Donovanosis

Notification requirement for donovanosis

Donovanosis is a ‘routine’ notifiable condition and must be notified by medical practitioners and pathology services in writing within 5 days of diagnosis.

Notification of selected sexually transmissible infections (STIs) is required under the Public Health and Wellbeing Regulations 2009. To maintain confidentiality, only the name code (the first two letters of the surname followed by the first two letters of the first name) is required.

Registered medical practitioners have a statutory obligation under the Children, Youth and Families Act 2005 to notify the department’s Child Protection, Placement and Family Services Branch if they believe that a child is in need of protection on the basis of sexual abuse.

This is a Victorian statutory requirement.

Primary school and children’s services centre exclusion for donovanosis

Exclusion is not applicable.

Infectious agent of donovanosis

Previously known as Calymmatobacterium granulomatis, a gram-negative bacillus, the causative agent is now named Klebsiella granulomatis.

Identification of donovanosis

Clinical features

Donovanosis is a chronic, progressively destructive infection that affects the skin and mucous membranes of the external genitalia, inguinal and anal regions – hence the name granuloma inguinale. After infection, the disease begins as a single or multiple subcutaneous nodules that erode, leaving beefy-red, fleshy, relatively painless lesions that bleed on contact. This presentation is the most common ulcerogranulomatous form of the disease. Symptoms general appear within 3-40 days after infection.

Other presentations included hypertrophic (an ulcer with a raised cauliflower-like edge), necrotic (a deep ulcer with extensive tissue damage) and sclerotic (typified by excess scar tissue formation).

Complications of donovanosis include genital destruction, disseminated disease and secondary skin malignancy.

Diagnosis

Histopathological examination of tissue biopsies is the most reliable means of diagnosing donovanosis.

The diagnosis is confirmed by demonstrating ‘Donovan bodies’ in slides prepared from tissue, a swab specimen or impression smear on Giemsa stain or silver stain, or by histological examination of biopsy specimens.

Polymerase chain reaction (PCR) detection on swab or tissue specimens may have similar performance characteristics as histopathology. Biopsy and histopathology is the gold standard, and donovanosis PCR should only be considered as an alternative test when biopsy is not possible.

Microscopic examination of tissue smears is insensitive and probably highly nonspecific when performed by an inexperienced microbiologist.

Incubation period of Klebsiella granulomatis

The incubation period is weeks to months. Occasionally, symptoms may take as long as a year to develop.

Public health significance and occurrence of donovanosis

Donovanosis is rare in industrialised countries but endemic in some tropical and subtropical countries and areas, including Papua New Guinea, areas of Central America, southern Africa and southern India.

No cases of donovanosis have been notified in Victoria since at least 1992. Fewer than 10 cases have been notified annually in Australia since 2006, and the most recent recorded case was in 2012. The National Donovanosis Elimination Project aims to reduce the incidence of donovanosis in Australia to zero. This will be confirmed when no cases have been reported in Australia for 3 years.

Infections that cause ulcers and sores around the genitals increase the risk of HIV transmission.

Reservoir of Klebsiella granulomatis

Humans are the reservoir.

In Australia, the people most at risk are:

• Aboriginal people living in remote or marginalised communities
• people who have sex with someone from a country with high rates of donovanosis.

Mode of transmission of Klebsiella granulomatis

Donovanosis is a sexually transmissible infection. A small proportion of people may be infected by direct nonsexual contact.

Period of communicability of donovanosis

The period of communicability is unknown but may be months to years.

Susceptibility and resistance to donovanosis

Everyone is susceptible to infection.

Control measures for donovanosis

Preventive measures

Preventive measures include education about safe sex practices, including use of condoms when having vaginal or anal sex, and early detection of infection by testing of people at risk.

Control of case

Donovanosis can be cured with antibiotics. Without treatment, substantial tissue destruction may occur. First-line treatment for donovanosis is azithromycin or doxycycline. (See Therapeutic guidelines: antibiotics and National management guidelines for sexually transmissible infections). Treatment should be directly observed. Follow-up is important, as resolution may be slow and recurrence may occur.

Control of contacts

Sexual contacts should be examined for possible infection. Contacts dating back weeks or months should be traced, according to the sexual history, and advised to have a sexual health check.

Control of environment

Not applicable.

Outbreak measures for donovanosis

Not applicable.

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