Granuloma Inguinale (Donovanosis Granuloma Venereum)

Introduction

Granuloma Inguinale is a mildly contagious (sexually transmitted) disease caused by Klebsiella granulomatis.
It leads to chronic inflammation and scarring of the genitals.
Granuloma inguinale typically causes a painless, red lump on or near the genitals, which slowly enlarges, then breaks down to form a sore.
It is currently rare in several parts of Africa but endemic in Southeast Asia, Southern India, the Caribbean and South America.

Symptoms and clinical features of Granuloma inguinale

  1. Granuloma Inguinale is a chronic mildly contagious disease with a potentially progressive and destructive character
  2. Its incubation period ranges from 10 – 40 days.
  3. The early lesion is a papule or nodule which soon becomes ulcerated and has an offensive
    discharge
  4. The floor of the ulcer may be covered with a dirty grey material; its walls may be overhanging, or a papillomatous fungating mass may arise from the growth of vegetations
  5. Progressive indolent, serpiginous ulceration of the groins, pubis, genitals and anus may form.
  6. Pain (due to Ulceration) on walking may be excrutiating
  7. Persisting sinuses and hypertrophic depigmented scars are fairly characteristic
  8. Regional lymph nodes are not enlarged but with cicatrisation, the lymph channels may be blocked causing pseudoelephantiasis of the genitalia. Both the fibrotic scarring and elephantiasis-like lesion could cause obstructed labour
  9. Subcutaneous extension and abscesses may occur and form a pseudo-bubo in the inguinal region
  10. Healing is unlikely without treatment; the locally destructive lesion may eventually involve the groins, pubis and anus
  11. A squamous cell carcinoma may arise from chronic lesions.

Differential diagnoses

  • Syphilis Chancroid
  • Lymphogranuloma venereum
  • Lupus vulgaris
  • Deep mycosis
  • Amoebic ulcer
  • Pyoderma gangrenosum
  • Squamous cell and basal cell carcinoma

Complications of Granuloma inguinale

  • Obstructed labour
  • Squamous cell carcinoma

Investigations

  • Direct microscopy

Treatment for Granuloma inguinale

Treatment objectives

  1. Eliminate the organism in the patient and sexual partner(s)
  2. Prevent re-infection
  3. Prevent complications
  4. Counsel and screen for possible co-infection with HIV so that appropriate management can be instituted

Drug therapy

A. Recommended regimen:
Azithromycin 1g orally on first day, then 500 mg orally, once a day

Or:

Doxycycline 100 mg orally every 12 hours
Therapy should be continued until the
lesions have completely epithelialized
B. Alternative regimen:

  • Erythromycin 500 mg orally every 6 hours

Or:

  • Tetracycline 500 mg orally every 6 hours

Or:

  • Trimethoprim 80 mg/ sulfamethoxazole 400 mg, (i.e. 960 mg) orally, 12 hourly

All treatment should be for a minimum of 14 days

  • Note: The addition of a parenteral aminoglycoside such as gentamicin should be carefully considered for treating HIV-infected patients

Follow-up

  • Patients should be followed up clinically until signs and symptoms have resolved

Notable adverse drug reactions, caution and contraindications

Sulfamethoxazole/ trimethoprim

  • Contraindicated in persons with
    hypersensitivity to sulfonamides or
    trimethoprim; porphyria
  • Caution required in renal
    impairment (avoid if severe); hepatic impairment (avoid if severe);
  • maintain adequate fluid intake (to avoid crystalluria)
  • May cause nausea, vomiting, diarrhoea, headache, hypersensitivity reactions, including fixed drug eruption, pruritus, photo-sensitivity reactions, exfoliative dermatitis, and erythema nodosum

Others
See Chlamydia

Prevention

  • Counselling, Compliance, Condom use and Contact treatment