DESCRIPTION 
- Sexually transmitted genital ulcerative disease:
- A common cause of genital ulceration in Africa, southeast Asia, and Latin America:
ETIOLOGY
Causative agent: Haemophilus ducreyi
- Highly infectious bacterium
[Outline]
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:
- 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:
- Noninfectious:
- Drug eruption
- Less common:
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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 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
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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)
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