174: Granuloma Inguinale Flashcards
What is Granuloma Inguinale and what are its primary characteristics?
Granuloma Inguinale (GI) is a rare, chronic, progressive ulcerative disease primarily affecting the genital and perigenital skin, caused by infection with Klebsiella granulomatis, a gram-negative bacterium, and is primarily sexually transmitted. Diagnosis is confirmed by the presence of intracellular Donovan bodies on histology.
What is the typical incubation period for Granuloma Inguinale?
The typical incubation period for Granuloma Inguinale is 2 to 3 weeks.
What are the most common sites affected by Granuloma Inguinale in men?
Most common sites in men: 1. Coronal sulcus 2. Prepuce 3. Glans penis
What are the most common sites affected by Granuloma Inguinale in women?
Most common sites in women: 1. Labia minora 2. Fourchette 3. Perineum
What are the four clinical types of Granuloma Inguinale?
The four clinical types of Granuloma Inguinale are: 1. Ulcerogranulomatous (MC): Highly vascular, beefy red ulcers that are nontender but bleed to touch. 2. Hypertrophic: Resembles condylomata acuminata. 3. Necrotic: Foul-smelling, deep ulcer with copious gray exudate and extensive destruction to surrounding tissues. 4. Sclerotic: Nonbleeding ulcers that form fibrous band-like scars.
How does the transmission rate of Granuloma Inguinale compare to other sexually transmitted infections (STIs)?
The transmission rate of Granuloma Inguinale between sexual partners is lower compared to other STIs.
What is the most likely diagnosis for a man with a single, firm papule on his genital area that ulcerated and increased in size over two weeks?
The most likely diagnosis is Granuloma Inguinale (GI), caused by Klebsiella granulomatis.
What clinical type of Granuloma Inguinale is characterized by beefy red, non-tender ulcers that bleed to touch?
This is the ulcerogranulomatous type of Granuloma Inguinale.
What clinical type of Granuloma Inguinale involves foul-smelling, deep ulcers with copious gray exudate?
This describes the necrotic type of Granuloma Inguinale.
What clinical type of Granuloma Inguinale is characterized by fibrous band-like scars?
This is the sclerotic type of Granuloma Inguinale.
What does the presence of anal lesions in men involved in receptive anal intercourse suggest about Granuloma Inguinale?
It suggests a venereal origin of Granuloma Inguinale.
How can Granuloma Inguinale be transmitted to a newborn?
In rare cases, Granuloma Inguinale can be transmitted transvaginally during delivery.
What phenomenon in Granuloma Inguinale can lead to the formation of multiple ulcers?
The phenomenon of self-inoculation can lead to the formation of multiple ulcers, also known as ‘kissing lesions.’
What percentage of Granuloma Inguinale cases involve extragenital sites?
Extragenital sites are involved in 6% of cases.
What is a subcutaneous granuloma called in the context of Granuloma Inguinale?
In Granuloma Inguinale, a subcutaneous granuloma is referred to as a ‘pseudobubo.’
What are the most common sites of involvement in women with Granuloma Inguinale?
The most common sites of involvement in women are the labia minora, fourchette, and perineum.
What are the most common sites of involvement in men with Granuloma Inguinale?
The most common sites of involvement in men are the coronal sulcus, prepuce, and glans penis.
What clinical type of Granuloma Inguinale resembles condylomata acuminata?
This describes the hypertrophic type of Granuloma Inguinale.
What is the hallmark feature of the ulcerogranulomatous type of Granuloma Inguinale?
The hallmark feature is highly vascular, beefy red ulcers that bleed to touch.
What does the presence of lesions on the cervix suggest about Granuloma Inguinale?
It supports the venereal origin of Granuloma Inguinale.
What is the primary mode of transmission for Granuloma Inguinale?
The primary mode of transmission is sexual, with a predominance of genital lesions.
What are the common clinical features of Granuloma Inguinale?
Common clinical features include: 1. Incubation period: 2 to 3 weeks 2. Initial presentation: A single firm papule or subcutaneous nodule that ulcerates and gradually increases in size.
What are the distinguishing features of Granuloma Inguinale?
Distinguishing features include: 1. Lack of pain 2. Beefy red appearance 3. Presence of kissing lesions.
What complications may arise if Granuloma Inguinale is left untreated?
If left untreated, it may progress to pseudoelephantiasis, paraphimosis, phimosis, and increase the risk of HIV transmission.
What is the recommended duration of treatment for Granuloma Inguinale?
The duration of treatment should be at least 3 weeks and until complete healing is achieved.
What are the recommended management strategies for Granuloma Inguinale?
Management strategies include prolonged therapy, consideration of aminoglycoside if no improvement, and prophylaxis with azithromycin for children.
What diagnostic methods are used for Granuloma Inguinale?
Diagnostic methods include: 1. Donovan bodies stained with Giemsa, Wright, Gram, and silver stains. 2. Rapid Giemsa method. 3. Tissue biopsy from the advancing edge of the ulcer.
What staining methods can confirm the presence of Donovan bodies?
Donovan bodies can be confirmed using Giemsa, Wright, Gram, and silver stains.
What histological findings might be present in a biopsy from a Granuloma Inguinale lesion?
Histological findings may include pseudoepitheliomatous hyperplasia and a dense mixed inflammatory infiltrate.
What does the ‘closed safety pin’ appearance on microscopy indicate?
This describes the immature form of Klebsiella granulomatis.
What additional treatment can be considered if a patient with Granuloma Inguinale is not responding to initial therapy?
The addition of aminoglycoside (gentamicin) can be considered.
What prophylactic regimen should be administered to children with Granuloma Inguinale?
Children should receive a prophylactic 3-day course of azithromycin 20 mg/kg once daily.
What other severe complications might occur if Granuloma Inguinale is left untreated?
Untreated Granuloma Inguinale may lead to paraphimosis, phimosis, increased risk of HIV transmission, and carcinoma development.
Is relapse common after treatment for Granuloma Inguinale?
Yes, relapse may occur 6-18 months after effective therapy.
Which infections should patients with Granuloma Inguinale be screened for?
Patients should be screened for HIV and syphilis.
What is the typical clinical course of Granuloma Inguinale?
Granuloma Inguinale shows no tendency for spontaneous healing and may progress to severe complications if untreated.
What are the distinguishing features of Granuloma Inguinale lesions?
Distinguishing features include lack of pain, beefy red appearance, and the presence of kissing lesions.
How long should therapy for Granuloma Inguinale continue?
Therapy should continue for at least 3 weeks and until complete healing is achieved.
What should be done if a Granuloma Inguinale lesion has not improved after three weeks of therapy?
Therapy should be prolonged until complete healing is achieved.
What should be done for a lesion that has not healed after three weeks of therapy?
Therapy should be prolonged until complete healing is achieved, and additional treatments like aminoglycosides may be considered.
What is the typical relapse period for Granuloma Inguinale?
Relapse may occur 6-18 months after effective therapy.
What histological findings are expected in a biopsy of Granuloma Inguinale?
Histological findings may include pseudoepitheliomatous hyperplasia, ulcerations, and a dense mixed inflammatory infiltrate in the dermis.
What staining methods are used to identify Donovan bodies?
Donovan bodies can be identified using Giemsa, Wright, Gram, and silver stains.
What cells are used for successful culture of Klebsiella granulomatis?
Successful culture can be achieved using human peripheral blood mononuclear cells and HEp-2 cells.
What are the distinguishing features of Granuloma Inguinale lesions?
- Lack of pain
- Beefy red appearance
- Presence of kissing lesions
What is the recommended duration of therapy for Granuloma Inguinale?
The recommended duration of therapy is at least 3 weeks and until complete healing is achieved.
What are the common presentations of Granuloma Inguinale in infants?
- Otitis media
- Lymphadenitis
- Mastoiditis
- Meningitis
What is the causative agent of Granuloma Inguinale?
Klebsiella granulomatis, a facultative gram-negative, nonmotile, pleomorphic bacterium that resides in the cytoplasm of large mononuclear cells.
What are the potential complications if Granuloma Inguinale is left untreated?
- Progression to pseudoelephantiasis, paraphimosis, and phimosis
- Increased risk of HIV transmission
- 0.25% development of carcinoma
What is the role of aminoglycosides in the management of Granuloma Inguinale?
Aminoglycosides, such as gentamicin, can be added if improvement is not evident within the first few days of therapy.
What should be done for children diagnosed with Granuloma Inguinale?
Children should receive prophylaxis with a 3-day course of azithromycin 20 mg once daily.
What are the histological findings associated with Granuloma Inguinale?
Histological findings may include pseudoepitheliomatous hyperplasia or ulcerations, dense mixed inflammatory infiltrate composed of histiocytes, plasma cells, and rare lymphocytes.
What is the clinical course of Granuloma Inguinale if left untreated?
If left untreated, Granuloma Inguinale may disseminate to the liver, ovaries, uterus, or bone, which can be fatal.
What are the potential long-term complications of Granuloma Inguinale?
Long-standing cases may be complicated by secondary bacterial infections, fistula, and abscess formation.
What is the importance of screening for other STIs in patients with Granuloma Inguinale?
Patients should be screened for other STIs, notably HIV and syphilis, due to the increased risk of transmission.
What is the appearance of the immature form of Klebsiella granulomatis?
The immature form is unencapsulated and has a ‘closed safety pin’ appearance.
What is the significance of the Giemsa stain in the diagnosis of Granuloma Inguinale?
Giemsa stain is used to identify Donovan bodies, which are characteristic of Granuloma Inguinale.
What are the clinical implications of the lack of spontaneous healing in Granuloma Inguinale?
The lack of spontaneous healing indicates that treatment is necessary to prevent progression and complications of the disease.
What is the recommended approach for biopsy in suspected cases of Granuloma Inguinale?
Tissue for biopsy should be taken from the advancing edge of the ulcer to ensure accurate diagnosis.
What are the potential risks associated with untreated Granuloma Inguinale?
Untreated Granuloma Inguinale may lead to severe complications such as tissue destruction and increased risk of HIV transmission.
What is the role of reepithelialization in the management of Granuloma Inguinale?
Reepithelialization is crucial for healing ulcers, and prolonged therapy is required to permit this process.
What is the expected timeline for relapse after effective treatment of Granuloma Inguinale?
Relapse may occur 6-18 months after effective therapy.
What are the characteristics of the mature form of Klebsiella granulomatis?
The mature form is encapsulated, which differentiates it from the immature form.
What is the significance of the presence of kissing lesions in Granuloma Inguinale?
Kissing lesions are a distinguishing feature of Granuloma Inguinale, indicating the presence of the disease.
What is the recommended treatment for secondary bacterial infections in patients with Granuloma Inguinale?
Secondary bacterial infections should be managed appropriately, often requiring antibiotics based on culture results.
What is the histological composition of the dermis in Granuloma Inguinale?
The dermis contains dense mixed inflammatory infiltrate composed of histiocytes, plasma cells, and rare lymphocytes.
What is the clinical significance of the beefy red appearance of Granuloma Inguinale lesions?
The beefy red appearance is a characteristic feature of the lesions, indicating active inflammation and the need for treatment.
What is the role of tissue biopsy in the diagnosis of Granuloma Inguinale?
Tissue biopsy helps confirm the diagnosis by revealing characteristic histological features and the presence of Donovan bodies.
What are the implications of the 0.25% risk of carcinoma in untreated Granuloma Inguinale?
The 0.25% risk of carcinoma highlights the importance of early diagnosis and treatment to prevent malignant transformation.
What is the importance of monitoring for HIV in patients with Granuloma Inguinale?
Monitoring for HIV is crucial due to the increased risk of transmission associated with untreated Granuloma Inguinale.
What is the expected outcome of treatment for Granuloma Inguinale?
With appropriate treatment, the progression of lesions halts, and healing typically occurs inward from the ulcer margins.
What are the potential effects of Granuloma Inguinale on the gastrointestinal system?
Granuloma Inguinale shows no tendency for spontaneous healing, which can lead to severe complications if untreated.
What is the recommended follow-up for patients treated for Granuloma Inguinale?
Patients should be monitored for signs of relapse and complications, including secondary infections and abscess formation.
What is the significance of the Rapid Giemsa method in diagnosing Granuloma Inguinale?
The Rapid Giemsa method is a quick diagnostic tool that aids in identifying Donovan bodies in suspected cases.
What are the implications of the presence of hypertrophic and cicatricial forms of Granuloma Inguinale?
Hypertrophic and cicatricial forms may exhibit fibrosis, indicating chronicity and the need for more aggressive treatment.
What is the clinical approach to managing long-standing cases of Granuloma Inguinale?
Long-standing cases require careful management to address complications such as secondary infections and abscess formation.
What is the role of patient education in the management of Granuloma Inguinale?
Patient education is essential to ensure adherence to treatment and awareness of potential complications and the importance of follow-up.
What should be done regarding sexual contacts in the previous 6 months for individuals diagnosed with Granuloma Inguinale?
All sexual contacts in the previous 6 months should be examined.
Is treatment of sexual partners necessary for Granuloma Inguinale?
Treatment of sexual partners is not necessary unless they develop signs and symptoms of Granuloma Inguinale.
Should a sexual partner without symptoms be treated if they are in contact with a patient with Granuloma Inguinale?
Treatment of sexual partners is not necessary unless they develop signs and symptoms of Granuloma Inguinale.
What should be done if a patient with Granuloma Inguinale has been in contact with multiple partners in the past six months?
All sexual contacts in the previous 6 months should be examined.
What is the recommended protocol for examining sexual contacts of a patient diagnosed with Granuloma Inguinale?
All sexual contacts in the previous 6 months should be examined.
Under what circumstances should sexual partners of a patient with Granuloma Inguinale be treated?
Treatment of sexual partners is not necessary unless they develop signs and symptoms of Granuloma Inguinale.
What is the recommended treatment for Granuloma Inguinale according to the CDC (2015)?
Azithromycin 1 g orally once weekly or 500 mg/day.
What are the alternative treatments for Granuloma Inguinale as per the CDC (2015)?
- Doxycycline 100 mg orally twice daily
- Ciprofloxacin 750 mg orally twice daily
- Erythromycin base 500 mg orally four times daily
- Trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) tablet orally twice daily.
What is the recommended treatment for Granuloma Inguinale according to the WHO (2003)?
Azithromycin 1 g orally once; then 500 mg/day or Doxycycline 100 mg orally twice daily or Erythromycin 500 mg four times daily or Tetracycline 500 mg four times daily or Trimethoprim 80 mg/sulfamethoxazole 400 mg, 2 tablets, twice daily for a minimum of 14 days.
What is the recommendation for treating pregnant patients with Granuloma Inguinale?
Macrolide antibiotic (azithromycin or erythromycin) as dosed above.
What is the minimum duration of treatment for any regimen for Granuloma Inguinale?
At least 3 weeks and until all lesions have completely epithelialized.
What are the characteristics of primary syphilis in the differential diagnosis of granuloma inguinale?
Chancres are painless, punched-out, pink ulcer with a nonpurulent clean base and irregular raised border, usually hard and firm.
How does secondary syphilis present in the context of granuloma inguinale differential diagnosis?
Condyloma lata is present as a pale, white, mossy warty plaque but may rarely ulcerate.
What initial symptoms are associated with lymphogranuloma venereum?
Initially presents as an asymptomatic genital papule or pustule or a symptomatic ulceration; later, inguinal buboes form.
What are the characteristics of chancroid in the differential diagnosis of granuloma inguinale?
Chancroid presents with painful ulcers, often yellow in color, with surrounding erythema and painful lymphadenopathy.
What are the features of condyloma acuminatum in the differential diagnosis?
Condyloma acuminatum appears as white, gray, or skin-colored warty papules or may be giant cauliflower-like lesions.
What is the significance of squamous cell carcinoma in the context of long-standing necrotic lesions?
It is important to rule out malignancy in long-standing necrotic lesions, especially those that do not respond to conventional therapy.
How does genital amebiasis present in the differential diagnosis of granuloma inguinale?
Genital amebiasis presents with painful genital ulcers without genitourinary discharge.
What are the characteristics of chronic herpes simplex in the differential diagnosis?
May present with chronic nonhealing genital ulcers with exuberant granulation tissue or with more verrucous growth.
What are the features of leishmaniasis in the context of extragenital involvement?
Leishmaniasis often presents as a nonhealing papule or nodule that enlarges slowly and may develop central ulceration or raised, indurated border.
What are the characteristics of paracoccidioidomycosis in the differential diagnosis?
Paracoccidioidomycosis presents with red painful plaques on oral and nasal mucosa.
What are the features of pyoderma gangrenosum in the differential diagnosis?
Pyoderma gangrenosum presents as painful solitary nodules or pustules that transform into ulcers with undermined borders.
How does cutaneous tuberculosis present in the differential diagnosis of granuloma inguinale?
Cutaneous tuberculosis presents with tuberculous chancres: firm, shallow ulcer with granular base; may also have dissemination to organs such as liver or bone.
What is condyloma acuminatum as a differential diagnosis of granuloma inguinale?
White, gray, or skin-colored warty papules or may be giant cauliflower-like lesions.
What is malacoplakia and how does it present?
Solitary or multiple soft papules and nodules, often in the urinary tract.
How do genital amebiasis ulcers present as a differential diagnosis of granuloma inguinale?
Painful genital ulcers with or without genitourinary discharge.
What are the characteristics of chronic herpes simplex as a differential diagnosis of granuloma inguinale?
May present with chronic nonhealing genital ulcers with exuberant granulation tissue or with more verrucous growth.
What are the features of leishmaniasis as a differential diagnosis of granuloma inguinale?
Often starts as nonhealing papule or nodule that enlarges slowly and may develop central ulceration or raised, indurated border.
What are the symptoms associated with paracoccidioidomycosis as a differential diagnosis of GI?
Red painful plaques that may involve oral and nasal mucosa.
What is the presentation of cutaneous tuberculosis as a differential diagnosis of granuloma inguinale?
Tuberculous chancres: firm shallow ulcer with granular base; may also have dissemination to organs such as liver or bone.
