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Granuloma Inguinale (Donovanosis)

What is Granuloma inguinale (donovanosis)?

Granuloma inguinale, also known as donovanosis or Calymmatobacterium granulomatis infection, is a rare sexually transmitted disease (STD) caused by the bacterium Klebsiella (formerly Calymmatobacterium) granulomatis. The infection produces painless, beef‑steak‑like ulcerative lesions that most often appear on the genitals, perineum, or inner thighs, but they can also affect the rectum, mouth, or other moist skin surfaces. Unlike many other STDs, donovanosis does not cause lymphadenopathy (swollen lymph nodes) and is not associated with an increased risk of HIV transmission.

The disease is uncommon in most high‑income countries but remains endemic in parts of India, Papua New Guinea, the Caribbean, Africa, and the Pacific Islands. Prompt recognition and treatment are essential because lesions can become large, bleed easily, and lead to disfigurement if left unchecked.

Common Causes

Granuloma inguinale is caused by a single organism, but several factors increase the likelihood of acquiring the infection:

• Unprotected vaginal or anal intercourse with an infected partner.
• Oral sex if the partner has oral lesions.
• Contact with contaminated genital secretions (the bacteria survive best in a moist environment).
• Multiple sexual partners – higher exposure risk.
• Co‑infection with other STDs (e.g., syphilis, chancroid) that break down skin barriers.
• Poor genital hygiene that maintains a moist, warm environment favorable to bacterial growth.
• Living or traveling in endemic regions where the disease is more common.
• Compromised immune system (e.g., HIV infection) – may increase lesion size and duration.
• Use of contaminated objects (rare) such as towels or clothing that have been in contact with an infected lesion.
• Skin trauma (abrasions, cuts) that provides an entry point for the bacterium.

Associated Symptoms

Granuloma inguinale often starts as a small, painless papule or nodule that slowly enlarges into an ulcer. Typical accompanying features include:

• Painless, progressive ulcer – usually beef‑steak in appearance, with rolled, raised edges.
• Granular, “pseudobuboes” – small sub‑cutaneous nodules that may mimic swollen lymph nodes but are not true lymphadenopathy.
• Friable (easily bleeding) tissue – lesions bleed with minimal trauma.
• Foul‑smelling discharge – especially in larger ulcerations.
• Scar formation – after healing, lesions often leave raised, hypertrophic scars.
• Secondary bacterial infection – can cause increased pain, redness, and pus.
• Rectal involvement – in anal intercourse, ulcers may develop inside the rectum causing tenesmus or bleeding.
• Oral lesions – rare, but possible after oral sex with an infected partner.

Most patients do **not** experience systemic symptoms such as fever or malaise, which helps differentiate donovanosis from other ulcerative STDs like syphilis or chancroid.

When to See a Doctor

Because the lesions can grow rapidly and cause significant morbidity, seek medical care promptly if you notice any of the following:

• Any new genital, anal, or oral ulcer that does not heal within 1–2 weeks.
• Ulcers that are painless but continuously enlarging.
• Bleeding or foul‑smelling discharge from a genital lesion.
• Visible “granular” nodules near an ulcer.
• History of recent unprotected sexual contact, especially with a partner from an endemic area.
• Signs of secondary bacterial infection (increased redness, swelling, warmth, pus, or fever).

Early evaluation helps prevent complications such as extensive tissue loss, scarring, and spread to other body sites.

Diagnosis

Diagnosis is based on a combination of clinical appearance, sexual history, and laboratory testing.

1. Physical Examination

• Clinician inspects the lesion(s) for the characteristic beef‑steak appearance and pseudobuboes.
• Palpation of surrounding tissue to assess for secondary infection.

2. Microscopic Examination (Donovan bodies)

• Scraping or swab of the ulcer base is stained with Giemsa or Wright stain.
• Under the microscope, the intracellular organisms appear as “Donovan bodies” – safety‑pin‑shaped, oval‑to‑cigar shaped organisms within macrophages.

3. Tissue Biopsy

• In ambiguous cases, a skin biopsy is taken.
• Histopathology reveals granulomatous inflammation with intracellular organisms.

4. Molecular Tests (PCR)

• Polymerase chain reaction (PCR) can detect K. granulomatis DNA from lesion material – increasingly used in reference labs.

5. Rule‑out Other STDs

• Serologic testing for syphilis (RPR/VDRL), HSV PCR, and tests for HIV are recommended because co‑infection is common.

6. Laboratory Safety

• Specimens should be handled with standard precautions; the bacterium is not considered highly transmissible in the laboratory setting.

Treatment Options

Antibiotic therapy is the mainstay of treatment. No vaccine exists, and surgery is rarely required.

First‑line Antibiotics (WHO‑recommended)

• Doxycycline 100 mg orally twice daily for 3 weeks (minimum 21 days).
• Azithromycin 1 g orally once weekly for 3 weeks.
• Ciprofloxacin 500 mg orally twice daily for 3 weeks.
• Erythromycin 500 mg orally four times daily for 3 weeks.

All regimens require a minimum of 21 days of therapy **and** continuation until the lesion has completely healed (usually an additional 1–2 weeks after the ulcer crusts over).

Alternative/Second‑line Options

• Trimethoprim‑sulfamethoxazole (TMP‑SMX) 160/800 mg twice daily for 3 weeks.
• Gentamicin 80 mg intramuscularly once daily for 10 days (used in severe cases or when oral agents are contraindicated).

Management of Complications

• Secondary bacterial infection – add a broad‑spectrum antibiotic (e.g., amoxicillin‑clavulanate) based on culture results.
• Large, necrotic lesions – surgical debridement may be needed after antimicrobial therapy has reduced bacterial load.
• Scarring – after healing, silicone gel sheets or pressure therapy can minimize hypertrophic scars; dermatologic referral may be appropriate.

Home Care & Symptom Relief

• Keep the area clean and dry; gentle washing with mild soap twice daily.
• Avoid tight clothing that can cause friction.
• Use a non‑adhesive dressing (e.g., sterile gauze) to protect the ulcer and absorb any discharge.
• Over‑the‑counter pain relievers (acetaminophen or ibuprofen) may be used if discomfort occurs.
• Do not apply topical antibiotics or herbal remedies without medical advice, as they can obscure the clinical picture.

Prevention Tips

Because donovanosis is sexually transmitted, the most effective preventive strategies focus on safer sex practices and early detection:

• Consistent condom use during vaginal, anal, and oral sex (covers most, but not all, exposed skin).
• Limit the number of sexual partners and engage in mutual monogamy when possible.
• Regular STD screening for sexually active individuals, especially if you travel to endemic regions.
• Pre‑exposure counseling for travelers to high‑risk areas – obtain information on local STD prevalence.
• Prompt treatment of any genital lesions in you or your partner to reduce transmission.
• Good genital hygiene – keep the area clean and dry, especially after sweating or sexual activity.
• Avoid sharing towels or clothing that have been in contact with an ulcer.
• Vaccination against other STDs (e.g., HPV, Hepatitis B) reduces overall risk of co‑infection that could facilitate transmission.

Emergency Warning Signs

Key Take‑aways

• Granuloma inguinale is a rare, painless ulcerative STD caused by Klebsiella granulomatis.
• Early recognition and a 3‑week course of appropriate antibiotics lead to cure in >90 % of cases.
• Safe sex, regular screening, and prompt treatment of any genital lesions are the best prevention strategies.
• Seek immediate medical attention for rapid bleeding, severe pain, fever, or urinary/rectal obstruction.

For more detailed guidance, consult reputable sources such as the CDC, Mayo Clinic, and the World Health Organization.

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