Granuloma inguinale is a chronic, relapsing, granulomatous anogenital infection caused by the bacterium Klebsiella granulomatis (formerly known as Calymmatobacterium granulomatis), which is endemic in tropical and developing areas, including India, Guyana, New Guinea, central Australia, and southern Africa. Symptoms usually occur 1-12 weeks after infection. The infection begins with the appearance of relatively painless nodules that break down into shallow, sharply demarcated ulcers with a beefy-red friable base of granulation tissue. The lesions may occur on the skin, genitalia, or perineal areas, and slowly spread to the lower abdomen and thighs. The lesions may develop secondary bacterial infection and can co-exist with other sexually transmitted infections.

Diagnosis requires visualization of Donovan bodies (numerous bacilli in the cytoplasm of macrophages demonstrated with Giemsa or Wright’s stain) in smears of scrapings from the ulcer base or histologic sections. Culture of C. granulomatis is difficult to perform and not routinely available.

Multiple antimicrobial regimens have been effective; however, only a limited number of controlled trials have been published (538). Treatment has been reported to halt progression of lesions, and healing typically proceeds inward from the ulcer margins. Prolonged therapy is usually required to permit granulation and reepithelialization of the ulcers. Relapse can occur 6–18 months after apparently effective therapy.

Recommended Regimen

Azithromycin 1 gm orally once weekly or 500 mg daily for > 3 weeks and until all lesions have completely healed

Alternative Regimens

Doxycycline 100 mg orally 2 times/day for at least 3 weeks and until all lesions have completely healed
OR
Erythromycin base 500 mg orally 4 times/day for >3 weeks and until all lesions have completely healed
OR
Trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) tablet orally 2 times/day for > 3 weeks and until all lesions have completely healed

The addition of another antibiotic to these regimens can be considered if improvement is not evident within the first few days of therapy.

Other Management Considerations

Patients should be followed clinically until signs and symptoms have resolved. All persons who receive a diagnosis of granuloma inguinale should be tested for HIV.

Follow-Up

Patients should be followed clinically until signs and symptoms resolve.

Management of Sex Partners

Persons who have had sexual contact with a patient who has granuloma inguinale within the 60 days before onset of the patient’s symptoms should be examined and offered therapy. However, the value of empiric therapy in the absence of clinical signs and symptoms has not been established.

Special Considerations

Pregnancy

Use of doxycycline in pregnancy might be associated with discoloration of teeth; however, the risk is not well defined. Doxycycline is compatible with breastfeeding (431). Sulfonamides can be associated with neonatal kernicterus among those with glucose-6-phospate dehydrogenase deficiency and should be avoided during the third trimester and while breastfeeding (431). For these reasons, pregnant and lactating women with granuloma inguinale should be treated with a macrolide regimen (erythromycin or azithromycin).

HIV Infection

Persons with granuloma inguinale and HIV infection should receive the same regimens as those who do not have HIV.