Chancroid is a bacterial infection caused by the Haemophilus ducreyi bacillus. This infectious organism is transmitted sexually and penetrates through breaks in the exposed epithelium of the genital mucosa or skin. In most infected people, chancroid presents a painful genital ulcer with inguinal lymphadenopathy. The differential diagnosis for a person with genital ulcers with inguinal lymph nodes includes not only chancroid but also syphilis, genital herpes, and lymphogranuloma venereum. Genital ulcers may serve as a portal of entry for HIV and increase the likelihood of HIV infection after sexual contact with an HIV-infected person. For an HIV-infected person with a genital ulcer, the presence of the ulcer increases the probability of transmission of HIV to an uninfected sex partner.
The number of cases of chancroid in the United States has increased in recent years, with over 5,000 cases reported in 1987. Due to the difficulty in making a definitive laboratory diagnosis, the disease is underreported.
Information on the transmission and epidemiology of chancroid has come primarily from Africa. Chancroid is most prevalent in subtropical and tropical regions of the world. In such areas, its incidence may be greater than that of syphilis, and close to the incidence of gonorrhea in men. However, chancroid is becoming increasingly common in temperate areas. Individuals from temperate areas who have traveled to tropical or subtropical areas, or who have had sexual contact with people from these areas, are at increased risk for contracting chancroid.
In general, chancroid is usually seen among persons with multiple sexual partners. In the United States, chancroid occurs most commonly in heterosexual men.
The incubation period for chancroid is usually from 3 to 5 days, although it may extend up to 2 weeks. Chancroid infection can be transmitted as long as the original sore or oozing lymph node remains infected with the bacteria. Chancroid ulcers typically improve within 3 to 7 days after institution of therapy and healing is usually complete in 2 weeks.
Patients should be counseled to refrain from sexual contact until treatment is completed. In addition, safer sex guidelines should be followed and condoms used during sexual intercourse to prevent future infection. Patients should be counseled that chancroid has been associated with an increased risk of acquiring HIV infection.
In both sexes, chancroid is characterized by one or a few painful, infected sores at the site of the infection. Both men and women rarely have lesions outside the genital area. In men, the lesions occur most often on the penis, where they are visible and generally easily recognized by a trained health professional. Uncircumcised men are at greater risk for infection than circumcised men. In women, the lesions occur primarily in the following areas: fourchette, labia, perianal area, and medial aspects of the thigh. Cervical ulcers and ulcers of the vaginal wall are uncommon.
The chancroid ulcer is painful and bleeds readily. The chancre of primary syphilis is painless. The exudate that oozes from the ulcer is grayish, necrotic, and purulent. In addition, an infected person may have not only the genital ulcer, but also inguinal lymphadenopathy (40 percent of cases). The lymphadenitis is painful and may form an abscess. It is sometimes necessary to aspirate the infected inguinal nodes to prevent rupture and to afford symptomatic relief.
There is no serologic test for chancroid. The organism is frequently difficult to recover from the ulcer. The base of the purulent ulcer should be swabbed without cleaning the affected area. The culture specimen should be quickly transported to the microbiology laboratory and inoculated onto appropriate media. The person in the clinic setting who obtains the culture should contact the microbiology laboratory where the specimen is being sent and have the laboratory set up the appropriate media for chancroid. Despite the frequently significant inguinal lymphadenitis, recovery of the organism from the aspirated lymph node is uncommon.
Given the problems with making a specific laboratory diagnosis, the Centers for Disease Control and Prevention (CDC) has defined probable chancroid. A probable case of chancroid is an illness with one or more painful genital ulcers and inguinal adenopathy, a clinical appearance not typical of genital herpes, and negative tests for syphilis (darkfield microscopy and/or serology).
Chancroid responds to treatment with appropriate antibiotics. The recommended treatment regimens are presented in table 1.
The response of chancroid to drug therapy varies among individuals. HIV-infected persons may respond more slowly or require longer therapy and individuals known to be HIV-infected are probably best treated with regimens other than ceftriaxone or azithromycin. The inguinal lymphadenopathy in any infected person may be slow to resolve. Patients should be observed until the genital ulcer has resolved. Serologic tests for syphilis should be done at the time of presentation and again within 3 months of therapy. Herpes simplex culture may be indicated.
Sexual partners who had contact with the infected person within 10 days of the onset of symptoms should be notified and treated whether or not they are symptomatic.
From studies done in Africa, it appears that the genital ulcers of chancroid serve as a portal of entry for HIV infection in both men and women. Many persons newly diagnosed with HIV report recent genital ulcers. In addition, persons with HIV infection have more severe and numerous ulcers when infected with chancroid. Chancroid and HIV together amplify the infectivity of each. Controlling the spread of chancroid will serve also to limit the spread of HIV. Any person with chancroid should be tested for HIV infection.
Chancroid. In: Sexually Transmitted Diseases. Clinical Practice Guidelines--May 1991. Atlanta, GA: U.S. Department of Health and Human Services, 1991. pp. III-5-III-6.
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