2. The Definition
• Donovanosis (Granuloma inguinale) is a sexually
transmitted (Venereal), bacterial infection that
affects skin and mucous membranes of anal and
genital areas.
• Its name is derived from granuloma, a medical ter
m for a mass or growth of granulation tissue, and
inguinale, a Latin word that means located in the
groin.
• Granulation tissue is tissue formed during wound
healing that is rich in blood capillaries and has a
rough lumpy surface.
3. The Definition
• Diagnosis is made by microscopic examination
and identification of “Safety-Pin” shaped
cellular bodies named as “Donovan Bodies” in
the cytoplasm of phagocytes (Macrophages)
taken from a lesion and dyed with Wright's or
Giemsa stain or by histological examination of
a biopsy specimen.
• Therefore it is called Donovanosis
4. The Etiology
• Donovanosis is caused by Klebsiella
granulomatis (formerly called as
Calymmatobacterium granulomatis); small
gram-negative rod bacillus.
• They are non motile and encapsulated
organisms
• There are observed in macrophages cytoplasm
as “Donovan Bodies”
5. Donovan Bodies
Clusters of blue- or black-staining, bipolar chromatin condensations in
large mononuclear cells in granulation tissue infected with Klebsiella
(Calymmatobacterium granulomatis).
6. Epidemiology
• It occurs worldwide but is most common in
tropical or subtropical countries, where it is
associated with poverty and poor hygiene.
• As many as 20% of male patients with sexually
transmitted diseases (STDs) in tropical countries
have granuloma inguinale.
• All patients who have or are suspected of having
granuloma inguinale are also tested for syphilis
because concurrent infection is common.
7. Epidemiology
• Most patients are between are between the ages of
20 and 40 years.
• It occurs more frequently in men than in women
and is associated with anal intercourse.
• Its occurrence in children and sexually inactive
adults indicates that it may also be spread by
contact with human faeces.
• Granuloma inguinale is not highly contagious;
however, persons with weakened immune systems
are at greater risk of infection (HIV/AIDS)
8. Clinical Presentation
• The bacteria has an incubation period ranging
from eight days to twelve weeks, with an
average of two weeks to four weeks.
• This disease has gradual and slow onset, begins
with discreet papule or small pustule or lumpy
eruption of the skin.
• In 90% of patients, the initial sign of infection is
in the genital region, but a minority of patients
will develop the papule in their mouth or anal
area if their sexual contact involved those parts of
the body.
9. Clinical Presentation
• Many patients do not notice the sore because it
is small and not usually painful. In some
women, the first symptom of granuloma
inguinale is bleeding from the genitals.
10. The initial papule or pustule is typically followed by
three stages of disease;
1. In the first stage, the patient develops a mass of
pink or dull red granulation tissue in the area
around the anus.
2. In the second stage, the bacteria erode the skin to
form shallow, foul-smelling ulcers which spread
from the genital and anal areas to the thighs and
lower abdomen. The edges of the ulcers are
marked by granulation tissue.
Clinical Presentation
11. 3. In the third stage, the ulcerated areas form
deep masses of keloid or scar tissue that may
spread slowly for many years.
• Patients with long-term infections are at risk
for serious complications.
• The ulcers in second-stage granuloma
inguinale often become superinfected with
syphilis or other STD organisms.
Clinical Presentation
12. • Superinfected ulcers become painful to touch,
filled with pus and dead tissue, and are much
more difficult to treat.
• There may be sizable areas of tissue
destruction in superinfected patients.
• In addition, the scar tissue produced by third-
stage infection can grow until it closes off
parts of the patient's urinary tract.
Clinical Presentation
13. Major Sites of Lesions
• Penile ulcers (sulcocoronal and
balanopreputial)
• Labia minora
• Fourchette
• Cervix (uncommon)
14. Types of Skin Lesions
1. Ulcero-vegetative (most commonly seen) -
Painless, beefy red ulcers with clean, friable
bases and distinct, raised/rolled margins.
Autoinoculation is common.
2. Nodular - Pruritic, soft, red nodules that
ulcerate at the site of inoculation. Pseudobubo:
nodule appears clinically as a lymph node.
3. Cicatricial - Dry ulcers that progress into
scarring plaques. Lymphedema may be present
4. Hypertrophic or verrucous (relatively rare)
16. Nodular type lesion
The initial granuloma inguinale lesion is a papule or nodule that
arises at the site of inoculation. The nodule is soft, often pruritic
and erythematous, and eventually ulcerates. A nodule may be
mistaken for a lymph node [ie, pseudobubo]
18. Diagnosis
• Made by swabbing the lesion and Giemsa
staining of the air dried smear.
• Other stains that may be used are Warthin-
Starry, Gram stain, Toulidine blue and
Leishman stain.
• Smear or biopsy with Wright, Giemsa or
Warthin-Starry (silver) stain: Donovan bodies:
intracytoplasmic bipolar staining, safety pin–
shaped, inclusion bodies seen in histiocytes
19. Diagnosis
• Recommended to acquire specimen at base or
edge of ulceration or by aspirating enlarged
regional lymph node
• Culture of the organism is difficult, and needs
specialized methods using human peripheral
blood mononuclear cells or Hep-2 cells
• Polymerase chain reaction and indirect
immunofluorescence are available but not
commonly used.
20. Diagnosis
• Histology: acanthosis, dermis with histiocytes
and plasma cells, large and vacuolated
macrophages with intracellular bacilli (i.e.,
Donovan bodies).
• Granulomatous inflammation, neutrophilic
micro abscesses (particularly in ulcer bed).
• Acute and chronic granulation tissue, fibrosis
(dermal and subcutaneous cicatricial) in late
stages
21. Differential Diagnosis
1. Mycobacterial infection
2. Cutaneous tuberculosis
3. Ovarian cancer: One case report describes a
patient with chronic granuloma inguinale
(donovanosis) who presented with recurrent
abdominal pain. Results of abdominal computed
tomography (CT) scanning showed pelvic
masses that mimicked ovarian cancer.
4. Carcinoma of the cervix: One report describes
cervical donovanosis, which, on an MRI, was
indistinguishable from carcinoma of the cervix.
22. Differential Diagnosis
5. Dermatologic Manifestations of Chancroid
6. Dermatologic Manifestations of Herpes
Simplex
7. Dermatologic Manifestations of
Lymphogranuloma Venereum
8. Pediatric Syphilis
23. Treatment
• The current first-line drug is azithromycin.
• Alternative regimens include doxycycline,
ciprofloxacin, erythromycin base, and
trimethoprim-sulfamethoxazole.
• All antibiotics should be given for at least a 3-
week course and continued until re-
epithelialization of the ulcer occurs and all
signs of the disease have resolved.
24. • If the granuloma inguinale ulcers do not respond
within the first days of therapy, add an
aminoglycoside (eg, gentamicin 1 mg/kg IV q8h).
• Relapse of granuloma inguinale may occur 6-18
months after apparently effective therapy and
treatment should be reinitiated at that time.
• Since there have been past documented reports of
tetracycline resistance, it is no longer
recommended.
Treatment
25. Goal of Treatment
• The goal of pharmacotherapy for granuloma
inguinale is to reduce morbidity and to prevent
complications.
