Granuloma Inguinale (Donovanosis) Don’t Miss These Warning Signs

Granuloma Inguinale, also known as Donovanosis, is a rare sexually transmitted infection (STI) in Thailand but remains a public health concern in various tropical regions. It is characterized by chronic, progressive ulcers in the groin or genital area that can lead to serious tissue destruction if not treated properly.

The infection is caused by Klebsiella granulomatis and is primarily transmitted through contact with open sores during sexual activity. Without timely diagnosis and treatment, complications such as scarring, fibrosis, or systemic infections may occur.

This article provides a comprehensive overview of Granuloma Inguinale—covering symptoms, causes, diagnostic methods, treatments, prevention strategies, and differential diagnoses—to help readers make informed decisions and seek medical care promptly.

What is Granuloma Inguinale (Donovanosis)?

Granuloma Inguinale, also known as Donovanosis, is a rare sexually transmitted infection (STI) that causes chronic ulcerative lesions primarily in the groin and genital area. If left untreated, the condition can lead to progressive tissue destruction and secondary infections.

It is caused by a bacterium known as Klebsiella granulomatis (formerly Calymmatobacterium granulomatis), which spreads through direct sexual contact with the open sores of an infected person, particularly in the genital, anal, or inguinal regions.

Although rare in Thailand, the disease is more commonly reported in tropical and subtropical areas such as India, South Africa, and parts of Southeast Asia. Proper diagnosis requires laboratory testing and evaluation by a qualified healthcare professional.

What causes Granuloma Inguinale (Donovanosis)?

Granuloma Inguinale is primarily caused by Klebsiella granulomatis, a gram-negative intracellular bacterium. This pathogen invades the subcutaneous tissues and triggers a chronic inflammatory response, leading to progressive ulceration in the genital or inguinal areas.

The infection is most commonly transmitted through unprotected sexual contact with an infected individual, particularly if there are small cuts, abrasions, or weakened mucosal surfaces that facilitate bacterial entry. Oral sex contact or direct exposure to infected lesions may also pose a transmission risk.

While sexual transmission remains the predominant route, there have been rare reports of nonsexual transmission via direct contact with contaminated fluids on broken skin. Therefore, appropriate precautions are advised, especially in regions where the disease remains endemic.

What are the early symptoms of Granuloma Inguinale (Donovanosis)?

Early signs of Granuloma Inguinale typically begin with small, painless red bumps or raised lesions on the genital area, groin, or perianal region. These bumps gradually enlarge and ulcerate into soft, beefy-red sores with well-defined edges. The ulcers are often painless, though some patients may experience mild discomfort.

The lesions tend to spread slowly and may bleed easily upon contact. In certain cases, symptoms may include foul-smelling discharge, swollen lymph nodes, or blood-streaked pus from the ulcer site. The severity of symptoms often correlates with the patient’s immune response and the duration of infection prior to treatment.

Because the appearance of these sores can resemble other sexually transmitted infections such as syphilis or herpes, misdiagnosis or delayed medical attention is common. Prompt consultation with a specialist is essential for accurate diagnosis and timely treatment.

How is Granuloma Inguinale different from other sexually transmitted ulcerative diseases?

Granuloma Inguinale presents with distinct features that differentiate it from other ulcerative sexually transmitted infections such as syphilis, genital herpes, and chancroid. These differences lie in the appearance, progression, and associated symptoms of the lesions.

The ulcers caused by Granuloma Inguinale are soft, beefy-red, painless or mildly tender, and have well-defined edges. They expand slowly and can progressively destroy underlying tissue if left untreated. In contrast, syphilitic chancres are typically firm, painless, and may resolve on their own. Herpes lesions start as small vesicles that rupture into painful shallow ulcers. Chancroid ulcers, caused by Haemophilus ducreyi, tend to be painful, have ragged edges, and are often accompanied by purulent discharge.

Accurate diagnosis requires laboratory testing, as visual inspection alone is often insufficient for distinguishing between these infections. Misdiagnosis can lead to inappropriate treatment and prolonged infection.

How is Granuloma Inguinale diagnosed?

Diagnosing Granuloma Inguinale requires clinical evaluation by a medical professional due to its similarity in appearance to other sexually transmitted ulcerative diseases. The process typically begins with a detailed sexual history and physical examination of the affected area.

Definitive diagnosis involves laboratory testing. A smear from the lesion may be stained using Wright or Giemsa stain to identify Donovan bodies—intracellular inclusions within macrophages that are characteristic of Klebsiella granulomatis. In some cases, a tissue biopsy or bacterial culture may be necessary for confirmation.

Comprehensive STI screening is often recommended, including tests for HIV, syphilis, and gonorrhea, to ensure appropriate and complete treatment planning.

How is Granuloma Inguinale treated?

Treatment for Granuloma Inguinale focuses on eradicating Klebsiella granulomatis and preventing further tissue damage. The primary approach involves a course of antibiotics continued for at least 3 weeks, or until the lesions have completely healed.

Common antibiotic regimens include

• Azithromycin: 1 gram weekly or 500 mg daily
• Doxycycline: 100 mg twice daily
• Ciprofloxacin: 750 mg twice daily
• Erythromycin or Trimethoprim-sulfamethoxazole may be alternatives in cases of drug intolerance

Because the ulcers are chronic and may be extensive, the duration of treatment can be prolonged. Patients are advised to strictly adhere to the prescribed regimen to prevent antibiotic resistance and recurrence.

In cases with large or aggressive lesions, additional wound care or minor procedures may be required to promote healing—always under close medical supervision.

How should patients care for themselves after treatment for Granuloma Inguinale?

After completing antibiotic treatment for Granuloma Inguinale and as the ulcers begin to heal, continued self-care is essential to prevent recurrence and avoid secondary infections.

Recommended self-care includes:

• Strictly completing the full course of antibiotics as prescribed
• Avoiding sexual activity until a doctor confirms full resolution of infection
• Keeping the wound area clean and dry, using clean towels or gauze
• Avoiding the use of creams or topical products without medical guidance
• Attending all follow-up appointments to monitor healing and reassess if necessary

Proper post-treatment care not only supports faster recovery but also reduces the risk of transmission to partners and enhances the long-term success of therapy.

What are the possible side effects or complications?

If left untreated or improperly managed, Granuloma Inguinale can lead to serious complications. The ulcers may become progressively destructive and may result in secondary bacterial infections.

Potential complications include:

• Extensive tissue destruction due to ulcer enlargemen
• Permanent scarring or fibrosis, which can interfere with sexual function or mobility
• Urethral or vaginal strictures, especially when ulcers occur near these structures
• Systemic infections, if the bacteria spread into the bloodstream
• Unintended transmission to sexual partners in the absence of proper diagnosis

Individuals with weakened immune systems—such as those living with HIV—may experience more severe manifestations and require longer or more intensive treatment and follow-up care.

How can Granuloma Inguinale be prevented?

Although Granuloma Inguinale is rare, prevention remains essential—particularly for individuals with high-risk sexual behaviors or those living in endemic areas.

Effective preventive measures include

• Consistent use of condoms during all forms of sexual activity, including anal and oral sex
• Avoiding sexual contact with partners who have visible genital or groin ulcers
• Not sharing personal items like towels or undergarments
• Undergoing regular STI screening, especially for those with multiple partners
• Educating sexual partners to encourage mutual vigilance and early detection

Proper prevention reduces both individual risk and broader public health burdens, supporting long-term sexual health and safety.

Who is at higher risk of contracting Granuloma Inguinale?

While Granuloma Inguinale is rare in the general population, certain groups are considered at higher risk of infection and should be more vigilant about their sexual health.

High-risk groups include:

• Individuals with multiple sexual partners, especially without consistent condom use
• Those who engage in sexual contact with partners who have visible genital or groin ulcers
• People with a history of other STIs, such as syphilis, gonorrhea, or HIV
• Residents of or travelers to endemic regions, such as parts of Africa, India, or Southeast Asia
• Immunocompromised individuals, including those with HIV or on immunosuppressive therapy

Recognizing one’s risk can lead to better preventive choices and earlier medical attention in case of symptoms.

What else could a chronic groin ulcer be if it’s not Granuloma Inguinale?

A chronic ulcer in the groin or genital area is not always indicative of Granuloma Inguinale. Several other conditions—both infectious and non-infectious—can present with similar lesions.

Possible differential diagnoses include

• Primary Syphilis: Typically presents as a painless, firm ulcer that may heal spontaneously
• Chancroid: Painful ulcer with ragged edges, often with purulent discharge
• Genital Herpes: Starts with painful vesicles that rupture into shallow ulcers
• Fungal or bacterial skin infections: Often accompanied by itching or erythema
• Skin cancer (e.g., squamous cell carcinoma): May present as a persistent ulcerative lesion (PrEP)

Because these conditions can closely resemble one another, proper diagnosis should involve clinical examination and laboratory tests by a qualified healthcare provider to guide appropriate treatment.

Can Granuloma Inguinale be associated with HIV?

While Granuloma Inguinale and HIV are distinct infections, they are closely linked in terms of transmission risk—especially among individuals with high-risk sexual behavior.

The chronic open ulcers caused by Granuloma Inguinale can significantly increase susceptibility to HIV infection during sexual contact. These ulcers disrupt the mucosal barrier and expose underlying blood vessels, creating an easier entry point for the HIV virus. Conversely, individuals already living with HIV may experience more severe or persistent forms of Granuloma Inguinale due to their weakened immune systems.

Therefore, anyone diagnosed with Granuloma Inguinale should also be screened for HIV. If HIV is detected, a coordinated care plan that addresses both conditions is essential for optimal treatment outcomes.

What kind of ulcers should prompt immediate medical attention?

If you notice any abnormal ulcer or sore in the groin, genital, or perianal area, it’s important to monitor closely and seek medical evaluation—especially if the lesion shows the following characteristics:

• Ulcers that persist for more than 1–2 weeks without healing
• Lesions that bleed easily, produce pus, or emit a foul odor
• Ulcers that appear to be expanding or worsening over time
• Associated symptoms like pain, burning, itching, or swelling
• Systemic symptoms such as fever, chills, or fatigue
• History of unprotected sex with partners of unknown STI status

Early diagnosis ensures timely treatment, prevents complications, and reduces the risk of transmitting infections to others.

Conclusion

Though rare, Granuloma Inguinale can have serious consequences if left untreated. Recognizing early signs and understanding the causes and treatment options can help reduce complications and improve the likelihood of a full recovery.

Those with high-risk behaviors or exposure should seek regular sexual health screenings. Prompt medical attention at the first sign of unusual genital ulcers is crucial for effective diagnosis and timely treatment.

Accurate knowledge and proactive care form the foundation for better sexual health—for both individuals and their partners.

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