Sexually Transmitted Infections: Chancroid

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Chapter 45 Sexually Transmitted Infections: Chancroid

INTRODUCTION

Description: Infection by Haemophilus ducreyi results in chancroid, one of a group of infrequently encountered sexually transmitted diseases (STDs). Chancroid is more common than syphilis in some areas of Africa and Southeast Asia, but it is uncommon in the United States.
Prevalence: In the United States, 1500 cases per year, generally in small, sporadic outbreaks.
Predominant Age: Younger reproductive.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: H. ducreyi is not capable of infecting intact skin; thus, the lesions of chancroid tend to be found in areas traumatized by sexual activity. Material from the vulvar ulcers is virulent and can infect other body sites.
Risk Factors: Sexual trauma and exposure to the infective agent, prostitution, and human immunodeficiency virus (HIV) infection.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• One to three painful “soft chancres” 3 to 10 days after exposure (these break down over about 2 weeks to form shallow, progressive ulcers with red, ragged, undermined edges, with little surrounding inflammation; autoinoculation is common, resulting in lesions at various stages of evolution)
• Unilateral adenopathy progressing to massive enlargement and inflammation (“buboes,” 50%)

(The combination of a painful ulcer and tender inguinal adenopathy, symptoms occurring in one third of patients, suggests chancroid; when accompanied by suppurative inguinal adenopathy, they are almost pathognomonic. A definitive diagnosis of chancroid requires identification of H. ducreyi on special culture media that is not widely available from commercial sources; even using these media, sensitivity is ≤80%.)

DIAGNOSTIC APPROACH

Differential Diagnosis

• Herpes simplex
• Syphilis
• Granuloma inguinale
• Lymphogranuloma venereum

Associated Conditions: Other sexually transmitted infections, HIV. (About 10% of persons who have chancroid acquired in the United States are coinfected with Treponema pallidum or herpes simplex virus (HSV); this percentage is higher in persons acquiring chancroid outside the United States.)

Workup and Evaluation

Laboratory: Gram stain and culture of material from open ulcers. Because of the growing association with HIV, serum testing for HIV infections is highly recommended.
Imaging: No imaging indicated.
Special Tests: None indicated.
Diagnostic Procedures: The diagnosis is established based on clinical findings, finding the gram-negative coccobacillus on smears from the primary lesion, or (rarely) on culture of aspirates of the bubo. Biopsy is also diagnostic, although not often performed.

Pathologic Findings

The H. ducreyi bacillus is a gram-positive, nonmotile, facultative anaerobe that can be seen in chains on Gram stain or in culture. Superficial and deep ulcers with granulomatous inflammation are found on biopsy.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation, culture or Gram stain, topical cleansing, and care.
Specific Measures: Antibiotic treatment for patient and her sexual partner(s). Fluctuant nodes may be drained by aspiration through adjacent normal tissue, but incision and drainage delay healing and should not be attempted.
Diet: No specific dietary changes indicated.
Activity: No sexual activity until lesions have healed.
Patient Education: American College of Obstetricians and Gynecologists Patient Education Pamphlet AP009 (How to Prevent Sexually Transmitted Diseases). Patients should be advised to have all sexual partners seen for diagnosis and treatment.

Drug(s) of Choice

Azithromycin 1 g PO single dose or ceftriaxone 250 mg IM single dose or ciprofloxacin 500 mg PO twice a day for 3 days or erythromycin 500 mg PO four times a day. Treatment must continue for no less than 10 days or until the lesions heal, whichever is longer.
Contraindications: Erythromycin estolate and ciprofloxacin are contraindicated in pregnancy and should not be used. Ciprofloxacin is contraindicated in patients younger than 18 years of age.
Precautions: See individual agents. The safety of azithromycin in pregnancy has not been established.
Interactions: See individual agents.

Alternative Drugs

Trimethoprim 160 mg plus sulfamethoxazole 800 mg PO twice a day. Treatment must continue for no less than 10 days or until the lesions heal, whichever is longer.
Amoxicillin 500 mg plus clavulanic acid 125 mg (Augmentin) PO every 8 hours for 7 days.

FOLLOW-UP

Patient Monitoring: Follow-up evaluation for cure (improvement in 3 to 7 days), culture or other tests should be carried out, as well as screening for other sexually transmitted diseases. (As with all sexually transmitted diseases, all sexual partners who have had sexual contact with the patient within the preceding 10 days should be screened and treated for probable infections.)

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Prevention/Avoidance: Use of barrier contraception (condoms, diaphragm), limitation or elimination of risky behavior (sexual promiscuity).
Possible Complications: Buboes may rupture and drain, causing extensive soft-tissue and skin damage. Chronic draining sinus tracts and abscesses may occur. Scarring is common.
Expected Outcome: If detected early, successful treatment with minimal sequelae may be expected. Buboes, if present, may take several weeks to resolve. Up to 10% of patients have a recurrence at the site of old ulcers.

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy, although the possibility of vertical transmission of other associated conditions (such as HIV infection) should be considered.
ICD-9-CM Codes: 099.0.

REFERENCES

Level I

Al-Tawfiq JA, Palmer KL, Chen CY, et al. Experimental infection of human volunteers with Haemophilus ducreyi does not confer protection against subsequent challenge. J Infect Dis. 1999;179:1283.

Kaul R, Kimani J, Nagelkerke NJ, et alKibera HIV Study Group. Monthly antibiotic chemoprophylaxis and incidence of sexually transmitted infections and HIV-1 infection in Kenyan sex workers: a randomized controlled trial. JAMA. 2004;291:2555.

Malonza IM, Tyndall MW, Ndinya-Achola JO, et al. A randomized, double-blind, placebo-controlled trial of single-dose ciprofloxacin versus erythromycin for the treatment of chancroid in Nairobi, Kenya. J Infect Dis. 1999;180:1886.

Palmer KL, Thornton AC, Fortney KR, et al. Evaluation of an isogenic hemolysin-deficient mutant in the human model of Haemophilus ducreyi infection. J Infect Dis. 1998;178:191.

Thornton AC, O’Mara EMJr, Sorensen SJ, et al. Prevention of experimental Haemophilus ducreyi infection: a randomized, controlled clinical trial. J Infect Dis. 1998;177:1608.

Level II

American College of Obstetricians and Gynecologists. Sexually transmitted diseases in adolescents. ACOG Committee Opinion 301. Washington, DC: ACOG, 2004.

Chen CY, Mertz KJ, Spinola SM, Morse SA. Comparison of enzyme immunoassays for antibodies to Haemophilus ducreyi in a community outbreak of chancroid in the United States. J Infect Dis. 1997;175:1390.

Dillon SM, Cummings M, Rajagopalan S, McCormack WC. Prospective analysis of genital ulcer disease in Brooklyn, New York. Clin Infect Dis. 1997;24:945.

Level III

Abeck D, Freinkel AL, Korting HC, et al. Immunohistochemical investigations of genital ulcers caused by Haemophilus ducreyi.. Int J STD AIDS. 1997;8:585.

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR. 2006;55:15.

Eckert LO, Lentz GM. Infections of the lower genital tract. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:582.

Eichmann A. Chancroid. Curr Probl Dermatol. 1996;4:20.

Wilkinson EJ, Stone IK. Atlas of vulvar disease. Baltimore: Williams & Wilkins, 1995;137.

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