Klebsiella granulomatis

Background

• Also called granuloma inguinale, donovanosis, granuloma venereum

Microbiology

• Gram-negative bacillus
• Previously known as Donovania granulomatis and Calymmatobacterium granulomatis

Epidemiology

• Rare, with most cases in Papua New Guinea, KwaZulu-Natal and eastern Transvaal in South Africa, India, Brazil, and Aboriginal communities in Australia

Clinical Manifestation

• Incubation period is unclear, possibly somewhere between 50 days with a wide range from 1 to 360 days
• Presents as a firm papule or subcutaneous nodule that eventually ulcerates
  • Almost all in genitals, but 10% can be inguinal
  • Case reports of extragenital lesions in lips, gums, cheeks, palate, pharynx, neck, nose, larynx, and chest
• Four types:
  • Ulcerogranulamatous: most common type, shows as a beefy red, non-tender ulcer that bleed
  • Hypertrophic: raised, irregular edge, sometimes dry
  • Necrotic: deep ulcer causing tissue destruction and foul odor
  • Sclerotic: fibrous with scar tissue
• Rarely disseminates to liver and bone
• Major complication is squamous cell carcinoma

Differential Diagnosis

• Refer to genital ulcer disease
• Also includes squamous cell carcinoma of the penis

Diagnosis

• Direct microscopy
  • Swab rolled across lesion then across a slide
  • Stain with Giemsa, which should show large mononuclear cells with intracytoplasmic cysts fillwed with Gram-negative Donovan bodies
• Culture not available
• PCR where available
• Serology not reliable

Management

• Test for other sexually-transmitted infections
• Azithromycin 1 g PO weekly (or 500 mg PO daily) for at least 3 weeks and until lesion is healed
  • Second-line is TMP-SMX 160/800 mg PO bid or doxycycline 100 mg PO bid
  • In pregnancy, can use erythromycin 500 mg PO qid
  • Can add adjunctive gentamicin 1 mg/kg q8h if the lesion is slow to heal
  • In children, azithromycin 20 mg/kg
• If it does not heal, it may need biopsy to exclude squamous cell carcinoma

Prevention

Neonatal Infection

• To prevent neonatal acquisition, children born to mothers with donovanosis should be prophylactically treated with azithromycin 20 mg/kg PO daily for 3 days

Further Reading

• 2016 European guideline on donovanosis. Int J STD AIDS. 2016;27(8):605-607. doi: 10.1177/0956462416633626