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Granuloma inguinale is a progressive infection of genital skin caused by Calymmatobacterium granulomatis. Skin lesions are beefy red, raised, and often ulcerated. Diagnosis is by clinical criteria and microscopy. Treatment is with antibiotics, usually tetracyclines, macrolides, or trimethoprim/sulfamethoxazole.
The bacteria Calymmatobacterium (formerly Donovania) granulomatis are very rare in most of the world. Current epidemiologic data are unavailable, but historically, granuloma inguinale has been reported in areas such as Papua New Guinea, northern Australia, southern Africa, and parts of Brazil and India.
Symptoms and Signs
Sites of infection are
After an incubation period of about 1 to 12 wk, a painless, red skin nodule slowly enlarges, becoming a raised, beefy red, moist, smooth, foul-smelling lesion. The lesion slowly enlarges and may spread to other skin areas. Lesions heal slowly, with scarring. Secondary infections with other bacteria are common and can cause extensive tissue destruction.
Occasionally, granuloma inguinale spreads through the bloodstream to the bones, joints, or liver; without treatment, anemia, wasting, and uncommonly death may occur.
Diagnosis
Granuloma inguinale is suspected in patients from endemic areas with characteristic lesions. Diagnosis is confirmed microscopically by the presence of Donovan bodies (numerous bacilli in the cytoplasm of macrophages shown by Giemsa or Wright's stain) in smears of fluid from scrapings from the edge of lesions. These smears contain many plasma cells. Biopsy specimens are taken if the diagnosis is unclear or if adequate tissue fluid cannot be obtained because lesions are dry, sclerotic, or necrotic. The bacteria do not grow on ordinary culture media.
Treatment
Many oral antibiotics kill the bacteria, but tetracyclines, macrolides, and trimethoprim/sulfamethoxazole (TMP/SMX) are most effective, followed by ceftriaxone, aminoglycosides, fluoroquinolones, and chloramphenicol. Recommended oral regimens include doxycycline 100 mg bid for 3 wk, TMP/SMX 160/800 mg bid for 3 wk, erythromycin 500 mg qid for 3 wk, or azithromycin 1 g/wk for 3 wk. IV or IM antibiotics (eg, ceftriaxone) are an alternative.
Response to treatment should begin within 7 days, but healing of extensive disease may be slow and lesions may recur, requiring longer treatment. HIV-infected patients may also require prolonged or intensive treatment. After apparently successful treatment, follow-up should continue for 6 mo. Current sex partners should be examined and, if infected, treated.
Last full review/revision November 2008 by J. Allen McCutchan, MD, MSc
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