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Granuloma Inguinale

Granuloma inguinale, or donovanosis, is a result of infection with Calymmatobacterium granulomatis. After an incubation period of 8 days to 12 weeks, single or multiple subcutaneous nodules develop at the site of inoculation.


These lesions erode to form painless ulcerations that have clean, friable bases and distinct rolled margins.


True inguinal lymphadenopathy does not occur, although a few patients have associated swelling and ulceration in the inguinal area because of infection around the lymph node. This entity is described as a pseudobubo. Without treatment, granuloma inguinale does not tend to heal spontaneously but leads to progressive destruction of the genitalia, with extensive scarring and fibrosis.


Multiple variants of granuloma inguinale exist

  1. The Ulcerovegetative Or Ulcerogranulomatous Form Is The Most Common Variant, producing large, extensive ulcerations.
  2. Nodular Granuloma inguinale consists of soft, red nodules, which then erode to form ulcers.
  3. The Hypertrophic Form produces large vegetating masses that may resemble condylomata acuminata. 4.Lastly, cicatricial granuloma inguinale is a rare form associated with expanding scar tissue formation.

Isolation of C. granulomatis is difficult and impractical. Hence diagnosis is based on direct visualization of the intracytoplasmic Donovan bodies (safety pin-shaped organisms). This is achieved with Giemsa or Wright staining of tissue smears or skin biopsy specimens.

  1. Granuloma Inguinale (Donovanosis)
    Trime thoprim - sulfamethoxazole one double-strength (800mg/160mg) tablet orally twice a day for at least 3 weeks. Or till ulcer heals
    No response in 7 days-Add gentamicin 1 mg/kg IV – 8hrly
    Allergic to sulpha –Doxycycline 100mg BD –21 d
  2. Special Considerations:
    Pregnancy, - Erythromycin 500 mg orally QID for 21 days
    HIV Infection, - Add gentamicin.
    Sex partner - Offer same trt
  3. Genital Herpes
    Genital herpes has traditionally been associated with herpes simplex virus type 2 (HSV-2).  10% of these infections are due to HSV-1 as a result of orogenital sex.
  4. Aetiology
    1. Herpes simplex viruses include two distinct but closely related viruses, namely, HSV-1 and HSV-2. Both viruses can cause genital herpes.
    2. Roughly speaking, HSV-2 causes 90% and HSV-1 causes 10% of all genital herpes.
    3. Herpes simplex virus is a linear double-stranded DNA virus. HSV-1 and HSV-2 share approximately 50% homology of their genetic materials and they even express type-common surface antigens. It accounts for the high degree of cross-reactivity and the technical difficulty in differentiating the 2 viruses.
    4. On the other hand, HSV-1 & HSV-2 antibodies offer some degree of cross protection.
    5. Cell-mediated immune responses is more important than humoral responses in determining the severity of HSV infections.
    6. Hence, HIV patients often have chronic and severe anogenital herpes.
    7. Genital herpes is transmitted by sexual intercourse.
    8. Direct inoculation of virus occurs through contact with infected secretions or mucosal surfaces.
    9. Orogenital contact with a partner with type 1 herpes labialis can also result in genital herpes.
    10. Asymptomatic shedding of HSV is the most common mode of transmission of genital herpes infection.
    11. It is estimated that more than half of the HSV-2 genital infections are asymptomatic.
      The average incubation period for HSV is 7 to 10 days, with a range of 2 to 21 days. After incubation, the primary lesion arises, comprised of multiple, small, grouped vesicles on an erythematous base.
  5. Clinical Features
    1. Primary Genital Herpes
      1. Primary attack tends to be more severe than recurrent attacks and is more severe in women than men. The average duration of the attack is about 3 weeks.
      2. Typically, the disease present as multiple painful genital or peri-genital ulcerations. The ulcerations are preceded by erythematous vesicles.
      3. Subsequently, crusts are formed and eventually, they heal spontaneously with no scarring.
      4. In women, lesions usually occur on the labia minora, clitoris, perineum, perianal area and the cervix.
      5. In men, the penis, perianal area and anus are commonly involved sites. Cutaneous lesions and viral shedding last about 2 weeks. It takes another 1 week for the lesions to heal. Anorectal herpes gives rise to pain, discharge and constipation.
      6. Bilateral tender inguinal lymphadenopathy is a common associated feature of primary but not recurrent attacks. Primary genital herpes tends to produce more systemic symptoms (i.e. fever, malaise, arthralgia, headache) than recurrent attacks.
    2. Recurrent Infections
      After penetrating the host mucocutaneous surface, HSV is taken up by the peripheral sensory nerves and is carried centripetally to the sensory or autonomic ganglion, where they establish prolong, latent infection. Reactivation of latent infection gives rise to local recurrent skin lesions.
      Recurrent infection tends to be more localized, shorter duration and produces less systemic symptoms than the primary attack.
      The exact mechanism of reactivation of the virus is unknown but is associated with the following factors:
      1. local trauma (e.g. abrasion resulting from sexual intercourse)
      2. menstruation
      3. stress
      4. exposure to sunlight
      5. HSV type: HSV-2 has a higher risk of recurrence than HSV-1
        Prodromal symptoms of local tingling, burning or paraesthesia occur in 50% of recurrent infections. They may precede the localized painful erythematous vesicles or ulcerations by 24-48 hours. The lesions heal more quickly than the primary attack.
    3. Diagnosis of genital herpes is often based on clinical presentation but should be confirmed by viral culture, if possible.
      Other means of diagnosis are visualization of multinucleated giant cells on Tzanck or Papanicolaou smears, viral antigen and DNA detection tests, and electron microscopy.
      Serologic assays are significantly less sensitive and less specific than viral isolation and are not useful for the diagnosis of genital herpes.
  6. Genital Herpes
    1. First Clinical Episode of Genital Herpes
    2. Acyclovir 200 mg orally five times a day for 7 days,
      Famciclovir 250 mg orally three times a day for 7 days, (secondary infection septran DS one BD –7 day)
    3. Episodic Therapy for Recurrent Genital Herpes
    4. Acyclovir 200 mg orally five times a day for 5 days
      Famciclovir 125 mg orally twice a day for 5 days, (Initiate within 1 day of lesion onset or during prodrome)
    5. Suppressive Therapy for Recurrent Genital Herpes
    6. Acyclovir 400 mg orally twice a day,(>6episodes/yr)
      Famciclovir 250 mg orally twice a day (for minimum 1 year)
  7. Special Considerations:

Severe (Pnemonitis, hepatitis CNS)

- Inj Acyclovir 5- 10 mg /kg IV 8 hrly –2-7 days,


F/B-Oral acyclovir to complete – total of 10 days

Genital Herpes in Pregnancy

- First, second, third trimester


Supportive trt + / -


Acyclovir 200 mg orally five times a day for 7 days—depending on severity of episode


During labour


If active genital lesion-LSCS


Women without known genital herpes should be counseled to avoid intercourse during the third trimester with partners known or suspected of having genital herpes.


HIV Infection

- Episodic Infection in Persons with HIV


Acyclovir 200 mg five times a day for 5--10 days,




Famciclovir 500 mg orally twice a day for 5--10 days,


a. Daily Suppressive Therapy in HIV


b. Acyclovir 400--800 mg orally twice to three times a day,


OR Famciclovir 500 mg orally twice a day,

Neonatal Herpes

-Acyclovir 20 mg/kg body weight IV every 8 hours for 21 days for disseminated and CNS disease, or 14 days for disease limited to the skin and mucous membranes.


Sex partner

- Symptomatic - same trt


Asymptomatic –counseling


- Inform –about chronicity and recurrences


Inform –sexual partner


Encourage use of latex condom

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