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. [5]
Physical Examination
Morphology
The four main types of cutaneous lesions are as follows:
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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].
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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.
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Cicatricial: Dry ulcers evolve into cicatricial plaques and may be associated with lymphedema.
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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.
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. [6] 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. [5]
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. Recognition of extragenital donovanosis as a cause of lymphadenopathy is important in patients with HIV. [7]
Lymphadenopathy does not occur as a result of the primary infection with Klebsiella 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. [5] Hematogenous dissemination to the spleen, lungs, liver, bones, and the orbits may occur and occasionally results in death.
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 and basal 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. [8, 9]
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. [5, 7]
Autoamputation of the penis has been reported in a man with long-standing granuloma inguinale associated with underlying HIV-2 infection. [10]
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Beefy-red penile ulcers.
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Courtesy of Hon Pak, MD.
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Courtesy of Hon Pak, MD.
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Courtesy of Hon Pak, MD.
