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Emergency and acute medicine – chancroid
Basic description
Chancroid is a sexually transmitted genital ulcer disease associated with an increased risk of HIV acquisition. It is common in parts of Africa, Southeast Asia, and Latin America but uncommon in the United States, where herpes simplex virus and syphilis are far more frequent causes of genital ulcers. Despite this, chancroid is likely underreported due to diagnostic challenges.
Cause and microbiology
The disease is caused by Haemophilus ducreyi, a highly infectious gram-negative bacterium transmitted through sexual contact.
Clinical presentation
Chancroid typically begins as a small erythematous papule or pustule that rapidly ulcerates into a painful lesion measuring 1–20 mm. The ulcers are soft, friable, and have ragged, irregular borders with an excavated appearance. The base contains moist granulation tissue and may produce purulent or hemorrhagic exudate.
In men, lesions most often involve the penile shaft, glans, foreskin, or anus, whereas in women they may occur on the cervix, vagina, vulva, perineum, or anus. Symptoms usually appear 4–7 days after exposure, with an incubation period ranging from 1–35 days.
Painful inguinal lymphadenopathy develops in approximately half of affected men and less frequently in women. These nodes are typically unilateral, may become suppurative, and can rupture to form chronic draining sinuses. Dysuria and dyspareunia may occur due to lesion contact. Several variants exist, including phagedenic chancroid with rapid tissue destruction, giant chancroid with a single large ulcer, serpiginous ulcers that spread superficially, and follicular chancroid with multiple small perifollicular lesions.
Diagnostic approach
Diagnosis is primarily clinical but often inaccurate because laboratory confirmation is difficult. The Centers for Disease Control and Prevention defines a probable diagnosis as the presence of typical painful genital ulcers with negative testing for syphilis and herpes simplex virus. A definite diagnosis requires isolation of H. ducreyi on culture, which is rarely feasible in routine practice.
Laboratory evaluation
Gram stain is unreliable and shows characteristic gram-negative coccobacilli in a linear “school-of-fish” pattern in only 50–80% of cases. Culture requires specialized media and has variable sensitivity. Polymerase chain reaction testing is sensitive and specific but not widely available. Serologic testing for syphilis, herpes simplex virus, and HIV is recommended because coinfection is common.
Differential diagnosis
Infectious considerations include syphilis, genital herpes, granuloma inguinale, and lymphogranuloma venereum. Noninfectious causes such as drug reactions, pyoderma gangrenosum, and Behçet disease should also be considered when presentation is atypical.
Management principles
Standard infection control precautions should be used during evaluation. Treatment should not be delayed when clinical criteria for probable chancroid are met.
Emergency department treatment
First-line therapy includes single-dose azithromycin or intramuscular ceftriaxone, with ceftriaxone preferred during pregnancy. Alternative regimens include ciprofloxacin for three days (avoided in pregnancy and lactation) or erythromycin for seven days. Suppurative lymph nodes larger than 5 cm should be aspirated with a large-bore needle through intact skin to prevent chronic sinus formation. Patients should undergo concurrent testing for HIV, syphilis, and herpes simplex virus, with repeat testing at three months if initially negative.
Medications
Recommended regimens include azithromycin 1 g orally once or ceftriaxone 250 mg intramuscularly once. Alternatives are ciprofloxacin 500 mg orally twice daily for three days or erythromycin base 500 mg orally four times daily for seven days.
Disposition and follow-up
Patients should abstain from sexual activity or use condoms until complete lesion healing. Clinical improvement is usually seen within two days, with ulcer resolution in 3–7 days, though healing may be delayed in HIV-positive or uncircumcised patients.
Ongoing care recommendations
All sexual partners with exposure within 10 days of symptom onset should be examined and treated regardless of symptoms. HIV-positive patients require close follow-up, particularly when treated with single-dose regimens due to higher failure rates.
Key clinical pearls
Treatment should be initiated based on clinical probability rather than awaiting culture confirmation. Treatment failure should prompt evaluation for nonadherence, antimicrobial resistance, or coinfection, particularly syphilis.
Basic description
Chancroid is a sexually transmitted genital ulcer disease associated with an increased risk of HIV acquisition. It is common in parts of Africa, Southeast Asia, and Latin America but uncommon in the United States, where herpes simplex virus and syphilis are far more frequent causes of genital ulcers. Despite this, chancroid is likely underreported due to diagnostic challenges.
Cause and microbiology
The disease is caused by Haemophilus ducreyi, a highly infectious gram-negative bacterium transmitted through sexual contact.
Clinical presentation
Chancroid typically begins as a small erythematous papule or pustule that rapidly ulcerates into a painful lesion measuring 1–20 mm. The ulcers are soft, friable, and have ragged, irregular borders with an excavated appearance. The base contains moist granulation tissue and may produce purulent or hemorrhagic exudate.
In men, lesions most often involve the penile shaft, glans, foreskin, or anus, whereas in women they may occur on the cervix, vagina, vulva, perineum, or anus. Symptoms usually appear 4–7 days after exposure, with an incubation period ranging from 1–35 days.
Painful inguinal lymphadenopathy develops in approximately half of affected men and less frequently in women. These nodes are typically unilateral, may become suppurative, and can rupture to form chronic draining sinuses. Dysuria and dyspareunia may occur due to lesion contact. Several variants exist, including phagedenic chancroid with rapid tissue destruction, giant chancroid with a single large ulcer, serpiginous ulcers that spread superficially, and follicular chancroid with multiple small perifollicular lesions.
Diagnostic approach
Diagnosis is primarily clinical but often inaccurate because laboratory confirmation is difficult. The Centers for Disease Control and Prevention defines a probable diagnosis as the presence of typical painful genital ulcers with negative testing for syphilis and herpes simplex virus. A definite diagnosis requires isolation of H. ducreyi on culture, which is rarely feasible in routine practice.
Laboratory evaluation
Gram stain is unreliable and shows characteristic gram-negative coccobacilli in a linear “school-of-fish” pattern in only 50–80% of cases. Culture requires specialized media and has variable sensitivity. Polymerase chain reaction testing is sensitive and specific but not widely available. Serologic testing for syphilis, herpes simplex virus, and HIV is recommended because coinfection is common.
Differential diagnosis
Infectious considerations include syphilis, genital herpes, granuloma inguinale, and lymphogranuloma venereum. Noninfectious causes such as drug reactions, pyoderma gangrenosum, and Behçet disease should also be considered when presentation is atypical.
Management principles
Standard infection control precautions should be used during evaluation. Treatment should not be delayed when clinical criteria for probable chancroid are met.
Emergency department treatment
First-line therapy includes single-dose azithromycin or intramuscular ceftriaxone, with ceftriaxone preferred during pregnancy. Alternative regimens include ciprofloxacin for three days (avoided in pregnancy and lactation) or erythromycin for seven days. Suppurative lymph nodes larger than 5 cm should be aspirated with a large-bore needle through intact skin to prevent chronic sinus formation. Patients should undergo concurrent testing for HIV, syphilis, and herpes simplex virus, with repeat testing at three months if initially negative.
Medications
Recommended regimens include azithromycin 1 g orally once or ceftriaxone 250 mg intramuscularly once. Alternatives are ciprofloxacin 500 mg orally twice daily for three days or erythromycin base 500 mg orally four times daily for seven days.
Disposition and follow-up
Patients should abstain from sexual activity or use condoms until complete lesion healing. Clinical improvement is usually seen within two days, with ulcer resolution in 3–7 days, though healing may be delayed in HIV-positive or uncircumcised patients.
Ongoing care recommendations
All sexual partners with exposure within 10 days of symptom onset should be examined and treated regardless of symptoms. HIV-positive patients require close follow-up, particularly when treated with single-dose regimens due to higher failure rates.
Key clinical pearls
Treatment should be initiated based on clinical probability rather than awaiting culture confirmation. Treatment failure should prompt evaluation for nonadherence, antimicrobial resistance, or coinfection, particularly syphilis.
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