Granuloma Inguinale

Definition

Granuloma inguinale is a sexually transmitted infection that affects the skin and mucous membranes of the anal and genital areas. Its name is derived from granuloma, a medical term for a mass or growth of granulation tissue, and inguinale, a Latin word that means located in the groin. Granulation tissue is tissue formed during wound healing that is rich in blood capillaries and has a rough or lumpy surface.

Description

Granuloma inguinale is a chronic infection with frequent relapses caused by a rod-shaped bacterium. It occurs worldwide but is most common in tropical or subtropical countries, where it is associated with poverty and poor hygiene. As many as 20% of male patients with sexually transmitted diseases (STDs) in tropical countries have granuloma inguinale. The disease is less common in the United States, with fewer than 100 reported cases per year. Most patients are between the ages of 20 and 40 years, with a 2:1 male-to-female ratio.

Although granuloma inguinale is relatively uncommon in the United States in comparison with other STDs, it is still a significant public health problem. It can be acquired through casual sexual contacts when traveling abroad. Moreover, patients with granuloma inguinale are vulnerable to superinfection (infection by other disease agents) with other STDs, especially syphilis. Patients with granuloma inguinale are also a high-risk group for Acquired Immune Deficiency Syndrome (AIDS ) transmission, because the disease causes open genital ulcers that can be easily invaded by the AIDS virus.

Granuloma inguinale is spread primarily through heterosexual and male homosexual contact; however, its occurrence in children and sexually inactive adults indicates that it may also be spread by contact with human feces. Granuloma inguinale is not highly contagious; however, persons with weakened immune systems are at greater risk of infection.

Causes and symptoms

Granuloma inguinale, which is sometimes called donovanosis, is caused by Calymmatobacterium granulomatis, a rod-shaped bacterium formerly called Donovania granulomatis. The bacterium has an incubation period ranging from eight days to 12 weeks, with an average of two to four weeks. The disease has a slow and gradual onset, beginning with an inconspicuous pimple or lumpy eruption on the skin. In 90% of patients, the initial sign of infection is in the genital region, but a minority of patients will develop the sore in their mouth or anal area if their sexual contact involved those parts of the body. Many patients do not notice the sore because it is small and not usually painful. In some women, the first symptom of granuloma inguinale is bleeding from the genitals.

The initial pimple or sore is typically followed by three stages of disease. In the first stage, the patient develops a mass of pink or dull red granulation tissue in the area around the anus. In the second stage, the bacteria erode the skin to form shallow, foul-smelling ulcers which spread from the genital and anal areas to the thighs and lower abdomen. The edges of the ulcers are marked by granulation tissue. In the third stage, the ulcerated areas form deep masses of keloid or scar tissue that may spread slowly for many years.

Patients with long-term infections are at risk for serious complications. The ulcers in second-stage granuloma inguinale often become superinfected with syphilis or other STD organisms. Superinfected ulcers become painful to touch, filled with pus and dead tissue, and are much more difficult to treat. There may be sizable areas of tissue destruction in superinfected patients. In addition, the scar tissue produced by third-stage infection can grow until it closes off parts of the patient's urinary tract. It is also associated with a higher risk of genital cancer.

Diagnosis

The most important aspect of diagnosis is distinguishing between granuloma inguinale and other STDs, particularly since many patients will be infected with more than one STD. Public health officials recommend that patients tested for granuloma inguinale be given a blood test for syphilis as well. In addition, the doctor will need to distinguish between granuloma inguinale and certain types of skin cancer, amebiasis, fungal infections, and other bacterial ulcers. The most significant distinguishing characteristic of granuloma inguinale is the skin ulcer, which is larger than in most other diseases, painless, irregular in shape, and likely to bleed when touched.

The diagnosis of granuloma inguinale is made by finding Donovan bodies in samples of the patient's skin tissue. Donovan bodies are oval rod-shaped organisms that appear inside infected tissue cells under a microscope. The doctor obtains a tissue sample either by cutting a piece of tissue from the edge of an skin ulcer with a scalpel or by taking a punch biopsy. To make a punch biopsy, the doctor will inject a local anesthetic into an ulcerated area and remove a piece of skin about 1/16 of an inch in size with a surgical skin punch. The tissue sample is then air-dried and stained with Wright's stain, a chemical that will cause the Donovan bodies to show up as dark purple safety pin-shaped objects inside lighter-staining capsules.

Treatment

Granuloma inguinale is treated with oral antibiotics. Three weeks of treatment with erythromycin, streptomycin, or tetracycline, or 12 weeks of treatment with ampicillin are standard forms of therapy. Although the skin ulcers will start to show signs of healing in about a week, the patient must take the full course of medication to minimize the possibility of relapse.

KEY TERMS

Donovan bodies— Rod-shaped oval organisms found in tissue samples from patients with granuloma inguinale. Donovan bodies appear deep purple when stained with Wright's stain.

Granulation tissue— A kind of tissue formed during wound healing, with a rough or irregular surface and a rich supply of blood capillaries.

Granuloma— An inflammatory swelling or growth composed of granulation tissue, as in granuloma inguinale.

Keloid— An unusual or abnormal growth of scar tissue, as in the third stage of granuloma inguinale.

Punch biopsy— A method of obtaining skin samples under local anesthesia using a surgical skin punch.

Superinfection— A condition in which a patient with a contagious disease acquires a second infection, as when a patient with granuloma inguinale is also infected with syphilis.

Wright's stain— A chemical used to stain tissue samples for laboratory analysis.

Prognosis

Most patients with granuloma inguinale recover completely, although superinfected ulcers may require lengthy courses of medication. Early treatment prevents the complications associated with second- and third-stage infection.

Prevention

Prevention of granuloma inguinale has three important aspects:

• Avoidance of casual sexual contacts, particularly among homosexual males, in countries with high rates of the disease
• Tracing and examination of an infected person's recent sexual contacts
• Monitoring the patient's ulcers or scar tissue for signs of reinfection for a period of six months after antibiotic treatment

Resources

BOOKS

Chambers, Henry F. "Infectious Diseases: Bacterial & Chlamydial." In Current Medical Diagnosis and Treatment, 1998. edited by Stephen McPhee, et al., 37th ed. Stamford: Appleton & Lange, 1997.