Chancroid

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.
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

Increased association with sex workers and individuals involved in drug use

General Prevention

Condom use

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

H. ducreyi, a gram-negative coccobacillus

Commonly Associated Conditions

Associated with HIV transmission and infection
Coinfection with syphilis and human herpesvirus may occur (10%).

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

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

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

Diagnosis is made by clinical findings and exclusion of other causes of genital ulcers.

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

General Measures

Condom use if consenting teen and sexually active

Medication (Drugs)

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 500 mg PO q.i.d. for 7 days (≥18 years)
One-time directly observed dosing with azithromycin or ceftriaxone is recommended.

Issue for Referral

Patients should follow up 1 week after diagnosis for monitoring symptom resolution.

Diagnostic Procedures/Other

Persistent inguinal fluctuant adenitis may be treated with either needle aspiration or incision and drainage.

Inpatient Consideratons

Patients should be admitted to the hospital if they are systemically ill and unwell appearing or for concerns of ongoing sexual abuse and safety.

Ongoing Care

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

Prevention: condom use with all sexual activity

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

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. 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

ICD-9

099.0 Chancroid
099.0 Chancroid

ICD-10

A57.00000 Chancroid

SNOMED

266143009 Chancroid (disorder)

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

Evelyn Porter, MD, MS

Christine S. Cho, MD, MPH, MEd