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Chancroid, Emergency Medicine

Basics

Description

- 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

- Giant chancroid: - Serpiginous ulcer: - Rapidly spreading, indolent, shallow ulcers in groin or thigh

- Gram stain unreliable (positive in 50-80%): - Gram-negative coccobacilli - Linear or "school-of-fish"¯ pattern

- Granuloma inguinale (donovanosis) (Klebsiella granulomatis): - Ulcer margins elevated; + induration

- Noninfectious: - Drug eruption - Less common: - Pyoderma gangrenosum - Beh §et disease

  • 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, anusFemale: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 womenAppears 3-14 days after initial ulcerUnilateral (usually)PainfulSuppurative 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 destructionGiant chancroid:Serpiginous ulcer:Rapidly spreading, indolent, shallow ulcers in groin or thighFollicular: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. ducreyiProbable: 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 coccobacilliLinear or "school-of-fish"¯ pattern
  • Culture extremely difficult (positive in 0-80%); requires complex media:Obtain specimen from:Base of ulcerNeedle 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 commonPart 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, cleanHerpes genitalis (HSV):Vesicular, multiple, recurrentGranuloma inguinale (donovanosis) (Klebsiella granulomatis):Ulcer margins elevated; + indurationLymphogranuloma venereum (Chlamydia trachomatis):Often single lesion; tender, fluctuant, unilateral lymphadenopathy
  • Noninfectious:Drug eruptionLess common:Pyoderma gangrenosumBeh §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:
  • Needle aspiration of suppurative nodes (>5 cm diameter):To prevent chronic sinus drainage from spontaneous ruptureUse 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 treatmentUlcers improve within 3-7 daysPossible 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)