AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Chancroid is a sexually transmitted disease (STD) characterized by one or more painful genital ulcers usually accompanied by painful inguinal lymphadenopathy. The infection, while worldwide in distribution, generally is uncommon in industrialized countries; however, difficulty in definitively diagnosing the infection may somewhat cloud the true incidence of this infection.

Pathophysiology

Chancroid is caused by the small, gram-negative, facultative anaerobic bacillus Haemophilus ducreyi, which produces a cytocidal distending toxin that appears to be responsible for its toxic effects. Transmitted by direct contact, the organism has an incubation period from 1 day to 2 weeks, with a median time of 5-7 days. The disease typically begins as a small inflammatory papule at the site of inoculation; within days, the papule erodes to form an extremely painful deep ulceration.

Frequency

United States

The incidence of chancroid has declined steadily from 1987 (when >5000 cases were reported to the Centers for Disease Control and Prevention [CDC]) to 1997 (when only 243 cases were reported involving a total of 19 different states). The disease is considered endemic in several large US cities, and 85% of the 243 cases reported in 1997 were confined to California, New York, Texas, and South Carolina. Epidemics of disease are associated with low socioeconomic status, poor hygiene, prostitution, and drug abuse. In 2003, only 54 cases were reported to the CDC, with 24 of these cases from South Carolina. The true incidence is difficult to determine and is likely largely underestimated because of the difficulties in culturing H ducreyi.

International

Worldwide, the true incidence of chancroid may surpass that of syphilis. Extremely common in Africa, the Caribbean basin, and Southwest Asia, the disease is thought to be the most common cause of genital ulceration in Kenya, Gambia, and Zimbabwe.

Mortality/Morbidity

• Chancroid is characterized by painful genital ulcers, which are associated with a unilateral painful inguinal lymphadenopathy in 50% of the population. Left untreated, suppurative bubo formation occurs in approximately 25% of cases, which can progress to spontaneous rupture with formation of a deep nonhealing inguinal ulcer. Chancroid is easily curable with appropriate antibiotic therapy, although patients with HIV require longer courses of therapy. The true impact of the disease lies in the well-known association of genital ulcer disease with increased transmission rates of HIV and other STDs.
• Superinfection of lesions, known as phagedenic chancroid, may lead to widespread disfiguring necrosis and may require surgical excision.

Race

Although no proven racial predilection exists, chancroid is most commonly observed in nonwhite people.

Sex

Chancroid is most commonly observed in nonwhite men who are uncircumcised. Women represent only 10% of known cases because they are more likely to be asymptomatic carriers.

Chancroid is more commonly identified in individuals of lower socioeconomic status, prostitutes and travellers from endemic areas. According to Benson and Hergenroeder, there have been no reported cases of chancroid among homosexual males, bisexuals or lesbian females.

Age

Although it can affect people of any age, chancroid predominantly affects younger sexually active people. Females aged 15-19 years have the highest prevalence among women in the United States, followed by those aged 20-24 years. In males, the highest prevalence is in those aged 20-24 years.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Patients usually present with single or multiple painful genital ulcers.
• In women with lesions of the vulva, vagina, or cervix, the chief symptom may be dysuria or dyspareunia.
• Painful inguinal lymphadenopathy, usually unilateral, develops in approximately 30-60% of patients within 1-2 weeks.

Physical

• Lesions
• • The lesion of chancroid begins as a small tender papule with surrounding erythema that rapidly becomes pustular and then erodes to form an extremely painful and deep ulcer with soft (compared to the chancre of syphilis) ragged margins.
  • The ulcer base is composed of easily friable granulation tissue that is usually covered with malodorous yellow-gray exudates.
  • Ulcers may be single or multiple, and as many as 10 ulcers have been reported on a single patient.
  • Men more commonly present with single ulcers, whereas women typically have multiple lesions.
  • Individual ulcers vary in size from 1-20 mm, with 1-2 cm being the most common size.
  • In circumcised men, lesions are most commonly found on the coronal sulcus; in uncircumcised men, the lesions are commonly found on the prepuce. Lesions may be obscured by a painful phimosis in uncircumcised men.
  • In women, lesions most commonly are found on the fourchette, labia, vestibule, clitoris, cervix, and anus.
  • In both men and women, adjacent lesions may merge and form confluent lesions.
  • Superinfection of ulcers, especially fusospirochetal, may occur and lead to rapid destruction of the external genitalia, known as phagedenic chancroid.
• Lymphadenopathy: Painful, usually unilateral, regional lymphadenopathy occurs in 30-60% of patients and is more common in men. Of the patients with lymphadenitis, 25% may have progression to a suppurative bubo, which may rupture spontaneously and ulcerate. If untreated, chronic draining sinuses may follow.
• Other types of chancroid: Although relatively rare, chancroid sometimes may be associated with a variety of presentations different from the classic form described above.
• • Transient chancroid produces an ulcer that rapidly resolves in 4-6 days, followed 10-20 days later by a suppurative lymphadenitis.
  • Dwarf chancroid manifests as one or several herpeslike ulcerations, with or without inguinal lymphadenopathy.
  • Follicular chancroid produces ulcerations of the pilar apparatus in hair-bearing areas.
  • Giant chancroid consists of multiple small ulcerations, which coalesce to form a single large lesion.
• Pseudogranuloma inguinale is another chancroid variety that closely resembles granuloma inguinale.

Causes

Chancroid is an STD resulting from direct contact with H ducreyi. Risk factors include residing in an endemic area, lower socioeconomic status, prostitution, and drug abuse.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Granuloma inguinale
Squamous cell carcinoma

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Gram stain: Gram stain of the ulcer exudates may demonstrate short, plump, gram-negative rods in the classic "school of fish" appearance; however, this method is notoriously unreliable because of the frequency of polymicrobial contamination.
• Culture: Definitive diagnosis rests with culture of the organism; however, this is also fraught with difficulty. A special medium of enriched chocolate-based agar (ie, Nairobi medium, Mueller-Hinton agar) to which 3 mg/mL of vancomycin has been added is required; incubation is at 90-95% humidity in 2-3% carbon dioxide. Even with an experienced laboratory using this technique, isolation rates of greater than 90% are rare, with most laboratories reporting an isolation rate of 0-80%.
• Monoclonal antibodies: Polymerase chain reaction (PCR) testing and indirect immunofluorescence using monoclonal antibodies have been touted to have high sensitivity and specificity; however, these tests are not widely available.
• CDC criteria: Because of the difficulty in definitively isolating the organism for diagnosis, the CDC has recommended the following criteria for diagnosis of chancroid:
• • One or more painful genital ulcers
  • Clinical presentation and associated lymphadenopathy
  • Characteristics of chancroid (eg, painful ulceration associated with tender inguinal lymphadenopathy is considered suggestive; an associated suppurative adenopathy is near pathognomonic)
  • Negative laboratory evaluation (serology or darkfield microscopy) for Treponema pallidum
  • Negative test result for herpes simplex

Procedures

• Needle aspiration and/or incision and drainage are recommended for treatment if clinically indicated.

Histologic Findings

Gram stain of the ulcer exudates may reveal short, plump, gram-negative rods in the classic school of fish appearance. Ulcer biopsy should reveal 3 distinct zones. The most superficial zone contains erythrocytes, fibrin, necrotic tissue, and neutrophils. The next zone consists of marked endothelial cell proliferation and many thrombosed new blood vessels. The deepest layer is characterized by a dense infiltrate of plasma and lymphoid cells.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Patients presenting with suspected or diagnosed chancroid should undergo complete evaluation for other possible concomitant STDs and receive appropriate antimicrobial therapy for the eradication of H ducreyi.

• The CDC recommends antibiotic therapy from 1 of 4 equally efficacious agents, as follows:
• • Azithromycin
  • Ceftriaxone
  • Erythromycin base
  • Ciprofloxacin
• Evaluate patients for syphilis, herpes simplex virus (HSV), and HIV.
• Drain fluctuant lymph nodes larger than 5 cm in diameter by either needle aspiration or incision and drainage.

Activity

Patients should abstain from unprotected sexual intercourse while undergoing treatment.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goal of therapy is the eradication of the organism.

Drug Category: Antibiotics

Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

In/Out Patient Meds

• See Medication.

Deterrence/Prevention

• Advise patients to always use condoms and to refrain from sexual activity with high-risk partners.

Complications

• Rupture of buboes, with subsequent scarring and/or chronic sinus tract drainage
• Phimosis and balanoposthitis

Prognosis

• With appropriate antibiotics, prognosis is excellent for complete disease resolution.
• Patients with HIV may require longer courses of antibiotics and have a protracted recovery phase.

Patient Education

• Emphasize avoidance of high-risk sexual activities, including unprotected sexual intercourse or sexual intercourse with high-risk partners.
• For excellent patient education resources, visit eMedicine's Sexually Transmitted Diseases Center and Pregnancy and Reproduction Center. Also, see eMedicine's patient education articles Sexually Transmitted Diseases, Birth Control Overview, and Birth Control FAQs.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to consider diagnosis
• Failure to check for syphilis, HIV, and HSV
• Failure to instruct the patient in safe sex techniques and partner testing

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Benson PA, Hergenroeder AC. Bacterial sexually transmitted infections in gay, lesbian, and bisexual adolescents: medical and public health perspectives. Semin Pediatr Infect Dis. Jul 2005;16(3):181-91. [Medline].
• Brown TJ, Yen-Moore A, Tyring SK. An overview of sexually transmitted diseases. Part I. J Am Acad Dermatol. Oct 1999;41(4):511-32. [Medline].
• Czelusta A, Yen-Moore A, Van der Straten M. An overview of sexually transmitted diseases. Part III. Sexually transmitted diseases in HIV-infected patients. J Am Acad Dermatol. Sep 2000;43(3):409-32; quiz 433-6. [Medline].
• Hand WL. Haemophilus species including chancroid. In: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Philadelphia, Pa:. Churchill Livingstone;2000:2380-2381.
• Rosen T, Brown TJ. Genital ulcers. Evaluation and treatment. Dermatol Clin. Oct 1998;16(4):673-85, x. [Medline].
• Schmid GP. Chancroid and granuloma inguinale. In: Kelley W, ed. Textbook of internal medicine. 3rd ed. Philadelphia, Pa:. Lippincott-Raven;1997:1670-1671.
• Tomecki. Chancroid and Haemophilus ducreyi: an update. J Am Acad Dermatol. 1997;36(5):776.
• Wang CC, Celum CL. Global risk of sexually transmitted diseases. Med Clin North Am. Jul 1999;83(4):975-95, vi. [Medline].
• Zuckerman JM. Macrolides and ketolides: azithromycin, clarithromycin, telithromycin. Infect Dis Clin North Am. 2004;18:621-649. [Medline].

Article Last Updated: May 12, 2006