Granuloma Inguinale (Donovanosis Granuloma venereum)

Introduction

A mildly contagious disease caused by Klebsiella granulomatis
Currently rare in several parts of Africa Endemic in Southeast Asia, Southern India, the Caribbean and South America

Clinical features

A chronic mildly contagious disease with a potentially progressive and destructive character
Incubation period ranges from 10 - 40 days
The early lesion is a papule or nodule which soon becomes ulcerated and has an offensive discharge
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
Progressive indolent, serpiginous ulceration of the groins, pubis, genitals and anus may form.
Pain on walking may be excrutiating
Persisting sinuses and hypertrophic depigmented scars are fairly characteristic
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
Subcutaneous extension and abscesses may occur and form a pseudo-bubo in the inguinal region
Healing is unlikely without treatment; the locally destructive lesion may eventually involve the groins, pubis and anus
A squamous cell carcinoma may arise from chronic lesions.

Differential diagnoses

Complications

Investigations

Treatment goals

Drug treatment

Recommended regimen:

Azithromycin - 1g orally on first day, then 500mg orally, once a day

Or:

Doxycycline - 100 mg orally every 12 hours

Therapy should be continued until the lesions have completely epithelialized

Alternative regimen:

Erythromycin - 500 mg orally every 6 hours

Or:

Tetracycline 500 mg orally every 6 hours

Or:

Trimethoprim 80 mg/sulfamethoxazole 400 mg, 2 tablets 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, contraindications and caution

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

Prevention

Nigeria