granuloma inguinale


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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.

granuloma

 [gran″u-lo´mah] (pl. granulomas, granulo´mata)
an imprecise term applied to (1) any small nodular, delimited aggregation of mononuclear inflammatory cells, or (2) a similar collection of modified macrophages resembling epithelial cells, usually surrounded by a rim of lymphocytes, often with multinucleated giant cells. Some granulomas contain eosinophils and plasma cells, and fibrosis is commonly seen around the lesion. Granuloma formation represents a chronic inflammatory response initiated by various infectious and noninfectious agents.
apical granuloma modified granulation tissue containing elements of chronic inflammation located adjacent to the root apex of a tooth with infected necrotic pulp.
actinic granuloma an annular lesion seen on skin chronically exposed to the sun, with a raised border and a center that appears normal but is actually elastotic.
benign granuloma of thyroid chronic inflammation of the thyroid gland, converting it into a bulky tumor that later becomes extremely hard.
coccidioidal granuloma the secondary stage of coccidioidomycosis.
dental granuloma one usually surrounded by a fibrous sac continuous with the periodontal ligament and attached to the root apex of a tooth.
eosinophilic granuloma
2. a disorder similar to eosinophilic gastroenteritis, characterized by localized nodular or pedunculated lesions of the submucosa and muscle walls, especially of the pyloric area of the stomach, caused by infiltration of eosinophils, but without peripheral eosinophilia and allergic symptoms.
granuloma fissura´tum a firm, whitish, fissured, fibrotic granuloma of the gum and buccal mucosa, occurring on an edentulous alveolar ridge and between the ridge and the cheek.
foreign-body granuloma a localized histiocytic reaction to a foreign body in the tissue.
giant cell reparative granuloma, central a lesion of the jaws composed of a spindle cell stroma punctuated by multinucleate giant cells, considered by most to be a central lesion of the bone of the jaws, presenting an inflammatory reaction to injury or hemorrhage. Some, however, consider it to be a giant cell tumor occurring in both benign and malignant forms, and others consider it to be a form of osteogenic sarcoma, varying in degree of malignancy.
granuloma inguina´le a granulomatous disease that is associated with uncleanliness and is caused by the microorganism Calymmatobacterium granulomatis (sometimes called a Donovan body). Called also granuloma venereum. Although granuloma inguinale is often considered to be a venereal disease, research does not support the hypothesis that it is transmitted by sexual contact. It is possible that natural resistance to the disease is high, so that only a few of the persons exposed are affected. About 10 days to 3 months may elapse after exposure until appearance of the first symptoms, usually small painless ulcers that bleed easily. Swelling in the groin may then follow. A new ulcer or ulcers may appear as the old one heals, so that granuloma inguinale may eventually cover the reproductive organs, buttocks, and lower abdomen, with extensive sores and a foul odor. As persons who have the disease seem to develop little immunity to it, granuloma inguinale can be present for many years.

Treatment of the disease may be with streptomycin. tetracyclines, or lincomycin. There is no known preventive for granuloma inguinale, although it is rare where sanitary living conditions prevail. The drainage from lesions may be infectious and handwashing and basic cleanliness are required. The Centers for Disease Control and Prevention recommends standard precautions.
lipoid granuloma xanthoma.
lipophagic granuloma a granuloma attended by the loss of subcutaneous fat.
Majocchi's granuloma trichophytic granuloma.
midline granuloma a rare disease of unknown etiology, characterized by granulomatous lesions of the nasal mucosa, sinuses, palate, and pharynx. Massive, progressive, erosive lesions that destroy the involved soft tissue, cartilage, and bone and sometimes extend to the brain are typical. Untreated cases are fatal (lethal midline granuloma).
paracoccidioidal granuloma paracoccidioidomycosis.
peripheral giant cell reparative granuloma giant cell epulis.
pyogenic granuloma a benign, solitary nodule resembling granulation tissue, found anywhere on the body, commonly intraorally, usually at the site of trauma as a response of the tissues to a nonspecific infection.
sarcoid granuloma the granuloma seen with sarcoidosis, consisting of multinucleated giant cells surrounded by macrophages and epithelioid cells derived from macrophages.
swimming pool granuloma a chronic granulomatous bacterial infection caused by contamination of an abrasion sustained in a swimming pool by Mycobacterium marinum, which histologically and clinically resembles tuberculosis. It tends to heal spontaneously within a few months to 2 years.
granuloma telangiecta´ticum a form characterized by numerous dilated blood vessels.
trichophytic granuloma a form of tinea corporis seen mainly on the lower legs, due to infection of hairs by the fungus Trichophyton; characteristics include raised, circumscribed, boggy granulomas that are disseminated or arranged in chains. Lesions are slowly absorbed or undergo necrosis, leaving depressed scars. Called also Majocchi's granuloma.
granuloma tro´picum yaws.
granuloma vene´reum granuloma inguinale.

gran·u·lo·ma in·gui·na·le

a specific granuloma, classified as a venereal disease and caused by Calymmatobacterium granulomatis observed in macrophages as Donovan bodies; the ulcerating granulomatous lesions occur in the inguinal regions and the genitalia; peripheral extension of the lesions produces extensive destruction.
Synonym(s): granuloma venereum

granuloma inguinale

a sexually transmitted disease characterized by ulcers of the skin and subcutaneous tissues of the groin and genitalia. It is caused by infection with Calymmatobacterium granulomatis, a small gram-negative rod-shaped bacillus. It occurs more frequently in men than in women and is associated with anal intercourse. Diagnosis is made by microscopic examination and identification of characteristic "safety-pin"-shaped bodies known as Donovan bodies in the cytoplasm of phagocytes taken from a lesion and dyed with Wright's or Giemsa stain or by histological examination of a biopsy specimen. Untreated, the lesions spread, deepen, multiply, and become secondarily infected, resulting in mutilation and destruction of genital tissue. Streptomycin is usually effective in treating the infection. All patients who have or are suspected of having granuloma inguinale are also tested for syphilis because concurrent infection is common. Also called Donovanosis.

granuloma inguinale

Donovanosis STD An indolent, skin ulcer caused by Calymmatobacterium granulomatosis, transmitted by sexual contact Management Streptomycin, chloramphenicol, tetracycline, ampicillin, gentamicin. See Sexually-transmitted diseases.

gran·u·lo·ma in·gui·na·le

(gran'yū-lō'mă ing-gwī-nā'lē)
A specific granuloma, classified as a sexually transmitted disease and caused by Klebsiella (Calymmatobacterium) granulomatis observed in macrophages as Donovan bodies; the ulcerating granulomatous lesions occur in the inguinal regions and on the genitalia.
Synonym(s): donovanosis, granuloma venereum, ulcerating granuloma of pudenda.

granuloma inguinale

A sexually transmitted disease, caused by an organism Donovania granulomatis , and almost confined to coloured people in the tropics. It starts as a small papule on the genitals which enlarges to form an extensive, velvety ulcer covering the genital area, the upper thighs and the buttock cleft. Streptomycin and oxytetracyline are effective.

gran·u·lo·ma in·gui·na·le

(gran'yū-lō'mă ing-gwī-nā'lē)
A specific granuloma; lesions occur in the inguinal regions and on the genitalia.
Synonym(s): donovanosis, ulcerating granuloma of pudenda.