Granuloma Inguinale

What is Granuloma Inguinale

Granuloma inguinale is an STD (sexually transmitted disease) of the genital area. The infection causes painless bumps and ulcers to form in the genital and anal areas.

If not treated early, the infection can damage genital tissue and lead to other infections.

What are the causes of Granuloma Inguinale?

This condition is caused by the bacteria Klebsiella granulomatis. It is spread through sexual contact. Most often, the infection spreads through vaginal or anal intercourse.

What increases the risk?

You are more likely to develop this condition if you are sexually active. You may also be more likely to develop granuloma inguinale if you are:

• Male.
• 20–40 years old.

What are the symptoms of Granuloma Inguinale?

Symptoms of Granuloma Inguinale may appear 1–12 weeks after having contact with the bacteria. Symptoms affect the genital and anal area, and they may include:

• Red bumps that are often painless.
• Breaks in the skin (ulcerations).
• The destruction of genital tissue that may spread to the legs.
• Loss of skin color of the genitals and surrounding area.

How is Granuloma Inguinale diagnosed?

This condition may be diagnosed with:

• A physical exam.
• A test in which a tissue sample is taken from the affected area and examined under a microscope (biopsy).

This condition can happen with other STDs, such as chlamydia, gonorrhea, syphilis, human papillomavirus (HPV), HIV (human immunodeficiency virus), or AIDS (acquired immunodeficiency virus). Your health care provider may test you for these STDs.

How is this treated?

Granuloma Inguinale is treated with antibiotic medicine for up to 4–6 weeks. Treatment lowers the risk of more damage and scarring to the affected area. You will need to follow-up with your health care provider after treatment because it is common for the condition to come back after treatment.

Follow these instructions at home:

• Take your antibiotic medicine as told by your health care provider. Do not stop taking the antibiotic even if you start to feel better.

Take over-the-counter and prescription medicines only as told by your health care provider.

• Do not engage in sexual activity until treatment is completed and any sores are healed.
• Tell your sexual partner(s) to get checked for this condition.
• Practice safe sex and use condoms to help prevent the spread of STDs.
• Keep all follow-up visits as told by your health care provider. This is important.

Get help right away if:

• You have a fever or symptoms that last for more than 2–3 days.
• You have a fever and your symptoms suddenly get worse.
• Your infection is not getting better after 7 days of treatment.
• Your infection comes back.

Detailed Info on Granuloma Inguinale

Granuloma inguinale is a genital ulcerative disease caused by a gram-negative bacterium, Klebsiella granulomatis, which may be sexually transmitted. It can also be spread through close, long-term, nonsexual contact.

Synonyms

• Donovanosis
• Calymmatobacterium granulomatis

Incidence

Rare in the U.S. (<100 cases reported annually) and other developed countries

Prevalence

Endemic in some tropical and developing areas, including India, Papua New Guinea, the Caribbean, Central Australia, and southern Africa; incubation period is variable (1-2 wk)

Predominant Sex

Can affect both males and females

Physical Findings & Clinicial Presentation

• •Clinically, the disease is commonly characterized as painless, slowly progressive ulcerative lesions on the genitals or perineum without regional lymphadenopathy; subcutaneous granulomas (pseudobuboes) might also occur. The lesions are highly vascular (i.e., beefy red appearance) and bleed easily on contact.
• •Extragenital infection can occur with extension of infection to the pelvis, or it can disseminate to bones, intraabdominal organs, or the mouth.
• •Pathogenic features:
  • 1.Large, infected mononuclear cell containing many Donovan bodies
  • 2.Intracytoplasmic location

Etiology

K. granulomatis is a gram-negative bacillus that reproduces within polymorphonuclear cells, plasma cells, and histiocytes, causing the infected cells to rupture, releasing 20 to 30 organisms.

Differential Diagnosis

• •Carcinoma
• •Secondary syphilis: Condylomata lata
• •Amebiasis: Necrotic ulceration
• •Concurrent infections
• •Lymphogranuloma venereum
• •Chancroid
• •Genital herpes

Workup

• •Check for clinical manifestations.
  • 1.Lesions bleed easily.
  • 2.Lesions are sharply defined and painless.
  • 3.Secondary infection may ensue.
  • 4.Inguinal involvement may cause pseudobuboes.
  • 5.Elephantiasis can result from obstruction of lymphatics.
  • 6.Suppuration and sinus formation are rare in female patients.
• •Screen for other sexually transmitted diseases.
• •Exclude other causes of lesions.
• •Obtain stained, crushed prep from lesion.

Laboratory Tests

• •The causative organism is difficult to culture and diagnosis requires visualization of dark-staining Donovan bodies with Wright stain (observation of Donovan bodies [intracellular bacteria]; organisms in vacuoles within macrophages) via biopsy of the ulcer or tissue crush prep. No FDA-cleared molecular tests for the detection of K. granulomatis DNA exist.
• •HIV testing of all patients.

Acute General Treatment

Recommended regimen:

• •Azithromycin 1 g PO once per wk or 500 mg daily for at least 3 wk and until all lesions have completely healed

Alternative regimens:

• •Doxycycline 100 mg PO bid for at least 3 wk and until all lesions have completely healed
• •Ciprofloxacin 750 mg PO bid for at least 3 wk and until all lesions have completely healed
• •Erythromycin base 500 mg PO qid for at least 3 wk and until all lesions have completely healed
• •Trimethoprim/sulfamethoxazole, one double-strength tablet (160 mg/800 mg) PO bid for at least 3 wk and until all lesions have completely healed
• •Add gentamicin 1 mg/kg IV q8h if no improvement within the first few days of therapy

Chronic Treatment

If there is a poor initial response, extend treatment. Treatment of relapses is often necessary. Patients should be counseled to avoid risky sex practices and to abstain from intercourse until infection is cleared.

Disposition

Follow up clinically until signs and symptoms have resolved, then routine annual or semiannual visits.

Referral

If response is poor, consider referral to an infectious disease specialist.

Pearls & Considerations

• •Sexual partners within 60 days before onset of patient’s symptoms should be examined and offered therapy.
• •Pregnant women should be treated with erythromycin regimen.
• •Patient education material can be obtained from local and state health clinics and also from American College of Obstetricians and Gynecologists.

Seek Additional Information

• Workowski KA, Bolan GA, Centers for Disease Control and Prevention: Sexually transmitted diseases treatment guidelines, 2015, MMWR Recomm Rep 64(RR-03):1–137, 2015. Erratum in: MMWR Recomm Rep 64(33):924, 2015.