View source for Granuloma inguinale

{{distinguish|text=[[Granuloma annulare]]}}
{{About|the ulcerative disease caused by Klebsiella granulomatis|the sexually transmitted infection caused by certain types of chlamydia|Lymphogranuloma venereum}}
{{Infobox medical condition (new)
| name            = Granuloma inguinale
| synonyms        = Donovanosis
| image           = Donovan-bodies.png
| caption         = Drawing of Donovan bodies
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'''Granuloma inguinale'''  is a [[bacteria]]l [[disease]] caused by ''[[Klebsiella granulomatis]]'' (formerly known as ''Calymmatobacterium granulomatis'')<ref>{{Cite journal|last=O’Farrell|first=N|date=2002|title=Donovanosis|pmc=1758360|journal=Sexually Transmitted Infections|doi=10.1136/sti.78.6.452|pmid=12473810|volume=78|issue=6|pages=452–7}}</ref> characterized by [[genital ulcer]]s.<ref name=Kumar2020>{{cite book |last1=Wilson |first1=Janet D. |last2=Anderson |first2=Jane |editor1-last=Feather |editor1-first=Adam |editor2-last=Randall |editor2-first=David |editor3-last=Waterhouse |editor3-first=Mona |title=Kumar and Clark's Clinical Medicine |date=2020 |publisher=Elsevier |isbn=978-0-7020-7870-5 |pages=1425 |edition=10th |chapter-url=https://books.google.com/books?id=sl3sDwAAQBAJ&pg=PA1425 |language=en |chapter=37. Sexually transmitted infections and human immunodeficiency virus }}</ref> It is [[Endemic (epidemiology)|endemic]] in many less-developed regions. It is also known as '''donovanosis''',<ref name="Bolognia">{{cite book |author=Rapini, Ronald P. |author2=Bolognia, Jean L. |author3=Jorizzo, Joseph L. |title=Dermatology: 2-Volume Set |publisher=Mosby |location=St. Louis |year=2007 |isbn=978-1-4160-2999-1 }}</ref> '''granuloma genitoinguinale''',<ref name="Bolognia" /> '''granuloma inguinale tropicum''',<ref name="Bolognia" /> '''granuloma venereum''',<ref name="Andrews">{{cite book |author=James, William D. |author2=Berger, Timothy G.|title=Andrews' Diseases of the Skin: clinical Dermatology |publisher=Saunders Elsevier |year=2006 |page=275 |isbn=978-0-7216-2921-6 |display-authors=etal}}</ref> '''granuloma venereum genitoinguinale''',<ref name="Bolognia" /> '''lupoid form of groin ulceration''',<ref name="Bolognia" /> '''serpiginous ulceration of the groin''','''<ref name="Bolognia" /> ulcerating granuloma of the pudendum''',<ref name="Bolognia" /> and '''ulcerating sclerosing granuloma'''. Oral manifestations are also notably seen. The lesions of oral cavity are usually secondary to active genital lesions.

The disease often goes untreated because of the scarcity of medical treatment in the countries in which it is found. In addition, the painless [[genital]] ulcers can be mistaken for [[syphilis]].<ref name="Murray P. 2005 p. 336">{{cite book |author=Murray, Patrick R |author2=Rosenthal, Ken S |author3=Pfaller, Michael A |title=Medical Microbiology |publisher=Elsevier Mosby |location=Philadelphia |year=2005 |isbn=978-0-323-03303-9 |page=336 |edition=5th }}</ref> The ulcers ultimately progress to destruction of internal and external tissue, with extensive leakage of [[mucus]] and [[blood]] from the highly [[Blood vessel|vascular]] lesions. The destructive nature of donovanosis also increases the risk of [[superinfection]] by other [[pathogen]]ic microbes.

==Symptoms and signs==
[[File:SOA-Donovanosis-female.jpg|thumb|Granulome inguinale on a vulva]]
Small, painless nodules appear after about 10–40 days of contact with the bacteria. Later, the nodules burst, creating open, fleshy red ulcers with rolled edges that have a tendency to bleed on contact. The [[infection]] spreads, mutilating the infected tissue. The infection will continue to destroy the tissue until treated, lesions can spread by [[autoinoculation]]. Inguinal spread can lead to the formation of pseudobubo without the involvement of the inguinal lymph nodes. The lesions frequently occur at the region of contact typically found on the shaft of the [[Human penis|penis]], the [[labia (genitalia)|labia]], or the [[perineum]], and in the oral region due to oral intercourse. Rarely, the [[vagina]]l wall or [[cervix]] is the site of the lesion. At least one case in [[India]] led to partial [[autoamputation]] of the penis. The patient tested positive for [[HIV]]-2 and had been infected for six years.<ref>{{cite journal |vauthors=Chandra Gupta TS, Rayudu T, Murthy SV |title=Donovanosis with auto-amputation of penis in a HIV-2 infected person |journal=Indian J Dermatol Venereol Leprol |volume=74 |issue=5 |pages=490–2 |year=2008 |pmid=19052412 |doi=10.4103/0378-6323.44308|doi-access=free |hdl=1807/48234 |hdl-access=free }}</ref>
Genital [[elephantiasis]] can occur because of the blockage of the lymphatic channels due to scarring of the ulcers. There is concern that there is a linkage between donovanosis and [[squamous cell carcinoma]].<ref>Arora AK, Kumaran MS, Narang T, et al. Donovanosis
and squamous cell carcinoma: the relationship
conundrum! Int J STD AIDS. 2017;28:411–414.</ref>

==Mechanism==
The microorganism, ''[[Klebsiella granulomatis]]'', spreads from one host to another through contact with the open sores. Typically, this contact occurs during sexual intercourse. As a result, granuloma inguinale is considered a [[sexually transmitted infection]].<ref>{{cite web |title=Granuloma Inguinale (Donovanosis) |url=https://www.cdc.gov/std/tg2015/donovanosis.htm}}</ref>

==Diagnosis==
The [[diagnosis]] is based on the patient's sexual history and on physical examination revealing a painless, "beefy-red ulcer" with a characteristic rolled edge of [[granulation tissue]]. In contrast to [[syphilitic]] ulcers, inguinal [[lymphadenopathy]] is generally mild or absent. Tissue [[biopsy]] and [[Wright-Giemsa stain]] are used to aid in the diagnosis. The presence of Donovan bodies in the tissue sample confirms donovanosis. Donovan bodies are rod-shaped, oval organisms that can be seen in the [[cytoplasm]] of [[mononuclear phagocyte]]s or [[histiocyte]]s in tissue samples from patients with granuloma inguinale.<ref name=thefreedictionary>[http://medical-dictionary.thefreedictionary.com/Donovan+bodies thefreedictionary.com > Donovan bodies] Retrieved on Nov 29, 2009</ref>

They appear deep purple when stained with [[Wright's stain]].<ref name=thefreedictionary/> These [[intracellular inclusion]]s are the encapsulated Gram-negative rods of the causative organisms.<ref name=thefreedictionary/> They were discovered by [[Charles Donovan]].<ref>{{cite journal |author=Donovan, C. |title=Ulcerating Granuloma of the Pudenda |journal=Ind Med Gaz |volume=40 |issue=11 |pages=414–418 |year=1905 |pmid=29004684 |pmc=5162824 }}</ref>

===Classification===
The first known name for this condition was "serpiginous ulcer", which dates to 1882.<ref name="pmid17459300">{{cite journal |vauthors=Rashid RM, Janjua SA, Khachemoune A |title=Granuloma inguinale: a case report |journal=Dermatol. Online J. |volume=12 |issue=7 |pages=14 |year=2006 |doi=10.5070/D387Q57161 |pmid=17459300 |url=http://dermatology-s10.cdlib.org/127/case_reports/inguinale/khachemoune.html|url-access=subscription }}</ref><ref>{{cite journal |author=McLeod K. |title=Precis of operations performed in the wards of the first surgeon, Medical College Hospital, during the year 1881 |journal=Ind Med Gaz |volume=11 |issue=5 |pages=113–119 |year=1882 |pmid=28997806 |pmc=5136093 }}</ref> The proper clinical designation for donovanosis is "granuloma inguinale".<ref name="Murray P. 2005 p. 336"/> A [[granuloma]] is a nodular type of [[inflammation|inflammatory]] reaction, and inguinale refers to the [[Groin|inguinal]] region, which is commonly involved in this infection. The disease is commonly known as donovanosis, after the Donovan bodies seen on microscopy, which are a diagnostic sign.<ref>{{cite journal |vauthors= Santiago-Wickey JN, Crosby B, Inguinale G |url=https://www.ncbi.nlm.nih.gov/books/NBK513306/| title=Granuloma Inguinale|website=National Center for Biotechnology Information, U.S. National Library of Medicine |year=2021|pmid=30020678|access-date= 12 July 2021}}</ref>

The causative organism, ''[[Klebsiella granulomatis]]'', was called ''Calymmatobacterium granulomatis'', and some sources still use this classification,<ref>{{DorlandsDict|four/000046076|granuloma inguinale}}</ref><ref>{{cite journal |author=O'Farrell N |title=Donovanosis |journal=Sex Transm Infect |volume=78 |issue=6 |pages=452–7 |date=December 2002 |pmid=12473810 |pmc=1758360 |doi= 10.1136/sti.78.6.452}}
</ref> from the Greek ''kalymma'' (a hood or veil), referring to the lesions that contain the bacteria. Prior to this, it was called ''Donovania granulomatis'', named after the Donovan bodies.<ref name="Murray P. 2005 p. 336"/>

The [[species|specific]] name ''granulomatis'' refers to the granulomatous lesions. The organism was recently reclassified under the [[genus]] ''Klebsiella'',<ref>* {{cite journal |vauthors=Boye K, Hansen DS |title=Sequencing of 16S rDNA of Klebsiella: taxonomic relations within the genus and to other Enterobacteriaceae |journal=Int. J. Med. Microbiol. |volume=292 |issue=7–8 |pages=495–503 |date=February 2003 |pmid=12635932 |doi= 10.1078/1438-4221-00228}}</ref> a drastic [[biological classification|taxonomic]] change since it involved changing the organism's [[phylum]]. However, [[polymerase chain reaction]] techniques using a [[colorimetry (chemical method)|colorimetric]] detection system showed a 99% similarity with other species in the genus ''Klebsiella''.<ref>{{cite journal |vauthors=Carter JS, Bowden FJ, Bastian I, Myers GM, Sriprakash KS, Kemp DJ |title=Phylogenetic evidence for reclassification of Calymmatobacterium granulomatis as Klebsiella granulomatis comb. nov |journal=Int. J. Syst. Bacteriol. |volume=49 |issue=Pt 4 |pages=1695–700 |date=October 1999 |pmid=10555350 | doi = 10.1099/00207713-49-4-1695 |doi-access=free }}</ref> The clinical appearances of this lesion orally are classified into three types: Ulcerative, exuberant, cicatricial.<ref>{{cite web |url=https://www.lecturio.com/concepts/donovanosis/| title=Donovanosis|website=The Lecturio Medical Concept Library |access-date= 12 July 2021}}</ref>

==Prevention==
The disease is effectively treated with [[antibiotics]], therefore, [[developed nation|developed countries]] have a very low incidence of donovanosis; about 100 cases are reported each year in the United States. However, sexual contact with individuals in endemic regions dramatically increases the risk of contracting the disease. Using condoms, [[sexually transmitted infection]] testing before beginning a sexual relationship, and avoidance of these sexual contacts are effective preventative measures for donovanosis.<ref>{{cite web |url=https://www.msdmanuals.com/home/infections/sexually-transmitted-diseases-stds/granuloma-inguinale| title=Granuloma Inguinale
|website=MSD |access-date= 12 July 2021}}</ref>

==Treatment==
Recommended regimen is [[azithromycin]] 1 gram oral/IV once per week, alternatively [[doxycycline]] 100&nbsp;mg orally twice a day or [[ciprofloxacin]] 750&nbsp;mg orally twice a day or [[erythromycin]] base 500&nbsp;mg orally four times a day or [[trimethoprim-sulfamethoxazole]] one double-strength (160&nbsp;mg/800&nbsp;mg) tablet orally twice a day. All antibiotic regimens should last for at least 3 weeks and until all lesions have completely healed. Association with gentamicin is sometimes used in severe cases, specially in cases of AIDS. Normally, the infection will begin to subside within a week of treatment, but the full treatment period must be followed to minimize the possibility of relapse.{{citation needed|date=May 2021}}
Sporadic surgical resection of the lesions has been used in extensive perineal fistulae refractory to pharmacological 
intervention.
The CDC 2015 guidelines give azithromycin as the antibiotic of choice.<ref>{{Cite web|url=https://www.cdc.gov/std/tg2015/donovanosis.htm|title=Granuloma Inguinale (Donovanosis) - 2015 STD Treatment Guidelines|website=www.cdc.gov|language=en-us|access-date=2018-08-23}}</ref>

== See also ==
* [[Chancroid]]
* [[List of cutaneous conditions]]

==References==
{{Reflist}}

==Further reading==
* Gavin Hart MD, MPH [https://web.archive.org/web/20090415114106/http://www.stdservices.on.net/std/donovanosis/illustratedtranscript.htm Transcript] of the lecture given at the Australian Society for Infectious Diseases/Australasian College of Tropical Medicine Conference at Palm Cove (Cairns), Queensland on 19 April 1999.

== External links ==
* [https://web.archive.org/web/20090925005719/http://ijs.sgmjournals.org/cgi/content/abstract/49/4/1695 Research supporting Klebsiella Genus classification]

{{Medical resources
|  DiseasesDB = 3888
|  ICD11 = {{ICD11|1A91}}
|  ICD10 = {{ICD10|A|58||a|50}}
|  ICD9 = {{ICD9|099.2}}
|  ICDO =
|  OMIM =
|  MedlinePlus = 000636
|  eMedicineSubj = derm
|  eMedicineTopic = 172
|  MeshID = D006100
}}
{{STD/STI}}
{{Bacterial diseases}}
{{Bacterial cutaneous infections}}

{{DEFAULTSORT:Granuloma Inguinale}}
[[Category:Bacterial diseases]]
[[Category:Bacterium-related cutaneous conditions]]
[[Category:Infections with a predominantly sexual mode of transmission]]