- Charles B Hicks, MD
Charles B Hicks, MD
- University of California, San Diego
Chancroid is an extremely uncommon infection in the United States and most other developed countries. However, the true incidence of chancroid is often unknown since a definitive diagnosis requires detection of the causative organism, Haemophilus ducreyi, and few laboratories have the capability for proper microbiologic diagnosis (eg, culture or nucleic acid amplification testing) [1,2]. In addition, many sexually transmitted disease clinics do not attempt to diagnose genital ulcer disease caused by pathogens other than Treponema pallidum or herpes simplex virus.
This topic will review the clinical manifestations, diagnosis, and treatment of chancroid. Topic reviews that discuss the approach to patients with genital ulcer disease, syphilis, and genital herpes are found elsewhere. (See "Approach to the patient with genital ulcers" and "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in HIV-uninfected patients" and "Epidemiology, clinical manifestations, and diagnosis of genital herpes simplex virus infection".)
H. ducreyi is a small, fastidious, gram-negative rod that requires an enriched growth medium containing hemin and usually serum for successful cultivation . Cultures must be delivered expeditiously to the laboratory and incubated at 33º to 35ºC in high humidity with CO2 enrichment. Small, heterogeneous colonies appear on culture medium after 48 to 72 hours. The gray to tan translucent colonies slide intact across the agar plate when pushed.
When examined by Gram stain, organisms from culture often clump in long parallel strands, producing a so-called "school of fish" or "railroad track" appearance. This morphology can occasionally be seen in Gram-stained smears from clinical specimens, but it is not a consistent or reliable clinical finding.
The pathogenesis of chancroid is incompletely understood. In the vast majority of cases, organisms are thought to gain access to tissues via microabrasions in the skin that occur during sexual intercourse, since H. ducreyi does not typically infect intact skin. However, the organism has also been identified as a cause of cutaneous ulcers in children and young adults on islands in the South Pacific Islands and in parts of equatorial Africa where yaws is endemic [4-6]. (See "Yaws, bejel, and pinta".)
- Lewis DA. Epidemiology, clinical features, diagnosis and treatment of Haemophilus ducreyi - a disappearing pathogen? Expert Rev Anti Infect Ther 2014; 12:687.
- Lewis DA, Müller E, Steele L, et al. Prevalence and associations of genital ulcer and urethral pathogens in men presenting with genital ulcer syndrome to primary health care clinics in South Africa. Sex Transm Dis 2012; 39:880.
- Trees DL, Morse SA. Chancroid and Haemophilus ducreyi: an update. Clin Microbiol Rev 1995; 8:357.
- Gangaiah D, Webb KM, Humphreys TL, et al. Haemophilus ducreyi Cutaneous Ulcer Strains Are Nearly Identical to Class I Genital Ulcer Strains. PLoS Negl Trop Dis 2015; 9:e0003918.
- Ghinai R, El-Duah P, Chi KH, et al. A cross-sectional study of 'yaws' in districts of Ghana which have previously undertaken azithromycin mass drug administration for trachoma control. PLoS Negl Trop Dis 2015; 9:e0003496.
- Ussher JE, Wilson E, Campanella S, et al. Haemophilus ducreyi causing chronic skin ulceration in children visiting Samoa. Clin Infect Dis 2007; 44:e85.
- Janowicz DM, Ofner S, Katz BP, Spinola SM. Experimental infection of human volunteers with Haemophilus ducreyi: fifteen years of clinical data and experience. J Infect Dis 2009; 199:1671.
- Al-Tawfiq JA, Harezlak J, Katz BP, Spinola SM. Cumulative experience with Haemophilus ducreyi 35000 in the human model of experimental infection. Sex Transm Dis 2000; 27:111.
- Alfa MJ, DeGagne P. Attachment of Haemophilus ducreyi to human foreskin fibroblasts involves LOS and fibronectin. Microb Pathog 1997; 22:39.
- Parsons LM, Limberger RJ, Shayegani M. Alterations in levels of DnaK and GroEL result in diminished survival and adherence of stressed Haemophilus ducreyi. Infect Immun 1997; 65:2413.
- Cope LD, Lumbley S, Latimer JL, et al. A diffusible cytotoxin of Haemophilus ducreyi. Proc Natl Acad Sci U S A 1997; 94:4056.
- Purvén M, Frisk A, Lönnroth I, Lagergard T. Purification and identification of Haemophilus ducreyi cytotoxin by use of a neutralizing monoclonal antibody. Infect Immun 1997; 65:3496.
- Cortes-Bratti X, Chaves-Olarte E, Lagergård T, Thelestam M. The cytolethal distending toxin from the chancroid bacterium Haemophilus ducreyi induces cell-cycle arrest in the G2 phase. J Clin Invest 1999; 103:107.
- Magro CM, Crowson AN, Alfa M, et al. A morphological study of penile chancroid lesions in human immunodeficiency virus (HIV)-positive and -negative African men with a hypothesis concerning the role of chancroid in HIV transmission. Hum Pathol 1996; 27:1066.
- Spinola SM, Orazi A, Arno JN, et al. Haemophilus ducreyi elicits a cutaneous infiltrate of CD4 cells during experimental human infection. J Infect Dis 1996; 173:394.
- King R, Gough J, Ronald A, et al. An immunohistochemical analysis of naturally occurring chancroid. J Infect Dis 1996; 174:427.
- Gelfanova V, Humphreys TL, Spinola SM. Characterization of Haemophilus ducreyi-specific T-cell lines from lesions of experimentally infected human subjects. Infect Immun 2001; 69:4224.
- Mertz KJ, Trees D, Levine WC, et al. Etiology of genital ulcers and prevalence of human immunodeficiency virus coinfection in 10 US cities. The Genital Ulcer Disease Surveillance Group. J Infect Dis 1998; 178:1795.
- DiCarlo RP, Armentor BS, Martin DH. Chancroid epidemiology in New Orleans men. J Infect Dis 1995; 172:446.
- The Centers for Disease Control and Prevention. 2014 sexually transmitted disease surveillance. http://www.cdc.gov/std/stats14/tables/44.htm (Accessed on May 12, 2016).
- Hope-Rapp E, Anyfantakis V, Fouéré S, et al. Etiology of genital ulcer disease. A prospective study of 278 cases seen in an STD clinic in Paris. Sex Transm Dis 2010; 37:153.
- Beck-Sague CM, Cordts JR, Brown K, et al. Laboratory diagnosis of sexually transmitted diseases in facilities within the United States. Results of a national survey. Sex Transm Dis 1996; 23:342.
- Dillon SM, Cummings M, Rajagopalan S, McCormack WC. Prospective analysis of genital ulcer disease in Brooklyn, New York. Clin Infect Dis 1997; 24:945.
- Centers for Disease Control and Prevention (CDC). Chancroid detected by polymerase chain reaction--Jackson, Mississippi, 1994-1995. MMWR Morb Mortal Wkly Rep 1995; 44:567, 573.
- Mertz KJ, Weiss JB, Webb RM, et al. An investigation of genital ulcers in Jackson, Mississippi, with use of a multiplex polymerase chain reaction assay: high prevalence of chancroid and human immunodeficiency virus infection. J Infect Dis 1998; 178:1060.
- Risi JB Jr, Centers for Disease Control (CDC). Using surveillance data for decision making in public health. MMWR Morb Mortal Wkly Rep 1992; 41 Suppl:57.
- O'Farrell N, Hoosen AA, Coetzee KD, van den Ende J. Genital ulcer disease: accuracy of clinical diagnosis and strategies to improve control in Durban, South Africa. Genitourin Med 1994; 70:7.
- Morse SA, Trees DL, Htun Y, et al. Comparison of clinical diagnosis and standard laboratory and molecular methods for the diagnosis of genital ulcer disease in Lesotho: association with human immunodeficiency virus infection. J Infect Dis 1997; 175:583.
- Totten PA, Kuypers JM, Chen CY, et al. Etiology of genital ulcer disease in Dakar, Senegal, and comparison of PCR and serologic assays for detection of Haemophilus ducreyi. J Clin Microbiol 2000; 38:268.
- Department of Communicable Disease Control MoPH, Thailand. Reported incidence of primary syphilis, chancroid and genital herpes from Bangkok and 12 regional CDC centres, 1982-1997. Bangkok; 1998
- Kaul R, Kimani J, Nagelkerke NJ, et al. Monthly antibiotic chemoprophylaxis and incidence of sexually transmitted infections and HIV-1 infection in Kenyan sex workers: a randomized controlled trial. JAMA 2004; 291:2555.
- Suntoke TR, Hardick A, Tobian AA, et al. Evaluation of multiplex real-time PCR for detection of Haemophilus ducreyi, Treponema pallidum, herpes simplex virus type 1 and 2 in the diagnosis of genital ulcer disease in the Rakai District, Uganda. Sex Transm Infect 2009; 85:97.
- Ministry of Health and Social Services. Microbiological surveillance for sexually transmitted infections: Namibia 2007 survey. Ministry of Health and Social Service; Windhoek, Namibia: 2007
- O'Farrell N, Lazaro N. UK National Guideline for the management of Chancroid 2014. Int J STD AIDS 2014; 25:975.
- Riedner G, Todd J, Rusizoka M, et al. Possible reasons for an increase in the proportion of genital ulcers due to herpes simplex virus from a cohort of female bar workers in Tanzania. Sex Transm Infect 2007; 83:91.
- Gomes Naveca F, Sabidó M, Amaral Pires de Almeida T, et al. Etiology of genital ulcer disease in a sexually transmitted infection reference center in Manaus, Brazilian Amazon. PLoS One 2013; 8:e63953.
- Makasa M, Buve A, Sandøy IF. Etiologic pattern of genital ulcers in Lusaka, Zambia: has chancroid been eliminated? Sex Transm Dis 2012; 39:787.
- The World Heatlh Organization. Guidelines for the management of sexually transmitted infections. 2004. http://apps.who.int/iris/bitstream/10665/42782/1/9241546263_eng.pdf?ua=1 (Accessed on June 08, 2016).
- Lewis DA, Mitjà O. Haemophilus ducreyi: from sexually transmitted infection to skin ulcer pathogen. Curr Opin Infect Dis 2016; 29:52.
- Mitjà O, Lukehart SA, Pokowas G, et al. Haemophilus ducreyi as a cause of skin ulcers in children from a yaws-endemic area of Papua New Guinea: a prospective cohort study. Lancet Glob Health 2014; 2:e235.
- McBride WJ, Hannah RC, Le Cornec GM, Bletchly C. Cutaneous chancroid in a visitor from Vanuatu. Australas J Dermatol 2008; 49:98.
- DiCarlo RP, Martin DH. The clinical diagnosis of genital ulcer disease in men. Clin Infect Dis 1997; 25:292.
- Lewis DA. Diagnostic tests for chancroid. Sex Transm Infect 2000; 76:137.
- Centers for Disease Control and Prevention. Chancroid (Haemophilus ducreyi) 1996 case definition. https://wwwn.cdc.gov/nndss/conditions/chancroid/case-definition/1996/ (Accessed on April 04, 2016).
- Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64:1.
- Morse SA. Chancroid and Haemophilus ducreyi. Clin Microbiol Rev 1989; 2:137.
- Joseph AK, Rosen T. Laboratory techniques used in the diagnosis of chancroid, granuloma inguinale, and lymphogranuloma venereum. Dermatol Clin 1994; 12:1.
- Orle KA, Gates CA, Martin DH, et al. Simultaneous PCR detection of Haemophilus ducreyi, Treponema pallidum, and herpes simplex virus types 1 and 2 from genital ulcers. J Clin Microbiol 1996; 34:49.
- Naamara W, Plummer FA, Greenblatt RM, et al. Treatment of chancroid with ciprofloxacin. A prospective, randomized clinical trial. Am J Med 1987; 82:317.
- Plourde PJ, D'Costa LJ, Agoki E, et al. A randomized, double-blind study of the efficacy of fleroxacin versus trimethoprim-sulfamethoxazole in men with culture-proven chancroid. J Infect Dis 1992; 165:949.
- Abeck D, Johnson AP, Dangor Y, Ballard RC. Antibiotic susceptibilities and plasmid profiles of Haemophilus ducreyi isolates from southern Africa. J Antimicrob Chemother 1988; 22:437.
- Knapp JS, Back AF, Babst AF, et al. In vitro susceptibilities of isolates of Haemophilus ducreyi from Thailand and the United States to currently recommended and newer agents for treatment of chancroid. Antimicrob Agents Chemother 1993; 37:1552.
- Tyndall MW, Agoki E, Plummer FA, et al. Single dose azithromycin for the treatment of chancroid: a randomized comparison with erythromycin. Sex Transm Dis 1994; 21:231.
- Ballard RC, Ye H, Matta A, et al. Treatment of chancroid with azithromycin. Int J STD AIDS 1996; 7 Suppl 1:9.
- Bowmer MI, Nsanze H, D'Costa LJ, et al. Single-dose ceftriaxone for chancroid. Antimicrob Agents Chemother 1987; 31:67.
- Tyndall M, Malisa M, Plummer FA, et al. Ceftriaxone no longer predictably cures chancroid in Kenya. J Infect Dis 1993; 167:469.
- Martin DH, Sargent SJ, Wendel GD Jr, et al. Comparison of azithromycin and ceftriaxone for the treatment of chancroid. Clin Infect Dis 1995; 21:409.
- Malonza IM, Tyndall MW, Ndinya-Achola JO, et al. A randomized, double-blind, placebo-controlled trial of single-dose ciprofloxacin versus erythromycin for the treatment of chancroid in Nairobi, Kenya. J Infect Dis 1999; 180:1886.
- Quale J, Teplitz E, Augenbraun M. Atypical presentation of chancroid in a patient infected with the human immunodeficiency virus. Am J Med 1990; 88:43N.
- Sullivan, M. Chancroid. Am J Syphilis Gonorrhea Venereal Dis 1940; 24:480.
- Ernst AA, Marvez-Valls E, Martin DH. Incision and drainage versus aspiration of fluctuant buboes in the emergency department during an epidemic of chancroid. Sex Transm Dis 1995; 22:217.
- Schmid GP. The treatment of chancroid. JAMA 1986; 255:1757.
- Plummer FA, D'Costa LJ, Nsanze H, et al. Antimicrobial therapy of chancroid: effectiveness of erythromycin. J Infect Dis 1983; 148:726.
- United States and developed countries
- Developing countries
- CLINICAL MANIFESTATIONS
- Genital ulcers
- Non-sexually transmitted cutaneous ulcers
- Approach to diagnosis
- Diagnostic criteria
- Tests to identify the organism
- - Gram stain
- - Culture
- - Polymerase chain reaction
- DIFFERENTIAL DIAGNOSIS
- Antimicrobial therapy
- - Preferred regimens
- - Alternative regimens
- - Special populations
- HIV-infected patients
- Pregnant women
- Management of buboes
- Patient monitoring
- SEX PARTNERS
- SUMMARY AND RECOMMENDATIONS