Donovanosis

Overview

Donovanosis is a rare cause of genital ulceration but should be considered in patients returning from areas where the disease may be endemic e.g. PNG, Southern Africa, India and parts of South America.
Primarily sexually transmissible but may be transmitted vertically and by casual contact.
Incident cases were found as recently as mid 2000s in northern and tropical Australia among Aboriginal and Torres Strait Islander people, but it is now very rare in these areas.

Cause

Klebsiella granulomatis

Clinical presentation

Male	Female
Symptoms
Relatively painless ano-genital ulceration	Relatively painless ano-genital ulceration
Lesions may be ulcerative: shallow ulcers which bleed on contact; proliferative: raised lesions with a ‘beefy’ appearance or ulcero-proliferative: a combination of the two.	Lesions may be ulcerative: shallow ulcers which bleed on contact; proliferative: raised lesions with a ‘beefy’ appearance or ulcero-proliferative: a combination of the two.
Secondary anaerobic bacterial infection may result in offensive odour in association with the primary lesions.	Lesions may involve the vulvo-labial area, vagina, cervix, perineum and perianal area.
Complications
Extra-genital disease is rare but may involve non-genital mucous membranes e.g. mouth, external ear canal and distant sites through haematogenous spread e.g. long bones, psoas muscle.	Extra-genital disease is rare but may involve non-genital mucous membranes e.g. mouth, external ear canal and distant sites through haematogenous spread e.g. long bones, psoas muscle.
Chronic, untreated ulcers may undergo neoplastic transformation.	Contiguous spread from cervix to pelvis may involve uterus, fallopian tubes, ovaries and other pelvic structures.
Increase in HIV transmission risk.	Chronic lesions may cause local tissue lymphatic destruction with subsequent pseudo-elephantiasis of genitalia.
	Vertical transmission to neonate during vaginal delivery.

See STI Atlas for images.

Diagnosis

Test	Site/Specimen	Consideration
Histology	Punch biopsy of lesion – formalin fixation (preferred specimen). Impression smear – glass slide pressed onto lesion, air dried. Sections and smears are Giemsa-stained.	Low to moderate sensitivity but highly specific; requires experienced histopathologist as classic Donovan bodies may be sparse.
NAAT	Dry swab or punch biopsy of lesions.	Highly sensitive and specific but NAAT only available in research laboratories.
NAAT – Nucelic Acid Amplification Test

Test

Site/Specimen

Consideration

Histology

Punch biopsy of lesion – formalin fixation (preferred specimen).
Impression smear – glass slide pressed onto lesion, air dried.
Sections and smears are Giemsa-stained.

Low to moderate sensitivity but highly specific; requires experienced histopathologist as classic Donovan bodies may be sparse.

NAAT

Dry swab or punch biopsy of lesions.

Highly sensitive and specific but NAAT only available in research laboratories.

NAAT – Nucelic Acid Amplification Test

Specimen collection

Clinician collected | Self-collection

Investigations

Extra-genital disease should be considered in patients with current genital infection and in patients with a past history of donovanosis who present with unusual symptoms.

Management

Principal Treatment Options
Situation	Recommended	Alternative
Ano-genital lesions	Azithromycin 500mg PO, daily for 7 days OR Azithromycin 1g PO, once weekly for at least 4 weeks, until complete resolution of lesions	Doxycycline 100mg PO, BD for a minimum of 4 weeks, until complete resolution of lesions.

Treatment advice

Azithromycin is highly effective and well tolerated.
Adherence to treatment is essential to ensure cure. Consider directly-observed therapy. Presumptive treatment should be commenced on clinical grounds while waiting for diagnostic confirmation or if laboratory services are not available.
Seek specialist advice.

Other immediate management

Advise no sexual contact for 7 days after treatment is administered
Advise no sex with partners from the last 6 months until the partners have been reviewed and treated if necessary
Contact tracing
Provide patient with factsheet
Notify the state/territory health department.

Special treatment situations

Special considerations

Consider seeking specialist advice before treating this rare condition in any complicated presentation.
Neonates born to a mother with untreated donovanosis at time of delivery should be followed closely for the development of lesions.
Patients may require hospital admission if compliance with treatment is poor or disseminated disease present.
Many guidelines recommend treating with azithromycin until lesions have completely healed but there is no evidence that longer treatment is beneficial. Non-azithromycin regimens should be continued until complete resolution of lesions.

Situation

Recommended

Complicated or disseminated infection

May require prolonged treatment.

Pregnant women

Azithromycin is the recommended treatment.

Allergy to principal treatment choice

See alternative treatment option above.

Contact tracing

Contact tracing of sexual partners in last 6 months is recommended but yield is low.

See Australasian Contract Tracing Manual – Donovanosis for more information.

Follow up

Review in 1 week provides an opportunity to:

Confirm patient adherence to treatment and assess for symptom resolution.
Confirm contact tracing has been undertaken or offer more contact tracing support.
Provide further sexual health education and prevention counselling.

Test of Cure (TOC)

Relapse/re-infection occurs and patients should be reviewed at completion of treatment course and at 3 months.
Recurrence of lesions may represent development of skin cancer in previous lesions and requires biopsy.

Retesting

Not required but provides the opportunity to retest, post the window period, for other STIs, if not undertaken at first presentation.

Auditable outcomes

100% of diagnoses are notified to the state/territory health department.

Last Updated: Wednesday, 11 July 2018