Chancroid, Emergency Medicine

Basics

Description

Sexually transmitted genital ulcerative disease:
- Increased risk for HIV infection
A common cause of genital ulceration in Africa, southeast Asia, and Latin America:
- Uncommon in US where herpes simplex virus (HSV) > syphilis >> chancroid, but likely underreported

Etiology

Causative agent: Haemophilus ducreyi

Highly infectious bacterium

Diagnosis

Signs and Symptoms

Begins as a single erythematous papule or pustule:
- Quickly erodes into painful chancres (1-20 mm)
- Soft and friable with ragged, irregular borders
Primary ulcer usually excavated
Moist, granulation tissue at base
Purulent or hemorrhagic exudate
Location:
- Male:
  - Penile shaft, glans, internal surface of foreskin, anus
- Female:
  - Cervix, vagina, vulva, perineum, anus
Occurs 4-7 days (median) after exposure
Incubation period 3-10 days (range 1-35 days)
Inguinal adenopathy:
- In ~50% of men; less common in women
- Appears 3-14 days after initial ulcer
- Unilateral (usually)
- Painful
- Suppurative large nodes (buboes)
- May rupture and form chronic draining sinuses
Dysuria, dyspareunia secondary to contact with lesions
Variants:
- Phagedenic:
  - Secondary superinfection (especially fusospirochetal) and rapid extensive tissue destruction
- Giant chancroid:
  - Very large single ulcer
- Serpiginous ulcer:
  - Rapidly spreading, indolent, shallow ulcers in groin or thigh
- Follicular:
  - Multiple small ulcers with perifollicular distribution

Essential Workup

Clinical diagnosis based on appearance is often inaccurate, and lab tests difficult or unavailable, so consider:

CDC case definitions:
- Definite: Positive culture of H. ducreyi
- Probable: Typical signs, symptoms of chancroid + negative dark-field exam for Treponema pallidum + negative syphilis serology + negative culture for HSV (or clinical exam atypical for herpes)

Diagnosis Tests & Interpretation

Lab

Gram stain unreliable (positive in 50-80%):
- Gram-negative coccobacilli
  - Linear or "school-of-fish"¯ pattern
Culture extremely difficult (positive in 0-80%); requires complex media:
- Obtain specimen from:
  - Base of ulcer
  - Needle aspiration of inguinal node by placing needle through normal skin (to avoid formation of fistula)
Polymerase chain reaction (PCR) assay:
- Sensitive and specific, but not widely available
RPR:
- Coinfection with syphilis is common
- Part of CDC guidelines for probable clinical diagnosis of chancroid
HSV culture:
- Part of CDC guidelines for probable clinical diagnosis of chancroid
HIV testing

Differential Diagnosis

Infectious:
- Syphilis (T. pallidum):
  - Chancre usually painless, indurated, clean
- Herpes genitalis (HSV):
  - Vesicular, multiple, recurrent
- Granuloma inguinale (donovanosis) (Klebsiella granulomatis):
  - Ulcer margins elevated; + induration
- Lymphogranuloma venereum (Chlamydia trachomatis):
  - Often single lesion; tender, fluctuant, unilateral lymphadenopathy
Noninfectious:
- Drug eruption
- Less common:
  - Pyoderma gangrenosum
  - Beh §et disease

Treatment

Initial Stabilization/Therapy

Usual precautions for patient exam and handling of specimens

Ed Treatment/Procedures

Antibiotics:

Azithromycin: Single PO dose
Ceftriaxone: Single IM dose (pregnancy: 1st line)
Ciprofloxacin: PO — 3 days:
- NOT for pregnant/lactating patients
Erythromycin base: PO — 7 days:
- Pregnancy: 2nd line
Needle aspiration of suppurative nodes (>5 cm diameter):
- To prevent chronic sinus drainage from spontaneous rupture
- Use 18G needle through lateral intact skin.
- May require repetition
Recommend concurrent HIV, syphilis, HSV testing, and follow-up testing in 3 mo if initially negative

Medication

First Line

Azithromycin: 1 g PO — 1
Ceftriaxone: 250 mg IM — 1

Second Line

Ciprofloxacin: 500 mg PO BID for 3 days
Erythromycin base: 500 mg PO QID for 7 days

Follow-Up

Disposition

Admission Criteria

Sexual abstinence or condom use until lesions healed
Clinical course:
- Symptoms improve within 2 days of treatment
- Ulcers improve within 3-7 days
- Possible delayed resolution in those HIV-positive or uncircumcised

Follow-Up Recommendations

Examine and treat sexual partners (regardless of presence/absence of symptoms) if contact within 10 days of symptom onset
HIV-positive patients require assured follow-up if using single-dose therapy (higher treatment failure rate)

Pearls and Pitfalls

Initiate treatment if probable CDC case guidelines met; do not wait for culture results
Higher risk of treatment failure in HIV-infected patients
Presumptive treatment of sexual contacts
Treatment failure: Consider drug resistance, medication noncompliance, coinfection (syphilis).

Additional Reading

Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines 2010. Available at www.cdc.gov/std/treatment. Accessed March 1, 2013.
Chancroid. UpToDate Online. 2013;v21.2. Available at www.uptodate.com
Marx JA, Hockberger RS, Walls RM, eds. Rosens Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2010.

Codes

ICD9

099.0 Chancroid

ICD10

A57 Chancroid

SNOMED

266143009 Chancroid (disorder)
402954007 Penile chancroid (disorder)
402955008 Vulval chancroid (disorder)
240586001 Chancroid - extragenital ulcer (disorder)
240585002 chancroid - anogenital ulcer (disorder)

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