Granuloma inguinale (Donovanosis)

KAYACHIKITSA SYLLAUS, PAPER 2, PART B

1. GRANULOMA INGUINALE
(Donovanosis)
ProfSriramChandraMishra
KayachikitsaDepartment
VYDSAyurvedMahavidyalaya,Khurja

2. Definition
Granulomainguinaleisasexualtransmitteddisordercaused
bythebacteriaKlebsiellagranulomatischaracterisedbyprogressive
ulcerativegranulationsonthegenitalregions.
ItisalsocalledDonovanosisbecauseDonovanbodiesare
presentinthescrapingfromtheedgeofthelesions.
Formerlyknownas
•Calymmatobacteriumgranulomatis
•Donovaniagranulomatis

3. •Agent-Klebsiellagranulomatis(Gram-negativebacterium)
•Incubationperiod-8daysto12weeks
•Transmission
Primarilythroughsexualcontact
Alsobespreadbycontactwithhumanfaeces
•Epidemiology
Itisendemicinsometropicalanddevelopingareas,includingIndia;
Papua,NewGuinea;theCaribbean;centralAustralia;andsouthern
Africa
Inindiaitisendemicalongtheeastcoasti.e.Odisha,Andhra,
Tamilnadu.

4. Clinicalfeatures
•Thediseasehasapainless,slowlyprogressiveonset.
•Beginningwithaninconspicuous(notvisible)pimpleorlumpy
eruptionontheskinofgenitalregion.
•Soreinthemouthoranalareaaccordingtoexposure.
•Maynotnoticethesoreduetopainlessandsmallsize.
•Insomewomenthefirstsymptomisbleedingfromthegenitals.
(Aninconspicuous-notvisible)

5. Lesions largerthan
inmostother diseases
Theedges oftheulcersaremarkedbygranulationtissue.

6. Theinitialpimpleorsoreistypicallyfollowedbythreestagesofdiseas
e.
1.Firststage - The patient develops a mass
ofpinkordullredgranulationtissueintheareaaroundtheanusandbleeds.
(granulationtissue-roughorirregularsurfaceandarichsupplyofblood)
2.Secondstage-Thebacteriaerodetheskintoformshallow,foul
smellingulcerswhichspreadfromthegenitalandanalareastothe
thighs and lower abdomen. The edges
oftheulcersaremarkedbygranulationtissue.
3.Thirdstage-Theulceratedareasformdeepmassesofkeloid(scar)
tissuethatmayspreadslowlyformanyyears.
(keloidAnunusualorabnormalgrowthofscartissue)

7. Complications
•Extragenitalinfectioncanoccurwithextensionofinfectiontothe
pelvisoritcandisseminatetointra-abdominalorgans,bonesorthe
mouth.
•Superinfectedulcersbecome painfultotouch,filled
withpusanddeadtissue.
•The scar tissue produced by third
stageinfectioncangrowuntilitclosesoffpartsof
thepatient'surinarytract.
•Itisalsoassociatedwithahigherriskofgenitalcancerandcan
coexistwithothersexuallytransmittedpathogens.

8. Investigations
Tissuesmear-FindingDonovanbodies(skintissue).
Donovanbodiesareovalrodshapedorganismsthatappearinsideinfectedtissuecells.
Clustersofblueorblackstaining,bipolarchromatincondensationsinlargemononuclearcellsin
granulationtissueinfectedwithCalymmatobacteriumgranulomatis.

9. Management
•Oralantibioticsforatleast3weeksoruntilalllesionshavecompletely
healed
•Azithromycin1gorallyonceperweekor500mgdaily OR
•Doxycycline100mgorallytwiceaday OR
•Ciprofloxacin750mgorallytwiceaday OR
•Erythromycinbase500mgorallyfourtimesaday OR
•12weeksoftreatmentwithampicillin
•Theadditionofanotherantibiotictotheseregimenscanbeconsideredif
improvementisnotevidentwithinthefirstfewdaysoftherapy.(aminoglycoside-
Gentamicin1mg/kgIVevery8hours).
•Allpersonswhoreceiveadiagnosisofgranulomainguinaleshouldbetested
forHIV.

10. ManagementofSexPartners
Personswhohavehadsexualcontactwithapatientwhohas
granulomainguinalewithinthe60daysbeforeonsetofthepatient’s
symptomsshouldbeexaminedandofferedtherapy.
Prognosis
•Treatmenthasbeenshowntohaltprogressionoflesions.
•Theskinulcerswillstarttoshowsignsofhealinginaboutaweek
•Healingtypicallyproceedsinwardfromtheulcermargins
•Prolongedtherapyisusuallyrequiredtopermitgranulationand
re-epithelializationoftheulcers.
•Relapsecanoccur6–18monthsafterapparentlyeffective

11. Herpes Syphilis Chancroid
Lymphogranulo
maVenereum
Granuloma
Inguinale
Appearanc
e
Often purulent "Clean" Purulent May be purulent "Beefy,"
hemorrhagic
Number Usually multipleSingle Often multipleSingle or multiple Multiple
Pain Yes No Yes Ulcer: no
Nodes: yes
No
Preceded by Papule, then
vesicle
Papule Papule Papule; ulcer often
unnoticed
Nodule(s)
Adenopathy Painful with
primary outbreak
Painless Painful; may
suppurate
Painful; may
suppurate
No, unless
secondary
bacterial infection
Systemic
symptoms
Often with
primary outbreak
Usually notOccasionally Usually not No
DIFFERENTIAL DIAGNOSIS