Granuloma Inguinale

What is Granuloma Inguinale?

Granuloma inguinale is chronic bacterial infection that is characterized by Donovan bodies (intracellular cysts). This condition is frequently associated with other sexually transmitted infections (STIs). Granuloma inguinale generally affects the skin and mucous membranes of the genitalia, where nodular lesions form and soon turn into ulcers. The ulcers progress and enlarged lymph nodes appear. If granuloma inguinale remains untreated, many secondary infections could occur. This could result in male infertility as the testes, epididymis, and prostate are at risk. For women, infections of the uterus, cervix, and fallopian tubes could result in scarring and subsequent infertility. The possible complications of granuloma inguinale include loss of skin color in the genital or anal area, genital damage, genital or anal scarring, and permanent genital swelling. Untreated STIs have critical implications for reproductive health. Approximately 12 percent of women with an STI develop pelvic inflammatory disease (PID), which leads to infertility.

Overview of Granuloma Inguinale

Also called Donovanosis after the doctor who discovered the condition, granuloma inguinale is a disease that spreads through vaginal or anal intercourse. Men are affected twice as often as women, and the condition is rarely seen in children or the elderly. With this bacterial infection, the affected person develops one of four types of lesions on the genitalia and/or anus. To preserve fertility, immediate medical attention is warranted.

Cause of Granuloma Inginale

Granuloma inguinale is caused by Kebsiella granulomatis, a microorganism that was first described by physician researcher Dr. Dononvan over a century ago. This organism is a gram-negative pleomorphic bacillus that is spread via sexual contact. Experts believe that K. granulomatis has low infectious capabilities because repeated exposure must happen in order for the person to become infected. Granuloma inguinale also can be transmitted by the fecal route or when an infant passages through the birth canal of an infected woman.

Incidence and Prevalence

In the U.S., fewer than 100 cases of granuloma inguinale are reported annually. Experts believe that the organism is acquired through foreign travel, since it is a rarely diagnosed condition in America. Internationally, granuloma inguinale is common in the tropical regions, particularly South Africa, Brazil, Southeast Asia, Australia, and the Caribbean.

Granuloma inguinale is more common among blacks than whites in the U.S., and men are affected twice as often as women. For those outside the U.S., the incidence is higher among those who have low socioeconomic conditions. Sexually active men and women aged 20 to 40 years are most likely to have this disease.

Types of Granuloma Inguinale

Granuloma inguinale has an unpredictable incubation period, ranging from one day to one year. However, the average incubation time is two months. There are four main types of lesions. These include:

  • Nodular. This is the initial stage, where the lesion is only a small bump or nodule that arises at the site of contact. The nodule is soft, reddened, often filled with pus, and they eventually ulcerate. Nodular lesions are often mistaken for an enlarged lymph node.
  • Ulcerative. This is the most common type of granuloma inguinale lesion. These develop from nodular lesions and are usually painless, raised sores. They often bleed easily, look "beefy red," and are located in the skin folds. When these ulcers become infected with other forms of bacteria, they can become pus-filled and have a putrid, offensive odor.
  • Cicatrical. These are dry ulcers that form into plaques and lead to skin swelling and redness.
  • Hypertrophic. Also called verrucous lesions, these very rare ulcers occur from a proliferative reaction and resemble genital warts.

Symptoms and Signs

The most common locations for granuloma inguinale in men are the genitals and anus. For women, the lesions occur on the labia, external vaginal, pubic area, inside the vagina, and on the cervix. Symptoms occur as soon as one day after coming in contact with the bacteria, or they could not appear until 12 to 24 weeks later.

About half of infected men and women experience sores on the anal region. When the skin wears away, velvety red nodules appear (called granulation tissue). Unless injured, these lesions are painless, but they tend to bleed easily if injured. The disease will gradually spread and destroy the genital and/or anal tissue. When tissue damage occurs, it can progress to the inguinal folds, where the legs meet the torso.

Diagnosis and Treatment

The causative organism (K. granulomatis) is difficult to culture for diagnosis. Most doctors diagnose the condition by taking a smear of the lesion and then looking under a microscope. The Donovan bodies can also be identified in tissue biopsies with the use of special stains.

If quick diagnosis is made, treatment can completely eradicate the microorganism and preserve the flesh. The most commonly used antibiotics are doxycycline and trimethoprim/sulfamethoxazole (sulfur drug). During treatment, the infected person should not have unprotected sexual intercourse, and all partners must be also treated.

Resources

  • eMedicine (2013). Granuloma inguinale. Retrieved from: http://emedicine.medscape.com/article/1052617-overview
  • World Health Organization (2013). Sexually transmitted infections. Retrieved from: http://www.who.int/mediacentre/factsheets/fs110/en/

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