AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

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INTRODUCTION

Section 2 of 11  

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Background

Chancroid is a sexually transmitted genital ulcer disease (GUD) caused by the gram-negative bacillus Haemophilus ducreyi. It is characterized by the presence of painful ulcers and inflammatory inguinal adenopathy. Chancroid is often referred to as a soft chancre because the lesions are usually not indurated. In contrast, a syphilitic chancre is nontender and indurated.

Pathophysiology

H ducreyi produces a potent cytolethal distending toxin, which is an important virulence factor in the pathogenesis of chancroid, probably contributing to both the generation and the slow healing of ulcers.

Chancroid facilitates human immunodeficiency virus transmission. The chemokine receptors CCR5 and CXCR4 belong to the class of 7 transmembrane G-protein–coupled receptors, and their natural ligands are key players in the recruitment of immune cells to sites of inflammation. CCR5 and CXCR4 are the 2 main co-receptors essential for HIV entry. Macrophages in lesions of chancroid have significantly increased expression of CCR5 and CXCR4 compared with peripheral blood cells, and CD4 T cells had significant up-regulation of CCR5. The beta-chemokine RANTES (regulated on activation, normal T cell expressed and secreted) are important ligands for CCR5. RANTES is present throughout the papular and pustular stages of chancroid infection but is not present in uninfected control skin.

Together with the disruption of mucosal and skin barriers, the presence of cells with up-regulated HIV-1 co-receptors in H ducreyi–infected lesions provides an environment that facilitates the acquisition of HIV-1 infection. Effective and early treatment of genital ulceration, and chancroid in particular, is an important part of any strategy to control the spread of HIV infection in tropical countries.

Frequency

United States

Chancroid is rarely reported in the United States, but regional outbreaks and some endemic transmission occur, principally among migrant farm workers and poor inner city residents.

International

Because of a lack of readily available, accurate diagnostic tests, the global incidence of chancroid is unknown. An estimated 6 million cases of chancroid occur each year. Chancroid is common in many of the world's poorest regions such as areas of Africa, Asia, and the Caribbean. These regions also have some of the highest rates of HIV infection in the world, and chancroid is common in all 18 countries where adult HIV prevalence surpasses 8%. In addition to regional outbreaks, individual cases are reported sporadically in the developed world, usually in individuals who have recently returned from chancroid endemic areas or occasionally within the context of localized urban outbreaks, which may be associated with commercial sex work.

Mortality/Morbidity

• Chancroid produces painful ulcers on the genitals, often (50%) associated with unilateral tender inguinal lymphadenitis (ie, a bubo). Left untreated, the buboes can form fluctuant abscesses that spontaneously rupture, resulting in a nonhealing ulcer.
• Chancroid has been shown to be a major cofactor in the transmission of HIV-1 infection. This relationship has been especially significant in the heterosexual spread of HIV in Africa.

Sex

Males develop the disease most often, with a male-to-female ratio of 3-25:1.

• Uncircumcised men develop chancroid more often than circumcised men. Patients who are uncircumcised do not respond as well to treatment as those who are circumcised.
• Chancroid is more common in heterosexual men.
• Female prostitutes, either with active disease in the form of genital ulcers or as asymptomatic carriers, are an important reservoir for infection.

Age

Chancroid is most prevalent in sexually active and promiscuous males, with a mean patient age of 30 years.

CLINICAL

Section 3 of 11  

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History

• After an incubation period of 3-7 days, the patient develops painful, erythematous papules at the site of contact. The papules become pustular and then rupture, usually forming 1-3 painful ulcers.
• Men usually have symptoms directly related to the painful genital lesions or inguinal tenderness. Most females are asymptomatic but may present with less obvious symptoms, such as dysuria, dyspareunia, vaginal discharge, pain on defecation, or rectal bleeding. Constitutional symptoms, such as malaise and low-grade fevers, may be present.
• Most commonly, males report a history of recent contact with a prostitute. In addition, men who are infected are less likely to have used condoms and more likely to report a history of more than 2 sexual partners in the preceding 3 months.
• Oral sex has also been documented in the transmission of chancroid.

Physical

• A small papule is the initial lesion at the site of infection. The papule rapidly becomes pustular and eventually ulcerates. The ulcer enlarges, develops ragged undermined borders, and is surrounded by a rim of erythema. The border of the ulcer is not indurated as in syphilis. A grayish fibrinous membrane covers the base of the ulcer. Autoinoculation results in multiple sites of infection in various stages of evolution.
• In men, the most common site of infection is the foreskin, but it may also occur less commonly on the shaft, the glans, or the meatus of the penis. In women, ulcers most commonly occur on the labia majora, but they may also occur on the labia minora, the thighs, the perineum, or the cervix.
• As many as 50% of patients have tender, fixed, inguinal lymphadenopathy, usually unilaterally, that when fluctuant is called a bubo and is highly specific for chancroid (see Media Files 2-3).
• A probable diagnosis can be made if all the following criteria are met:
  
  
  • The patient has one or more painful genital ulcers.
  • The patient has no evidence of Treponema pallidum infection by darkfield examination of ulcer exudate or by a serologic test for syphilis performed at least 7 days after onset of ulcers.
  • The clinical presentation, appearance of genital ulcers, and if present, regional lymphadenopathy are typical for chancroid.
  • Test results for herpes simplex virus (HSV) performed on the ulcer exudate are negative.
• The combination of a painful ulcer and tender inguinal adenopathy, symptoms occurring in one third of patients, suggests a diagnosis of chancroid; when accompanied by suppurative inguinal adenopathy, these signs are almost pathognomonic.

Causes

• H ducreyi (a short gram-negative bacillus) causes chancroid.
• See Pathophysiology.
• Chancroid is closely associated with prostitution. H ducreyi can survive only in subgroups of the population with a sufficient turnover of sex partners. Chancroid is not a sustainable infection in sexual networks with low rates of partner change.

DIFFERENTIALS

Section 4 of 11  

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Other Problems to be Considered

Extracutaneous Crohn disease
Fixed drug eruption

WORKUP

Section 5 of 11  

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Lab Studies

• The diagnosis of chancroid based solely on the ulcer's appearance is accurate only in 30-50% of cases. In areas of high prevalence, the accuracy for clinical diagnosis of chancroid is as high as 80%; however, in areas where the disease is less common, the clinical basis for diagnosing chancroid leads to overdiagnosis. Considerable overlap exists between the major causes of GUD: herpes simplex, syphilis, chancroid, and often co-infection with 2 diseases at the same time. Co-infection with syphilis or HSV occurs in as many as 10% of patients. Realizing that no etiology can be found in 25-50% of all cases of GUD is important.
• Gram staining may show gram-negative coccobacilli singly, in clusters, or in various morphological forms described as "schools of fish,railroad tracks," or "fingerprints." The organisms are visualized extracellularly more often than intracellularly and tend to occur in close proximity to polymorphonuclear leukocytes.
• • Gram staining of an ulcer specimen is not highly specific or sensitive. Interpretation is hampered by polymicrobial contamination. However, slides with gram-negative coccobacilli in parallel rows or in a clustered school of fish pattern have been reported to have a sensitivity of 62% and a specificity of 99% for chancroid.
  • Direct microscopy should not be used in the routine diagnosis of chancroid.
• Culture is now the accepted standard for diagnosis in most areas, but even in an experienced laboratory, it is only 60-80% sensitive. Numerous selective artificial media have been developed, but 2 media are commonly used. Nairobi medium consists of a biplate of (1) gonococcal agar base with 2% bovine hemoglobin and 5% fetal calf serum and (2) Mueller-Hinton agar with 5% chocolatized horse blood. Both media contained vancomycin (3 µg/ml) and 1% CVA (ie, cephalothin, vancomycin, and amphotericin B) enrichment. The use of both media together increases the yield of positive cultures. Most H ducreyi organisms are resistant to vancomycin, but some strains are inhibited by its presence. Therefore, negative cultures in the setting of high suspicion should prompt screening for vancomycin-sensitive organisms.
• • A simple inexpensive medium containing gonococcal agar base supplemented with 5% Fildes' extract and unchocolated horse blood or a medium containing 0.2% activated charcoal instead of fetal calf serum are suitable alternatives for diagnostic purposes in resource poor countries.
  • H ducreyi is a fastidious organism. Patients' specimens must either be plated out directly on an appropriate culture medium or sent to the microbiology laboratory for culture as soon as possible. There is no widely available transport medium.
  • Studies have shown cultures to be less sensitive in women than in men.
• Purulent material aspirated from intact buboes is almost always sterile.
• Polymerase chain reaction (PCR) amplification is replacing culture as the diagnostic test of choice in some major medical centers. PCR amplification using a variety of primers may provide a useful alternative to culture for the detection of H ducreyi. Although PCR assays perform well on samples prepared from H ducreyi cultures, they are less sensitive when used to test genital ulcer specimens.
• A multiplex PCR (M-PCR) assay has been developed for the simultaneous amplification of DNA targets from H ducreyi, T pallidum, and HSV types 1 and 2 and appears more sensitive than standard diagnostic tests for the detection of these etiologic agents in genital ulcer specimens. The M-PCR assay has been developed but is not yet commercially available.
• Monoclonal antibody–based technology has the potential to provide a simple, inexpensive, rapid, and sensitive means of detecting H ducreyi in genital ulcer specimens, but no assay kits are commercially available.
• Serology has limited usefulness in the routine diagnosis of chancroid infection.
• Tissue biopsy is not a recommended diagnostic method for chancroid but may be useful as a means to exclude malignancy in nonhealing or atypical ulcers.
• Serologic tests for syphilis include Venereal Disease Research Laboratory (VDRL) test, rapid plasma reagin (RPR) test, and a darkfield examination.
• Tests for HSV include a Tzanck smear, direct fluorescence microscopy, and culture.
• HIV testing should be performed in all patients who have genital ulcers caused by H ducreyi.
• Patients should be retested for syphilis and HIV 3 months after the diagnosis of chancroid if the initial test results were negative.
• Consider tests for other STDs, including hepatitis B, Chlamydia trachomatis, and gonorrhea.
• As PCR and other techniques become available, cultures may be indicated to obtain a specimen for antibiotic sensitivity testing.

Histologic Findings

Histologic features from a biopsy sample of a chancroid ulcer may be sufficiently distinct to permit a presumptive diagnosis. Lesions show 3 zones. The most superficial zone is narrow and consists of neutrophils, fibrin, erythrocytes, and necrotic tissue. The second zone is wider and contains newly formed blood vessels with marked endothelial cell proliferation. The lumina of many of these vessels are occluded, leading to thrombosis. The deepest zone is composed of a dense infiltrate of plasma cells and lymphoid cells. Ducrey bacilli are seldom demonstrable on biopsy samples. Tissue biopsy is not a recommended diagnostic method for chancroid but may be useful as a means to exclude malignancy in nonhealing or atypical ulcers.

TREATMENT

Section 6 of 11  

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Medical Care

• Local therapy includes gentle topical cleansing, soaks, and measures to reduce edema.
• Patients with nonfluctuant buboes respond well to antibiotics, and the lesions do not need to be drained.
• If appropriate therapy is provided and no clinical improvement is evident, the clinician must consider whether the diagnosis is correct, whether the patient is co-infected with another STD, whether the patient is infected with HIV, whether the treatment was used as instructed, and whether the H ducreyi strain is resistant to the prescribed antimicrobial.
• In resource poor settings, where diagnostic facilities are not readily available, the World Health Organization advocates the use of a syndromic approach for the therapy of GUD.
• • The syndromic approach for the therapy of STDs delivers effective treatment quickly to people when they first come for care and is focused on the most common STDs that can be cured, including syphilis, gonorrhea, chlamydia, chancroid, trichomoniasis, and candidiasis.
  • The syndromic approach does not require the use of expensive tests, which often are not available. People who may have more than one STD infection are treated with the most effective drug available. In some undeveloped regions, 6 out of every 10 patients with an STD have 2 or more different infections at the same time. This approach also emphasizes treatment during the first visit. Treating curable STDs as soon as possible limits future spread of STDs, including HIV.
  • STD syndromes that cause similar signs and symptoms are included in a simple flow chart to help health care workers use the syndromic approach to make a diagnose and begin appropriate therapy.
  • Using the syndromic approach is as follows:
    • Men who present with a urethral discharge are treated for both gonorrhea and chlamydia.
    • Women who present with lower abdominal pain are treated for gonorrhea, chlamydia, and other bacteria.
    • Women who present with vaginal discharge and cervicitis are treated for gonorrhea and chlamydia.
    • Women who present with vaginal discharge and vaginitis are treated for trichomoniasis and candidiasis.
    • Men or women who present with genital ulcers are treated for syphilis, chancroid, and genital herpes.
  • Treating people with STDs in this way is less expensive long term because more people are cured the first time they come for care and the spread of STD may be limited.
  • The recommended drugs for STDs should be selected based upon cost, availability, and local resistance patterns.
  • A proper supply of STD drugs and training programs for health care workers are essential.
  • With the syndromic approach there is less emphasis placed on identifying the cause of a particular STD. This may be difficult for some health care workers to accept when they have been trained to identify the specific cause of a disease before starting therapy. However, in a setting where rapid therapy is of utmost importance and sophisticated laboratories are not available the syndromic approach provides effective treatment.
  • Prompt, effective therapy and education of patients helps them decide to use condoms, change their risky sexual behavior, and convince their partner to get treatment.

Surgical Care

• Fluctuant buboes should be drained under local anesthesia. Insert a large-gauge needle into the bubo, passing through normal tissue from the side or the top of the lesion rather than the bottom, thus avoiding continuous dependent drainage and fistula formation (see Media File 4).
• Incision and drainage is an effective method for treating fluctuant buboes and may be preferable to traditional needle aspiration considering the frequency of required repeat aspirations in some studies.
• If circumcision is needed, it should be completed after the patient successfully completes treatment with antibiotics.

Activity

Patients should refrain from sexual activity until ulcers are healed. Untreated chancroid ulcers may persist for 1-3 months. Chancroid ulcers treated with the appropriate antibiotic agent resolve within 7-14 days.

MEDICATION

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Recommended antibiotic regimens are generally all effective and well tolerated. Studies have shown that patients who are infected with HIV do not respond to therapy as well as patients who are HIV negative, and patients who are uncircumcised may not respond to therapy as well as patients who are circumcised.

Virtually all strains of H ducreyi are resistant to penicillin and tetracycline. Trimethoprim and sulfamethoxazole is no longer used because of the development of high rates of resistance. Worldwide, several isolates with intermediate resistance to either ciprofloxacin or erythromycin have been reported.

Relapses after antibiotic therapy occur in as many as 5% of patients and are more common in patients who are uncircumcised or are also infected with HIV. If they are not infected with HIV, repeating the original therapy is usually effective.

Some specialists suggest using the erythromycin 7-day regimen for treating HIV-infected persons because the data concerning the therapeutic efficacy of ceftriaxone and azithromycin regimens in HIV-infected patients are limited.

Because treatment is often accompanied by treatment for gonococcal infections, it is important to be aware of changes to the CDC guidelines for STDs. In April 2007, the Centers for Disease Control and Prevention (CDC) updated treatment guidelines for gonococcal infection and associated conditions. Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the United States. The recommendation was based on analysis of new data from the CDC's Gonococcal Isolate Surveillance Project (GISP). The data from GISP showed the proportion of gonorrhea cases in heterosexual men that were fluoroquinolone-resistant (QRNG) reached 6.7%, an 11-fold increase from 0.6% in 2001.
 
The data were published in the April 13, 2007 issue of the Morbidity and Mortality Weekly Report. This limits treatment of gonorrhea to drugs in the cephalosporin class (eg, ceftriaxone 125 mg IM once as a single dose). Fluoroquinolones may be an alternative treatment option for disseminated gonococcal infection if antimicrobial susceptibility can be documented. For more information, see the CDC's Antibiotic-Resistant Gonorrhea Web site, CDC Updated Gonococcal treatment recommendations (April 2007), or Medscape Medical News on CDC Issues - New Treatment Recommendations for Gonorrhea.

Drug Category: Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. The syndromic approach to therapy of GUD may be appropriate in some settings.

Drug Name	Azithromycin (Zithromax)
Description	Treats mild-to-moderate microbial infections. More expensive than other therapies.
Adult Dose	1 g PO once
Pediatric Dose	10 mg/kg PO once; not to exceed 500 mg/d
Contraindications	Documented hypersensitivity; hepatic impairment; coadministration with pimozide
Interactions	May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in patients who are hospitalized, debilitated, or elderly

Drug Name	Erythromycin (E.E.S., E-Mycin, Ery-Tab)
Description	Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections. In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half-total daily dose may be taken q12h. For more severe infections, double the dose.
Adult Dose	500 mg PO qid for 7 d
Pediatric Dose	20 mg/kg PO 2 h prior to procedure, followed by 10 mg/kg 6 h after initial dose 30-50 mg/kg/d (15-25 mg/lb/d) PO divided q6-8h; double dose for severe infection
Contraindications	Documented hypersensitivity; hepatic impairment
Interactions	Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur

Drug Name	Ciprofloxacin (Cipro)
Description	Fluoroquinolone that inhibits bacterial DNA synthesis and, consequently, growth by inhibiting DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material. Quinolones have broad activity against gram-positive and gram-negative aerobic organisms. Has no activity against anaerobes. Continue treatment for at least 2 d (7-14 d typical) after signs and symptoms have disappeared. CDC no longer recommends fluoroquinolones for gonorrhea because of increased resistance.
Adult Dose	500 mg PO bid for 3 d
Pediatric Dose	<18 years: Not recommended ³18 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Pregnancy	C - Safety for use during pregnancy has not been established
Precautions	Dosage adjustments (adult adjustments) CrCl (mL/min) <10: 50% of PO or IV dose q12h HD: 0.25-0.5 g PO or 0.2-0.4 g IV q12h During peritoneal dialysis: 0.25-0.5 g PO or 0.2-0.4 g IV q8h In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy Not drug of first choice in pediatric patients because of increased incidence of adverse events (including arthropathy) compared with controls; no data for dose for pediatric patients with renal impairment (ie, CrCl <50 mL/min)

FOLLOW-UP

Section 8 of 11  

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Further Outpatient Care

• Patients should receive follow-up care to ensure resolution of the disease. Clinical improvement should occur over 7 days, and healing should be complete in 2 weeks with appropriate antibiotic therapy. Healing is slower for some uncircumcised men who have ulcers under the foreskin. Lymphadenopathy may be slow to resolve and may require needle aspiration if a significant bubo is present.
• Because of the highly infectious nature of chancroid, routine treatment of contacts of men with chancroid is recommended even if they are asymptomatic. All sexual contacts during the 10 days prior to the development of the genital lesion should be treated.
• Empirical treatment of high-risk women has been shown to significantly decrease the prevalence of disease.
• Isolation or quarantine is not required, but patients must avoid sexual contact until all lesions, including discharging regional lymph nodes, are healed.

Deterrence/Prevention

• Eradication of chancroid is a feasible public health objective. H ducreyi has a short duration of infectivity and requires frequent contacts to spread within a population. Humans are the only reservoir for H ducreyi, and rates of infection can be easily reduced through a variety of methods. Simple washing with soap and water within a few hours of sexual exposure is effective in reducing risk of chancroid.
• Instituting a condom policy directed at protecting sex workers and their clients from exposure to STDs and improving curative services are among the most effective strategies.
• Offering regular examination and treatment for registered sex workers or monthly presumptive antibiotic treatment to women at risk have both been shown to dramatically reduce the prevalence of chancroid. Antibiotic treatment of the highest-risk populations can reduce chancroid transmission in the short term and lead to a rapid decline in chancroid prevalence in a community.
• Breaking the chancroid transmission cycle in any of these ways can markedly reduce the prevalence of chancroid even when other conditions favor its spread.

Complications

• Phimosis, balanoposthitis, and rupture of buboes with fistula formation and scarring are reported complications.

Prognosis

• The prognosis is excellent if chancroid is treated properly and if no co-infection with HIV is present.
• As many as 5% of patients have a relapse of their disease and usually respond to a repeat course of their original therapy.
• No adverse effects of chancroid on pregnancy outcome have been reported.
• Chancroid-infected patients who have HIV should be monitored closely because they are more likely to experience treatment failure and to have ulcers that heal slowly.

Patient Education

• The patient should be strongly advised to avoid sexual contacts while the ulcers are open because they are highly infectious and may lead to outbreaks.
• Patients should be advised to avoid prostitutes, to use condoms, and to avoid having multiple partners.
• Cocaine and alcohol abuse should be addressed because both contribute to higher rates of the disease.
• For excellent patient education resources, visit eMedicine's Men's Health Center and Sexually Transmitted Diseases Center. Also, see eMedicine's patient education articles Sexually Transmitted Diseases, Birth Control Overview, and Birth Control FAQs.

MISCELLANEOUS

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Medical/Legal Pitfalls

• Failure to evaluate and treat co-infections, such as syphilis, herpes simplex, or HIV, is a pitfall.

Special Concerns

• Confirmed cases should be reported to the Division of Sexually Transmitted Diseases at the Centers for Disease Control and Prevention (CDC).
• Mother-to-infant transmission has not been reported. Because sexual contact is the only known route of transmission, the diagnosis of chancroid in infants and young children is strong evidence of sexual abuse.

MULTIMEDIA

Section 10 of 11  

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Media file 1:  Chancroid usually starts as a small papule that rapidly becomes pustular and eventually ulcerates. The ulcer enlarges, develops ragged undermined borders, and is surrounded by a rim of erythema. Unlike syphilis, lesions are tender and the border of the ulcer is not indurated. Courtesy of Hon Pak, MD.
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Media type:  Photo

Media file 2:  This patient shows the characteristic lesions of chancroid. The bubo on the right side drained spontaneously. The bubo in the left inguinal canal required needle aspiration.
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Media type:  Photo

Media file 3:  Close-up view of the chancroid ulcers in Media File 2.
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Media type:  Photo

Media file 4:  Large fluctuant buboes should be drained with local anesthesia and a large-gauge needle inserted through surrounding healthy skin. The insertion site should be superior or lateral to the bubo to prevent chronic drainage from the site.
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Media type:  Photo

REFERENCES

Section 11 of 11

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• Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect. Feb 1999;75(1):3-17. [Medline].
• Fulcher RA, Cole LE, Janowicz DM, Toffer KL, Fortney KR, Katz BP, et al. Expression of Haemophilus ducreyi collagen binding outer membrane protein NcaA is required for virulence in swine and human challenge models of chancroid. Infect Immun. May 2006;74(5):2651-8. [Medline].
• Hammond GW. A history of the detection of Haemophilus ducreyi, 1889-1979. Sex Transm Dis. Mar-Apr 1996;23(2):93-6. [Medline].
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Article Last Updated: Jan 30, 2007