Rosen & Barkin's 5-Minute Emergency Medicine Consult (149 page)

BASICS

• Sexually transmitted genital ulcerative disease:
  
  • Increased risk for HIV infection
    
• A common cause of genital ulceration in Africa, southeast Asia, and Latin America:
  
  • Uncommon in US where herpes simplex virus (HSV) > syphilis >> chancroid, but likely underreported
    

Causative agent:
Haemophilus ducreyi

• Highly infectious bacterium
  

DIAGNOSIS

• Begins as a single erythematous papule or pustule:
  
  • Quickly erodes into painful chancres (1–20 mm)
    
  • Soft and friable with ragged, irregular borders
    
• Primary ulcer usually excavated
  
• Moist, granulation tissue at base
  
• Purulent or hemorrhagic exudate
  
• Location:
  
  • Male:
    
    • Penile shaft, glans, internal surface of foreskin, anus
      
  • Female:
    
    • Cervix, vagina, vulva, perineum, anus
      
• Occurs 4–7 days (median) after exposure
  
• Incubation period 3–10 days (range 1–35 days)
  
• Inguinal adenopathy:
  
  • In ∼50% of men; less common in women
    
  • Appears 3–14 days after initial ulcer
    
  • Unilateral (usually)
    
  • Painful
    
  • Suppurative large nodes (buboes)
    
  • May rupture and form chronic draining sinuses
    
• Dysuria, dyspareunia secondary to contact with lesions
  
• Variants:
  
  • Phagedenic:
    
    • Secondary superinfection (especially fusospirochetal) and rapid extensive tissue destruction
      
  • Giant chancroid:
    
    • Very large single ulcer
      
  • Serpiginous ulcer:
    
    • Rapidly spreading, indolent, shallow ulcers in groin or thigh
      
  • Follicular:
    
    • Multiple small ulcers with perifollicular distribution
      

Clinical diagnosis based on appearance is often inaccurate, and lab tests difficult or unavailable, so consider:

• CDC case definitions:
  
  • Definite: Positive culture of
    H. ducreyi
    
  • Probable: Typical signs, symptoms of chancroid + negative dark-field exam for
    Treponema pallidum
    + negative syphilis serology + negative culture for HSV (or clinical exam atypical for herpes)
    

• Gram stain unreliable (positive in 50–80%):
  
  • Gram-negative coccobacilli
    
    • Linear or “school-of-fish” pattern
      
• Culture extremely difficult (positive in 0–80%); requires complex media:
  
  • Obtain specimen from:
    
    • Base of ulcer
      
    • Needle aspiration of inguinal node by placing needle through normal skin (to avoid formation of fistula)
      
• Polymerase chain reaction (PCR) assay:
  
  • Sensitive and specific, but not widely available
    
• RPR:
  
  • Coinfection with syphilis is common
    
  • Part of CDC guidelines for probable clinical diagnosis of chancroid
    
• HSV culture:
  
  • Part of CDC guidelines for probable clinical diagnosis of chancroid
    
• HIV testing
  

• Infectious:
  
  • Syphilis (
    T. pallidum
    ):
    
    • Chancre usually painless, indurated, clean
      
  • Herpes genitalis (
    HSV):
    
    • Vesicular, multiple, recurrent
      
  • Granuloma inguinale (donovanosis) (
    Klebsiella granulomatis
    ):
    
    • Ulcer margins elevated; + induration
      
  • Lymphogranuloma venereum (
    Chlamydia trachomatis
    ):
    
    • Often single lesion; tender, fluctuant, unilateral lymphadenopathy
      
• Noninfectious:
  
  • Drug eruption
    
  • Less common:
    
    • Pyoderma gangrenosum
      
    • Behcçet disease
      

TREATMENT

Usual precautions for patient exam and handling of specimens

Antibiotics:

• Azithromycin: Single PO dose
  
• Ceftriaxone: Single IM dose (pregnancy: 1st line)
  
• Ciprofloxacin: PO × 3 days:
  
  • NOT for pregnant/lactating patients
    
• Erythromycin base: PO × 7 days:
  
  • Pregnancy: 2nd line
    
• Needle aspiration of suppurative nodes (>5 cm diameter):
  
  • To prevent chronic sinus drainage from spontaneous rupture
    
  • Use 18G needle through lateral intact skin.
    
  • May require repetition
    
• Recommend concurrent HIV, syphilis, HSV testing,
  and
  follow-up testing in 3 mo if initially negative
  

• Azithromycin: 1 g PO × 1
  
• Ceftriaxone: 250 mg IM × 1
  

• Ciprofloxacin: 500 mg PO BID for 3 days
  
• Erythromycin base: 500 mg PO QID for 7 days
  

FOLLOW-UP

• Sexual abstinence or condom use until lesions healed
  
• Clinical course:
  
  • Symptoms improve within 2 days of treatment
    
  • Ulcers improve within 3–7 days
    
  • Possible delayed resolution in those HIV-positive or uncircumcised
    

• Examine and treat sexual partners (regardless of presence/absence of symptoms) if contact within 10 days of symptom onset
  
• HIV-positive patients require assured follow-up if using single-dose therapy (higher treatment failure rate)
  

• Initiate treatment if probable CDC case guidelines met; do not wait for culture results
  
• Higher risk of treatment failure in HIV-infected patients
  
• Presumptive treatment of sexual contacts
  
• Treatment failure: Consider drug resistance, medication noncompliance, coinfection (syphilis).
  

• Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines 2010. Available at
  www.cdc.gov/std/treatment
  . Accessed March 1, 2013.
  
• Chancroid.
  UpToDate Online
  . 2013;v21.2. Available at
  www.uptodate.com
  
• Marx JA, Hockberger RS, Walls RM, eds.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice
  . 7th ed. St. Louis, MO: Mosby; 2010.
  

CODES

099.0 Chancroid

BASICS

Chemical agents that affect CNS, pulmonary, cardiovascular, dermal, ocular, or GI systems when exposed to victims