Sexually Transmitted Infections: Granuloma Inguinale (Donovanosis)

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Chapter 49 Sexually Transmitted Infections: Granuloma Inguinale (Donovanosis)

INTRODUCTION

Description: Granuloma inguinale (also called donovanosis) is relatively common in the tropics, New Guinea, and Caribbean areas but accounts for less than 100 cases per year in the United States. This infection is caused by the intracellular gram-negative bacterium Klebsiella granulomatis (formerly known as Calymmatobacterium granulomatis).

Prevalence: Uncommon, 100 cases per year in United States, up to 25% of the population in some subtropical areas.

Predominant Age: Younger reproductive.

Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Infection is caused by the bipolar, gram-negative bacterium K. granulomatis.

Risk Factors: Sexual trauma and exposure to the infective agent.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Single or multiple painless subcutaneous papules that evolve to raised, beefy-red, granulomatous lesions that bleed on contact, undergo ulceration and necrosis, and heal slowly (lesions are confined to the genitalia in 80% of patients; lesions generally appear within 2 weeks of exposure)

• Painless papules with rolled borders and friable base

• Marked adenopathy not present

• Hypertrophic, necrotic, or sclerotic variants exist

DIAGNOSTIC APPROACH

Differential Diagnosis

• Lymphogranuloma venereum

• Herpes simplex

Associated Conditions: Brawny edema of the external genitalia.

Workup and Evaluation

Laboratory: Gram stain and culture of material from open ulcers. Culture for other sexually transmitted infections should also be considered.

Imaging: No imaging indicated.

Special Tests: Samples for biopsy may be taken from the edge of the ulcer to confirm the diagnosis. A crushed tissue smear may be examined for Donovan bodies.

Diagnostic Procedures: Diagnosis is established clinically or through the identification of intracytoplasmic bacteria (Donovan bodies) in mononuclear cells.

Pathologic Findings

Granulation tissue associated with an extensive chronic inflammatory cell infiltrate and endarteritis. The ulcer is filled with fibrinous exudate and necrosis; plasma cells and mononuclear cells predominate. Donovan bodies (large vacuolated histiocytes with encapsulated bacilli) are diagnostic. Granuloma inguinale extends by local infiltration and by lymphatic permeation in later stages.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation, culture or Gram stain, topical cleansing and care.

Specific Measures: Antibiotic therapy.

Diet: No specific dietary changes indicated.

Activity: No restriction. (Sexual continence required until infection is resolved.)

Patient Education: American College of Obstetricians and Gynecologists Patient Education Pamphlet AP009 (How to Prevent Sexually Transmitted Diseases). Patients should be advised to have all sexual partners seen for diagnosis and treatment.

Alternative Drugs

Ciprofloxacin 750 mg PO twice a day for a minimum of 3 weeks.

Erythromycin 500 mg PO four times a day for a minimum of 3 weeks.

If lesions fail to show improvement after the first week of treatment, chloramphenicol (500 mg PO three times a day) or gentamicin (1 mg/kg twice a day) should be considered.

FOLLOW-UP

Patient Monitoring: Because of relapse and late scarring, these patients should be followed carefully for several weeks. Follow-up evaluation for cure with culture or other tests should be carried out, as should screening for other sexually transmitted diseases. (As with all sexually transmitted diseases, all sexual partners within the preceding 30 days should be screened and treated for probable infections as well.)

Prevention/Avoidance: None.

Possible Complications: Secondary infection or significant scarring may occur in patients with untreated disease.

Expected Outcome: Gradual healing with antibiotic treatment, but scarring and vulvar stenosis are common and may require surgical treatment.

MISCELLANEOUS

Pregnancy Considerations: No direct effect on pregnancy. Women who are pregnant or lactating should be treated with erythromycin plus parenteral aminoglycoside (e.g., gentamicin).

ICD-9-CM Codes: 099.2.

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR. 2006;55:20-21.

Eckert LO, Lentz GM. Infections of the lower genital tract. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:580-582.

Goens JL, Schwartz RA, De Wolf K. Mucocutaneous manifestations of chancroid, lymphogranuloma venereum and granuloma inguinale. Am Fam Physician. 1994;49:415-418. 423–5.

Keck JW. Ulcerative lesions. Clin Fam Pract. 2005;7:13-30.

Krieger JN. Biology of sexually transmitted diseases. Urol Clin North Am. 1984;11:15-25.

Kuberski T. Granuloma inguinale (donovanosis). Sex Transm Dis. 1980;7:29.

Lynch PJ. Therapy of sexually transmitted diseases. Med Clin North Am. 1982;66:915-925.

Rackel RE, Bope ET. Granuloma inguinale. In Conn’s Current therapy 2005, 57th ed., St. Louis: Saunders; 2005:859.

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