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Klebsiella granulomatis : Granuloma Inguinale (Donovanosis)
Granuloma inguinale, also known as donovanosis, is a chronic, slowly destructive, ulcerative disease of the skin and subcutaneous tissues caused by Klebsiella (formerly Calymmatobacterium ) granulomatis . , Uncommon in industrialized countries, donovanosis historically has been seen among adolescents and adults (and rarely among children) in some tropical and developing regions, including Papua New Guinea, central Australia, South Africa, Brazil, and regions of India. Sporadic cases also have been reported in the West Indies, South America, and other areas of southern Africa.
In recent years, several endemic regions have reported substantial declines in prevalence, and case reports from developed countries often involve people who have migrated from endemic areas. The published literature on donovanosis represents few geographic locations, reflects limited microbiologic or molecular testing, and relies on syndromic genital ulcer disease surveillance in areas where donovanosis is thought to be most common. Increased awareness of the role of genital ulcer disease in human immunodeficiency virus (HIV) transmission emphasizes the public health importance of donovanosis.
The sexual transmission of donovanosis has been controversial, but there is substantial evidence that K. granulomatis is transmitted sexually. , Transmission rates of up to 52% have been reported among steady sexual partners of those with donovanosis, and case reports among victims of chronic sexual abuse further support a sexual route of transmission. Although rare, vertical transmission of donovanosis has been reported. There also is evidence that transmission can occur through fecal contamination.
Clinical Manifestations
Donovanosis lesions involve the genitalia (typically the prepuce or glans in men and the vagina or labia minora in women) in 80%–90% of cases but also can involve the inguinal and anal regions ( Fig. 139.1A and B). Beginning as a small papule or multiple papules at the site of inoculation, donovanosis typically manifests with painless, easily bleeding ulcers or vegetative lesions ( Fig. 139.1C ), which can be ulcerogranulomatous, hypertrophic, necrotic, or sclerotic. Ulcerative lesions expand slowly and become clean, shallow, well-demarcated ulcers with a beefy red granular base ( Fig. 139.1D ). Prominent lymphadenopathy often develops, leading to further ulceration of overlying skin. Exaggerated hypertrophic lesions have been reported in pregnancy. In most cases, clinical findings suggest donovanosis but are not highly specific. ,
Untreated lesions can cause extensive local tissue damage, including pelvic and perianal fistulas, urethral obstruction, and lymphedema. Although uncommon, lesions can develop secondary bacterial infection and cellulitis. Systemic infections can cause fever, weight loss, and anemia. Involvement of the bone, joint, and liver occurs infrequently and is likely more common in pregnant women. Involvement of the head and neck has been described. , , Unusual manifestations in HIV-infected patients have been reported, including penile autoamputation and malignant transformation to squamous cell carcinoma.
The differential diagnosis of donovanosis includes syphilis, lymphogranuloma venereum, chancroid, lymphoma, carcinoma, tuberculosis, blastomycosis, and other granulomatous diseases. People suspected of having donovanosis should have a thorough examination and should be tested for syphilis and other sexually transmitted infections, including HIV, which can coexist with donovanosis. , , , , The increased risk of HIV transmission associated with genital ulcer disease (e.g., syphilis, herpes simplex virus infection, donovanosis) underscores the importance of prompt recognition and treatment. ,
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