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Granuloma Inguinale

Donovanosis

Granuloma inguinale (donovanosis) is a rare genital ulcerative bacterial infection that is usually found in tropical or subtropical areas. Klebsiella granulomatis is the bacteria responsible for granuloma inguinale.


Presentation

Repetitive exposure may be required for the infection to develop. Symptoms may not appear immediately after the exposure and it could take up to twelve weeks for the symptoms to occur after exposure to the bacteria.

Symptoms and features of the infection include small red papules or nodules on the genitals or around the anal area and sores or ulceration in the genital area. The infection may spread to the inguinal folds and may cause damage to the genital tissue, and the skin gradually wears away [6]. Color loss in the infected area may also be noticed.

Inguinal Lymphadenopathy
  • Donovanosis is a sexually transmitted infection which presents with genital ulceration and inguinal lymphadenopathy. Rarely, it presents with extra-genital manifestations.[ncbi.nlm.nih.gov]
  • In contrast to syphilitic ulcers, inguinal lymphadenopathy is generally mild or absent. Tissue biopsy and Wright-Giemsa stain are used to aid in the diagnosis. The presence of Donovan bodies in the tissue sample confirms donovanosis.[en.wikipedia.org]
  • Donovanosis ulcers bleed to the touch and are not usually associated with inguinal lymphadenopathy as with LGV and chancroid. Most regular sexual partners of infected patients have no evidence of co-existent infection with donovanosis.[dartmouth.edu]
  • Signs and Symptoms Granuloma inguinale presents with progressive painless genital ulcers without inguinal lymphadenopathy. The genital ulcers are destructive and can affect the genital organs, the groin and the perineal region.[urology-textbook.com]
  • lymphadenopathy, darkfield positive – Chancroid—more typically painful and often with inguinal lymphadenopathy – Genital warts (human papillomavirus)—rarely bleed, can be confused with verrucous GI – Penile or vulvar cancer—see below under complications[clinicaladvisor.com]
Prostitute
  • Prostituted women appear to be the usual reservoir. In Africa, chancroid is emerging as the major risk factor for acquisition of HIV-1 following heterosexual intercourse.[ncbi.nlm.nih.gov]
  • The incidence of GI is also relatively low among both prostitutes and their conjugal partners.[accessmedicine.mhmedical.com]
  • The following general measures can help prevent granuloma inguinale (and other sexually transmitted diseases): Avoidance of unsafe sex practices, such as frequently changing sex partners or having sexual intercourse with prostitutes or with partners who[merckmanuals.com]
  • There was a history of unprotected intercourse with a prostitute about 2 months prior to the eruption.[dermatology-s10.cdlib.org]
Inguinal Lesions
  • Diagnosis and management o... 099.2 Granuloma inguinale 28867007 Granuloma inguinale (disorder) 240607002 Donovanosis - inguinal lesion 240606006 Donovanosis - anogenital ulcer Presents as SC nodules or superficial blisters in the genital area that develop[5minuteconsult.com]
  • However inguinal lesions occur in only 10-15% of cases and are usually associated with concurrent genital lesions as in this case.[web.archive.org]
  • However, of the 720 cases mentioned in a Peruvian study of this disease, only 10% demonstrated inguinal lesions, usually associated with concurrent genital lesions. Other synonymies reveal clinical epidemiologic aspects of the disease.[scielo.br]
Inguinal Mass
  • Rinsho Geka Volume 48, Issue 8 (August 1993) 臨床外科 48巻8号 (1993年8月) Japanese English 臨床報告 鼠径部腫瘤を主訴とした木村病(軟部好酸球肉芽腫症)の1例 A case report of Kimura disease (eosinophilic granuloma of soft tissue) with the chief complaint about the inguinal mass 大澤 武 1, 平野 誠[webview.isho.jp]
Swollen Knee
  • A 41-year-old female presented with fever, a swollen knee joint and osteolytic lesions involving distal bones, and a 49-year-old male had multiple faecal fistulae in the lower abdomen with extensive involvement of pelvic organs.[ncbi.nlm.nih.gov]
Aspiration
  • A radiographically guided fine needle aspiration (FNA) of the presacral mass showed findings characteristic of granuloma inguinale.[ncbi.nlm.nih.gov]
  • Biopsy, aspirate of lesion with smear and histology. Smear of granulation tissue with microscopy (including special stains) for intracellular bacteria ( Calymmatobacterium granulomatis ), also known as 'Donovan bodies'.[rcpa.edu.au]
  • […] spread Diagnosis Made by swabbing the lesion and Giemsa staining of the air dried smear Other stains that may be used are Warthin-Starry, Gram stain, Toluidine blue and Leishman stain Recommended to acquire specimen at base or edge of ulceration or by aspirating[pathologyoutlines.com]
  • A biopsy specimen, scrapings from the base of the ulcer, or aspirated exudate can also be used. This allows direct visualization of Donovan bodies after applying Giemsa or Wright stain [ 7, 9 ].[dermatology-s10.cdlib.org]
Recurrent Abdominal Pain
  • A 63-year-old Hispanic man from Peru who recently had immigrated to the United States presented with progressive weakness, weight loss, recurrent abdominal pain and passing bright red blood per rectum. Rectal carcinoma was suspected.[ncbi.nlm.nih.gov]
Skin Ulcer
  • The doctor obtains a tissue sample either by cutting a piece of tissue from the edge of an skin ulcer with a scalpel or by taking a punch biopsy.[encyclopedia.com]
  • An accurate diagnosis of Granuloma Inguinale might involve the following procedures and exams: Complete evaluation of medical history, along with a thorough physical examination Genital examination to check for skin ulcers that are painless, likely to[dovemed.com]
Denial
  • Estimates range between 1–360 days, 31 3–40 days, 32 14–28 days, 33 and 17 days. 34 This wide range is probably multifactorial and may reflect either late presentation and denial or non-sexual transmission.[doi.org]
Withdrawn
  • […] acquired through sexual intercourse in the presence of ulcers. 64 Despite this, no specific control measures for donovanosis were introduced locally and indeed with the move to decentralise STI treatment and provide syndromic management, trained staff were withdrawn[doi.org]
Low Self-Esteem
  • They may have low self esteem because of the physical nature of the lesions—large genital sores with an offensive odour—and may have delayed in presenting for help because of a sense of shame.[doi.org]
Chancroid
  • In Africa, chancroid is emerging as the major risk factor for acquisition of HIV-1 following heterosexual intercourse.[ncbi.nlm.nih.gov]
  • A case report. ( 2749430 ) O'Farrell N. 1989 48 Lymphogranuloma venereum, chancroid, and granuloma inguinale. ( 2687744 ) Faro S. 1989 49 Chancroid and granuloma inguinale. ( 2676322 ) Ronald A.R....Plummer F.A. 1989 50 A clinicopathological study of[malacards.org]
Cesarean Section
  • Sixty-nine percent (n 36) delivered vaginally while the remaining (n 16) were delivered by cesarean section. The indications for cesarean section were obstetric except for a patient in labor with extensive untreated vulval granuloma.[ncbi.nlm.nih.gov]
Salpingitis
  • Granulomatous involvement of the parametrium, salpinges, ovaries, and ureters was associated with ureteric obstruction and bilateral hydronephrosis.[ncbi.nlm.nih.gov]
Foul Smelling Vaginal Discharge
  • Both patients presented with a bloody foul-smelling vaginal discharge. Speculum examination confirmed cervical ulceration, prompting the diagnosis of cervical carcinoma in both patients.[ncbi.nlm.nih.gov]

Workup

The diagnosis depends on the clinical features and appearance of the lesions on the genital area of the patient [7]. If the condition is suspected based on the clinical findings, a smear is taken from the edge of the lesions and examined microscopically to confirm the diagnosis of granuloma inguinale. If the smear shows Donovan bodies (multiple bacilli in macrophages cytoplasm shown by Write or Giemsa stain), the daignosis of granuloma inguinale is confirmed.

If the lesions are dry or the diagnosis was unclear, a biopsy specimen may be taken and examined to confirm the diagnosis. Ordinary bacterial cultures do not help in the diagnosis of granuloma inguinale because the bacateria Klebsiella granulomatis do not grow on these culture media.

Calymmatobacterium Granulomatis
  • From Wikidata Jump to navigation Jump to search bacterial disease caused by Klebsiella granulomatis (formerly known as Calymmatobacterium granulomatis) characterized by genital ulcers (Granuloma inguinale) or (donovanosis) or (pudendal ulcer) Granuloma[wikidata.org]
  • Infection with calymmatobacterium granulomatis is usually localized to the genital organs but rarely may be disseminated.[ncbi.nlm.nih.gov]

Treatment

Granuloma inguinale is a bacterial infection and treatment with antibiotics is required to resolve the infection and the related signs and symptoms. Different antibiotics may be used in the treatment of the infection. However, the most commonly used ones are either trimethoprim/sulfamethoxazole or doxycycline. Other antibiotics include azithromycin, erythromycin, or ciprofloxacin [8]. The course of the antibiotics should not be less than three weeks and should last until the signs and symptoms of the condition have resolved and the reepitheliaization of the ulcers occurs. Tetracycline was used for the treatment of the infection. However, it is not used anymore in some countries because of the bacterial resistance to tetracycline [9].

An aminoglycoside should be added if there was no response after a few days of initiation of the antibiotics treatment. Tissue and skin damage in the genital area may not heal with medical treatment, and surgical repair may be required to correct the tissue damage. Even with successful treatment, relapses of granuloma inguinale are possible, and may occur any time up to 18 months after successful treatment.

Prognosis

The prognosis of granuloma inguinale depends on the treatment, and the lesions may continue to expand causing genital tissue damage if left untreated. Relapses of the infection are possible and may develop up to 18 months after successful treatment of the condition.

Etiology

Granuloma inguinale is a sexually transmitted disease, which means it could be transmitted through vaginal, anal or even oral sex in rare cases. The infection is caused by the gram negative bacteria Klebsiella granulomatis [1].

Epidemiology

Granuloma inguinale is a very rare infection (less than 100 cases are reported annually), and the number of cases have been decreasing recently due to good preventive measures. Patients who get infected with granuloma inguinale are usually in endemic or tropical areas, such as India, the Caribbean, South Africa, Australia, Western New Guinea, and Papua [4] [5]. Granuloma inguinale is rarely reported in the United States.

The incidence of the infection differs between races. Like for example, in Western New Guinea the incidence among the native population is higher than the incidence in Europeans. This difference in incidence between races is most likely due to the difference in the socioeconomic status.

Sex distribution
Age distribution

Pathophysiology

Granuloma inguinale is transmitted sexually. However, the risk of transmission is very low and repetitive exposure is required in order for the infection to be transmitted from a partner to another. Granuloma inguinale may also be transmitted through the fecal route, or from the mother to her baby through the birth canal.

Prevention

Granuloma inguinale is a rare infection and only a few cases are reported annually. The number of reported cases is even decreasing more and more because of the good preventive measures that have been taken for several years.

A committee was established, in Australia and other areas were the infection was reported, under the name of (National Donovanosis Eradication Advisory Committee). The main goal of this committee is to decrease the incidence and the risk of the infection by developing educational materials, services, and protocols for the treatment, management and prevention of granuloma inguinale. This committee was very successful in the control and prevention of granuloma inguinale, and since the establishment of the committee, there is a substantial decrease in the incidence of infection [10].

Summary

Granuloma inguinale is a genital infection, which usually causes painless ulceration of the genitals. Granuloma inguinale is a bacterial infection caused by the gram negative bacteria Klebsiella granulomatis (formerly called Calymmatobacterium granulomatis) [1] [2]. The bacteria responsible for the infection was initially classified as Calymmatobacterium granulomatis in 1913. However, it was reclassified as Klebsiella granulomatis because it was found that its molecular structure was similar to the molecular structure of the Klebsiella species [1] [3].

Granuloma inguinale is found in different areas of the world. However, it is most commonly found in poor tropical areas, such as India, South Africa, and some areas in Australia. The condition presents with ulcerative lesions on the genital tract, which may spread and cause damage to the genital tissue and skin. Treatment of granuloma inguinale may include different antibiotics. However, trimethoprim/sulfamethoxazole or doxycycline are the most commonly used antibiotics in the treatment of the infection.

Patient Information

Granuloma inguinale is a rare sexually transmitted bacterial infection caused by Klebsiella granulomatis. The infection is manifested by genital ulceration and lesions, which may spread wider and cause damage to the genital tissue and skin.

The symptoms of granuloma inguinale may not appear immediately after exposure to the bacteria. It could take several weeks for the symptoms to appear and they include painless ulceration and lesions around the genital area.

The doctor will make the diagnosis of granuloma inguinale based on the clinical appearance and features of the infection, which are noticed around the genital area. A smear may be taken from the lesions and examined microscopically to confirm the diagnosis. In rare cases, when the diagnosis is hard to make, a biopsy specimen could be taken from the lesions and examined.

Granuloma inguinale is a bacterial infection, and once diagnosed, treatment with antibiotics should start immediately and last for at least three weeks and until the signs and symptoms of the infection resolve. Different antibiotics may be used in the treatment, however, trimethoprim/sulfamethoxazole and doxycycline are the ones most commonly used.

After successful treatment with antibiotics, surgical repair may be needed to repair the damaged tissue and skin.

Good treatment with antibiotics plays an important role in the outcome of the condition. If left untreated, the genital lesions could expand and spread to the inguinal folds and cause damage to the surrounding tissue and skin. Relapse of the infection is possible and could develop up to 18 months after treatment.

Due to good preventive measures, including protocols for management, and educational materials in endemic areas, the incidence of the condition has decreased significantly in the last few years. Education about the condition and sexually transmitted infections is very important in raising awareness and decreasing the risk of getting infected.

References

Article

  1. Carter JS, Bowden FJ, Bastian I, et al. Phylogenetic evidence for reclassification of Calymmatobacterium granulomatis as Klebsiella granulomatis comb nov. Int J Syst Bacteriol. 1999; 49: 1695–700.
  2. Kharsany AB, Hoosen AA, Kiepala P, et al. Phylogenetic analysis of Calymmatobacterium granulomatis based on 16S sequences. J Med Microbiol. 1999; 48: 841–7.
  3. Anderson K. The Cultivation From Granuloma Inguinale of a Microorganism Having the Characteristics of donovan bodiesin the yolk sac of chick embryos. Science. June 18, 1943; 97(2529): 560-561.
  4. Bowden FJ. National Donovanosis Eradication Advisory Committee. Donovanosis in Australia: going, going. Sex Transm Infect. 2005; 81: 365–6. 
  5. O'Farrell N. Donovanosis. Sex Transm Infect. 2002; 78: 452–7.
  6. Govender D, Naidoo K, Chetty R. Granuloma inguinale (donovanosis): an unusual cause of otitis media and mastoiditis in children. Am J Clin Pathol. November 1997; 108(5): 510-4.
  7. O’Farrell N, Hoosen AA, Coetzee KD, et al. Genital ulcer disease: accuracy of clinical diagnosis and strategies to improve control in Durban, South Africa. Genitourin Med. 1994; 70: 7–11.
  8. Bowden FJ, Savage J. Azithromycin for the treatment of donovanosis. Sex Transm Infect. February 1998; 74(1): 78-9.
  9. Rosen T, Vandergriff T, Harting M. Antibiotic use in sexually transmissible diseases. Dermatol Clin. January 2009; 27(1): 49-61.
  10. Bowden FJ. Donovanosis in Australia: going, going... Sex Transm Infect. October 2005; 81(5): 365-6.

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Last updated: 2019-06-28 11:21