eMedicine Specialties > Emergency Medicine > Infectious Diseases

Chancroid

Ninfa Mehta, MD, Staff Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Kings County Hospital
Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn

Updated: Sep 1, 2009

Introduction

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.¹ 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 where it may coexist with other STDs.

International

Annual global incidence is about 6 million cases per year.² 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.³ 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 and quickly. 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 sores secondary to H ducreyi infection also facilitate the transmission of HIV. Immunocompromised patients have lower cure rates and more complications.

Sex

The male-to-female ratio is between 3 and 25:1² , 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

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.⁴ Lymphadenopathy is usually unilateral, and lymph nodes may rupture.

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

Chancroid usually starts as a small papule that rapidly becomes pustular and eventually ulcerates. The ulcer enlarges, develops ragged undermined borders, and is surrounded by a rim of erythema. Unlike syphilis, lesions are tender and the border of the ulcer is not indurated. Courtesy of Hon Pak, MD.

This patient shows the characteristic lesions of chancroid. The bubo on the right side drained spontaneously. The bubo in the left inguinal canal required needle aspiration.

Causes

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

Differential Diagnoses

Herpes Simplex
Lymphogranuloma Venereum
Syphilis

Other Problems to Be Considered

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

Workup

Laboratory Studies

• Culture is unreliable and insensitive. Sensitivities have been found to be between 50% and 100%.⁵ 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.⁵ 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".⁴ 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%.⁵ 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

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.⁶
• 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

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.⁷ 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.

Antibiotics

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

Azithromycin (Zithromax)

Used to treat mild to moderately severe infections caused by susceptible strains of microorganisms. Indicated for chlamydial and gonorrheal infections of genital tract.

Dosing

Adult

1 g PO once

Pediatric

<12 years: Not established
>12 years: 10 mg/kg PO on day 1 followed by 5 mg/kg days 2-5 suggested

Interactions

May increase toxicity of theophylline, warfarin, and digoxin; aluminum and/or magnesium antacids may decrease effects; cyclosporine may increase risk of nephrotoxicity and neurotoxicity

Contraindications

Documented hypersensitivity; hepatic impairment; concurrent pimozide use (sudden death may occur)

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged use; may increase hepatic enzymes and cholestatic jaundice; caution in impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients

Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms and higher efficacy against resistant organisms than earlier generation cephalosporins. Arrests bacterial growth by binding to 1 or more penicillin-binding proteins.

Dosing

Adult

250 mg IM once

Pediatric

Not established
50-75 mg/kg/d IV divided q12h suggested; not to exceed 2 g/d

Interactions

Probenecid may increase levels; ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; caution in breastfeeding women and allergy to penicillin

Erythromycin (EES, E-Mycin, Ery-Tab)

Blocks peptide bond formation by blocking peptidyl tRNA translocation from the A- to the P- site. Inhibits bacterial growth.

Dosing

Adult

250 mg erythromycin stearate/base (or 400 mg ethylsuccinate) PO q6h 1 h ac, or 500 mg q12h
Alternatively, use 333 mg PO q8h; increase up to 4 g/d depending on severity of infection

Pediatric

Not established
30-50 mg/kg/d (15-25 mg/lb/d) PO in divided doses suggested

Interactions

May increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; lovastatin or simvastatin increases risk of rhabdomyolysis

Contraindications

Documented hypersensitivity; hepatic impairment

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in liver disease; estolate formulation may cause cholestatic jaundice; adverse GI effects are common (give doses pc); discontinue if nausea, vomiting, malaise, abdominal colic, or fever occur

Ciprofloxacin (Cipro)

Bactericidal antibiotic that inhibits bacterial DNA synthesis, and consequently growth, by inhibiting DNA-gyrase in susceptible organisms. Indicated for pseudomonal infections and those due to multidrug-resistant gram-negative organisms. If co-infection with gonorrhea suspected, do not use fluoroquinolones. CDC no longer recommends fluoroquinolones for gonorrhea or related conditions because of resistance.

Dosing

Adult

500 mg PO bid for 3 d

Pediatric

Not established

Interactions

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated therapy

Follow-up

Further Outpatient Care

• Patients should have outpatient follow-up within 1 week to go over culture results and evaluate progress of healing of ulcers.⁶

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

Medicolegal 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.

Multimedia

Media file 1: This photograph shows an early chancroid on the penis, along with accompanying regional lymphadenopathy. Courtesy of the CDC/Dr. Pirozzi.

Media file 2: Chancroid usually starts as a small papule that rapidly becomes pustular and eventually ulcerates. The ulcer enlarges, develops ragged undermined borders, and is surrounded by a rim of erythema. Unlike syphilis, lesions are tender and the border of the ulcer is not indurated. Courtesy of Hon Pak, MD.

Media file 3: This patient shows the characteristic lesions of chancroid. The bubo on the right side drained spontaneously. The bubo in the left inguinal canal required needle aspiration.

Media file 4: Large fluctuant buboes should be drained with the patient under local anesthesia and a large-gauge needle inserted through surrounding healthy skin. The insertion site should be superior or lateral to the bubo to prevent chronic drainage from the site.

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Keywords

chancroid, genital ulcer, chancre, STD, sexually transmitted disease, painful ulcers, bubo formation, painful inguinal lymphadenopathy, Haemophilus ducreyi, sexually transmitted infectious disease

Contributor Information and Disclosures

Author

Ninfa Mehta, MD, Staff Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Kings County Hospital
Ninfa Mehta, MD is a member of the following medical societies: American Association of Physicians of Indian Origin, American Medical Association, and American Medical Student Association/Foundation
Disclosure: Nothing to disclose.

Coauthor(s)

Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn
Mark A Silverberg, MD, FACEP, MMB is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

David FM Brown, MD, Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Barry J Sheridan, DO, Chief, Department of Emergency Medical Services, Brooke Army Medical Center
Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

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