para>Children born to mothers with untreated genital lesions of donovanosis are at risk of infection, and a course of prophylactic antibiotics should be considered.
Pregnancy Considerations
First-line treatment is erythromycin, 500 mg PO QID ± gentamicin 1 mg/kg IM/IV TID for at least 3 weeks and until all lesions have completely healed.
Doxycycline and ciprofloxacin are contraindicated in pregnancy.
Sulfonamides are relatively contraindicated.
ISSUES FOR REFERRAL
- Surgical referral (e.g., urologic, gynecologic, colorectal), based on complications
- Infectious disease consultation may be helpful if coexisting HIV infection or other STIs are present or suspected.
SURGERY/OTHER PROCEDURES
May need surgical correction for disfiguring genital lesions, abscess drainage, or correction of urethral/lymphatic obstruction
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Extensive, chronic, or necrotizing lesions
- Hematogenous dissemination
- Patient compliance with outpatient regimen is a concern.
- Usually not a concern unless patient presents with a surgical complication such as lymphatic or urethral obstruction
Nursing
- Wound care as needed
- Monitoring for evidence of secondary bacterial infection (i.e., careful review of vital signs)
Discharge Criteria
- Surgical clearance if surgical complications were part of the reason for admission
- Ability to access and tolerate oral antimicrobials if needed
- Clinical improvement
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
If treated in a timely manner, lesions usually resolve.
Patient Monitoring
- Monitor for hyperkalemia with extended TMP-SMX treatment.
- Other monitoring varies per treatment regimen.
- Monitor patient until resolution of symptoms.
PATIENT EDUCATION
- Patient rapport is critical because many patients may present late secondary to low self-esteem.
- Counseling on safe sex practices should be provided.
PROGNOSIS
- Goal of treatment is to reduce morbidity and prevent complications.
- Relapse may occur up to 18 months after treatment.
- If untreated, lesions may expand for years.
COMPLICATIONS
- Carcinoma (in 0.25%): squamous cell carcinoma of the penis, vulva, or cervix
- After ulcer healing, fibrosis, stricture formation, phimosis, and scarring can occur, leading to deformity and functional disability.
- Balanitis and secondary infection of ulcers
- Elephantiasis of the genitals may occur secondary to lymphatic obstruction.
- Extragenital involvement with potential fatal spread to the viscera
- Recurrent disease even months to years after treatment (usually associated with HIV infection)
REFERENCES
11 Richens J. Donovanosis (granuloma inguinale). Sex Transm Infect. 2006;82(Suppl 4):iv21-iv22.22 Roett MA, Mayor MT, Uduhiri KA. Diagnosis and management of genital ulcers. Am Fam Physician. 2012;85(3):254-262.33 Workowski KA, Berman S, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1-137.
CODES
ICD10
A58 Granuloma inguinale
ICD9
099.2 Granuloma inguinale
SNOMED
- Granuloma inguinale (disorder)
- Donovanosis - inguinal lesion
- Donovanosis - anogenital ulcer
CLINICAL PEARLS
- Presents as SC nodules or superficial blisters in the genital area that develop into open sores, usually painless.
- Unusual in the United States.
- The disease is transmitted usually through sexual activity, including vaginal and anal sex. It can, however, be transmitted through breaks in the skin such as contact with ulcers of an infected person.
- Antibiotic treatment is available and must be tailored to the patient (e.g., pediatric, pregnant, coexisting conditions).
- It can be transmitted through an infected birth canal from a pregnant woman to her fetus.