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Infectious Disease and Microbiology: Granuloma Inguinale (Donovanosis)
Granuloma inguinale, also known as donovanosis, is a chronic sexually transmitted infection characterized by progressive ulcerative lesions of the genital and perineal regions. It may present as a single lesion or multiple nodules that gradually enlarge and ulcerate. The disease is caused by Klebsiella granulomatis, a Gram-negative intracellular organism that is difficult to culture in laboratory settings.
Epidemiologically, granuloma inguinale is endemic in tropical and developing regions such as India, Papua New Guinea, central Australia, and southern Africa, while it remains rare in developed countries, including the United States. The primary risk factor is geographic exposure through residence, work, or travel in endemic areas. Transmission occurs via sexual contact, and preventive measures mainly involve the use of barrier contraceptives.
Following an incubation period of approximately 2–3 weeks, patients typically develop painless nodules on the genitalia that progressively enlarge and ulcerate. These ulcers are classically described as beefy-red, highly vascular, and prone to bleeding on contact. Unlike many other sexually transmitted infections, regional lymphadenopathy is usually absent. However, subcutaneous spread of infection may result in pseudobuboes. In some cases, verrucous lesions may develop in the perianal area, and advanced disease can lead to scarring and deformities.
Diagnosis is primarily clinical, supported by identification of characteristic “Donovan bodies,” which are intracellular organisms seen in tissue smears or biopsy specimens. The organism is notoriously difficult to culture, and widely available PCR testing is lacking. It is also important to assess for coexisting sexually transmitted infections, as coinfection is common. Differential diagnosis includes infections such as genital herpes, syphilis, chancroid, and lymphogranuloma venereum, as well as noninfectious conditions like malignancy and inflammatory dermatoses.
Treatment requires prolonged antibiotic therapy. First-line treatment consists of Doxycycline administered orally for at least three weeks and continued until complete healing of lesions. Alternative options include azithromycin, ciprofloxacin, erythromycin, and trimethoprim–sulfamethoxazole. In cases with poor response or in immunocompromised patients, an aminoglycoside such as gentamicin may be added. Special considerations are necessary in pregnancy, where erythromycin is preferred due to contraindications of certain antibiotics.
Follow-up is essential to ensure complete resolution, as healing typically occurs from the margins inward and relapses may occur months after treatment. Sexual contacts within the preceding 60 days should be evaluated and managed appropriately. Although prognosis is generally favorable with treatment, complications can include genital pseudoelephantiasis, significant tissue destruction, and, rarely, deep infections such as psoas abscess.
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