Should doctors be concerned over this 'flesh-eating' STD?

Headlines around the world are warning of a fast-spreading, "flesh-eating STD" that is chronic, progressive, and causes “beefy red” sores in the genital area. Unfortunately, it’s not fake news.

According to the CDC, donovanosis (also called granuloma inguinale) is a genital ulcerative disease caused by Klebsiella granulomatis, an intracellular gram-negative bacterium. The flesh-eating infection, which can be transmitted sexually, is characterized by ulcerative lesions on the genitals or perineum, which are painless but highly vascular and often bleed.

This particular sexually transmitted disease (STD) hit US headlines recently after the British publication Birmingham Live published a news item warning that donovanosis is becoming more common in the United Kingdom. But what does this mean for the United States? Should doctors be concerned? 

Here’s an overview of donovanosis and what experts say about the likelihood of it becoming a serious concern in the United States.

Donovanosis details

According to information published by StatPearls, if left untreated, the lesions caused by donovanosis can result in tissue destruction and scarring. This is how the STD got its “flesh-eating” descriptor. However, the disease tends to have a good prognosis if treatment is started early.

The first donovanosis diagnosis was recorded in India and, while it’s been considered an STD since 1947, there are rare cases of infection without sexual contact. That said, rates of infection are highest among groups with increased sexual activity. 

According to the CDC, infections can extend beyond the genitals to the pelvis, intra-abdominal organs, bones, or the mouth. In some cases, lesions can develop a secondary bacterial infection, and donovanosis can coexist with other STDs. Cases have been described in India, South Africa, and South America, and the disease was once endemic in Australia, although it has nearly been eradicated in that country. 

Symptoms, diagnosis, and treatment

According to StatPearls, standard donovanosis lesions eventually develop a “beefy-red” hue, with edges that are sometimes described as “snake-like” in appearance. Self-inoculation can occur, with lesions spreading to parts of the body that often touch each other. 

There are three other types of donovanosis lesions beyond the aforementioned “classic ulcerogranulomatous lesions,” which are non-tender ulcers and can bleed easily. Some patients develop hypertrophic or verrucous lesions, which are drier and have irregular edges; some patients present with necrotic lesions, which are deep ulcers that emit a foul odor and can cause tissue destruction. The final type includes sclerotic or cicatricial lesions, which are most likely to result in scarring. 

A variety of complications can occur, including the development of neoplasms, pseudo-elephantiasis, polyarthritis, vaginal bleeding, and others. The StatPearls authors point out that patients are often embarrassed or distressed by lesions, which means they tend to delay seeking help and commonly present with more progressed lesions.

According to the CDC, the primary method for diagnosing the disease is the “visualization of dark-staining Donovan bodies on tissue crush preparation or biopsy.” Before obtaining a sample, the lesion should be cleaned with a dry cotton swab (using saline can lead to insufficient sample collection). 

Once the disease is identified, treatment is fairly simple. The standard of care, according to StatPearls, is 1 g of azithromycin, followed by 500 mg daily. Alternatives include: 100 mg of doxycycline twice a day, 750 mg of ciprofloxacin twice a day, or 500 mg of erythromycin four times a day (which is the best medication for pregnant patients), and sulfamethoxazole/trimethoprim twice per day. Treatments should be continued until all lesions are healed, and StatPearls warns that relapses can still occur 6-18 months after treatment appears to have been successful. In some cases of extensive tissue destruction, surgery may also be required.

Will the flesh-eating STD show up in the US?

Donovanosis has been all over the news recently, after the aforementioned article UK news outlet Birmingham Live quoted a British physician who said, “Figures suggest that donovanosis—which was previously thought to be restricted to places including India, Brazil, and New Guinea—is becoming more common on these shores.” However, data from Public Health England (PHE) indicate that the descriptor “becoming more common” may not warrant alarm just yet. 

According to the PHE data, there were 30 cases of donovanosis reported in the UK in 2019, an increase from the 21 cases reported in 2018 and the 26 cases reported in 2017. In 2020, that figure decreased to 18 cases, a drop that may reflect the social isolation and distancing measures prompted by the coronavirus pandemic. 

Speaking with Birmingham Live, Katy Sinka of the UK Health Security Agency noted that donovanosis “remains rare” in the UK, adding that “there is no evidence that the infection is becoming more widespread.” But what’s the status of the disease in the United States?

Speaking to USA Today, Dr. Melinda Pettigrew, a professor of Epidemiology at Yale School of Public Health, said that the STD is “extremely rare” and called it a “small scale concern right now,” but spread in the United States is not out of the question. Likewise, in an article published by Prevention, several doctors agreed that there’s no need for Americans to panic over the disease, although practicing safe sex and getting regular STD tests is always a good idea.

According to information from the US National Library of Medicine, there are roughly 100 cases of donovanosis reported in the United States every year, and most cases occur in people who have traveled to other countries where the disease is more prevalent. In fact, according to the StatPearls article, the incidence of donovanosis has been decreasing worldwide, “most likely due to the realized role in HIV transmission.” 

In short: You probably don’t need to worry about the so-called “flesh-eating” STD. But if your patients are sexually active, they should keep getting regular screenings for STDs and always practice safe sex to avoid catching (or spreading) anything.

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