Granuloma Inguinale

Granuloma Inguinale overview and Definition

Granuloma inguinale is a sexually transmitted infection (STI). This STI causes lesions in the anal and genital regions. These lesions can recur, even after treatment.Granuloma inguinale is sometimes called “donovanosis.” The incubation period is 1-12 weeks.


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. it is more common among the peoples who are 20-40 years of age.


Ulcerovegetative type:

  • Single or multiple painless firm papules and nodules (granulomas) arise at the site of contact.
  • They then erode into soft, painless ulcers that bleed easily.
  • In skin folds, they have a linear ‘knife cut’ appearance.
  • The ulcer base consists of beefy red granulation tissue and the margins are sharp with rolled or heaped-up borders.

Nodular type:

The nodular type of granuloma inguinale is less common than the ulcerovegetative type and consists of a mixture of papules and nodules that are soft and red, also with some granulation tissue.

Hypertrophic type:

The hypertrophic type of granuloma inguinale consists of large vegetating masses, which has been described as a  ‘walnut' appearance.

Necrotic type:

The necrotic type of granuloma inguinale consists of a deep foul-smelling ulcer.

Cicatricial (sclerotic) type:

Cicatricial granuloma inguinale consists of extensive plaques of scar tissue.

  • Penis, scrotum, groin, and thighs in men
  • Vulva, vagina, and perineum in women
  • Anus and buttocks in patients who engage in anal-receptive intercourse
  • Face in both sexes
  • The intracellular organism responsible for granuloma inguinale was first describes by Donovn over and subsequently bacterium was classified as Calymmatobacterium granulomatis. The organism is termed as follows such as  Calymmatobacterium granulomatis , Donovian granulomatosis and Klebseilla granulomatis. The primary mode of transmission of granuloma inguinale occurs through sexual contact. But it tends to possess low infection because repeated exposure is necessary to cause the clinical infection. The organism can also be obtained through fecal route r by passage through an infected birth canal.

Routes of Transmission

The main route of transmission is by the sexual route.

Clinical signs & symptoms

The symptoms can take place at 50 days but it also can vary from few days to years. The initial lesion is usually a firm papule or subcutaneous nodule at the site of the contact which late than ulcerates. The areas most commonly affected are penis( corona, glans and prepiuce), the vulva that is labia minora and fourchette and the anal area which is more common in men.

Differential Diagnosis

The microscopic analysis provides the best result. The key is to observe adequately stained Donovan bodies (intracellular bacteria) .

Classical approach is a slow overnight staining by Giemsa method, Leishman’s stain or Wright’s stain. Before that the specimen has to be obtained by means of a forceps, currette, or the edge of a safety razor blade, and then crushed between two slides.

 A modified Giemsa stain also called as RapiDiff is known to give rapid results. The organisms stained in this way are ovoid and pleomorphic with pink capsule and bluish or purplr body. Donovan bodies have also been observed in papanicoulau smears.

In advanced laboraties, a transmitting electron microscopy may be used for the evaluation of the ultrastructural features of klebsiella granulomatis comb.  In endemic areas indirect immunofluorescence also plays a role, albeit the evidence for firm diagnosis lacking.

Culture and Histopathology:

Modified chlamydia culture was also used for this process. For lesions that are small, sclerotic, dry or necrotic then the biopsy is must and subsequent histological examination is also very important. Giemsa and silver staining are most efficient for visualizing the micro organisms in tissue sections. The characteristics histological finding reveals chromic inflammation with a preponderance of polymorphonuclears and plasma cells which can also be found in epidermis.

Molecular Techniques

Although the use of polymerase chain reaction (PCR), which is a molecular diagnostic tool, in diagnosing granuloma inguinale has been reported, the technique is still mostly available as a research tool. Amplification of Klebsiella-like sequences was initially achieved by using primers that target the phoE gene.

Later a diagnostic PCR tool was developed from the observation that two unique base changes in the aforementioned gene eliminate HaeIII restriction sites, which enables clear distinction from closely related Klebsiella species. This method was then further refined into a colorimetric PCR test that is becoming ever-more pervasive in diagnostic microbiology laboratories.

Recently introduced was also a multiplex PCR that targets genital ulcers, and hence includes Klebsiella granulomatis comb. nov. alongside Treponema pallidum (causative agent of syphilis), Haemophilus ducreyi (causative agent of chancroid) and herpes simplex viruses.

The skin lesions consists of 3 stages:

Stage 1:

Initially small pimple will begin to spread and eat away 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 can take place around the anus and genitalis. Although the bumps are painless, they can blees if they are injured.

Stage 2:

In the second stage the 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 or inguinal area.  You will notice that the perimeters of the ulcer are lined with the granulated tissue. A foul smell may accompany the ulcers.

Stage 3:

When granuloma inguinale advances to the third stage the ulcers become deep and mask into scar tissue



Relapse may occur up to 18 months after treatment. If untreated, the lesions may continue to expand for years. 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 carcinoma develops less often but basal call carcinoma develops in the longstanding ulcers.


Have safe sexual practices

Avoid multiple sexual partner

Avoid touching the contaminated inanimate objects