an aminoglycoside, such as gentamicin, is recommended by the CDC if lesions do not respond within the first few days.
Therapy should be continued until all lesions have healed completely. This typically starts at the outside margins and progresses inward. Despite seemingly effective initial therapy, a relapse can occur six to 18 months later. Surgical excision may be necessary for extensive disease unresponsive to antibiotic therapy.
Sexual partners of patients who have granuloma inguinale should be examined and treated if they had sexual contact with the patient during the 60 days preceding the onset of symptoms in the patient, or have clinical signs and symptoms of the disease.
Tissue smear or biopsy with Wright or Giemsa stains
Screen for other sexually transmitted infections (e.g., HIV, syphilis)
Culture (not readily available)
Polymerase chain reaction (not readily available)
O’Farrell N, Hoosen AA, Coetzee KD, Van den Ende J. Genitourin Med 1994; 70: 7–11.
The clinical diagnostic accuracy for donovanosis was relatively high (63% in men, 83% in women). Donovanosis ulcers bled to the touch, were larger, and were not usually associated with inguinal lymphadenopathy.
Hart G. Clin Infect Dis 1997; 25: 24–32.
Confirmation involves demonstration of typical intracellular Donovan bodies within large mononuclear cells visualized in smears prepared from lesions or biopsy specimens. The large mononuclear cells are 25–90 µm in diameter, with a vesicular or pyknotic nucleus.
Centers for Disease Control and Prevention. U.S. Department of Health and Human Services, Atlanta; 2011.
Cases are confirmed by demonstration of intracytoplasmic Donovan bodies in Wright or Giemsa-stained smears or biopsies of granulation tissue in a clinically compatible case (one or more painless or minimally painful granulomatous lesions in the anogenital area).
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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