Chancroid

Chancroid is a highly contagious yet curable sexually transmitted disease (STD) caused by the bacteria Haemophilus ducreyi [hum-AH-fill-us DOO-cray]. Chancroid causes ulcers, usually of the genitals. Swollen, painful lymph glands, or inguinal buboes [in-GWEEN-al BEW-boes], in the groin area are often associated with chancroid. Left untreated, chancroid may facilitate the transmission of HIV.

The prevalence of chancroid has declined in the United States. When infection does occur, it is usually associated with sporadic outbreaks. Worldwide, chancroid appears to have declined as well, although infection might still occur in some regions of Africa and the Caribbean. Chancroid, as well as genital herpes and syphilis, is a risk factor in the transmission of HIV infection.

A definitive diagnosis of chancroid requires the identification of H. ducreyi on special culture media that is not widely available from commercial sources; even when these media are used, sensitivity is less than 80 percent. No FDA-cleared PCR test for H. ducreyi is available in the United States, but such testing can be performed by clinical laboratories that have developed their own PCR test and have conducted a CLIA verification study.

The combination of a painful genital ulcer and tender suppurative inguinal adenopathy suggests the diagnosis of chancroid. A probable diagnosis of chancroid, for both clinical and surveillance purposes, can be made if all of the following criteria are met: 1) the patient has one or more painful genital ulcers; 2) the patient has no evidence of T. pallidum infection by darkfield examination of ulcer exudate or by a serologic test for syphilis performed at least seven days after onset of ulcers; 3) the clinical presentation, appearance of genital ulcers and, if present, regional lymphadenopathy are typical for chancroid; and 4) a test for HSV performed on the ulcer exudate is negative.

Chancroid is transmitted in two ways:

• sexual transmission through skin-to-skin contact with open sore(s).
• non-sexual transmission when pus-like fluid from the ulcer is moved to other parts of the body or to another person.

A person is considered to be infectious when ulcers are present. There has been no reported disease in infants born to women with active chancroid at time of delivery.

• Symptoms usually occur within four days to ten days from exposure. They rarely develop earlier than three days or later than ten days.
• The ulcer begins as a tender, elevated bump, or papule, that becomes a pus-filled, open sore with eroded or ragged edges.
• The ulcer is soft to the touch (unlike a syphilis chancre that is hard or rubbery). The term soft chancre is frequently used to describe the chancroid sore.
• The ulcers can be very painful in men but women are often unaware of them.
• Because chancroid is often asymptomatic in women, they may be unaware of the lesion(s).
• Painful lymph glands may occur in the groin, usually only on one side; however, they can occur on both sides.

Diagnosis is made by isolating the bacteria Haemophilus ducreyi in a culture from a genital ulcer. The chancre is often confused with syphilis, herpes or lymphogranuloma venereum; therefore, it is important that your health care provider rule these diseases out.
A Gram stain to identify H. ducreyi is possible but can be misleading because of other organisms found in most genital ulcers.

Successful treatment for chancroid cures the infection, resolves the clinical symptoms, and prevents transmission to others. In advanced cases, scarring can result, despite successful therapy.
Antibiotics used to treat chancroid include; Azithromycin 1 g orally, Ceftriaxone 250 mg intramuscularly (IM), Ciprofloxacin 500 mg orally or Erythromycin 500 mg orally.
Ciprofloxacin is contraindicated for pregnant and lactating women.
Azithomycin and ceftriaxone offer the advantage of single-dose therapy. Worldwide, several isolates with intermediate resistance to either ciprofloxacin or erythromycin have been reported. However, because cultures are not routinely performed, data are limited regarding the current prevalence of antimicrobial resistance.

Patients should be re-examined three days to seven days after initiation of therapy. If treatment is successful, ulcers usually improve symptomatically within three days and objectively within seven days after therapy. If no clinical improvement is evident, the clinician must consider whether 1) the diagnosis is correct, 2) the patient is coinfected with another STD, 3) the patient is infected with HIV, 4) the treatment was not used as instructed, or 5) the H. ducreyi strain causing the infection is resistant to the prescribed antimicrobial. The time required for complete healing depends on the size of the ulcer; large ulcers might require greater than two weeks. In addition, healing is slower for some uncircumcised men who have ulcers under the foreskin. Clinical resolution of fluctuant lymphadenopathy is slower than that of ulcers and might require needle aspiration or incision and drainage, despite otherwise successful therapy. Although needle aspiration of buboes is a simpler procedure, incision and drainage might be preferred because of reduced need for subsequent drainage procedures.

Men who are uncircumcised and patients with HIV infection do not respond as well to treatment as persons who are circumcised or HIV-negative. Patients should be tested for HIV infection at the time chancroid is diagnosed. If the initial test results were negative, a serologic test for syphilis and HIV infection should be performed three months after the diagnosis of chancroid.

Ciprofloxacin is contraindicated during pregnancy and lactation. No adverse effects of chancroid on pregnancy outcome have been reported.

• Abstinence (not having sex)
• Mutual monogamy [having sex with only one uninfected partner]
• Latex condoms for vaginal, oral and anal sex. Using latex condoms may protect the penis or vagina from infection, but does not protect other areas such as the scrotum or anal area. Chancroid lesions can occur in genital areas that are covered or protected by a latex condom, but may occur in areas that are not covered or protected by a condom. Latex condoms, when used consistently and correctly, can reduce the risk of chancroid, genital herpes, syphilis, and genital warts, only when the infected areas are covered or protected by the condom.

If you do get chancroid, avoid contact with the infected area to prevent chance of spreading the infection to other parts of the body.

Chancroid has been well established as a cofactor for HIV transmission. Moreover, persons with HIV may experience slower healing of chancroid, even with treatment, and may need to take medications for a longer period of time. Complications from chancroid include:

• In 50 percent of cases, the lymph node glands in the groin become infected within five to eight days of appearance of initial sores.
• Glands on one side become enlarged, hard, painful and fuse together to form a bubo (BEW-bo), an inflammation and swelling of one or more lymph nodes with overlying red skin. Surgical drainage of the bubo may be necessary to relieve pain.
• Ruptured buboes are susceptible to secondary bacterial infections.
• In uncircumcised males, new scar tissue may result in phimosis [constriction so the foreskin cannot be retracted over the head of the penis]. Circumcision may be required to correct this.

You should talk to your partner as soon as you learn you have chancroid. Telling a partner can be hard, but it's important that you talk to your partner as soon as possible so she or he can get treatment.

If you have a genital ulcer or painful, swollen lymph nodes, you need to talk to your doctor about whether or not you should be tested. However, it's important to remember that some people, usually women, are asymptomatic. If you are having unprotected sex or discover that your partner is having unprotected sex with another person, you may want to ask your doctor about being tested for STDs.