Chancroid

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Chancroid
Chancroid lesion haemophilus ducreyi PHIL 3728 lores.jpg
A chancroid lesion on penis
Specialty Infectious disease   Blue pencil.svg

Chancroid ( /ˈʃæŋkrɔɪd/ SHANG-kroyd) (also known as soft chancre [1] and ulcus molle [2] ) is a bacterial sexually transmitted infection characterized by painful sores on the genitalia. Chancroid is known to spread from one individual to another solely through sexual contact. While uncommon in the western world, it is the most common cause of genital ulceration worldwide.

Sexually transmitted infection Infection transmitted through human sexual behavior

Sexually transmitted infections (STI), also referred to as sexually transmitted diseases (STD), are infections that are commonly spread by sexual activity, especially vaginal intercourse, anal sex and oral sex. Many times STIs initially do not cause symptoms. This results in a greater risk of passing the disease on to others. Symptoms and signs of disease may include vaginal discharge, penile discharge, ulcers on or around the genitals, and pelvic pain. STIs can be transmitted to an infant before or during childbirth and may result in poor outcomes for the baby. Some STIs may cause problems with the ability to get pregnant.

Contents

Signs and symptoms

Buboes in a male Haemophilus ducreyi 5811 lores.jpg
Buboes in a male

These are only local and no systemic manifestations are present. [3] The ulcer characteristically:

Lymphadenopathy disorder of lymph nodes

Lymphadenopathy or adenopathy is disease of the lymph nodes, in which they are abnormal in size, number, or consistency. Lymphadenopathy of an inflammatory type is lymphadenitis, producing swollen or enlarged lymph nodes. In clinical practice, the distinction between lymphadenopathy and lymphadenitis is rarely made and the words are usually treated as synonymous. Inflammation of the lymphatic vessels is known as lymphangitis. Infectious lymphadenitis affecting lymph nodes in the neck is often called scrofula.

Dysuria refers to painful urination. Difficult urination is also sometimes, but rarely, described as dysuria.

Dyspareunia is painful sexual intercourse due to medical or psychological causes. The pain can primarily be on the external surface of the genitalia, or deeper in the pelvis upon deep pressure against the cervix. It can affect a small portion of the vulva or vagina or be felt all over the surface. Understanding the duration, location, and nature of the pain is important in identifying the causes of the pain.

About half of infected men have only a single ulcer. Women frequently have four or more ulcers, with fewer symptoms.

The initial ulcer may be mistaken as a "hard" chancre, the typical sore of primary syphilis, as opposed to the "soft chancre" of chancroid.

Chancre sore

A chancre is a painless genital ulcer most commonly formed during the primary stage of syphilis. This infectious lesion forms approximately 21 days after the initial exposure to Treponema pallidum, the gram-negative spirochaete bacterium yielding syphilis. Chancres transmit the sexually transmissible disease of syphilis through direct physical contact. These ulcers usually form on or around the anus, mouth, penis and vagina. Chancres may diminish between four and eight weeks without the application of medication.

Syphilis sexually transmitted infection

Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum subspecies pallidum. The signs and symptoms of syphilis vary depending in which of the four stages it presents. The primary stage classically presents with a single chancre but there may be multiple sores. In secondary syphilis, a diffuse rash occurs, which frequently involves the palms of the hands and soles of the feet. There may also be sores in the mouth or vagina. In latent syphilis, which can last for years, there are few or no symptoms. In tertiary syphilis, there are gummas, neurological problems, or heart symptoms. Syphilis has been known as "the great imitator" as it may cause symptoms similar to many other diseases.

Approximately one-third of the infected individuals will develop enlargements of the inguinal lymph nodes, the nodes located in the fold between the leg and the lower abdomen.

Half of those who develop swelling of the inguinal lymph nodes will progress to a point where the nodes rupture through the skin, producing draining abscesses. The swollen lymph nodes and abscesses are often referred to as buboes.

Males

Females

Causes

Chancroid is a bacterial infection caused by the fastidious Gram-negative streptobacillus Haemophilus ducreyi . It is a disease found primarily in developing countries, most prevalent in low socioeconomic groups, associated with commercial sex workers.

Chancroid, caused by H. ducreyi has infrequently been associated with cases of Genital Ulcer Disease in the US, but has been isolated in up to 10% of genital ulcers diagnosed from STD clinics in Memphis and Chicago. [4]

Infection levels are very low in the Western world, typically around one case per two million of the population (Canada, France, Australia, UK and US).[ citation needed ] Most individuals diagnosed with chancroid have visited countries or areas where the disease is known to occur frequently, although outbreaks have been observed in association with crack cocaine use and prostitution.[ citation needed ]

Chancroid is a risk factor for contracting HIV, due to their ecological association or shared risk of exposure, and biologically facilitated transmission of one infection by the other. Approximately 10% of people with chancroid will have a co-infection with syphilis and/or HIV.

Pathogenesis

H. ducreyi enters skin through microabrasions incurred during sexual intercourse. A local tissue reaction leads to development of erythomatous papule, which progresses to pustule in 4–7 days. It then undergoes central necrosis to ulcerate. [5]

Diagnosis

Variants

Some of clinical variants are as follows. [5]

VariantCharacteristics
Dwarf chancroidSmall, superficial, relatively painless ulcer.
Giant chancroidLarge granulomatous ulcer at the site of a ruptured inguinal bubo, extending beyond its margins.
Follicular chancroidSeen in females in association with hair follicles of the labia majora and pubis; initial follicular pustule evolves into a classic ulcer at the site.
Transient chancroidSuperficial ulcers that may heal rapidly, followed by a typical inguinal bubo.
Serpiginous chancroidMultiple ulcers that coalesce to form a serpiginous pattern.
Mixed chancroidNonindurated tender ulcers of chancroid appearing together with an indurated nontender ulcer of syphilis having an incubation period of 10 to 90 days.
Phagedenic chancroidUlceration that causes extensive destruction of genitalia following secondary or superinfection by anaerobes such as Fusobacterium or Bacteroides.
Chancroidal ulcerMost often a tender, nonindurated, single large ulcer caused by organisms other than Haemophilus ducreyi ; lymphadenopathy is conspicuous by its absence.

Laboratory findings

From bubo pus or ulcer secretions, H. ducreyi can be identified. PCR-based identification of organisms is available. Simple, rapid, sensitive and inexpensive antigen detection methods for H. ducreyi identification are also popular. Serologic detection of H. ducreyi is and uses outer membrane protein and lipooligosaccharide.

Differential diagnosis

CDC's standard clinical definition for a probable case of chancroid
# Patient has one or more painful genital ulcers. The combination of a painful ulcer with tender adenopathy is suggestive of chancroid; the presence of suppurative adenopathy is almost pathognomonic.
  1. No evidence of Treponema pallidum infection by darkfield microscopic examination of ulcer exudate or by a serologic test for syphilis performed greater than or equal to 7 days after onset of ulcers and
  2. Either a clinical presentation of the ulcer(s) not typical of disease caused by herpes simplex virus (HSV) or a culture negative for HSV.

Despite many distinguishing features, the clinical spectrums of following diseases may overlap with chancroid:

Practical clinical approach for this STI as Genital Ulcer Disease is to rule out top differential diagnosis of Syphilis and Herpes and consider empirical treatment for Chancroid as testing is not commonly done for the latter.

Comparison with syphilis

There are many differences and similarities between the conditions syphilitic chancre and chancroid.

Similarities
Differences

Prevention

Chancroid spreads in populations with high sexual activity, such as prostitutes. Use of condom, prophylaxis by azithromycin, syndromic management of genital ulcers, treating patients with reactive syphilis serology are some of the strategies successfully tried in Thailand. [5]

Treatment

The CDC recommendation for chancroid is either a single oral dose (1 gram) of azithromycin, a single IM dose of 250 mg ceftriaxone, oral 500 mg of erythromycin q.i.d for seven days, or 500 mg of Ciprofloxacin b.i.d for three days. [6] Treatment may include more than one prescribed medication.

Abscesses are drained.

H. ducreyi is resistant to sulfonamides, tetracyclines, penicillins, chloramphenicol, ofloxacin, and trimethoprim.Recently, several erythromycin resistant isolates have been reported. [5]

Aminoglycosides such as Gentamicin, Streptomycin, and Kanamycin have been used to successfully treat Chancroid; however aminoglycoside-resistant strain of H. ducreyi have been observed in both laboratory and clinical settings. [7] Treatment with aminoglycosides should be considered as only a supplement to a primary treatment.

Pregnant and lactating women, or those below 18 years of age regardless of gender, should NOT use Ciprofloxacin as treatment for Chancroid. Treatment failure is possible with HIV co-infection and extended therapy is sometimes required.

Over the last two decades, no new treatment regime for Chancroid or H. ducreyi infection has been published. It is still assumed that the above described treatment regime is and will be effective against H. ducreyi infection. [6]

Complications

Prognosis

Prognosis is excellent with proper treatment. Treating sexual contacts of affected individual helps break cycle of infection.

History

Chancroid has been known to humans since time of ancient Greeks. [8] Some of important events on historical timeline of chancre are:

YearEvent
1852Leon Bassereau distinguished chancroid from syphilis (i.e. soft chancre from hard chancre)
1890sAugusto Ducrey identified H. ducreyi
1900Benzacon and colleagues isolated H. ducreyi
1970sHammond and colleagues developed selective media

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Bubo

A bubo is defined as adenitis or inflammation of the lymph nodes and is an example of reactive lymphadenopathy.

A genital ulcer is located on the genital area, usually caused by sexually transmitted diseases such as genital herpes, syphilis or chancroid. Some other signs of having genital ulcers include enlarged lymph nodes in the groin area, or vesicular lesions, which are small, elevated sores or blisters. The syndrome may be further classified into penile ulceration and vulval ulceration for males and females respectively.

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Scrotum anatomical male reproductive structure that consists of a suspended sack of skin

The scrotum is an anatomical male reproductive structure that consists of a suspended dual-chambered sack of skin and smooth muscle that is present in most terrestrial male mammals and located under the penis. One testis is typically lower than the other to avoid compression in the event of impact. The perineal raphe is a small, vertical, slightly raised ridge of scrotal skin under which is found the scrotal septum. It appears as a thin longitudinal line that runs front to back over the entire scrotum. The scrotum contains the external spermatic fascia, testes, epididymis, and ductus deferens. It is a distention of the perineum and carries some abdominal tissues into its cavity including the testicular artery, testicular vein, and pampiniform plexus. In humans and some other mammals, the scrotum becomes covered with pubic hair at puberty. The scrotum will usually tighten during penile erection and when exposed to cold temperature.

Herpes simplex viral disease caused by the herpes simplex virus

Herpes simplex is a viral infection caused by the herpes simplex virus. Infections are categorized based on the part of the body infected. Oral herpes involves the face or mouth. It may result in small blisters in groups often called cold sores or fever blisters or may just cause a sore throat. Genital herpes, often simply known as herpes, may have minimal symptoms or form blisters that break open and result in small ulcers. These typically heal over two to four weeks. Tingling or shooting pains may occur before the blisters appear. Herpes cycles between periods of active disease followed by periods without symptoms. The first episode is often more severe and may be associated with fever, muscle pains, swollen lymph nodes and headaches. Over time, episodes of active disease decrease in frequency and severity. Other disorders caused by herpes simplex include: herpetic whitlow when it involves the fingers, herpes of the eye, herpes infection of the brain, and neonatal herpes when it affects a newborn, among others.

Herpes labialis Herpes simplex virus that primarily affects the lip

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Lipschütz ulcer

Lipschütz ulcer,ulcus vulvae acutum or reactive non-sexually related acute genital ulcers is a rare disease characterized by painful genital ulcers, fever, and lymphadenopathy, occurring most commonly, but not exclusively, in adolescents and young women. Previously, it was described as being more common in virgins. It is not a sexually transmitted disease, and is often misdiagnosed, sometimes as a symptom of Behçet's disease.

Vulva external genital organs of the female mammal

The vulva consists of the external female sex organs. The vulva includes the mons pubis, labia majora, labia minora, clitoris, vestibular bulbs, vulval vestibule, urinary meatus, the vaginal opening, and Bartholin's and Skene's vestibular glands. The urinary meatus is also included as it opens into the vulval vestibule. Other features of the vulva include the pudendal cleft, sebaceous glands, the urogenital triangle, and pubic hair. The vulva includes the entrance to the vagina, which leads to the uterus, and provides a double layer of protection for this by the folds of the outer and inner labia. Pelvic floor muscles support the structures of the vulva. Other muscles of the urogenital triangle also give support.

Herpes simplex keratitis keratitis that has material basis in herpes simplex type infection

Herpetic simplex keratitis is a form of keratitis caused by recurrent herpes simplex virus (HSV) infection in the cornea.

Bartholin gland carcinoma vulva carcinoma that has material basis in abnormally proliferating cells derives from epithelial cells and is located in Bartholins gland

Bartholin gland carcinoma is an uncommon type of malignancy in the Bartholin gland that accounts for 1% of all vulvar malignant neoplasms. It is most common in women in their mid-60s. The tumor can become large before a woman is aware of symptoms. One of the first symptoms can be dyspareunia. In other instances a woman may find a mass or ulcer in the vulva area. Many clinicians assume that an enlarged Bartholin gland is malignant in postmenopausal woman until proven otherwise. The growth of the tumor can spread to nearby areas such as the ischiorectal fossa and inguinal lymph nodes. Approximately 50% of bartholin gland carcinomas originate from squamous cell carcinomas. Another uncommon characteristic of Bartholin gland malignancies is that the growth of a lesion originates from the three types of epithelial tissue present in the gland: mucinous, transitional, and squamous.

Crohn’s disease (CD) of the vulva is a rare extra intestinal condition, with granulomatous cutaneous lesions affecting the female genitalia. Lesions connected to the affected gut via a healthy tissue are referred to as metastatic lesions.

References

  1. James, William D.; Berger, Timothy G.; et al. (2006). Andrews' Diseases of the Skin: clinical Dermatology. Saunders Elsevier. p. 274. ISBN   978-0-7216-2921-6.
  2. Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN   978-1-4160-2999-1.
  3. Medical Microbiology: The Big Picture. McGraw Hill Professional. 2008-08-05. p. 243. ISBN   9780071476614.
  4. "Error 404 - Page Not Found". pathmicro.med.sc.edu. Retrieved 19 April 2018.
  5. 1 2 3 4 CURRENT Diagnosis & Treatment of Sexually Transmitted Diseases. McGraw-Hill Companies, Inc. 2007. pp. 69–74. ISBN   9780071509619.
  6. 1 2 Lautenschlager, Stephan; Kemp, Michael; Christensen, Jens Jørgen; Mayans, Marti Vall; Moi, Harald (2017-01-12). "2017 European guideline for the management of chancroid". International Journal of STD & AIDS. 28 (4): 324–329. CiteSeerX   10.1.1.658.2375 . doi:10.1177/0956462416687913. ISSN   0956-4624. PMID   28081686.
  7. Morse, Stephen (1989). "Chancroid and Haemophilus ducreyi". www.europepmc.org. Retrieved 30 June 2018.
  8. Sexually Transmitted Diseases (4th ed.). McGraw Hill Professional. 2007. pp. 689–698. ISBN   9780071417488.
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