Introduction
Granuloma Inguinale is a mildly contagious (sexually transmitted) disease caused by Klebsiella granulomatis.
It leads to chronic inflammation and scarring of the genitals.
Granuloma inguinale typically causes a painless, red lump on or near the genitals, which slowly enlarges, then breaks down to form a sore.
It is currently rare in several parts of Africa but endemic in Southeast Asia, Southern India, the Caribbean and South America.
Symptoms and clinical features of Granuloma inguinale
- Granuloma Inguinale is a chronic mildly contagious disease with a potentially progressive and destructive character
- Its incubation period ranges from 10 – 40 days.
- The early lesion is a papule or nodule which soon becomes ulcerated and has an offensive
discharge - The floor of the ulcer may be covered with a dirty grey material; its walls may be overhanging, or a papillomatous fungating mass may arise from the growth of vegetations
- Progressive indolent, serpiginous ulceration of the groins, pubis, genitals and anus may form.
- Pain (due to Ulceration) on walking may be excruciating
- Persisting sinuses and hypertrophic depigmented scars are fairly characteristic
- Regional lymph nodes are not enlarged but with cicatrisation, the lymph channels may be blocked causing pseudo elephantiasis of the genitalia. Both the fibrotic scarring and elephantiasis-like lesion could cause obstructed labour
- Subcutaneous extension and abscesses may occur and form a pseudo-bubo in the inguinal region
- Healing is unlikely without treatment; the locally destructive lesion may eventually involve the groins, pubis and anus
- A squamous cell carcinoma may arise from chronic lesions.
Differential diagnoses
- Syphilis Chancroid
- Lymphogranuloma venereum
- Lupus vulgaris
- Deep mycosis
- Amoebic ulcer
- Pyoderma gangrenosum
- Squamous cell and basal cell carcinoma
Complications of Granuloma inguinale
- Obstructed labour
- Squamous cell carcinoma
Investigations
- Direct microscopy
Treatment for Granuloma inguinale
Treatment objectives
- Eliminate the organism in the patient and sexual partner(s)
- Prevent re-infection
- Prevent complications
- Counsel and screen for possible co-infection with HIV so that appropriate management can be instituted
Drug therapy
A. Recommended regimen:
Azithromycin 1g orally on first day, then 500 mg orally, once a day
Or:
Doxycycline 100 mg orally every 12 hours
Therapy should be continued until the
lesions have completely epithelialized
B. Alternative regimen:
- Erythromycin 500 mg orally every 6 hours
Or:
- Tetracycline 500 mg orally every 6 hours
Or:
- Trimethoprim 80 mg/ sulfamethoxazole 400 mg, (i.e. 960 mg) orally, 12 hourly
All treatment should be for a minimum of 14 days
- Note: The addition of a parenteral aminoglycoside such as gentamicin should be carefully considered for treating HIV-infected patients
Follow-up
- Patients should be followed up clinically until signs and symptoms have resolved
Notable adverse drug reactions, caution and contraindications
Sulfamethoxazole/ trimethoprim
- Contraindicated in persons with
hypersensitivity to sulfonamides or
trimethoprim; porphyria - Caution required in renal
impairment (avoid if severe); hepatic impairment (avoid if severe); - maintain adequate fluid intake (to avoid crystalluria)
- May cause nausea, vomiting, diarrhoea, headache, hypersensitivity reactions, including fixed drug eruption, pruritus, photo-sensitivity reactions, exfoliative dermatitis, and erythema nodosum
Others
See Chlamydia
Prevention
- Counselling, Compliance, Condom use and Contact treatment