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DESCRIPTION
Granuloma Inguinale (Donovanosis) is a Gram-negative bacterial (Calmmatobacterium granulomatis) sexually transmitted disease generally affecting people living in tropical climates. This disease is commonly found in areas such as Southeast India, Guyana, and New Guinea, but it occurs on occasion in the United states. It is becoming more common in the U.S., especially in the south, southeast and southwest regions.
Incubation period is 8 to 12 weeks. Because of the scarcity of medical treatment, the disease often goes untreated. Men are affected more than twice as often as women, with most infections occurring in people aged 20 to 40 years. The disease is seldom seen in children or the elderly.
It is thought that anal intercourse, rather than vaginal intercourse, is the most frequent source of infection. About 50% of infected men and women have lesions in the anal area.
The disease is characterized by painless genital ulcers which can be mistaken for syphilis. However, they ultimately progress to destructive nature of Donovanosis and also increases the risk of superinfection by other pathogenic microbes.
CLASSIFICATION INFORMATION
The proper clinical designation for Donovanosis is Granuloma Inguinale. Granuloma is a nodular type of inflammatory reaction, and inguinale refers to the inguinal region, which is commonly involved in this infection. The disease is commonly known as Donovanosis, after the Donovan Bodies which are a diagnostic sign. Discovered by a researcher named Donovan, these intracellular inclusions represent bacteria that have been engulfed by scavenger cells called mononuclear phagocytes or histiocytes.
The causative organism, Klebsiella granulomatis, used to be called Calymmatobacterium granulomatis, from the Greek kalymma (a hood or veil), referring to the lesions that contain the bacteria. Prior to this it was called Donovania granulomatis, named after the Donovan Bodies. The species name granulomatis refers to the granulomatous lesions. The organism was recently reclassified under the genus Klebsiella, a drastic taxonomic change, since it involved changing the organism's phylum. However, polymerase chain reaction (PCR) techniques using a colorimetric detection system showed a 99% similarity with other species in the Klebsiella genus.
FREQUENT SIGNS & SYMPTOMS
Formation of a small, beefy-red, painless lesion (cyst, papule, or nodule) in the genital area that does not readily heal. These nodules appear after about 10 to 40 days after the contact with the bacteria. It gradually eats away the skin and forms an elevated, beefy-red, velvety nodule (granulation tissue). Later, this lesion or lesions ulcerates (becomes open, fleshy and runny oozing lesions) and may spread, mutilating the infected tissue so that it involves most of the vulva, and sometimes the buttocks and lower abdomen.
The lesions occur at the region of contact, typically found on the shaft of the penis, the labia, or the perianal region. Rarely, the vaginal wall or cervix is the site of the lesion.
Marked discomfort occurs if the ulceration spreads to the urethra or anal area. Walking, sitting and sexual intercourse become painful.
Spread of the disease to the inguinal folds (where the legs meet the torso).
Vaginal discharge that has an unpleasant odor.
Nodules are usually painless and bleed easily if traumatized.
Depigmentation (loss of skin color) of the genitals and surrounding skin.
If left untreated, the disease results in mutilation and destruction of the genital tissue.
In its early stages, it may be difficult to differentiate granuloma inguinale from chancroid. In the later stages, granuloma inguinale may resemble advanced genital cancers, lymphogranuloma venereum, and anogenital cutaneous amebiasis.
CAUSES
An organism, Calymmatobacterium granulomatis (Donovan body), that is spread via sexual intercourse with an infected person.
The microorganism spreads from one host to another through contact with the open sores. Oral, vaginal, or anal intercourse are high risk behaviors to engage in with someone who is infected.
RISK INCREASES WITH
Multiple sexual partners.
Unprotected sexual intercourse.
Infection with other sexually transmitted diseases.
PREVENTIVE MEASURES
Monogamous sexual relationship with an uninfected person.
Sexual contact with people living in tropical and subtropical climates increases the likelihood of exposure.
Safe sex practices will prevent the spread of granuloma inguinale as well as other sexually transmitted diseases and will also prevent unwanted pregnancies. Having the male partner use a latex condom.
Cleansing of the genital area before and after sexual encounters. Douching is usually not effective.
If there has been possibility of exposure, seek medical care immediately. Early treatment may head off the infection.
The disease is effectively treated with antibiotics, therefore, developed countries, like the United States, have a very low incidence of Donovanosis, (approximately 100 cases reported each year in the United States.) However, sexual contacts with individuals in endemic regions dramatically increases the risk of contracting the disease. Avoidance of these sexual contacts, and STD testing before beginning a sexual relationship are effective preventative measures for Donovanosis.
EXPECTED OUTCOME
With treatment, healing should begin within a week, but complete resolution will take up to 3 weeks.
Treating this disease early decreases the chances of tissue destruction or scarring. Untreated disease can lead to complications.
POSSIBLE COMPLICATIONS
Secondary bacterial infection.
Relapse my occur if treatment is stopped too soon.
Scars may form where infection occurred.
Destruction of genital tissue.
Genital depigmentation (loss of skin color).
Permanent genital swelling from lymphatic scarring.
TREATMENT
GENERAL MEASURES
DIAGNOSIS
The patient's sexual history is requested. Experienced health care providers are able to diagnose Donovanosis by only looking at the ulcers. However, it may be necessary for the health care provider to take a sample of tissue to correctly diagnose the disease.
Classically, the diagnosis of granuloma inguinale should be considered if genital lesions have been present for a long time and have been progressively enlarging. Serological tests such as that used to detect syphilis are available only on a research basis for diagnosing granuloma inguinale.
Diagnosis is confirmed with laboratory studies of scrapings or biopsies of the lesions. Wright-Giesmsa stain may be added to the sample in order to better view the cells. Additionally, the presence of Donovan bodies in the tissue sample confirms Donovanosis.
Culture of tissue sample is difficult to do and not routinely available.
Testing (screening) for other sexually transmitted diseases is often recommended.
TREATMENT
Treatment is with medication. Three weeks of treatment with erythromycin, streptomycin, or tetracycline, or 12 weeks of treatment with ampicillin are standard forms of therapy. Normally, the infection will begin to subside within a week of treatment, however, the full treatment period must be followed in order to minimize the possibility of relapse.
Sitz baths frequently relieve soreness. Sit in a tub of hot water for 10 to 15 minutes. Repeat baths as often as 3 or 4 times a day. See Sitz Baths for more information.
Sexual partners should be examined for infection.
A follow-up medical examination after treatment is important to verify that healing is complete.
Additional information is available from the Sexually Transmitted Diseases Hotline (800) 227-8922.
MEDICATION
An antibiotic, such as tetracycline, may be prescribed. A complete cure of granuloma inguinale requires fairly long treatment. Most treatment courses run 3 weeks or until the lesions have completely healed. Do not discontinue medicine until healing is complete or when advised to by your health care provider.
The antibiotics used include:
- Tetracycline or doxycycline
- Sulfamethoxazole
- Gentamicin
- Streptomycin
- Ciprofloxacin
- Erythromycin
A follow-up examination is essential because the disease can reappear after an apparently successful cure.
ACTIVITY
Avoid sexual intercourse during the active phase of the infection.
DIET
No dietary restrictions. Eat a well-balanced diet to maintain a healthy immune system. If taking tetracycline, avoid dairy products within 3 hours of taking the medication.
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NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF...
You or a family member has symptoms of granuloma inguinale.
Symptoms worsen despite treatment.
New, unexplained symptoms develop. Drugs used in treatment may produce side effects.
MoonDragon's Obgyn Information: Sexually Transmitted Diseases (STDs)
