Other STDs

Lamis Ibrahim

James W. Myers

DONOVANOSIS

Introduction

Also known as Granuloma inguinale.
Causative agent is Klebsiella granulomatis (or Calymmatobacterium granulomatis), which is a gram-negative, pleomorphic bacterium.
Large mononuclear cells containing inclusion bodies (Donovan bodies) are characteristic.
It is not common in the United States.
Much more common in tropical, subtropical, and developing countries.
It is primarily transmitted sexually.
- Less commonly through fecal contamination.
- Rarely transmitted by passage through an infected birth canal.
It is mostly seen in sexually active people aged 20 to 40 years
It is more common in blacks in the United States.

Clinical Manifestations

Incubation period is uncertain, but it might even be up to a year. Probably ranges from 3 days up to 80 days in most patients.
Starts as a nodule and then ulcerates.
Classically there are four types of donovanosis:

1. ulcerogranulomatous: most common type, painless, beefy red ulcer that is highly vascular and bleeds easily.

2. hypertrophic or verrucous ulcer: dry ulcer with irregular edges.

3. necrotic ulcer: deep destructive ulcer with a foul smell.

4. cicatricial ulcer: lesion with scar tissue.
No lymphadenopathy is typically seen but may resemble pseudobuboes in the inguinal region.
Can disseminate to extra-abdominal organs, nose, neck, or bones.
May be complicated by stenosis of the urethral, vaginal, anal, and rectovaginal fistulas.

Diagnosis

1. Direct visualization of intracellular organism in macrophages (Donovan bodies) on biopsy or tissue crush preparation or smear.

2. Special stains such as a Warthin-Starry, Wright-Giemsa.

3. Bipolar staining giving a “safety-pin” appearance.

4. PCR more sensitive but mainly a research tool.

5. Culture: difficult to grow this organism.

6. IFA: less accurate.

Table 15-1 Treatment of Donovanosis^a

Regimens for recommended therapy^b	Regimens for alternative therapy (any of the following)
Doxycycline 100 mg orally twice a day for at least 3 weeks is the traditional therapy. Azithromycin 1 g orally once per week for at least 3 weeks is becoming the preferred regimen by some authors.	Ciprofloxacin 750 mg orally twice a day for at least 3 weeks Erythromycin base 500 mg orally four times a day for at least 3 weeks Trimethoprim-sulfamethoxazole one double-strength (160/800 mg) tablet orally twice a day for at least 3 weeks
^aAll of the above regimens should be given for at least 3 weeks or until lesions heal. ^bAminoglycoside (gentamicin 1 mg/kg IV every 8 hours) can be added if there is no evidence of improvement.

Management

Treatment prevents progression of lesions.
Usually prolonged till healing occurs.
Relapses can still occur despite appropriate therapy, especially in the first 2 years.
Regimens used: see Table 15-1

Follow-Up and Management of Sex Partners

Patients should be followed till resolution of symptoms and healing of lesions.
Sex partners of patients within the past 60 days should be evaluated and treated.

Donovanosis and HIV

Donovanosis and Pregnancy

Pregnant females should be treated with erythromycin regimen.
Doxycycline and ciprofloxacin are contraindicated, and sulfonamides are relatively contraindicated.