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Chancroid

  • Author: Joseph Adrian L Buensalido, MD; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
 
Updated: Jul 07, 2016
 

Background

Chancroid is a bacterial sexually transmitted disease (STD) caused by infection with Haemophilus ducreyi. It is characterized by painful necrotizing genital ulcers that may be accompanied by inguinal lymphadenopathy. It is a highly contagious but curable disease.

Chancroid was once highly prevalent in many areas of the world, but collaborated efforts in increasing social awareness and subsequent changes in sexual practices, along with improved diagnosis and treatment options, have eradicated chancroid as an endemic disease in industrialized countries.[25] In 2000, the proportion of chancroid among genital ulcerative diseases (GUD) decreased from 69% to 15%.[26] It remains prevalent in certain underdeveloped regions such as Asia, Africa, and the Caribbean.[26] However, despite the presence of joint STD/HIV control programs, prevention control methods have not been consistently implemented.[25] In these areas, outbreaks occur in cities among workers in the sex trade. Individuals traveling to these high-risk areas are at risk of contracting the disease. In addition, individuals from high-risk areas who travel to other countries to work in the sex industry remain a source of outbreaks in the industrialized world.

Chancroid is a subclass of sexually transmitted genital ulcerative diseases that are of worldwide concern owing to their role as cofactors in the transmission of HIV.[1, 2, 3, 4] Ulcerative STDs penetrate the skin of the external genitalia, colonize the subcutaneous tissue, and produce tissue damage, causing ulceration.[27] Skin abrasion and microtrauma is necessary to penetrate normal skin. The disruption of the mucosal barrier increases the risk of HIV access to the bloodstream and inflammatory cells and serves as a focus for bacterial and viral shedding.[29] A report from the World Health Organization (WHO) estimates that the presence of ulcerative STDs increases the risk of HIV transmission by 10%-50% in women and 50%-300% in men.[5] Multiple genital ulcers, purulent ulcer base, and multiple genital ulcerative lesions increase the likelihood of HIV shedding.[30]

Recently, the etiologic agent of chancroid, H ducreyi, has been isolated among chronic limb ulcers in the Asia Pacific region. H ducreyi should be considered as a cause of chronic limb ulcers in endemic areas.[31, 32]

This photograph shows an early chancroid on the pe This photograph shows an early chancroid on the penis, along with accompanying regional lymphadenopathy. Courtesy of the CDC/Dr. Pirozzi.

See 20 Signs of Sexually Transmitted Infections, a Critical Images slideshow, to help make an accurate diagnosis.

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Pathophysiology

Chancroid is caused by H ducreyi, a small, gram-negative, facultative anaerobic bacillus that is highly infective. It is pathogenic only in humans, with no intermediary environmental or animal host. H ducreyi enters the skin through disrupted mucosa and causes a local inflammatory reaction. It produces a cytocidal distending toxin that appears to be responsible for its destructive effects.

H ducreyi penetrates the skin through breaks in the mucosal barriers and microabrasions on the skin. It produces a cytocidal distending toxin (HdCDT), which causes cell cycle arrest and apoptosis/necrosis of human cells and contributes to the aggravation of ulcers.[33] Phagocytosis by macrophages is also impaired.[35, 36] Other virulence mechanisms include LspA proteins, which have antiphagocytic functions, DsrA map, which facilitates adherence, and an influx transporter that protects H ducreyi from antimicrobial killing.[37, 38, 39]

H ducreyi is transmitted sexually by direct contact with purulent lesions and by autoinoculation to nonsexual sites, such as the eye and skin. The organism has an incubation period of 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 may erode to form an extremely painful deep ulceration. Without treatment, the lesions may last weeks to months, and complications such as suppurative lymphadenopathy are more likely.[2, 6, 7]

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Epidemiology

Frequency

United States

The Centers for Disease Control and Prevention (CDC) collects data from state health departments in the United States and has published information regarding prevalence of STDs, including chancroid, since 1941, when 3,384 cases were reported. Starting in 1994, a significant decrease in the number of chancroid cases was reported. Only 782 cases were recorded in 1994 and steadily decreased over the following years. In 2010, 24 cases were reported from 9 different states, while, in 2013, only 10 cases of chancroid were documented.[40]

In the past, the disease was considered endemic in several large US cities but is currently seen in sporadic cases associated with low socioeconomic status, poor hygiene, prostitution among sex workers, and drug abuse. The true incidence is difficult to determine and is probably underestimated because of unavailable diagnostic resources and because of the difficulties in culturing H ducreyi, even when laboratory resources are available.[8]

International

Chancroid is still endemic in many areas of the world. No specific monitoring for this disease exists. The unavailability of diagnostic tests and facilities in resource-limited settings and the difficulty in isolating the organism are recognized factors that contribute to the underreporting of the disease. Therefore, the true incidence of chancroid at present worldwide is unavailable.

Data from the WHO in 1995 suggested that 7 million cases of chancroid existed worldwide. Globally, it has been surpassed by herpes simplex virus (HSV) type 2 as the most common genital ulcerative disease. Chancroid is prevalent in Africa, the Caribbean basin, and Southwest Asia. It is thought to be the most common cause of genital ulceration in Kenya, Gambia, and Zimbabwe.[9, 10, 11] Recently, the prevalence of chancroid decreased substantially in the Philippines, Senegal, and Thailand. This development was probably brought by joint programs against HIV/AIDS and related STDs in those areas.[41]

Local outbreaks in various parts of Europe have been reported. The Health Protection Agency in the United Kingdom reported 450 cases of chancroid from 1995-2000. From 1995-2005, 3% of genital ulcer cases from an STD clinic in Paris were due to chancroid.[12] The European Centre for Disease Prevention and Control released a surveillance report on sexually transmitted infections in Europe from 1990-2010, and it was noted that the prevalence of chancroid had decreased dramatically, that some countries had no reported cases, and that some countries even stopped mandatory notifications.[42]

Mortality/Morbidity

Chancroid is not a lethal disease. Even if left untreated, the genital lesion resolves spontaneously within 1-3 months. However, untreated infection can lead to development of painful inguinal lymphadenopathy, which can ulcerate to form buboes in 25% of cases. It is characterized by one or more painful genital ulcers that are associated with unilateral painful inguinal lymphadenopathy in approximately 50% of cases. 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 infection 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. Previous infection does not confer immunity against the disease, and reinfection is possible.[13] Patients with chancroid and HIV coinfection are more likely to experience multiple chronic genital ulcerations and inguinal lymphadenopathy.[43]

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. This observation is not unexpected, given the prevalence of the disease in areas of Africa, Asia, and the Caribbean.

Sex

Chancroid is most commonly observed in nonwhite men who are uncircumcised. A 2006 meta-analysis showed that circumcision is somewhat protective against infection with syphilis and chancroid.[44] Circumcision and its role in HIV and sexually transmitted infection (STI) risk reduction among men who have sex with men (MSM) still needs further investigation.[45] 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, commercial sex workers, and travellers from endemic areas.[14] According to Benson and Hergenroeder,[14] there have been no reported cases of chancroid among homosexual males, bisexuals, or lesbian females, but recent reports have documented chancroid to occur together with other STIs.[46, 47]

Age

Although it can affect people of any age, chancroid predominantly affects younger sexually active people. The most common age group affected was 21-30 years.[48] 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.

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Contributor Information and Disclosures
Author

Joseph Adrian L Buensalido, MD Clinical Associate Professor, Section of Infectious Diseases, Department of Medicine, Philippine General Hospital, University of the Philippines Manila College of Medicine

Joseph Adrian L Buensalido, MD is a member of the following medical societies: American Society for Microbiology, Infectious Diseases Society of America, Philippine Medical Association, Michigan Infectious Disease Society, Philippine College of Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Christian N Francisco, MD Chief Fellow, Section of Infectious Diseases, Department of Medicine, University of the Philippines-Philippine General Hospital

Christian N Francisco, MD is a member of the following medical societies: Philippine College of Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Charles V Sanders, MD Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine at New Orleans; Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans; Consulting Staff, Ochsner Medical Center

Charles V Sanders, MD is a member of the following medical societies: American College of Physicians, Alliance for the Prudent Use of Antibiotics, The Foundation for AIDS Research, Southern Society for Clinical Investigation, Southwestern Association of Clinical Microbiology, Association of Professors of Medicine, Association for Professionals in Infection Control and Epidemiology, American Clinical and Climatological Association, Infectious Disease Society for Obstetrics and Gynecology, Orleans Parish Medical Society, Southeastern Clinical Club, American Association for the Advancement of Science, Alpha Omega Alpha, American Association of University Professors, American Association for Physician Leadership, American Federation for Medical Research, American Geriatrics Society, American Lung Association, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Association of American Medical Colleges, Association of American Physicians, Infectious Diseases Society of America, Louisiana State Medical Society, Royal Society of Medicine, Sigma Xi, Society of General Internal Medicine, Southern Medical Association

Disclosure: Received royalty from Baxter International for other.

Chief Editor

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Chief of Infectious Disease, Program Director of Infectious Disease Fellowship, Department of Internal Medicine, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Larry I Lutwick, MD Professor of Medicine, State University of New York Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus

Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Pamela Arsove, MD, FACEP Associate Residency Director, Department of Emergency Medicine, Hofstra Northshore Long Island Jewish School of Medicine; Attending Physician, Department of Emergency Medicine, Long Island Jewish Medical Center; Assistant Professor, Department of Emergency Medicine, Northshore Long Island Jewish School of Medicine

Pamela Arsove, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Phi Beta Kappa, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Barbara Edwards, MD Associate Physician, Division of Infectious Diseases, Department of Medicine, Long Island Jewish Medical Center; Assistant Professor, Department of Medicine, Albert Einstein College of Medicine of Yeshiva University

Barbara Edwards, MD is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America, Society for Healthcare Epidemiology of America

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Alexandre F Migala, DO, and Gregory Shipkey, MD, to the development and writing of this article.

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This photograph shows an early chancroid on the penis, along with accompanying regional lymphadenopathy. Courtesy of the CDC/Dr. Pirozzi.
 
 
 
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