Granuloma Inguinale

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Granuloma inguinale is a chronic, progressive, sexually transmitted bacterial infection, caused by Calymmatobacterium (Klebsiella) granulomatis. The disease is prevalent in tropical and subtropical areas, and it is rarely seen in the United States. The incubation period is 8 to 12 weeks.

Clinically, the disease is characterized by an initial papule in the anogenital area that necroses to form an ulcerative mass with rolled edges of red granulation tissue. This tissue is highly vascular and bleeds easily with contact. Multiple ulcers may coalesce because of autoinoculation at adjacent sites. The ulcers spread and proliferate over the course of years to form large vascular granulomatous masses. If untreated, these lesions result in destruction of the genital tissue. The lesions can spread from the genital area to the thighs and lower abdomen. The course of the disease is divided into three stages. The exuberant stage involves a mass of granulation tissue. In the ulcerative stage, bacteria erode the skin to form shallow, foul-smelling ulcers. The cica-tricial stage is marked by scarring and keloid formation. Patients with granuloma

Table 6 Granuloma Inguinale

Clinical

Differential

Diagnosis

Symptoms

appearance

diagnosis

Therapy

Granuloma

Painless

Granulomatous

Chancroid, chancre,

Recommended

inguinale

ulcers, scarring,

lymphogranuloma

treatment:

depigmentation,

venereum,

doxycycline or

disfigurement

anogenital amebiasis, elephantiasis, genital cancer, fungal infection

trimethoprim-sulfamethoxa-zole.

Alternative treatment:

ciprofloxacin, erythromycin, azithromycin

inguinale are susceptible to superinfection by other bacteria and sexually transmitted diseases, especially syphilis. Open genital ulcers are a nidus for contracting AIDS.

Other diseases in the differential diagnosis in the early ulcerative stages include other sexually transmitted ulcers, including syphilis and chancroid. Later disease with scarring and granulation tissue can be confused with hidradenitis suppurativa, Crohn's disease, and genital malignancy. The diagnosis is usually made by punch biopsy. Donovan bodies are diagnostic and appear as intracytoplasmic inclusion bodies in hystiocytes. Complications of infection include permanent genital destruction and scarring, blockage of the urinary tract from stenosis, genital depigmentation, permanent genital swelling from lymphatic scarring, and even death. Affected areas are at increased risk of developing genital cancer.

Therapy consists of doxycycline 100 mg b.i.d. or trimethoprim-sulfamethoxazole DS b.i.d. for three weeks (8). Alternative medications include erythromycin, ciprofloxacin, and azithromycin (Table 6).

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