ConditionInfections
Granuloma Inguinale (Donovanosis)
Granuloma inguinale, also called donovanosis, is a rare sexually transmitted bacterial infection caused by Klebsiella granulomatis. It causes painless, slowly enlarging, beefy-red ulcers on the genitals or around the anus that bleed easily on contact. It is very uncommon in the US and mostly seen in parts of India, Papua New Guinea, southern Africa, Brazil and among Indigenous communities in Australia. It is cured with antibiotics, usually azithromycin, taken until the ulcers heal.
Also called: Donovanosis, granuloma venereum, chronic granulomatous ulceration, Klebsiella granulomatis infection
At a glance
- Cause
- The bacterium Klebsiella granulomatis (formerly Calymmatobacterium).
- Spread
- Mainly sexual contact; rarely from mother to baby or non-sexual skin contact.
- Key sign
- Painless, beefy-red ulcers that bleed easily and grow slowly.
- Where
- Rare in the US; endemic in some tropical and subtropical regions.
- Diagnosis
- Microscopy of tissue showing Donovan bodies; PCR in some labs.
- Treatment
- Azithromycin (or alternatives) for at least 3 weeks and until all lesions heal.
When to get help
See a doctor within a day or two
- Genital ulcers with fever, rapidly spreading tissue destruction, or heavy bleeding
- A genital sore during pregnancy
Book a routine appointment
- Any genital, groin or anal sore or ulcer, even if painless (testing for syphilis, herpes, HIV and others is needed)
- A sore that has lasted more than 2 weeks or keeps growing
- A sexual partner diagnosed with donovanosis in the past 60 days
What granuloma inguinale is
Granuloma inguinale is a chronic, progressive infection of the skin and tissues of the genital area. The bacteria live inside immune cells, forming characteristic structures called Donovan bodies, which are seen under the microscope and give the disease its alternative name. It is mildly contagious, and repeated exposure is usually needed. The incubation period ranges from about 1 to 12 weeks, sometimes longer.
Symptoms
The infection starts as one or more small, firm, painless bumps that break down into ulcers. Four forms are described:
| Form | Appearance |
|---|---|
| Ulcerogranulomatous (most common) | Beefy-red, velvety, painless ulcers that bleed easily and slowly enlarge |
| Hypertrophic or verrucous | Raised, wart-like, dry lesions |
| Necrotic | Deep, foul-smelling ulcers with tissue destruction |
| Sclerotic or cicatricial | Dry ulcers that heal with thick scar tissue |
Other features:
- located on the penis, scrotum, labia, vulva, perineum or around the anus
- lymph nodes are usually not swollen; instead, lesions under the groin skin can look like swollen nodes (pseudobuboes)
- secondary bacterial infection can make lesions painful and smelly
- rarely, spread to the mouth, bones or internal organs
How it differs from other genital ulcers
| Condition | Pain | Ulcer | Lymph nodes |
|---|---|---|---|
| Granuloma inguinale | Painless | Beefy red, bleeds easily, slow-growing | Usually not enlarged (pseudobuboes) |
| Syphilis | Painless | Clean, firm-edged chancre | Firm, painless nodes |
| Genital herpes | Painful | Clusters of small blisters and shallow ulcers | Tender nodes |
| Chancroid | Painful | Ragged, soft ulcer with pus | Painful, may form abscess |
| Lymphogranuloma venereum | Often painless, brief ulcer | Small, transient | Large, painful groin nodes |
Because symptoms overlap and co-infection is possible, testing is essential.
Diagnosis
- Tissue smear or biopsy: a sample from the edge of the ulcer is stained to look for Donovan bodies.
- PCR: available in some specialized and research labs.
- The bacterium is difficult to culture.
- Testing for other STIs: syphilis, HIV, herpes, chlamydia and gonorrhea, as recommended by CDC guidelines.
- Biopsy of long-standing lesions to rule out squamous cell carcinoma, which can develop in or mimic chronic ulcers.
Treatment
CDC guidelines recommend:
- Azithromycin as the preferred antibiotic, taken weekly or daily, for at least 3 weeks and until all lesions have completely healed.
- Alternatives: doxycycline, erythromycin (in pregnancy), or trimethoprim-sulfamethoxazole.
- Adding another antibiotic, such as gentamicin, if lesions do not improve within the first few days.
Healing begins from the edges inward. Relapse can occur 6 to 18 months later even after apparently successful treatment, so follow-up is needed. People with HIV may need longer treatment.
Severe scarring or deformity may require reconstructive surgery.
Sex partners and prevention
- Sex partners from the 60 days before symptoms began should be examined and offered treatment.
- Avoid sexual contact until treatment is complete and lesions have healed.
- Condoms reduce risk but may not cover all affected areas.
- Regular STI testing is recommended for people with new or multiple partners.
Complications
- extensive tissue destruction and scarring
- narrowing of the urethra, vagina or anus
- swelling of the genitals (pseudo-elephantiasis) from blocked lymph drainage
- increased risk of HIV transmission through open ulcers
- squamous cell carcinoma in long-standing lesions (rare)
Frequently asked questions
What does granuloma inguinale look like?
It typically looks like a painless, beefy-red, raw ulcer on the genitals or around the anus that bleeds easily when touched and slowly grows. Some forms are wart-like or deep and smelly. Lymph nodes are usually not swollen.
How is granuloma inguinale transmitted?
It spreads mainly through sexual contact with someone who has active lesions. It is not highly contagious, so repeated exposure is usually needed. Rarely, it passes from mother to baby during birth or by non-sexual skin contact.
Is granuloma inguinale curable?
Yes. Antibiotics, usually azithromycin, cure the infection when taken for at least 3 weeks and until all sores have healed. Relapse can occur months later, so follow-up is important. Scarring may remain if lesions were extensive.
Is granuloma inguinale common in the United States?
No. It is very rare in the US and most cases occur in people who had sexual contact in endemic areas such as parts of India, Papua New Guinea, southern Africa and Brazil. Any genital ulcer in the US is more likely to be herpes or syphilis.
What are Donovan bodies?
Donovan bodies are clusters of the Klebsiella granulomatis bacteria seen inside immune cells when a sample from the ulcer is stained and examined under a microscope. Finding them confirms the diagnosis of granuloma inguinale.
Sources
This guide was written from current patient and clinical guidance, including:
- CDC: Sexually transmitted infections treatment guidelines, granuloma inguinale (donovanosis)
- World Health Organization: Guidelines for the management of symptomatic sexually transmitted infections
- British Association for Sexual Health and HIV (BASHH): Guideline on the management of donovanosis
- MedlinePlus: Granuloma inguinale
- Merck Manual: Granuloma inguinale