DermNet NZ

Granuloma inguinale (Donovanosis)

What is granuloma inguinale?
Granuloma inguinale is a sexually transmitted infection (STI) caused by the
bacteria Calymmatobacterium or Klebsiella granulomatis. It is rare in New Zealand. It is characterised by
lesions on the genitals or perianal area that start as raised nodules (granulomas) and then erode to form
beefy-red velvety heaped-up ulcers that gradually increase in size.
Granuloma inguinale is also called Donovanosis. Donovan bodies are cellular components that are seen
when scrapings from the eg of the lesions are viewed under a microscope.

Who is at risk of granuloma inguinale?

Sexually active people may be at risk of getting granuloma inguinale. It is most commonly found in
tropical or subtropical areas of the world such as Papua New Guinea, central Australia, Southern India,
the Caribbean and Guyana. In countries where it is less frequently seen, cases are most probably related
to foreign travel.
It possibly occurs more frequently in men than women and the peak incidence is in persons between 20
40 years old.

What are the signs and symptoms of granuloma inguinale?

After contracting the infection it may take from 1 week to 3 months for any signs and symptoms to
appear. There are several types of lesions that may occur and symptoms are mild.

The nodular type consists of soft lumps that are typically beefy red in colour and tend to bleed
easily. These are usually painless despite ulceration.

The hypertrophic or verrucous type consists of large dry warty masses that resemble genital
warts.

The necrotic type presents as dry ulcers that evolve into scarred areas .

Complications such as bleeding, secondary infection and swelling (lymphoedema) may occur. Local lymph
nodes may be enlarged and may become abscesses or ulcers as the infection spreads into the overlying
skin.
In the early stages it may be difficult to differentiate granuloma inguinale from chancroid. In the later
stages, the condition may look like lymphogranuloma venereum. It may also be confused with other
conditions, such as penile or vulvar cancer or syphilis.

Granuloma inguinale

Images supplied by Dr Shahbaz A. Janjua

How is the diagnosis of granuloma inguinale made?

The main method of diagnosis is the demonstration of Donovan bodies in a tissue sample taken by crush
preparation or biopsy. Other tests such as culture, polymerase chain reaction (PCR) or serology are not
routinely available.

What is the treatment for granuloma inguinale?

Granuloma inguinale is treated with antibiotics. Treatment with antibiotics should be for at least 3 weeks
and then continued until the lesions have completely healed.

Trimethoprim-sulfamethoxazole and doxycycline are the antibiotics of choice.

Alternatives include erythromycin, ciprofloxacin and azithromycin.

If there are no signs of healing within the first few days of treatment with initial antibiotic
therapy, the addition of intravenous gentamicin may be necessary.

Sexual activity should not take place until all lesions are completely healed. Follow-up examination is
necessary to ensure a complete recovery.
If granuloma inguinale is left untreated or treatment is delayed it may cause widespread destruction of
the genitals and leave permanent swelling and scarring. Infection may also spread to other parts of the
body and cause secondary problems such as pneumonia or heart failure.

Can granuloma inguinale be prevented?

All sexual activity should be refrained from until the lesions have completely healed. As with other
sexually transmitted infections, if you think you are infected, stop all sexual contact and see your doctor
or sexual health clinic immediately. Safe-sex practices will prevent the spread of granuloma inguinale as
well as other sexually transmitted diseases.

What is granuloma inguinale?

Granuloma inguinale is a chronic bacterial infection of the genital region, generally regarded to be
sexually transmitted.

Who gets granuloma inguinale?

Granuloma inguinale is a relatively rare disease occurring in people living in tropical and subtropical
areas. It occurs more frequently in males. In the United States, while homosexuals are at greater risk, it
is relatively rare in heterosexual partners of those infected.

How is granuloma inguinale spread?

Granuloma inguinale is thought to be spread by sexual contact with an infected individual.

What are the symptoms of granuloma

inguinale?
The disease begins with the appearance of lumps or blisters in the genital area. The blister becomes a
slowly enlarging open sore.

How soon do symptoms appear?

The incubation period appears to be between eight and 80 days after infection.

When and for how long is a person able to

spread granuloma inguinale?
Granuloma inguinale is communicable as long as the infected person remains untreated and bacteria
from lesions are present.

Does past infection with granuloma inguinale

make a person immune?
Past infection does not make a person immune. Susceptibility is variable. There is no evidence of natural
resistance.

What is the treatment for granuloma

inguinale?
There are several antibiotics that will effectively cure granuloma inguinale. Response to the antibiotic
should be evident within seven days and total healing usually occurs within three to five weeks.

What complications can result from granuloma

inguinale?
If left untreated, granuloma inguinale can result in extensive destruction of genital organs and may also
spread to other parts of the body.

How can the spread of granuloma inguinale be

prevented?

Limit the number of your sex partners.

Use a condom.
Carefully wash the genitals after sexual relations.
If you think you are infected, avoid any sexual contact and visit your local sexually transmitted
disease (STD) clinic, a hospital or your doctor.
Notify all sexual contacts immediately so they can obtain medical care.

Part 1 of 6: Overview

What Is Granuloma Inguinale?

Granuloma inguinale is a sexually transmitted
infection (STI). It is a rare disease that does not
usually occur in the United States.
This STI causes lesions in the anal and genital regions. These lesions
often recur, even after treatment.
Granuloma inguinale is sometimes called donovanosis.
Part 2 of 6: Causes

What Causes Granuloma Inguinale?

A class of bacteria known as Klebsiella granulomatis causes this
infection. Granuloma inguinale is a sexually transmitted infection, and
you can contract it by having vaginal or anal intercourse with an
infected partner. In rare instances, it can be contracted through oral
sex.
Part 3 of 6: Symptoms and Stages

The Symptoms and Stages of

Granuloma Inguinale
Signs of the condition have a slow onset. It usually takes at least one
week to experience symptoms; however, it can take up to 12 weeks
for symptoms to reach their peak. Generally, you will first experience
a pimple or a lump on your skin. This blemish is small and not typically
painful, so you may not notice it at first. In 90 percent of cases, the
infection begins in the genital region. Anal or mouth sores occur only

in a minority of instances and only if the sexual contact involved these

areas.
The skin lesion progresses through three stages:
Stage One

In the first stage, the small pimple will begin to spread and eat away
at the surrounding tissue. As the tissue begins to wear away, it turns
pink or a faint red. The bumps then turn into raised red nodules with a
velvety texture. This happens around the anus and genitals. Although
the bumps are painless, they can bleed if they are injured.
Stage Two

In the second stage of the disease, bacteria begin to erode the skin.
Once this occurs, you will develop shallow ulcers that will spread from
the genitals and anus to the thighs and lower abdomen (inguinal
area). You will notice that the perimeters of the ulcers are lined with
granulated tissue. A foul smell may accompany the ulcers.
Stage Three

When granuloma inguinale advances to the third stage, the ulcers

become deep and morph into scar tissue.
Part 4 of 6: Diagnosis Process

How Is Granuloma Inguinale

Diagnosed?
Granuloma inguinale can be difficult to detect in the early stages,
since you may not notice the initial lesions. Your doctor will usually not
suspect granuloma inguinale unless ulcers have begun to form and do
not clear up.

If the ulcers do not heal after a prolonged period of time, your

physician may order a skin biopsy of the lesions. This will probably be
performed as a punch biopsy. When you undergo a punch biopsy, your
doctor will remove a small area of the ulcer with a circular blade. Once
removed, the sample will be tested for the presence of Klebsiella
granulomatis bacteria. It may also be possible to detect bacteria by
scraping some of the lesion and conducting further tests on the
sample.
Since having granuloma inguinale is know to raise your risk for other
sexually transmitted diseases (STDs), you may be given blood tests or
have other diagnostic testing or cultures taken to check for those as
well.
Part 5 of 6: Risk Factors

Who Is at Risk for Granuloma

Inguinale?
You put yourself at risk if you have sexual contact with individuals
from the tropical and subtropical regions where the disease is most
prevalent. most. Males are twice as likely to acquire granuloma
inguinale as women. As a result, homosexual men have a greater
likelihood of getting granuloma inguinale. Individuals who are between
the ages of 20 and 40 contract the condition more often than those in
other age groups.
Where you live plays a role in determining your risk of infection. For
instance, if you live in the United States and are infected, it is usually
because you had sexual contact with someone who lives abroad.
According to Medscape Reference, about 100 cases of granuloma
inguinale occur in the United States each year, and the southeastern
part of the country seems to be the most affected (Fasoldt, et al.,
2011).

According to the National Institutes of Health, tropical and subtropical

climates are the most likely areas where people encounter granuloma
inguinale. The disease is endemic in New Guinea, Guyana, Southeast
India, and some parts of Australia. A higher number of cases are also
reported in parts of Brazil and South Africa.
Part 6 of 6: Treatment

Treatment for Granuloma Inguinale

Granuloma inguinale can be treated using antibiotics like tetracycline
and the macrolide erythromycin. Streptomycin and ampicillin may also
be used. Most treatments are prescribed for three weeks, although
they will continue until the infection is cured. Early treatment is
advised to prevent the occurrence of permanent scarring and swelling
in the genital, anal and inguinal areas.
After you have been treated, you need to have routine examinations
to ensure that the infection does not come back. In some cases, it
recurs after it seems to have been cured.

Medscape
Granuloma Inguinale (Donovanosis)
Author: Jerry J Fasoldt, MD; Chief Editor: Dirk M Elston, MD

Background
Granuloma inguinale is a chronic bacterial infection that frequently is associated with other sexually transmitted
diseases. Granuloma inguinale is characterized by intracellular inclusions in macrophages referred to as Donovan
bodies. Granuloma inguinale usually affects the skin and mucous membranes in the genital region, where it results
in nodular lesions that evolve into ulcers. The ulcers progressively expand and are locally destructive, as
demonstrated in the image below.

Beefy-red penile ulcers.

Pathophysiology
The intracellular organism responsible for granuloma inguinale was initially described by Donovan over a century
ago, and subsequently, the bacterium was classified in 1913 as Calymmatobacterium granulomatis. Although
Anderson suggested that the organism be eponymously named Donovania granulomatosis, Carter et al
discovered that the molecular structure of the causative organism was similar to Klebsiella species and
reclassified the gram-negative pleomorphic bacillus as Klebsiella granulomatis.[1, 2]
The mode of transmission of granuloma inguinale primarily occurs through sexual contact; however, it is
hypothesized to have low infectious capabilities because repeated exposure is necessary for clinical infection to
occur. Additionally, granuloma inguinale may also be obtained through the fecal route or by passage through an
infected birth canal.

Epidemiology
Frequency
United States
Fewer than 100 cases of granuloma inguinale are reported annually, many of which are thought to be acquired
during foreign travel.
International
Granuloma inguinale is rare in temperate climates, but it is common in the tropics and subtropics. Granuloma
inguinale is endemic in Western New Guinea, the Caribbean, Southern India, South Africa, Southeast Asia,
Australia, and Brazil.

Mortality/Morbidity
If granuloma inguinale remains untreated, secondary infections and lymphedema/elephantiasis may occur.
Persistent granuloma inguinale lesions continue to expand and are locally destructive. Treated granuloma
inguinale lesions tend to exhibit extensive fibrosis, resulting in strictures. Squamous cell carcinomaand less
often basal cell carcinoma can develop in long-standing lesions and/or scars. Also see Complications.

Race
The incidence is higher in blacks than in whites in the United States. The incidence is higher in native persons
than in Europeans in Western New Guinea. The incidence is higher in Hindus than in Muslims in India. These
differences are more likely the result of disparities in socioeconomic status and living conditions than of a racial
susceptibility.[3]

Sex
No sexual predominance is reported for granuloma inguinale.

Age
Granuloma inguinale most commonly is seen in sexually active people aged 20-40 years.

History
Although the exact incubation period for granuloma inguinale is unknown, it ranges from a day to a year, with the
median time being 50 days. [3]

Physical
Morphology
The 4 main types of cutaneous lesions are as follows:

Nodular: The initial granuloma inguinale lesion is a papule or nodule that arises at the site of inoculation.
The nodule is soft, often pruritic and erythematous, and eventually ulcerates. A nodule may be mistaken for a
lymph node [ie, pseudobubo].

Ulcerovegetative (most common): These granuloma inguinale lesions develop from nodular lesions and
consist of large, usually painless, expanding, suppurative ulcers. The ulcers have clean, friable bases with
distinct, raised, rolled margins and have a tendency to bleed easily. The ulcers are "beefy red" and slowly
expand centrifugally, eventually becoming more granulomatous with serpiginous borders. They are commonly
located in the skin folds, and autoinoculation is a common feature, resulting in lesions on adjacent skin. Ulcers
often become secondarily infected with other types of bacteria and emit a putrid odor.

Cicatricial: Dry ulcers evolve into cicatricial plaques and may be associated with lymphedema.

Hypertrophic or verrucous (relatively rare): This proliferative reaction, with the formation of large
vegetating masses, may resemble genital warts.
Elephantiasislike swelling of the external genitalia is a frequent complication and is found most often in infected
females in the late stage of granuloma inguinale.
Note the clinical penile images below.

Courtesy of Hon Pak, MD.

MD.

Courtesy of Hon Pak,

Courtesy of Hon Pak, MD.

Distribution

The most common locations of granuloma inguinale lesions in men are the sulcocoronal and
balanopreputial regions, as well as the anus.
In women, granuloma inguinale lesions occur on the labia minora, the mons veneris, the fourchette,
and/or the cervix. Cervical involvement occurs in 10% of cases.
Children are frequently infected via contact with an adult; however, this is not necessarily the result of
sexual abuse.[3]

Extragenital involvement

Extragenital involvement occurs in 6% of granuloma inguinale cases.

Autoinoculation or direct extension may lead to involvement of the lips, oral/gastrointestinal mucosa,
scalp, abdomen, arms, legs, and bones.
Lymphadenopathy does not occur as a result of the primary infection withKlebsiella granulomatis, but,
rather, it occurs from secondary bacterial infections. Pseudobuboes resemble lymph nodes, but they are just
nodular lesions.
Disseminated lesions associated with systemic symptoms are frequently reported in endemic regions.
[3]
Hematogenous dissemination to the spleen, lungs, liver, bones, and the orbits may occur and occasionally
results in death.

Causes
Granuloma inguinale is caused by Klebsiella granulomatis, a gram-negative pleomorphic bacillus formerly known
as Calymmatobacterium granulomatis.

Diagnostic Considerations

Mycobacterial infection
Cutaneous tuberculosis
Ovarian cancer[4] : One case report describes a patient with chronic granuloma inguinale (donovanosis)
who presented with recurrent abdominal pain. Results of abdominal computed tomography (CT) scanning showed
pelvic masses that mimicked ovarian cancer.
Carcinoma of the cervix: One report describes cervical donovanosis, which, on an MRI, was
indistinguishable from carcinoma of the cervix. [5]

Differential Diagnoses

Chancroid
Herpes Simplex
Lymphogranuloma Venereum
Syphilis

Laboratory Studies

Although isolation of Klebsiella granulomatis has been reported, the organism is extremely fastidious and
culture is beyond the capability of most laboratories. The easiest method to visualize the organism is via smears
from the base of the ulcer. The organisms are seen within the cytoplasm of histiocytes. Characteristically, they
exhibit bipolar staining, which has been likened to a safety-pin appearance, and are referred to as Donovan
bodies. The organisms can occasionally be identified in tissue biopsy specimens with the use of special stains.
If a quick diagnosis is necessary, a smear can be performed. First, a cotton swab is gently rolled
over the ulcer so as not to cause bleeding. The swab is then rolled over a glass slide. The slide is allowed to air
dry and is then stained with Giemsa stain or pinacyanol to demonstrate Donovan bodies.
Alternatively, a crush preparation can be performed. A small piece of tissue should be obtained
from the ulcer edge or base via punch biopsy, curettage, or a thin wedge resection. Next, the tissue is crushed
between 2 glass slides, separated, and then air dried. A Wright-Giemsa, Warthin-Starry, toluidine blue, or
Leishman stain may be used to demonstrate the Donovan bodies.
Lastly, a tissue biopsy specimen can be obtained; however, the organisms may be difficult to find
in early or secondarily infected lesions, or on routine stained sections with hematoxylin and eosin. Thin, paraffinembedded sections stained with Giemsa or silver stain may facilitate identification of the rod-shaped,
encapsulated organisms within the macrophages.
Polymerase chain reaction techniques may be more sensitive ; however, they are currently only used for
scientific research.
An indirect immunofluorescent technique is available to test serum; however, it is not accurate enough for
confirmatory diagnosis.
Culture of Klebsiella granulomatis from feces has been reported using a monocyte co-culture system and
a modified Chlamydia culture.
Papanicolaou smears may identify Donovan bodies in patients undergoing routine cervical cytological
screening.

A British Association for Sexual Health and HIV (BASHH) clinical guideline summary is Donovanosis
(granuloma inguinale). In: Sexually transmitted infections: UK national screening and testing guidelines.[6]

Imaging Studies

If bony involvement is suspected in granuloma inguinale, radiography or other imaging studies are
indicated.

Other Tests

Testing for other sexually transmitted diseases is warranted because multiple coexisting infections are
common.

Histologic Findings
The epidermis displays acanthosis at the ulcer edge, with pseudoepitheliomatous hyperplasia variably present. A
dense dermal infiltrate of histiocytes and plasma cells is present, with a scattering of small neutrophilic abscesses.
The macrophages are large and vacuolated, and they contain intracellular bacilli (ie, Donovan bodies), which are
best visualized using special stains such as a Warthin-Starry, Wright-Giemsa, or Leishman stain. Klebsiella
granulomatis does not stain well with hematoxylin and eosin.

Medical Care
The recommended antibiotic for granuloma inguinale is either trimethoprim/sulfamethoxazole [7] or doxycycline.
Alternatives include ciprofloxacin, erythromycin, or azithromycin. [8] The antibiotic should be given for at least a 3week course and continued until reepithelialization of the ulcer occurs and any signs of the disease have resolved.
If the granuloma inguinale ulcers do not respond within the first days of therapy, add an aminoglycoside (eg,
gentamicin at 1 mg/kg IV q8h). Relapse of granuloma inguinale may occur up to 18 months after treatment. In
some countries, tetracycline is no longer recommended, owing to bacterial resistance. [9]

Special considerations
Pregnancy and HIV-associated granuloma inguinale are special concerns in the treatment of this condition. The
addition of a parenteral aminoglycoside (eg, gentamicin) to the treatment regimen should be considered for
pregnant women and for persons with HIV-associated granuloma inguinale.
Pregnancy is a relative contraindication for the use of sulfonamides. In pregnant and lactating women with
granuloma inguinale, the Centers for Disease Control and Prevention [10] recommends erythromycin with or without
a parenteral aminoglycoside; however, recent data suggest erythromycin may increase the risk of congenital
malformation.[11] Doxycycline and ciprofloxacin are contraindicated in pregnancy.
HIV-associated granuloma inguinale may take longer to heal, and the addition of a parenteral aminoglycoside to
the regimen is highly recommended.[12] Note that malignant transformation and autoamputation have both been
reported in HIV-positive patients with granuloma inguinale.[13, 14]
Sexual contacts within 60 days prior to the onset of the patient's symptoms of granuloma inguinale should be
examined and offered therapy.
A clinical guideline summary is available from the US Centers for Disease Control and Prevention: Diseases
characterized by genital ulcers. Sexually transmitted diseases treatment guidelines 2006.[15]

Surgical Care
Once granuloma inguinale is healed, disfiguring genital swellings may need to be surgically corrected.

Medication Summary
The goal of pharmacotherapy for granuloma inguinale is to reduce morbidity and to prevent complications.

Antibiotics
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the
clinical setting.
View full drug information

Trimethoprim/sulfamethoxazole (Bactrim IV, Bactrim SS, Bactrim DS, Septra)

Sulfamethoxazole inhibits bacterial synthesis of dihydrofolic acid. Trimethoprim reversibly inhibits dihydrofolate
reductase and blocks the production of tetrahydrofolic acid from dihydrofolic acid.
View full drug information

Doxycycline (Adoxa, Doryx, Vibramycin, Periostat)

Bacteriostatic tetracycline antibiotic that inhibits protein synthesis and thus bacterial growth by binding to 30S and
possibly 50S ribosomal subunits of susceptible bacteria.
View full drug information

Ciprofloxacin (Cipro)
Bactericidal fluoroquinolone antibiotic that inhibits the bacterial enzymes topoisomerase II (DNA gyrase) and
topoisomerase IV, which are required for bacterial DNA replication, transcription, repair, and recombination.
View full drug information

Erythromycin (E-Mycin, Ery-Tab, Eryc)

Macrolide antibiotic that inhibits bacterial protein synthesis by binding to 50S ribosomal subunits of susceptible
organisms; may be bacteriocidal or bacteriostatic depending on concentration and type of microorganism.
View full drug information

Azithromycin (Zithromax)
Azalide antibiotic (subclass of macrolide antibiotics) that inhibits bacterial protein synthesis by binding 50S
ribosomal subunits of susceptible organisms; may be bacteriocidal or bacteriostatic depending on concentration
and type of microorganism.

Deterrence/Prevention

Positive strides have been made in reducing the incidence of granuloma inguinale in endemic regions.
Australia and its surrounding indigenous areas have witnessed a decrease in the incidence of
granuloma inguinale through the establishment of a National Donovanosis Eradication Advisory Committee. The
committee consists of project officers representing different geographic areas who work closely with primary care
healthcare providers.
The goal is to develop educational materials, conduct in-service teaching for staff in rural and
remote areas, implement common protocols for treatment and diagnosis, and undertake active surveillance.
Since the development of the committee in 2001, the number of new cases of granuloma inguinale has fallen to
the lowest levels since the commencement of accurate epidemiological data collection.
This committee represents a proven model of public health intervention, using centralized officers
with expertise in sexually transmitted infection who liaise with primary healthcare providers. A similar model may
help reduce the incidence of disease in other endemic areas. [16]

Complications

The most serious complication of granuloma inguinale is carcinoma, which is reported to occur in 0.25%
of patients. This includes squamous cell carcinoma andbasal cell carcinoma. Of note, squamous cell carcinoma is
sometimes difficult to histologically distinguish from pseudoepitheliomatous hyperplasia associated with the
lesions of granuloma inguinale. Furthermore, it is possible for granuloma inguinale and squamous cell carcinoma
to coexist in the same lesion.[17]

Once the lesions have healed, extensive fibrosis, stricture formation, and phimosis, leading to significant
deformity and functional disability, may occur.
Elephantiasis of the genitals may develop secondary to lymphatic destruction.
Granuloma inguinale may also progress to involve extragenital sites, with potentially fatal systemic spread
to the viscera.
Granuloma inguinale also increases the risk of acquiring HIV, and the risk is augmented with chronic
lesions. Co-infection with HIV results in persistent ulcers that require intensive prolonged treatment with
antibiotics.[3]
Autoamputation of the penis has been reported in a man with long-standing granuloma inguinale
associated with underlying HIV-2 infection.[13]

Prognosis

Relapse may occur up to 18 months after treatment.

If untreated, the lesions may continue to expand for years.

Patient Education

For excellent patient education resources, visit eMedicineHealth's Sexual Health Center and Pregnancy
Center. Additionally, see eMedicineHealth's patient education articles Sexually Transmitted Diseases, Birth Control
Overview, andBirth Control Methods.

GRANULOMA INGUINALE
(Donovanosis)

1.
Identifikasi
Granuloma inguinale adalah penyakit menular yang disebabkan oleh bakteri, menyerang kulit dan selaput lendir
genitalia externa, daerah inguinal dan anal. Penyakit ini berlangsung kronis, progresif dan destruktif,
penularannya sangat lambat. Penyakit ditandai dengan munculnya nodula, papula menyebar secara pelahalahan, tidak lunak, exuberant, granulomatous, ulcerative dan terjadi pembentukan jaringan parut.
Lesi berbentuk khas berupa granuloma berwarna merah seperti daging sapi, meluas kepinggir dengan ciri khas
pada ujungnya menggulung dan akhirnya membentuk jaringan ikat. Lesi tidak mudah remuk (nontriable). Lesi
biasanya muncul pada bagian-bagian tubuh yang hangat dan lembab, misalnya didaerah lipat paha, daerah
perianal, serotum, vulca dn vagina. Hampir 90% daerah yang terkena adalah daerah genitalia, daerah inguinal
sekitar
10%,
daerah
anal
sekitar
1-5%.
Apabila tidak diobati penyakit ini sangat destruktif dan dapat merusk struktur alat kelamin dan menyebar
denan cara auto inokulasi kebagian lain dari tubuh. Diagnosa ditegakkan dengan pemeriksaan laboratorium
yaitu dengan ditemukannya Donovan bodies yaitu organisme berbentuk batang didalam sitoplasma. Donovan
bodies dapat dilihat pad preparat jaringn granulasi yag diwarnai dengan pengecatan Wright atau Giemsa.
Pemeriksaan histologis juga dapat dilakukan terhadap jaringan biopsi. Tanda phatoguonomis dan penyakit ini
adalah pada pemeriksaan mikroskopis sel-sel mononuklear yang terinfeksi dipenuhi dengan Donovan
bodies.Tidak dilakukan kultur, oleh karena sangat sulit dilakukan. Pemeriksaan serologis dan pemeriksaan PCR
hanya dilakukan untuk tujuan penelitian. Untuk menyingkirkan kemungkinan infeksi disebabkan oleh
Haemophilus

ducrey

dapat

dilakukan

dengan

kultur

menggunakan

media

selektif.

2.
Penyebab
Penyakit
Calymmatobacterium granulomatis (Donovania granulomatis), basil gram negatif, diduga sebagai penyebab,
namun

belum

pasti.

3.
Distribusi
Penyakit
Jarang ditemukan di negara maju (jarang ditemukan di Amerika Serikat, KLB kadang-kadang juga terjadi).
Penyakit ini endemis di wilayah tropis dan subtropis seperti: India Selatan, Papua Nugini, Australia tengah dan
utara, kadang-kadang Amerika Latin, Kepulauan Karibia, Afrika bagian tengah dan timur selatan. Lebih sering
ditemukan pada pria daripada wanita dan pada orang dengan status sosial ekonomi rendah; dapat terjadi pada
anak
berumur
1-4
tahun,
tetapi
paling
dominan
pada
usia
20-40
tahun.
4.

Reservoir: Manusia.

5.

Cara

Penularan

Diduga melalui kontak langsung dengan lesi selama melakukan hubungan seksual tetapi dalam berbagai studi
hanya 20-65% pasangan seksual yang terinfeksi, ada beberapa kasus penularan bukan melalui hubungan
seksual.
6.

Masa

Inkubasi: Tidak

diketahui,

mungkin

antara

sampai

16

minggu.

7.
Masa
Penularan
Tidak diketahui, penularan mungkin tetap berlangsun selama masih ada lesi terbuka pada kulit atau membrana
mukosa.
8.
Kerentanan

sangat

Kerentanan
bervariasi,

9.

tidak

terbentuk

dan
setelah

mendapatkan

Cara-cara

Kekebalan
infeksi.

Pemberantasan

A.
Upaya
Pencegahan
Kecuali cara-cara yang dapat diterapkan hanya untuk sifilis, maka cara-cara penanggulangan untuk sifilis,
seperti yang diuraikan pada 9A berlaku juga untuk pencegahan granuloma inguinalae. Program penyuluhan
kesehatan masyarakat pada daerah endemis ditekankan mengenai pentingnya diagnosa dini dan pengobatan
dini.
B.
Penanganan
Penderita,
Kontak
dan
Lingkungan
sekitar
1) Laporan kepada instansi kesehatan setempat: Penyakit ini wajib dilaporkan di semua negara bagian di
Amerika Serikat dan negara lain
2) Isolasi: Tidak ada, hindari

didunia,
kontak

Kelas
yang

3B (lihat pelaporan tentang penyakit menular).

erat dengan penderita sampai lesi sembuh.

3) Disinfeksi serentak: Disinfeksi dilakukan terhadap discharge dari lesi dan terhadap barang-barang yanga
tercemar.
4)
Karantina:
Tidak
ada.
5) Imunisasi Kontak: Tidak dilkakukan, berikan pengobatan dengan segera apabila secara klinis dicurigai telah
terjadi
6) Investigasi

kontak

dan

sumber

infeksi:

Lakukan

pemeriksaan

terhadap

kontak

infeksi.
seksual.

7) Pengobatan spesifik: Erythromycin, TP-SMX dan doxycycline, dilaporkan cukup efektif tetapi strain resisten
terhadap obat dapat terjadi. Pengobatan diteruskan selama 3 minggu sampai lesi sembuh, kambuh jarang
terjadi tetapi kalau terjadi maka respons terhadap pengobatan kedua kurang. Dosis tunggal dengan cefriaxone
IM atau ciprofloxacin PO dilaporkan juga cukup efektif.

Granuloma inguinale (GI) adalah peny. infeksi oleh bakteri yg sifatnya kronik, progressif, cukup
infeksius, yg menyebabkan destruksi permukaan & pembentukan granuloma di kulit & jar. subkutan,
umumnya ditularkan melalui hub. seksual.
ETIOLOGI
GI, peny. yg disebabkan oleh Calymatobacterium granulomatosis yg merupakan bakteri Gram
negatif dgn ukuran 1,5 m x 0,7 m, pleomorfik, dan non motil.
Bakteri ini harus diisolasi dlm yolk sac embrio ayam, walaupun kemudian diketahui dpt juga tumbuh
pada medium yg mengandung kuning telur.

Bingung mencari cream pemutih wajah yang komposisinya paling

lengkap, aman dan nyaman digunakan serta terdaftar resmi di Badan
POM? Klik di sini untuk mendapatkan jawabannya!
Pewarnaan jar dgn menggunakan metode Wright & Giemsa, Calymatobacterium granulomatosisdpt
terlihat bersama sel mononuklear yg besar yg dikenal sebagai Donovan bodies.
PATOGENESIS

Calymatobacterium granulomatosis diduga bakteri intestinal, dgn berhasilnya diidentifikasi dari

flora tinja yg nampak dgn pem. elektron mikroskop berupa bakteriofag dgn enterobacteriaceae, bakteri
ini menyebabkan terjadinya peny. GI melalui autoinokulasi, atau secara seksual melalui vagina
intercourse atau melalui rectal intercourse pada heteroseksual & homoseksual.Calymatobacterium
granulomatosis mungkin juga menginfeksi melalui inokulasi langsung melalui kulit & mukosa yg tdk
intak. Hal ini sering terjadi pada usia dewasa muda.
GAMBARAN KLINIS
Masa inkubasi biasanya antara 14-50 hari tapi bisa lebih lama, lesi yg pertama muncul berupa nodul
yg tdk nyeri & berwarna merah cerah yg akan mengalami ulserasi dlm beberapa hari. Lesi tampak
berbentuk polikistik & bisa didptkan gambaran fenomena satelit, lesi berbentuk ulkus & berwarna
merah cerah, seperti daging segar. Adenopati jarang, granuloma subkutaneus pada daerah inguinal
sering dlm btk pseudobubo. Pseudobubo, nodul subkutaneus yg sering diduga sebagai kelenjar limfe.
Terdapat 4 gejala klinis utama pada penyakit ini :
1.

Ulkus granulomatous

Tipe yg paling umum & paling sering ditemukan, berwarna merah terang, seperti

daging.

Non tender ulcer yg mudah berdarah saat penyentuhan & menjadi semakin parah bila tdk diterapi.
2.

Hipertrofi / ulkus vernicosa

Tipe ini terdiri dari ulkus bertepi verukoid atau ireguler yg meninggi, dengan dasar granulomatous.
Tumbuh dengan tepi yg ireguler, biasanya sangat kering & dpt terjadi edema.
3.

Nekrotik

Berbau busuk, ulkus yg dalam yg menyebabkan destruksi jaringan.

4.

Kekeringan, sklerosis atau lesi sikatriks dengan jaringan fibrous dan parut.

Secara anatomi area yg terkena pada pria sulkus koronarius, regio subpreputium, dan anus, wanita,
labium mayora, serviks & traktus genital atas. GI juga dpt mengenai tulang & hepar walaupun jarang &
hal ini biasanya berhubungan dgn kehamilan & infeksi servikal. Lesi primer bisa titik seperti papul,
nodul subkutan /ulkus.
Percobaan inokular pada manusia menghasilkan lesi sesudah 21 hari.

PEMERIKSAAN PENUNJANG

Hapusan jar. (tissue smears).

Mencari D.granulomatis dlm sel-sel mononuclear yg besar.

Bahan terdiri atas jaringan granulasi yg tipis, diambil dgn biopsy plong / scalpel dari lesi bagian dlm.
Setelah kering bahan diwarnai dgn Giemsa,Wright Leishman / Gram. Dpt juga dipakai bahan dari
biopsi paraffin yg diwarnai dgn HE /pewarna perak.
Biakan.
D.ganulomatis tidak dapat tumbuh pada media biasa.Dapat digunakan biakan jaringan dan telur
dengan hasil terbatas.
Biopsi.
Gambaran histopatologik terdiri atas : epidermis ditengah lesi hilang, sedangkan pada tepi lesi terjadi
akantosis yg kemudian menunjukkan gambaran hiperplasi pseudokarsinomatosa.
Tes Serum
Dpt ditemukan antibody ikatan komplemen terhadap D.garulomatis,tetapi sensitivitas & spesifitas
terbatas.
Inokulasi.
Tidak dpt diinokulasikan pada binatang yg lebih rendah.
DIAGNOSIS
Secara klinik ditegakkan berdasarkan riwayat & gambaran klinis apakah berada / pernah dari daerah
endemis. Secara laboratoris dgn menemukan badan-badan Donovan pada spesimen yg diambil baik
secara hapusan maupun biopsi kmd diwarnai dengan Wrigh / Giemsa. Gambaran karakteristik disini
berupa hiperplasia pseudoepitheliomna pada epidermis. Adanya mikroabses yg terdiri dari netrofil &
sel-sel mononukllear besar serta banyaknya badan Donovan dlm sitoplasma. Penggunaan tes serologis
seperti fiksasi komplemen hanya mempunyai sedikit nilai diagnostik.
DIAGNOSIS BANDING
1. Herpes Genitalis
2. Sifilis
3. Lymfogranuloma Venereum
4. Ulkus Molle
PENATALAKSANAAN
Terapi Sistemik
1.

Kotrimoksasol, (Trimetoprim 160 mg & sulfametoksasol 800 mg)

Dianjurkan 240 mg, 2 x/hr, selama 12 minggu.

Puncak konsentrasi metophrim dlm darah terjadi dalam 2 jam sedangkan sulfamethoxasole dlm

4 jam setelah dosis tunggal oral.

Jika 800 mg sulfamethoxasole diberikan dgn 160 mg trimetoprim 2 x/hr, maka puncak

konsentrasi obat dlm plasma + 40 & 2 ug/ml.

2.

Ampisilin.

Dapat diberikan dgn dosis 500 mg 4 x/hr selama 2 minggu.

Diabsorpsi baik dgn pemberian secara oral, dan dosis 0,5 mg mencapai pouncak kadar plasma 3 ug/ml
setelah 2 jam / waktu paruhnya berkisar antara 1 1,5 jam.
3.

Gentamisin.

Diberikan 1 mg/kg BB secara IM 2 x/hr selama 2 4 minggu.

Dengan penyuntikan akan menghasilkan puncak konsentrasi serum + 50 -56 ug/ml atau waktu
paruhnya berkisar 0,5 sampai 2 jam.
4.

Tetrasiklin.

Dianjurkan : 500 mg 4 x/hr, selama 10 20 hari. Tetrasiklin drug of choice untuk GI.
Tetrasiklin bersifat bakteriostatik, apabila diberikan dosis tunggal peroral puncak konsentrasi
tercapai dlm 2 4 jam. Tetrasiklin mempunyai waktu paruh 6 12 jam dianjurkan penggunaannya 2- 4
x/hr.
Penggunaan 250 mg setiap 6 jam menghasilkan konsentrasi plasma 2 2,5 ug/ml.
5.

Eritromisin.

Dianjurkan : 5 mg 4 x/hr selama 2 3 minggu.

Eritromisin bersifat bakteriostatik tetapi dpt pula bersifat bakterisidal pada konsentrasi tinggi. Pada
umumnya konsentrasi inhibisi minimum (MIC) dari eritromisin dlm plasma < 2 ug/ml.
Perlu dipertimbangkan penggunaannya pada wanita hamil.
6.

Kloramfenikol.

Diberikan 500 mg 3 x/hr selam 2 4 minggu.

Kloramfenikol diabsorpsi cepat dlm traktus gastro intestinal dan puncak konsentrasi 10 13 ug/ml, yg
terjadi setelah 2 3 jam dalam dosis 1 gr.

Terapi Topikal

Dpt diberikan kompres hangat dgn kompleks iodim polivynilpyrolidone, quinolol sulfat / dgn

potassium permanganat.

Sekalipun tanda-tanda penyembuhan lesi sudah terjadi seminggu setelah R/, terapi tetap perlu

dilanjutkan u/ mencegah relaps.

Terapi Pembedahan

Dapat dilakukan pada komplikasi GI seperti elefantiasis, striktur dan abses pelvis.