Chancroid
Basics
Basics
Basics
Description
Description
Description
Sexually transmitted infection caused by Haemophilus ducreyi that manifests as painful genital skin ulcerations and inguinal lymphadenopathy
Epidemiology
Epidemiology
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.
- The United States has seen a 99% decline in cases between 1990 and 2010; since then, the incidence has fluctuated.
- In 2016, there were seven reported cases.
Risk Factors
Risk Factors
Risk Factors
Increased association with sex workers and individuals involved in drug use
General Prevention
General Prevention
General Prevention
Condom use
Pathophysiology
Pathophysiology
Pathophysiology
- Transmission suspected via microabrasions sustained during sexual intercourse, allowing the organism to penetrate the epidermis
- 3 to 10 days later, an erythematous, tender papule develops and progresses to a pustule.
- The pustule ruptures after 2 to 3 days, leaving a shallow ulcer with a painful, necrotic base with undermined edges.
- Single or multiple ulcers may be present.
Etiology
Etiology
Etiology
H. ducreyi, a gram-negative coccobacillus
Commonly Associated Conditions
Commonly Associated Conditions
Commonly Associated Conditions
- Associated with HIV transmission and infection
- Coinfection with syphilis and human herpesvirus may occur (10%).
Diagnosis
Diagnosis
Diagnosis
- Diagnosis of chancroid is routinely based on clinical findings after the exclusion of other causes of genital ulcer disease.
- 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
Physical Exam
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.
Differential Diagnosis
Differential Diagnosis
Differential Diagnosis
- Chancroid must be distinguished from the other causes of genital ulcers, including:
- Syphilis
- Herpes simplex virus (HSV)
- Lymphogranuloma venereum
- Granuloma inguinale
- More than one of these pathogens may be present in individual cases.
- Uncommon etiologies include:
- Trauma
- Fixed drug eruptions
- Inflammatory bowel disease
- Behçet syndrome
Diagnostic Tests and Interpretation
Diagnostic Tests and Interpretation
Diagnostic Tests and Interpretation
Diagnosis is made by clinical findings and exclusion of other causes of genital ulcers.
Initial Tests
Initial Tests
Initial Tests
- 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 (GUM) polymerase chain reaction test has been developed for simultaneous amplification of DNA targets from H. ducreyi, Treponema pallidum, and 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 and dark field examination of ulcer or serologic testing for syphilis performed 7 days after ulcer onset
- HIV test
Treatment
Treatment
Ongoing Care
Ongoing Care
Ongoing Care
Follow-Up Recommendations
Follow-Up Recommendations
Follow-Up Recommendations
- Patients should be followed weekly until symptoms resolve.
- 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 Teaching
Patient Teaching
Patient Teaching
Prevention: condom use with all sexual activity
Prognosis
Prognosis
Prognosis
- Symptoms improve within 3 to 7 days.
- Ulcers heal between 1 and 4 weeks.
- Lymphadenopathy may take longer to regress; may become fluctuant despite adequate therapy
- 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.
Complications
Complications
Complications
- Draining bubo
- Coinfection with syphilis and HSV
- HIV infection
Additional Reading
Additional Reading
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. 2016 Sexually transmitted diseases surveillance. https://www.cdc.gov/std/stats16/other.htm. Accessed October 30, 2017.
- Kaliaperumal K. Recent advances in management of genital ulcer disease and anogenital warts. Dermatol Ther. 2008;21(3):196–204. [PMID:18564250]
- Lewis DA. Chancroid: clinical manifestations, diagnosis, and management. Sex Transm Infect. 2003;79(1):68–71. [PMID:12576620]
- 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. [PMID:16619156]
- Trager JD. Sexually transmitted diseases causing genital lesions in adolescents. Adolesc Med Clin. 2004;15(2):323–352. [PMID:15449848]
- World Health Organization; Communicable Disease Surveillance and Response; Epidemiology, Distribution, Surveillance and Control. Guidelines for sexually transmitted infections surveillance. UNAIDS/WHO Working Group on Global HIV/AIDS/STI surveillance. http://apps.who.int/iris/bitstream/10665/66421/1/WHO_CDS_CSR_EDC_99.3.pdf. Accessed October 30, 2017.
Codes
Codes
FAQ
FAQ
FAQ
- Q: If the culture is negative should I still consider chancroid?
- A: Yes. Sensitivity for cultures of genital ulcers caused by chancroid are only 75% sensitive.
- Q: Can a diagnosis of chancroid be made by clinical findings alone?
- A: In the United States, it is recommended that a combination of both clinical features as well as negative testing for HSV and syphilis be used for the diagnosis of chancroid.
- Q: Will the inguinal bubo heal with the recommended treatment?
- A: Inguinal lymphadenopathy and associated fluctuance may require incision and drainage.
Authors
Authors
Authors
Evelyn Porter, MD, MS
Christine S. Cho, MD, MPH, MEd
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