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Granuloma Inguinale (Donovanosis): Symptoms, Stages, Causes & Treatment

Granuloma inguinale is a genital ulcerative disease caused by the bacterium Klebsiella granulomatis. That is, Granuloma inguinale is a sexually transmitted infection (STI). Also known as donovanosis, the infection causes lesions in the genital and anal regions [1] . The STI is characterised by pain-free genital ulcers that look like the pox. The infection is mostly found in sub-tropical and tropical regions and is rarely reported in developed countries. In some of the developing countries, such as India, Papua New Guinea, and the Caribbean, the infection is regarded as an endemic[2] , [3] .

The bacterium Klebsiella granulomatis infects the skin around the genitals and causes ulcers which result in the destruction of the skin around the affected area. This destructive nature of the infection elevates the risk of getting affected by other pathogenic microbes.

Granuloma inguinale is infectious, that is, it can spread from one person to other [4] . It is mostly spread through the means of vaginal or anal intercourse and rare cases of infection through oral sex have been reported. However, anal intercourse is suspected to be the most frequent source of infection. About 50 per cent of the affected (men and women) have developed lesions in the anal region [5] .

Studies have revealed that men are most likely to be affected by the infection than women and commonly occurs in people aged between 20 to 40. Most of the cases of the STI reported are in people who have travelled to places that are at a high risk of the infection [6] . And, a very small proportion of people may be infected through direct, non-sexual contact (skin to skin).

Symptoms Of Granuloma Inguinale

The common signs indicating the development of the infection are small, painless nodules (pimple like) which develops into an open and fleshy lesion. The infection develops in the genital area and in some cases, mouth sores can also develop. This aggravates until the infected tissue gets mutilated and the infection will continue to latch onto other tissues [7] , [8] .

Apart from this, the symptoms of the sexually transmitted disease can be described in line with the stages of Granuloma inguinale.

Stages Of Granuloma Inguinale

The signs of the infection develop at a slow pace. That is, once the individual comes in contact with the bacteria it will take 7 to 10 days to experience the symptoms. Within a period of 12 weeks, the symptoms will be at their maximum capacity [9] .

  • Stage one: In the initial stage, the small nodule will spread to the surrounding tissue. The affected tissues will be lost and the area will turn pink (or a very light red). The small bumps found around the anus and genitals turn into raised red nodules with a velvety texture. The nodules will be painless, however, injuring them can cause bleeding.
  • Stage two: By now, the bacteria will begin to destroy the skin and cause shallow ulcers that will spread from the genitals and anus to the thighs and lower abdomen. The ulcers may have a foul smell and will be lined with granulated tissue.
  • Stage three: Upon reaching the third stage, the infection will become deep and the ulcers will turn into morph tissue.

Causes Of Granuloma Inguinale

The infection is caused by the Klebsiella granulomatis bacteria. One can contract the infection by having vaginal or anal intercourse with an infected partner. In very rare cases, it has spread through oral sex. Apart from these, it can spread from a mother to a child during delivery [10] .

Complications Of Granuloma Inguinale

  • Loss of skin colour in the genital area [11]
  • Genital damage and scarring
  • Permanent genital swelling due to scarring
  • Cancer in the sore
  • Narrowing of the vagina, anus or urethra [12]
  • Damage to the bones or bowel, if the bacteria spread through the blood to other sites

It is often difficult to diagnose the infection in its early stage due to the slow development of the ulcers.

If the ulcers do not heal after a month, your doctor will advise a skin biopsy of the lesions called the punch biopsy. Under this one, the doctor will remove a small area of the ulcer with a circular blade and will be tested for the presence of Klebsiella granulomatis bacteria [13] . In some cases, scrapings of the lesions are used to detect the presence of the bacteria.

The diagnosis will also include blood tests to check the presence of other sexually transmitted diseases [14] , [15] .

Treatment For Granuloma Inguinale

Antibiotics such as azithromycin, doxycycline, ciprofloxacin, erythromycin, and trimethoprim-sulfamethoxazole are used. The antibiotics will be used for a long period of time, until the sores are completely healed, and depending on the length of time since infection and the stage of infection. Most of the antibiotics are prescribed for a period of three weeks, however, some may take more time to heal the ulcer [16] .

If the ulcers are painful, the doctor will advise for painkillers [17] .

A follow-up examination is essential, as the sexually transmitted infection can reappear even if the lesions have gone down completely [18] .

Prevention Of Granuloma Inguinale

  • Using condoms for vaginal and anal sex significantly reduces the risk of the infection and sexually transmitted diseases [19] .
  • Avoid sex with individuals who have a visible genital ulcer or sore.
  • Before travelling to a developing country, run a thorough check on the diseases that are prevalent there, and adopt suitable preventive measures [20] .
View Article References
  1. [1] Rosen, T., Tschen, J. A., Ramsdell, W., Moore, J., & Markham, B. (1984). Granuloma inguinale.Journal of the American Academy of Dermatology,11(3), 433-437.
  2. [2] Richens, J. (1991). The diagnosis and treatment of donovanosis (granuloma inguinale).Sexually Transmitted Infections,67(6), 441-452.
  3. [3] Rajam, R. V., & Rangiah, P. N. (1954). Donovanosis (Granuloma Inguinale, Granuloma Venereum).Donovanosis (Granuloma Inguinale, Granuloma Venereum).
  4. [4] Lal, S., & Nicholas, C. (1970). Epidemiological and clinical features in 165 cases of granuloma inguinale.British Journal of Venereal Diseases,46(6), 461.
  5. [5] Greenblatt, R. B., Dienst, R. B., Pund, E. R., & TORPIN, R. (1939). Experimental and clinical granuloma inguinale.Journal of the American Medical Association,113(12), 1109-1116.
  6. [6] Davis, C. M. (1970). Granuloma inguinale: a clinical, histological, and ultrastructural study.Jama,211(4), 632-636.
  7. [7] Hammond, G. W., Slutchuk, M., Scatliff, J., Sherman, E., Wilt, J. C., & Ronald, A. R. (2015). 11.1. 2 Granuloma Inguinale.Vulval Dermatologic Diagnosis: Diagnosis by Clinical Presenting Sign,22, 241-4.
  8. [8] Ornelas, J., Kiuru, M., Konia, T., & Larsen, L. (2016). Granuloma inguinale in a 51-year-old man.Dermatology online journal,22(4).
  9. [9] Shi, W., Schultz, S., Strouse, A., & Gater, D. R. (2019). Successful treatment of stage III hidradenitis suppurativa with botulinum toxin A.BMJ Case Reports CP,12(1), e226064.
  10. [10] Thomas, M., Rao, R., & Kumar, G. N. (2018). An overview of suppurative granuloma.Indian Journal of Dermatopathology and Diagnostic Dermatology,5(1), 19.
  11. [11] Datta, P., & Gupta, V. (2018). An Update on Sexually Transmitted Infections: An Indian Context. InInfectious Diseases and Your Health(pp. 391-401). Springer, Singapore.
  12. [12] Javaid, S., Rasool, N., & Choudhry, M. L. (2018). Incidence of Post-Operative Complications of Inguinal Hernia and Hydrocele Open Surgery in Children.PAKISTAN JOURNAL OF MEDICAL & HEALTH SCIENCES,12(2), 440-442.
  13. [13] Habif, T. P. (2015).Clinical Dermatology E-Book: A Color Guide to Diagnosis and Therapy. Elsevier Health Sciences.
  14. [14] Curran, D., Delancey, J. O., & Haefner, H. K. (2018). Dysuria, painful lesions in 26-year-old woman: What's your diagnosis and treatment plan for this patient?.Contemporary OB/GYN,63(4), 16-19.
  15. [15] Wick, M. R., & Patterson, J. W. (2018, October). Diagnostic histochemistry in non-neoplastic skin diseases. InSeminars in diagnostic pathology. WB Saunders.
  16. [16] Macpherson, P. A., & Cameron, D. W. (2017). Lymphogranuloma Venereum, Chancroid and Granuloma Inguinale. InInfectious Diseases(pp. 585-591). Elsevier.
  17. [17] Magalhães, B. M., Veasey, J. V., Mayor, S. A. S., & Lellis, R. F. (2018). Donovanosis in a child victim of sexual abuse: response to doxycycline treatment.Anais brasileiros de dermatologia,93(4), 592-594.
  18. [18] Wick, M. R. (2017, May). Granulomatous & histiocytic dermatitides. InSeminars in diagnostic pathology(Vol. 34, No. 3, pp. 301-311). WB Saunders.
  19. [19] Ceovic, R., & Gulin, S. J. (2015). Lymphogranuloma venereum: diagnostic and treatment challenges.Infection and drug resistance,8, 39.
  20. [20] O’Farrell, N., & Moi, H. (2016). 2016 European guideline on donovanosis.International journal of STD & AIDS,27(8), 605-607.
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Story first published: Wednesday, April 17, 2019, 15:55 [IST]