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 infectious disease characterized by painful ulcers, bubo formation, and painful inguinal lymphadenopathy. The causative organism, Haemophilus ducreyi, was found by Ducrey in 1889. It is a gram-negative coccoid-bacillary rod, which is usually located in the extracellular spaces.

Pathophysiology

H ducreyi enters the skin through an epithelial break, usually following some minor trauma such as sexual intercourse. Once the bacteria have breached the integument, it recruits keratinocytes, fibroblasts, endothelial cells, and melanocytes to secrete interleukin 6 (IL-6) and interleukin 8 (IL-8). IL-8 induces polymorphonuclear neutrophils (PMNs) and macrophages to form intradermal pustules. IL-6 stimulates T-cell interleukin 2 (IL-2) receptor expression, which, in turn, stimulates CD4 cells in the region. H ducreyi secretes a cyto-lethal distending toxin (HdCDT) that causes apoptosis and necrosis of human cells such as myeloid cells, epithelial cells, keratinocytes, and primary fibroblasts. This toxin inhibits cell proliferation and induces cell death causing the characteristic ulcer formation seen in chancroid.

H ducreyi is also able to evade phagocytosis leading to slow healing of ulcers. For an unknown reason, macrophages in ulcers have greater CCR5 and CXCR4 chemokine receptors, which are receptors for human immunodeficiency virus (HIV) entry, than normal cells.

Frequency

United States

Chancroid is rare in the United States. Localized endemic outbreaks may occur within isolated STD and prostitution populations.

International

Annual global incidence is about 6 million cases per year.¹ Chancroid is more common in areas of low socioeconomic status such as Africa, Asia, and the Caribbean. It has also been found to be more common in areas where the prevalence of HIV is high (>8%). Other risk factors are low education level, risky sexual behavior, other sexually transmitted diseases, noncircumcision, and older male homosexuals.² Note that the frequency of chancroid as well as other bacterial STDs has recently shifted away from bacterial infections and toward viral etiologies such as herpes simplex virus (HSV) and HIV.

Mortality/Morbidity

If chancroid is diagnosed and treated early, it can be cured easily. H ducreyi produces painful ulcers and painful inguinal lymphadenopathy known as buboes. These may rupture after becoming an abscess. Scarring in this region may be permanent. Open sore secondary to H ducreyi infection also facilitates the transmission of HIV. Immunocompromised patients have lower cure rates and more complications.

Sex

The male-to-female ratio is between 3 and 25:1¹, depending on the geographic region being studied. Although males are affected more often, female sex workers appear to be the reservoir of the disease.

Age

Mean patient age is 30 years.

CLINICAL

Section 3 of 10  

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

History

The patient complains of painful papules, pustules, or ulcers. They may also have dyspareunia, vaginal discharge, fever, or weakness. Patients may report a history of unprotected contact with a prostitute. HIV-positive and other immune compromised patients may have an atypical presentation.

Physical

The organisms enter through breaks in the skin on the genitals, which is where an erythematous papule will form, becoming a pustule in 2-3 days. The pustule ulcerates in a matter of weeks, and lymphadenopathy also usually is seen. The ulcer is characterized by a soft chancre with irregular borders and possibly a ring of erythema. Painful inguinal lymphadenopathy or bubo formation is present in 50% of patients.³ Lymphadenopathy is usually unilateral, and lymph nodes may rupture.

Causes

H ducreyi, a gram-negative bacillus, is the causative organism.

DIFFERENTIALS

Section 4 of 10  

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

Other Problems to be Considered

Traumatic ulceration
Squamous cell carcinoma
Granuloma inguinale
Behçet disease
Extracutaneous Crohn disease
Drug eruption
Allergic reaction
Chlamydia trachomatis

WORKUP

Section 5 of 10  

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

Lab Studies

• Culture is unreliable and insensitive. Sensitivities have been found to be between 50% and 100%.⁴ Use of a special medium is required to culture H ducreyi due to its heme dependence. The growth temperature is also lower (33°C) than most organisms. If cultures are going to be positive, they usually grow organisms within 3 days.
• Polymerase chain reaction (PCR) is 100% sensitive.⁴ However, PCR is not usually performed on site, therefore, causing a time delay in making the diagnosis as well as being expensive. PCR directed against one of two genomic segments (either the ribosomal RNA gene, rrs-rrl ribosomal intergenic spacer region, or the GroEL gene, which encodes a heat shock protein) can be used.
• Gram stain is similar to PCR in the time it takes and the delay in diagnosis and treatment. Microbiologists have described H ducreyi to look like "schools of fish," "railroad tracks," and "fingerprints".³ Histologic findings include neutrophils, fibrin, erythrocytes, and necrotic tissue.
• Immunochromatography is a rapid diagnostic test that usually takes approximately 15 minutes to perform. Immunochromatography tests use monoclonal antibodies to the hemoglobin receptor of H ducreyi, hgbA, which is an outer membrane protein. Patterson reported this test to have a specificity of 100%.⁴ However, sensitivity is not as good. Positive characteristics are ease of use, low cost, and stability in a variety of climates. This test will not be commercially available until the sensitivity can be increased.
• The syndromic management approach by the World Health Organization and Centers for Disease Control and Prevention (CDC) suggests a positive diagnosis if the patient has one or more painful ulcers (ulcers with painful adenopathy are pathognomonic) with no evidence of syphilis (darkfield examination of ulcer exudates) or herpes simplex virus.

TREATMENT

Section 6 of 10  

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

Emergency Department Care

• Clean the local area. Local cleaning should be completed with plain antibacterial soap and water or any other skin cleansing solution.
• Incision and drainage of fluctuant buboes is preferable over needle aspiration because aspiration frequently needs to be repeated because of recurrence.
• If syndromic management is used, patients should be treated for other STDs as well. In endemic areas, patients should be treated for granuloma inguinale. Therapy for lymphogranuloma venereum should be given if inguinal buboes are present.
• Health education and safe sex practices should be encouraged.
• Serologic testing for syphilis, HIV, and all other STDs should be performed, retesting 3 months later if test results are negative.
• HIV-positive patients may fail single-dose therapy.
• For treatment with antibiotics, the CDC recommends the following: azithromycin 1 g PO single dose, ceftriaxone 250 mg IM single dose, erythromycin 500 mg PO qid for 7 days, or ciprofloxacin 500 mg PO bid for 3 days.
• Streptomycin and ceftriaxone have been shown to be synergistic in the treatment of chancroid.
• Single-dose ciprofloxacin (92% cure rate) and azithromycin are effective.
• Treatment of partners is similar to the source patient.
• Patients should not engage in sexual activity until the ulcers are healed.

MEDICATION

Section 7 of 10  

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

The goal of therapy is to eradicate the microorganism. Since treatment of chancroid may accompany treatment of gonorrhea, it is important to be aware of the updated CDC guidelines for treating 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

These agents are always indicated in chancroid. Therapy must be aimed at covering all likely pathogens according to the clinical setting.

FOLLOW-UP

Section 8 of 10  

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

Further Outpatient Care

• Patients should have outpatient follow-up within 1 week to go over culture results and evaluate progress of healing of ulcers.

Deterrence/Prevention

• Patients need to be educated about safe sex practices.

Complications

• Scarring, phimosis, balanoposthitis, ruptured buboes with severe pain, and fistula formation are complications. Sexual dysfunction due to scar formation may also occur.

Prognosis

• Chancroid can be cured with early antibiotic treatment in immunocompetent patients. If chancroid has already progressed to later stages or the host is immunocompromised, it can be more difficult to treat and may have more complications (stated above).

Patient Education

• Patients need to be educated about safe sex practices including condom use, regular genital self-examination, and informing their partners.
• For excellent patient education resources, visit eMedicine's Sexually Transmitted Diseases Center and Pregnancy and Reproduction Center. Also, see 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

• Physicians need to provide information on prevention, treatment, and testing for all other STDs. Co-infections (ie, syphilis, gonorrhea, HSV) must all be treated.

REFERENCES

Section 10 of 10

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

1. Spinola SM, Bauer ME, Munson RS Jr. Immunopathogenesis of Haemophilus ducreyi infection (chancroid). Infect Immun. Apr 2002;70(4):1667-76. [Medline].
2. Kyriakis KP, Hadjivassiliou M, Paparizos VA, Flemetakis A, Stavrianeas N, Katsambas A. Incidence determinants of gonorrhea, chlamydial genital infection, syphilis and chancroid in attendees at a sexually transmitted disease clinic in Athens, Greece. Int J Dermatol. Nov 2003;42(11):876-81. [Medline].
3. Lewis DA. Diagnostic tests for chancroid. Sex Transm Infect. Apr 2000;76(2):137-41. [Medline].
4. Patterson K, Olsen B, Thomas C, Norn D, Tam M, Elkins C. Development of a rapid immunodiagnostic test for Haemophilus ducreyi. J Clin Microbiol. Oct 2002;40(10):3694-702. [Medline].
5. Annan NT, Lewis DA. Treatment of chancroid in resource-poor countries. Expert Rev Anti Infect Ther. Apr 2005;3(2):295-306. [Medline].
6. Centers for Disease Control and Prevention. 1993 sexually transmitted diseases treatment guidelines. MMWR Morb Mortal Wkly Rep. Sep 24 1993;42(RR-14):1-102. [Medline].
7. Cole LE, Toffer KL, Fulcher RA, San Mateo LR, Orndorff PE, Kawula TH. A humoral immune response confers protection against Haemophilus ducreyi infection. Infect Immun. Dec 2003;71(12):6971-7. [Medline].
8. Dallabetta GA, Gerbase AC, Holmes KK. Problems, solutions, and challenges in syndromic management of sexually transmitted diseases. Sex Transm Infect. Jun 1998;74 Suppl 1:S1-11. [Medline].
9. DiCarlo RP, Armentor BS, Martin DH. Chancroid epidemiology in New Orleans men. J Infect Dis. Aug 1995;172(2):446-52. [Medline].
10. Ernst AA, Marvez-Valls E, Martin DH. Incision and drainage versus aspiration of fluctuant buboes in the emergency department during an epidemic of chancroid. Sex Transm Dis. Jul-Aug 1995;22(4):217-20. [Medline].
11. 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].
12. Goens JL, Schwartz RA, De Wolf K. Mucocutaneous manifestations of chancroid, lymphogranuloma venereum and granuloma inguinale. Am Fam Physician. Feb 1 1994;49(2):415-8, 423-5. [Medline].
13. Hammond GW. A history of the detection of Haemophilus ducreyi, 1889-1979. Sex Transm Dis. Mar-Apr 1996;23(2):93-6. [Medline].
14. Hollier LM, Workowski K. Treatment of sexually transmitted diseases in women. Obstet Gynecol Clin North Am. Dec 2003;30(4):751-75, vii-viii. [Medline].
15. Htun Y, Morse SA, Dangor Y, Fehler G, Radebe F, Trees DL, et al. Comparison of clinically directed, disease specific, and syndromic protocols for the management of genital ulcer disease in Lesotho. Sex Transm Infect. Jun 1998;74 Suppl 1:S23-8. [Medline].
16. Humphreys TL, Baldridge LA, Billings SD, Campbell JJ, Spinola SM. Trafficking pathways and characterization of CD4 and CD8 cells recruited to the skin of humans experimentally infected with Haemophilus ducreyi. Infect Immun. Jul 2005;73(7):3896-902. [Medline].
17. Humphreys TL, Schnizlein-Bick CT, Katz BP, Baldridge LA, Hood AF, Hromas RA, et al. Evolution of the cutaneous immune response to experimental Haemophilus ducreyi infection and its relevance to HIV-1 acquisition. J Immunol. Dec 1 2002;169(11):6316-23. [Medline].
18. Joseph AK, Rosen T. Laboratory techniques used in the diagnosis of chancroid, granuloma inguinale, and lymphogranuloma venereum. Dermatol Clin. Jan 1994;12(1):1-8. [Medline].
19. Lewis DA. Chancroid: clinical manifestations, diagnosis, and management. Sex Transm Infect. Feb 2003;79(1):68-71. [Medline].
20. Marrazzo JM, Handsfield HH. Chancroid: new developments in an old disease. Curr Clin Top Infect Dis. 1995;15:129-52. [Medline].
21. Martin DH, Mroczkowski TF. Dermatologic manifestations of sexually transmitted diseases other than HIV. Infect Dis Clin North Am. Sep 1994;8(3):533-82. [Medline].
22. Martin DH, Sargent SJ, Wendel GD Jr, McCormack WM, Spier NA, Johnson RB, et al. Comparison of azithromycin and ceftriaxone for the treatment of chancroid. Clin Infect Dis. Aug 1995;21(2):409-14. [Medline].
23. Mayaud P, Ka-Gina G, Grosskurth H. Effectiveness, impact and cost of syndromic management of sexually transmitted diseases in Tanzania. Int J STD AIDS. 1998;9 Suppl 1:11-4. [Medline].
24. Mertz KJ, Weiss JB, Webb RM, Levine WC, Lewis JS, Orle KA, et al. An investigation of genital ulcers in Jackson, Mississippi, with use of a multiplex polymerase chain reaction assay: high prevalence of chancroid and human immunodeficiency virus infection. J Infect Dis. Oct 1998;178(4):1060-6. [Medline].
25. Morse SA. Chancroid and Haemophilus ducreyi. Clin Microbiol Rev. Apr 1989;2(2):137-57. [Medline].
26. O'Farrell N. Soap and water prophylaxis for limiting genital ulcer disease and HIV-1 infection in men in sub-Saharan Africa. Genitourin Med. Aug 1993;69(4):297-300. [Medline].
27. O'Farrell N. Targeted interventions required against genital ulcers in African countries worst affected by HIV infection. Bull World Health Organ. 2001;79(6):569-77. [Medline].
28. Paz-Bailey G, Rahman M, Chen C, Ballard R, Moffat HJ, Kenyon T, et al. Changes in the etiology of sexually transmitted diseases in Botswana between 1993 and 2002: implications for the clinical management of genital ulcer disease. Clin Infect Dis. Nov 1 2005;41(9):1304-12. [Medline].
29. Pillay A, Hoosen AA, Loykissoonlal D, Glock C, Odhav B, Sturm AW. Comparison of culture media for the laboratory diagnosis of chancroid. J Med Microbiol. Nov 1998;47(11):1023-6. [Medline].
30. Post DM, Mungur R, Gibson BW, Munson RS Jr. Identification of a novel sialic acid transporter in Haemophilus ducreyi. Infect Immun. Oct 2005;73(10):6727-35. [Medline].
31. Prather DT, Bains M, Hancock RE, Filiatrault MJ, Campagnari AA. Differential expression of porins OmpP2A and OmpP2B of Haemophilus ducreyi. Infect Immun. Nov 2004;72(11):6271-8. [Medline].
32. Rome ES. Sexually transmitted diseases: testing and treating. Adolesc Med. Jun 1999;10(2):231-41, vi. [Medline].
33. Rosen T, Brown TJ. Cutaneous manifestations of sexually transmitted diseases. Med Clin North Am. Sep 1998;82(5):1081-104, vi. [Medline].
34. Schmid GP, Faur YC, Valu JA, Sikandar SA, McLaughlin MM. Enhanced recovery of Haemophilus ducreyi from clinical specimens by incubation at 33 versus 35 degrees C. J Clin Microbiol. Dec 1995;33(12):3257-9. [Medline].
35. Schmid GP, Sanders LL Jr, Blount JH, Alexander ER. Chancroid in the United States. Reestablishment of an old disease. JAMA. Dec 11 1987;258(22):3265-8. [Medline].
36. Spinola SM, Fortney KR, Katz BP, Latimer JL, Mock JR, Vakevainen M, et al. Haemophilus ducreyi requires an intact flp gene cluster for virulence in humans. Infect Immun. Dec 2003;71(12):7178-82. [Medline].
37. Steen R. Eradicating chancroid. Bull World Health Organ. 2001;79(9):818-26. [Medline].
38. Steen R. Sex, soap and antibiotics: the case for chancroid eradication. Int J STD AIDS. 2001;12(Suppl 2):147.
39. Steen R, Dallabetta G. Genital ulcer disease control and HIV prevention. J Clin Virol. Mar 2004;29(3):143-51. [Medline].
40. Trager JD. Sexually transmitted diseases causing genital lesions in adolescents. Adolesc Med Clin. Jun 2004;15(2):323-52. [Medline].
41. WHO. World Health Organization. Management of sexually transmitted diseases. (WHO/GPA/TEM/94.1 Rev 1 ed). 1997. [Full Text].
42. WHO: World Health Organization. - Syndromic Case Management of STD (Sexually Transmitted Diseases)- A Guide for Decision-makers, Health Care Workers, and Communicators. 1997. [Full Text].
43. Wising C, Azem J, Zetterberg M, Svensson LA, Ahlman K, Lagergård T. Induction of apoptosis/necrosis in various human cell lineages by Haemophilus ducreyi cytolethal distending toxin. Toxicon. May 2005;45(6):767-76. [Medline].
44. Workowski KA, Berman SM. CDC sexually transmitted diseases treatment guidelines. Clin Infect Dis. Oct 15 2002;35(Suppl 2):S135-7. [Medline].

Article Last Updated: Sep 20, 2007