Klebsiella granulomatis

Background

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

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

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

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

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

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