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Granuloma Inguinale (Donovanosis)
Granuloma inguinale (donovanosis) is a genital ulcerative disease caused by the intracellular gram-negative bacterium Klebsiella granulomatis (formerly known as Calymmatobacterium granulomatis). The disease occurs rarely in the United States; however, sporadic cases have been described in India, South Africa, and South America (526–535). Although granuloma inguinale was previously endemic in Australia, it is now extremely rare (536,537). Clinically, the disease is characterized as painless, slowly progressive ulcerative lesions on the genitals or perineum without regional lymphadenopathy; subcutaneous granulomas (pseudobuboes) also might occur. The lesions are highly vascular (i.e., beefy red appearance) and can bleed. Extragenital infection can occur with infection extension to the pelvis, or it can disseminate to intra-abdominal organs, bones, or the mouth. The lesions also can develop secondary bacterial infection and can coexist with other sexually transmitted pathogens.
Diagnostic Considerations
The causative organism of granuloma inguinale is difficult to culture, and diagnosis requires visualization of dark-staining Donovan bodies on tissue crush preparation or biopsy. Although no FDA-cleared molecular tests for the detection of K. granulomatis DNA exist, molecular assays might be useful for identifying the causative agent.
Treatment
Multiple antimicrobial regimens have been effective; however, only a limited number of controlled trials have been published (538). Treatment has been reported to halt progression of lesions, and healing typically proceeds inward from the ulcer margins. Prolonged therapy is usually required to permit granulation and reepithelialization of the ulcers. Relapse can occur 6–18 months after apparently effective therapy.
Azithromycin 1 gm orally once weekly or 500 mg daily for > 3 weeks and until all lesions have completely healed
Doxycycline 100 mg orally 2 times/day for at least 3 weeks and until all lesions have completely healed
OR
Erythromycin base 500 mg orally 4 times/day for >3 weeks and until all lesions have completely healed
OR
Trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) tablet orally 2 times/day for > 3 weeks and until all lesions have completely healed
The addition of another antibiotic to these regimens can be considered if improvement is not evident within the first few days of therapy.
Other Management Considerations
Patients should be followed clinically until signs and symptoms have resolved. All persons who receive a diagnosis of granuloma inguinale should be tested for HIV.
Follow-Up
Patients should be followed clinically until signs and symptoms resolve.
Management of Sex Partners
Persons who have had sexual contact with a patient who has granuloma inguinale within the 60 days before onset of the patient’s symptoms should be examined and offered therapy. However, the value of empiric therapy in the absence of clinical signs and symptoms has not been established.
Special Considerations
Pregnancy
Use of doxycycline in pregnancy might be associated with discoloration of teeth; however, the risk is not well defined. Doxycycline is compatible with breastfeeding (431). Sulfonamides can be associated with neonatal kernicterus among those with glucose-6-phospate dehydrogenase deficiency and should be avoided during the third trimester and while breastfeeding (431). For these reasons, pregnant and lactating women with granuloma inguinale should be treated with a macrolide regimen (erythromycin or azithromycin).
HIV Infection
Persons with granuloma inguinale and HIV infection should receive the same regimens as those who do not have HIV.