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 detection of Donovan bodies (intracytoplasmic macrophages containing bacteria) in ulcer smears or biopsies. Management focuses on antibiotic treatment with azithromycin, which is continued until the ulcers have completely healed. Surgical treatment may be necessary for patients who develop genital pseudoelephantiasis, a complication seen most commonly in women. In these cases, ulcers or scar tissue obstruct lymph drainage and lead to severe localized edema.

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

References:^[1]

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

References:^[2]

• Incubation period: highly variable (1 day to 1 year); median time ∼ 50 days
• Clinical features
  • Painless genital lesion: begin as one or more nodules; eventually ulcerate to form large, beefy-red lesions that bleed easily
  • Localization
    • ♂: foreskin, coronal sulcus, glans
    • ♀: labia minora, cervix
    • Rarely presents in the oral cavity or pharynx
  • Regional lymph nodes 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!

References:^[1][2][3]

Granuloma inguinale is a clinical diagnosis supported by the presence of Donovan bodies in smears from the lesion.

• Confirmatory test: demonstration of Donovan bodies in biopsies and/or smears from lesions
  • Intracytoplasmic cysts filled with deeply staining , safety-pin shaped bodies within macrophages (Pud cells)
• PCR: if no Donovan bodies could be demonstrated and to differentiate K. granulomatis from other Klebsiella species
• K. granulomatis cannot be cultured.

References:^[1][4][5]

• See the differential diagnoses of genital lesions.

The differential diagnoses listed here are not exhaustive.

• Antibiotics
  • First-line: azithromycin
  • Alternatives: doxycycline, ciprofloxacin, trimethoprim/sulfamethoxazole
• Surgery: may be necessary for correction of disfiguring genital swellings

References:^[1][4][5]

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

References:^[1]

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