Basics
Description
Sexually transmitted infection caused by Haemophilus ducreyi that manifests as painful genital skin ulcerations and inguinal lymphadenopathy
Epidemiology
- Low incidence in the United States with sporadic outbreaks
- In underdeveloped countries, a major cause of genital ulcer syndrome
- Probably underreported due to difficulty with definitive diagnosis via culture in developing areas
- Increases the risk of HIV transmission
- Seen more commonly in males; females are more likely to be asymptomatic.
- Sexual contact is the only known route of transmission.
- If diagnosed in children, sexual abuse should be considered.
Incidence
Cases in the United States steadily declined until 2000; since then, the incidence has fluctuated. In 2012, there were 15 reported cases.
Risk Factors
Increased association with sex workers and individuals involved in drug use
General Prevention
Pathophysiology
- Transmission suspected via microabrasions sustained during sexual intercourse, allowing the organism to penetrate the epidermis
- 3-10 days later, an erythematous, tender papule develops and progresses to a pustule.
- The pustule ruptures after 2-3 days, leaving a shallow ulcer with a painful, necrotic base with undermined edges.
- Single or multiple ulcers may be present.
Etiology
H. ducreyi, a gram-negative coccobacillus
Commonly Associated Conditions
- Associated with HIV transmission and infection
- Coinfection with syphilis and human herpes virus may occur (10%).
Diagnosis
Diagnosis of chancroid is routinely based on clinical findings after the exclusion of other causes of genital ulcer disease.
History
- Males usually present with symptoms referable to an acute, painful genital ulcer.
- Females may be asymptomatic or present with nonspecific symptoms (dysuria, vaginal discharge, pain with stooling or sexual intercourse, rectal pain, or bleeding).
Physical Exam
Classic findings:
- Extremely painful ulcer with an irregular, undermined border and a gray, necrotic center
- In males: found on prepuce or coronal sulcus
- In females: found on the vulva, cervix, or perianal area
- Painful, unilateral, inguinal lymphadenopathy (bubo) in 50% which may spontaneously drain
- Extragenital sites are rare and include the inner thigh area, breasts, fingers, and mouth.
Diagnostic Tests & Interpretation
Diagnosis is made by clinical findings and exclusion of other causes of genital ulcers.
Lab
- Gram stain from the base of the ulcer: may show short gram-negative coccobacilli in parallel "school of fish" arrangement. Not reliable as a screening test as ulcers may contain multiple organisms; routine use is not helpful.
- Cultures from the ulcer
- H. ducreyi is a fastidious organism and requires specialized media and technique for successful isolation.
- Compared with newer amplification techniques, it has been proven to be 75% sensitive.
- Currently the only method routinely available for the definite diagnosis of chancroid
- DNA amplification
- A genital ulcer multiplex polymerase chain reaction (GUM) test has been developed for simultaneous amplification of DNA targets from H. ducreyi, Treponema pallidum, and herpes simplex virus (HSV) types 1 and 2; offers improved sensitivity when compared with culture
- This technology is not routinely available.
- Monoclonal antibody
- Monoclonal antibody against the outer membrane protein of H. ducreyi using immunofluorescent antibody has also proven to be more sensitive than culture.
- Could provide easy, rapid, inexpensive, sensitive testing but not available currently
- Additional testing
- Evaluation for the common causes of genital ulcer syndrome should be done routinely: culture and PCR for HSV 1 and 2, RPR
- HIV test
Differential Diagnosis
- Chancroid must be distinguished from the other causes of genital ulcers, including syphilis, HSV, lymphogranuloma venereum, and granuloma inguinale. More than one of these pathogens may be present in individual cases.
- Uncommon etiologies include the following:
- Trauma
- Fixed drug eruptions
- Inflammatory bowel disease
- Beh §et syndrome
Treatment
Medication
- Azithromycin 20 mg/kg (max 1 g) PO, once
- Ceftriaxone 50 mg/kg (max 250 mg) IM, once
- Ciprofloxacin 500 mg b.i.d. for 3 days (patients >18 years)
- Erythromycin base (≥18 years) 500 mg PO q.i.d. for 7 days
- One-time directly observed dosing with azithromycin or ceftriaxone is recommended.
Surgery/Other Procedures
Persistent inguinal fluctuant adenitis may be treated with either needle aspiration or incision and drainage.
Ongoing Care
Follow-up Recommendations
- Symptoms improve within 3-7 days.
- Ulcers heal between 1 and 4 weeks.
- Lymphadenopathy may take longer to regress; may become fluctuant despite adequate therapy
- Patients should be followed weekly until symptoms resolve.
- For patients who do not follow the typical course, consider other causes of genital ulcers; noncompliance; presence of a coexisting sexually transmitted disease, especially HIV; and, rarely, presence of a resistant organism.
- Recent sexual partners (within the preceding 10 days) should be treated.
- If initial HIV and syphilis test results are negative, they should be repeated in 3 months following diagnosis of chancroid.
Patient Education
Prevention: condom use with all sexual activity
Complications
- Draining bubo
- Coinfection with syphilis and HSV
- HIV infection
Additional Reading
- American Academy of Pediatrics. Chancroid. In: Pickering LK, Baker CJ, Kimberlin DW, et al, eds. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012:271-272.
- Centers for Disease Control and Prevention. STD surveillance 2012. http://www.cdc.gov/std/general/other.htm. Accessed February 13, 2014.
- Kaliaperumal K. Recent advances in management of genital ulcer disease and anogenital warts. Dermatol Ther. 2008;21(3):196-204. [View Abstract]
- Lewis DA. Chancroid: clinical manifestations, diagnosis, and management. Sex Transm Infect. 2003;79(1):68-71. [View Abstract]
- Mackay IM, Harnett G, Jeoffreys N, et al. Detection and discrimination of herpes simplex viruses, Haemophilus ducreyi, Treponema pallidum, and Calymmatobacterium (Klebsiella) granulomatis from genital ulcers. Clin Infect Dis. 2006;42(10):1431-1438. [View Abstract]
- Trager JD. Sexually transmitted diseases causing genital lesions in adolescents. Adolesc Med Clin. 2004;15(2):323-352. [View Abstract]
Codes
ICD09
- 099.0 Chancroid
- 099.0 Chancroid
ICD10
SNOMED
- 266143009 Chancroid (disorder)