Granuloma inguinale

Granuloma inguinale is a sexually transmitted bacterial disease caused by Klebsiella granulomatis. It is seen most commonly in sexually active individuals between 20 and 40 years of age. Clinically, granuloma inguinale manifests with one or more genital nodules that develop into red, painless ulcers. The regional lymph nodes are typically spared. Diagnosis of granuloma inguinale is based primarily on clinical findings and is confirmed through the detection of Donovan bodies (intracytoplasmic macrophages containing bacteria) in ulcer smears or biopsies. Antibiotic therapy (preferably with azithromycin) should be continued for at least 3 weeks and until the ulcers have completely healed.

• Prevalence: endemic to tropical and subtropical countries
• Incidence: rare (< 100 cases annually) in the US
• Age range: 20–40 years

Epidemiological data refers to the US, unless otherwise specified.

• Pathogen: Klebsiella granulomatis (gram-negative, facultative anaerobe, encapsulated)
• Route of transmission
  • Sexual transmission
  • Autoinoculation of adjacent skin
  • Perinatal transmission
• Risk factors
  • Men who have sex with men
  • Uncircumcised men
  • Low socioeconomic status

• Incubation period: highly variable (1 day to 1 year); median time ∼ 50 days
• Clinical features ^[1][2]
  • Painless genital lesion: begin as one or more nodules; eventually ulcerate to form large, beefy-red lesions that bleed easily
    • ♂: foreskin, coronal sulcus, glans
    • ♀: labia minora, cervix
  • Often malodorous because of bacterial coinfection
  • Can rarely extend to extragenital sites (including the oral cavity, pharynx, and intrabdominal organs)
  • Regional lymph nodes are typically spared.

Granuloma inguinale (Klebsiella granulomatis) should not be mistaken for lymphogranuloma inguinale (Chlamydia trachomatis serotype L1–L3), which is commonly known as lymphogranuloma venereum!

• Microscopic examination of fluid, tissue scrapings, or biopsy of the genital lesion: The presence of Donovan bodies on microscopy confirms the diagnosis.
  • Intracytoplasmic cysts filled with deeply staining , safety-pin shaped bodies within macrophages (Pud cells)
• Molecular assays : Can be considered to identify the causative pathogen if Donovan bodies were not detected on microscopy.
• K. granulomatis is difficult to culture.

HIV testing is recommended for all patients with granuloma inguinale. ^[1]

• See the differential diagnoses of genital lesions.

The differential diagnoses listed here are not exhaustive.

• Antibiotics for granuloma inguinale
  • First line: azithromycin ^[1]
  • Alternatives
    • Doxycycline ^[1]
    • OR erythromycin base ^[1]
    • OR trimethoprim-sulfamethoxazole ^[1]
• Follow-up patients until complete symptomatic resolution.
• Prevent onward transmission and reinfection: See “Management of sexual partners.”

• Genital pseudoelephantiasis (seen especially in women)
• Bacterial superinfection of the ulcer
• Neoplastic transformation of the ulcer
• Osteomyelitis (rare)

We list the most important complications. The selection is not exhaustive.