Granuloma inguinale, or donovanosis, is a chronic ulcerative disease which ordinarily affects the genitalia. This is an important clinical entity when assessing genital ulcer disease, particularly in the tropical and subtropical regions of the world. It is also an important co-factor in the spread of human immunodeficiency virus (HIV).
Granuloma inguinale was one among the handful of bacterial infections that could be managed in the pre-antibiotic era. Antimony compounds were successfully used for primary infections, although with limited efficacy for disease recurrences and reinfections.
The first antimicrobial drug shown to be effective in the treatment of donovanosis was streptomycin in 1947; today, a plethora of different therapeutic regimens are at our disposal, partially reflecting local availability of various drug preparations.
Guidelines from the World Health Organization (WHO) endorse taking azithromycin 1 gram immediately, followed by 500 milligrams daily (without stating the recommended duration of therapy). Similarly, the Centers for Disease Control and Prevention (CDC) recommends 1 gram of azithromycin weekly for at least three weeks, or until all lesions show complete healing.
Alternative regimens may include doxycycline, ciprofloxacin, erythromycin base and trimethoprim-sulfamethoxazole for a minimum three-week course. Addition of intravenous or intramuscular gentamicin (in a dose of 1 milligram per kilogram every eight hours) should be considered if lesions fail to respond adequately in the first couple of days of treatment. In pregnancy, erythromycin (500 milligrams four times per day) is still the preferred drug.
Children with granuloma inguinale should receive a short course of azithromycin (20 milligrams per kilogram). Moreover, children born to mothers with untreated granuloma inguinale should be given a prophylactic three-day course of azithromycin (20 milligrams per kilogram) once daily.
Education and Counseling
In the past, poor understanding and recognition of this clinical entity resulted in patients with severe donovanosis becoming shunned and rejected from the society. Many affected individuals had profound feelings of guilt, shame and embarrassment – some of them even resorting to (or contemplating) suicide.
As patients with large ulcerations and lesions necessitate prolonged courses of antimicrobial drugs, there is definitely a need for careful explanation and adequate reassurance. Health personnel that works in outpatient clinics for sexually-transmitted infections is often the best choice for non-judgmental, supportive approach.
Naturally, there is a need for continuing education of health-care workers about granuloma inguinale in endemic areas, and also a need to increase community awareness of the significance of genital ulcer disease (since it is a long-established risk factor for the transmission of HIV).
CDC recommends that individuals who have had sexual relations with a donovanosis patient (within the sixty days prior to the onset of patient’s symptoms) should be properly examined and offered antimicrobial therapy. Nevertheless, the value of prescribing empiric therapy without apparent symptoms and/or clinical signs has not yet been established.
The usefulness and justification of mass treatment campaigns is still questionable, but some examples show potential applicability of such approaches. For example, mass treatment of donovanosis cases that were identified in house-to-house visits in Papua New Guinea were instrumental in curbing a localized epidemic in the 1950s.
In conclusion, global eradication of donovanosis is feasible, but such effort will require substantial input and leadership from the WHO if the disease is to be placed on the eradication agenda. Until then, sustained vigilance will be needed, so that the diagnosis of granuloma inguinale is neither missed, nor forgotten.
Reviewed by Afsaneh Khetrapal Bsc (Hons)