Author:
Robert KreggLaundon
DaltonCox
Description
- Sexually transmitted genital ulcerative disease:
- A common cause of painful genital ulceration in Africa, Southeast Asia, and Latin America:
- Uncommon in the U.S. where herpes simplex virus (HSV) > syphilis >> chancroid, but likely underreported
- Newly identified as causative agent in chronic cutaneous ulcers of the lower limb in children in the tropics in the Pacific island s
Etiology
Causative agent: Haemophilus ducreyi
- Highly infectious bacterium
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 d (median) after exposure
- Incubation period 3-10 d (range 1-35 d)
- Inguinal adenopathy:
- In ∼50% of men; less common in women
- Appears 3-14 d 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)
Diagnostic 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:
- Syphilis (T. pallidum):
- Chancre usually painless, indurated, clean
- Herpes genitalis (HSV):
- Vesicular, multiple, recurrent
- Granuloma inguinale (donovanosis) (Klebsiella granulomatis):
- Ulcer margins elevated; + induration
- Lymphogranuloma venereum (Chlamydia trachomatis):
- Noninfectious:
- Drug eruption
- Less common:
- Pyoderma gangrenosum
- Behçet disease
- Pediatric lower limb skin ulcers
- Yaws - (T. pallidum subspecies pertenue)
- Chronic lower limb skin ulcers in children
Initial Stabilization/Therapy
Usual precautions for patient exam and hand ling of specimens
ED Treatment/Procedures
Antibiotics:
- Azithromycin: Single PO dose
- Ceftriaxone: Single IM dose (pregnancy: First line)
- Ciprofloxacin: PO × 3 d:
- NOT for pregnant/lactating patients
- Erythromycin base: PO × 7 d:
- 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 b.i.d for 3 d
- Erythromycin base: 500 mg PO q.i.d for 7 d
Disposition
Admission Criteria
- Sexual abstinence or condom use until lesions healed
- Clinical course:
- Symptoms improve within 2 d of treatment
- Ulcers improve within 3-7 d
- 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 d of symptom onset
- HIV-positive patients require assured follow-up if using single-dose therapy (higher treatment failure rate)