Atlas of Chancroid, Chancroid, olor Atlas & Synopsis of Sexually Transmitted Diseases, Bacterial Sexually Transmitted Diseases
Chancroid is a genital ulcer disease caused by Haemophilus ducreyi, and one of the original five venereal diseases, along with gonorrhea, syphilis, lymphogranuloma venereum, and donovanosis. Chancroid was the first STD recognized to enhance the efficiency of sexual transmission of HIV. Although endemic in parts of the world, notably sub-Saharan Africa, Asia, and Latin America, in most areas chancroid is declining in incidence and has largely been supplanted by genital herpes as the most common cause of genital ulcer disease. Chancroid is currently rare in North America and western Europe but has the potential to reappear in localized outbreaks. Recent reports suggest occasional nonsexual transmission in tropical settings, based on identification of H. ducreyi in chronic lower leg ulcers of patients in the South Pacific. Autoinoculation lesions can occur in patients with sexually acquired chancroid, supporting the potential for nonsexual transmission. Diagnosis of chancroid is difficult, owing to unreliability of clinical criteria, insensitivity of H. ducreyi culture in routine laboratories, and lack of readily available alternative methods. However, it is likely that polymerase chain reaction (PCR) or other sensitive nucleic acid amplification tests will be available in the future.
EPIDEMIOLOGY
Incidence and Prevalence
• Declining incidence in the United States since 1990s; 17–30 reported cases per year 2004–2009
• True frequency may be higher, because of difficulties in recognition and diagnosis, but nevertheless
very rare
• Occasional localized outbreaks, usually in socioeconomically disadvantaged populations
• Remains common in some developing countries
Transmission
• Historically, thought to be transmitted exclusively by sexual contact
• Autoinoculation or contamination of preexisting cutaneous ulcers apparently explains some nongenital cases
Age
• All ages susceptible
• Most cases age 25–35 years
Sex
• No known predilection
• Reported cases primarily in men
• Clinical recognition and diagnosis are more difficult in women
Sexual Orientation
• No predilection known
Other Risk Factors
• Being uncircumcised probably elevates risk in men
HISTORY
Incubation Period
• Usually 2–5 days, up to 14 days
Symptoms
• Initial inflammatory papule with rapid progression to painful ulceration (1–2 days)
• Usually single lesions, sometimes multiple
• 50% of patients have painful regional (usually inguinal) lymphadenopathy
• No systemic symptoms
• Asymptomatic carriage of H. ducreyi is controversial, probably rare; most apparently asymptomatic
cases probably result from internal (e.g., intravaginal) lesions
Epidemiologic History
• Often commercial sex, illicit drug use, or recent travel to an endemic area
• May appear in discrete outbreaks
PHYSICAL EXAMINATION
• One or more nonindurated genital ulcers with purulent bases
• Males: most common sites are glans, corona, or inner surface of foreskin
• Women: most lesions are at introitus or labia, sometimes intravaginal
• Ulcers usually very tender, but nontender lesions sometimes present
• Surrounding erythema and undermined edges are common
• Multiple ulcers sometimes form “kissing” lesions, with ulceration on apposed surfaces (e.g., under foreskin); said to be pathognomonic for chancroid.
• Unilateral or bilateral inguinal lymphadenopathy in 50–60%
• Lymphadenopathy characteristic of pyogenic infection, i.e. overlying erythema, tenderness, often fluctuant, may spontaneously rupture.
LABORATORY DIAGNOSIS
• Isolation of H. ducreyi from lesion or lymph node aspirate
• Sensitivity of culture 60–80%, depending on specimen management, variations in media, and laboratory’s experience
• PCR test available in some research settings, with improved sensitivity compared to culture; commercial PCR or other NAATs may become available
• Gram stain of lymph node aspirate may show small gram-negative bacilli, but is insensitive and nonspecific
• All suspected cases require culture or PCR for HSV and darkfield microscopy and serological testing for syphilis.
DIAGNOSTIC CRITERIA
• Identification of H. ducreyi by culture or PCR is definitive
• In absence of microbiologic confirmation, diagnosis is based on clinical findings, epidemiologic setting, and exclusion of herpes and syphilis.
TREATMENT
Principles
• Resistance to penicillins and tetracyclines is common
• Third-generation cephalosporins are consistently active
• Fluoroquinolones and macrolides generally are active, but sporadic resistance occurs
• Higher clinical failure rates may occur in HIV-infected persons.
Recommended Treatments
• Azithromycin 1.0 g PO, single dose
• Ceftriaxone 250 mg IM, single dose
Alternative Treatments
• Ciprofloxacin 500 mg PO bid for 3 days
• Erythromycin base 500 mg PO tid for 7 days.
Partner Management
• Refer, examine, and treat all recent sex partners
• Expedited partner therapy (EPT) has not been studied but is a reasonable option if direct clinical intervention is not feasible.
PREVENTION
• Assure referral and treatment of sex partners
• Advise condoms and other elements of sexual safety
• Report cases to local or regional health authorities.
6–1. Chancroidal ulcer of penis
CASE 1
Patient Profile Age 26, unmarried salesman
History Painful sore on penis for 5 days; sex 10 days earlier with a female commercial sex worker in a developing country; had sex with regular partner once, before penile lesion noticed
Examination Tender, nonindurated ulcerative penile lesion with purulent base; uncircumcised; no
lymphadenopathy
Differential Diagnosis Chancroid, genital herpes, syphilis.
Laboratory Stat RPR and darkfield microscopy negative; culture of lesion positive for H. ducreyi; culture negative for HSV; urethral tests for Neisseria gonorrhoeae and Chlamydia trachomatis negative; HIV serology negative
Diagnosis Chancroid
Treatment Azithromycin 1.0 g PO, single dose
Partner Management Current partner had normal examination, with negative vaginal culture for H. ducreyi; treated with azithromycin
Comment Lesion pain improved in 2 days, healed by 14 days; patient scheduled for follow-up VDRL and repeat HIV serology 2–3 months later.
6–2. Chancroid. a. Large, irregularly shaped penile ulcers under foreskin; the ulceration had perforated the frenulum of the penis, through which a probe could be passed.
b. Inguinal swelling and erythema extending to lower abdomen. c. Healing ulcers
1 week after starting treatment; reduced purulent exudate and partial reepithelialization.
CASE 2
Patient Profile Age 60, businessman with a large international corporation
History Painful, enlarging penile ulcers for 2 weeks; onset 5 days after sexual exposure in equatorial Africa; painful right inguinal swelling for 3 days; company’s occupational medicine clinic prescribed amoxicillin, without improvement after 5 days.
Examination Multiple, coalescing, irregularly shaped, purulent tender ulcers under foreskin; 3 × 5-cm indurated, tender, nonfluctuant right inguinal lymph node; inguinal erythema extending to the low
abdominal wall
Differential Diagnosis Chancroid; herpes, syphilis, and lymphogranuloma venereum less likely; possible pyogenic infection
Laboratory H. ducreyi isolated by culture; darkfield examination, VDRL, culture for HSV (all negative); urethral cultures for N. gonorrhoeae and C. trachomatis (negative); HIV serology (negative)
Diagnosis Chancroid
Treatment Ceftriaxone 250 mg IM, single dose, followed by amoxicillin with clavulanic acid (Augmentin) 500/125 mg PO tid for 10 days.
Management of Sex Partners Patient advised to notify his distant partner; he had not resumed intercourse with his wife, who was not informed
Comment Amoxicillin/clavulanic acid was prescribed because the atypically extensive inguinal erythema suggested secondary pyogenic cellulitis. The ulcers healed rapidly and erythema regressed, but the right lymph node became fluctuant and required needle aspiration 10 days after start of treatment. Follow-up VDRL was negative after 1 month, and repeat HIV serology was negative after 1 month and 3 months. At numerous visits to his company’s occupational medicine clinic in anticipation of international travel, the patient, who regularly was sexually active with local residents when traveling, was offered appropriate immunizations and malaria prophylaxis and was counseled on avoidance of food-borne illness, but was not asked about plans for sexual activity or advised about condoms or other aspects of safer sex. Pretravel counseling should routinely include inquiry about plans for sex and, when appropriate, STD/HIV prevention advice.
6–3. Chancroid in a patient who presented with painful genital ulcers and
swelling in the groin that “opened and drained pus” 3 days earlier. a. Deeply
eroded ulcers under retracted foreskin. (Pearly penile papules also are present.)
b. Fluctuant lymph node with eschar at site of previous spontaneous rupture
and drainage. c. Needle aspiration of lymph node.
6–4. Chancroid, with penile ulcers and inguinal lymphadenopathy
with overlying cutaneous erythema. The small eschars lateral to the
lymph node mark the sites of needle aspirations.
6–5. Chancroidal ulcer of vaginal introitus.
6–6. Multiple introital and labial ulcers in a woman
with chancroid. Some lesions illustrate autoinoculation
between apposed surfaces, sometimes called “kissing
lesions,” a classical feature of chancroid.
with chancroid. Some lesions illustrate autoinoculation
between apposed surfaces, sometimes called “kissing
lesions,” a classical feature of chancroid.
REFERENCES
H. Hunter Handsfield, MD, Color Atlas & Synopsis of Sexually Transmitted Diseases, Third Edition.
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