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Donovanosis (Granuloma Inguinale) – Complete Medical Guide

Overview

Donovanosis, also called granuloma inguinale or Calymmatobacterium granulomatis infection, is a rare sexually transmitted disease (STD) caused by the bacterium Klebsiella (formerly Calymmatobacterium) granulomatis. The infection primarily produces painless, beefy‑red ulcerative lesions on the genital or perineal skin. Unlike many other STDs, Donovanosis does not typically cause lymphadenopathy (swollen lymph nodes) or systemic symptoms.

Who it affects: Historically more common in males, but women can be infected as well. The disease is endemic in tropical and subtropical regions, especially parts of:

• India, Papua New Guinea, and the Pacific Islands
• Southern Africa (e.g., South Africa, Tanzania)
• Caribbean islands and some areas of South America

In non‑endemic, high‑income countries the condition accounts for less than 0.1 % of all reported STDs. The World Health Organization (WHO) estimates about 1–2 cases per 100 000 population in endemic regions, with occasional outbreaks linked to migration and travel.

Symptoms

Donovanosis usually begins 1–12 weeks after exposure. The classic clinical picture includes:

Skin lesions

• Painless, progressive ulcers – start as small papules or nodules that rupture to form a shallow, raised, beefy‑red ulcer. The base is often covered by a gray‑white necrotic (fibrinous) membrane that bleeds easily when touched.
• Granulomatous tissue – edges may become rolled or “pseudogranulomatous,” giving a firm, raised border.
• Location – most commonly on the external genitalia (penis, vulva, labia), perineum, groin, inner thighs, or perianal region. In rare cases, lesions may appear on the oral cavity or neck after oral‑genital contact.
• Rapid spread – lesions can coalesce, forming large, beefy plaques that may cover significant surface area.

Associated signs

• Minimal to no pain, which often delays presentation.
• Occasional foul‑smelling discharge from the ulcer’s surface.
• Rarely, secondary bacterial infection leading to increased pain, erythema, or pus.
• Unlike chancroid or syphilis, significant inguinal lymphadenopathy is unusual.

Systemic symptoms

Systemic illness (fever, malaise) is uncommon; however, severe, untreated disease can cause:

• Weight loss
• Anemia (from chronic blood loss)
• Low‑grade fever

Causes and Risk Factors

Donovanosis is caused by the intracellular bacterium Klebsiella granulomatis. The organism is transmitted primarily through direct skin‑to‑skin contact with an infectious lesion during sexual activity.

Key risk factors

• Unprotected sexual intercourse (vaginal, anal, or oral) with an infected partner.
• Multiple sexual partners or a history of other STDs, which may reflect a higher‑risk sexual network.
• Living or traveling in endemic regions where the bacterium is more prevalent.
• Poor access to healthcare – delayed diagnosis can increase transmission.
• Co‑infection with other STDs (e.g., HIV) – immunosuppression may facilitate acquisition and worsen disease course.

Diagnosis

Because Donovanosis mimics several other ulcerative STDs, accurate diagnosis relies on a combination of clinical suspicion and laboratory confirmation.

Clinical assessment

• Detailed sexual history and travel exposure.
• Physical examination of lesions – typical beefy‑red ulcer without pain is a strong clue.

Laboratory tests

1. Microscopic examination (Donovan bodies) – Tissue scrapings or ulcer swabs are stained with Giemsa or Wright stain. Intracellular “safety‑pin” appearing bipolar organisms (Donovan bodies) confirm infection. Sensitivity ranges from 60–80 %.
2. Polymerase chain reaction (PCR) – Detects bacterial DNA with higher sensitivity and specificity (>95 %). Not universally available but the preferred method when accessible.
3. Culture – Difficult; the organism is fastidious and rarely grows in standard media, thus culture is not routinely used.
4. Serology – No reliable serologic test; testing for other STDs (syphilis, herpes, HIV) is recommended to rule out co‑infection.

Differential diagnosis

Clinicians must distinguish Donovanosis from:

• Primary syphilis (chancre)
• Chancroid (painful ulcer)
• Genital herpes (multiple vesicles/ulcers)
• Squamous cell carcinoma (especially in chronic lesions)

Treatment Options

Antibiotic therapy is highly effective; lesions typically begin to heal within 1–2 weeks of adequate treatment.

First‑line antibiotics (WHO‑recommended)

• Doxycycline – 100 mg orally twice daily for 3 weeks (or until lesions have fully granulated).
• Azithromycin – 1 g orally single dose **or** 500 mg daily for 7 days.
• Trimethoprim‑sulfamethoxazole (TMP‑SMX) – 160/800 mg orally twice daily for 3 weeks.
• Erythromycin – 500 mg orally four times daily for 3 weeks (alternative where other agents are contraindicated).

Second‑line or alternative regimens

• Fluoroquinolones (e.g., ciprofloxacin 500 mg twice daily) – limited data, used when first‑line agents are unavailable.
• Combination therapy in HIV‑positive patients may be considered to ensure rapid clearance.

Management of complications

• Secondary bacterial infection – Treat with appropriate broad‑spectrum antibiotics (e.g., amoxicillin‑clavulanate).
• Extensive tissue loss – Surgical debridement or reconstructive procedures may be required after infection control.

Lifestyle and supportive care

• Maintain genital hygiene; gently clean lesions with mild soap and water.
• Avoid sexual activity until lesions are fully healed and treatment completed.
• Use barrier protection (condoms) to prevent reinfection and transmission.

Living with Donovanosis

While the infection is curable, patients may face psychological and social concerns. Below are practical tips for daily life.

• Adhere to the full antibiotic course even if lesions look improved—this prevents relapse.
• Schedule follow‑up visits 2–4 weeks after starting therapy to document healing and assess for residual lesions.
• Partner notification – Inform sexual partners so they can be evaluated and treated if necessary.
• Emotional support – Consider counseling or support groups; STDs can cause stigma.
• Safe sex practices – Consistent condom use reduces the risk of future STDs, including re‑exposure to Donovanosis.
• Monitor for recurrence – Although rare after adequate treatment, any new ulcer should be examined promptly.

Prevention

• Barrier protection – Use condoms or dental dams for all sexual activities, especially in endemic areas.
• Limit number of sexual partners and practice mutual monogamy when possible.
• Routine STI screening – Annual testing (including for HIV, syphilis, chlamydia, and gonorrhea) helps identify co‑infections that increase susceptibility.
• Travel precautions – Seek pre‑travel counseling if visiting endemic regions; carry a supply of effective antibiotics (after discussing with a physician).
• Early medical evaluation – Promptly seek care for any genital lesion, even if painless.

Complications

If left untreated, Donovanosis can lead to serious morbidity.

• Extensive tissue destruction – Large ulcers can cause significant scarring, contractures, and functional impairment (e.g., difficulty with urination or sexual activity).
• Secondary bacterial infection – Can progress to cellulitis or sepsis.
• Elephantiasis‑like lymphedema – Chronic inflammation may obstruct lymphatic drainage.
• Rare malignant transformation – Long‑standing ulcerated lesions have been reported to undergo squamous cell carcinoma, emphasizing the need for histologic evaluation of persistent lesions.
• Increased HIV transmission risk – Ulcerative STDs facilitate HIV entry; co‑infection worsens outcomes.

When to Seek Emergency Care

References

• Mayo Clinic. “Granuloma Inguinale (Donovanosis).” https://www.mayoclinic.org. Accessed June 2026.
• World Health Organization. “Sexually transmitted infections (STIs).” https://www.who.int. 2022.
• Cleveland Clinic. “Donovanosis (Granuloma Inguinale).” https://my.clevelandclinic.org. Updated 2023.
• CDC. “STD Treatment Guidelines, 2021.” https://www.cdc.gov.
• Graham, S. M., et al. “Granuloma inguinale: a review of the clinical presentation, diagnosis, and management.” *International Journal of STD & AIDS*, vol. 33, no. 5, 2022, pp. 459‑467.
• National Institutes of Health (NIH). “Klebsiella granulomatis Infection (Donovanosis).” https://www.ncbi.nlm.nih.gov. 2021.

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