CHANCROID

SYNONYMS: Soft Sore,

Soft Chancre
Ulcusmolle
DEFINITION
Chancroid is an acute, ulcerative disease, usually of the genitals,
often associated with inguinal adenitis or buboes, caused by infection
with Hemophilus ducreyi, a gram negative, facultative anaerobic,
bacillus that requires hemin (X factor) for growth.
INCIDENCE
 Chancroid particularly affects the poor and unhygienic individuals.
 Is commonly caught from prostitutes.
 Chancroid prevalent through the world but improvement in living
standards have led to its decline.
 Common among less privileged populations in some tropical and
subtropical countries and eastern countries.
 More reported cases in males.
 Low incidence in women.

THE ORGANISM
HEMOPHILUS DUCREYI discovered by DUCREYI in 1889.
  Is a short gram negative facultative anaerobic bacillus with
rounded ends.
 1-2 micrometers long and 0.5 micrometers wide.
 It forms short chain of two to four (or more) organisms in length.
 Grouping in chains is more often seen in smears from cultures.
 Groups of organisms are often found in chains giving the
appearance of a “School of fish”.
CLINICAL CHARACTERISTICS
- Incubation period - 1-5 days.
- Occasionally as long as - 30 days.
- There may be only one lesion but often there are several lesions.
- Initial lesion almost inflammatory papule surrounded by a narrow
zone of bright erythema.
- It soon becomes pustular.
- Pustule ruptures to from a painful sharply circumscribed ulcer
with ragged undermined edges.
- The floor of the ulcer is seen to be formed by very vascular
granulation tissue.
- Lesions are shallow and very in diameter from a few millimeters to
1 to 2 cms.
ON PALPATION
- Ulcer are tender to touch and bleed easily on gentle manipulation.
- Palpation of the base of the sore shows it is usually free from
induration.
- Occasionally the ulcer spreads in linear fashion forming a long,
narrow superficial lesion
 TYPES OF CHANCROID
Depending on the variation in the clinical appearance of
chancroids

Clinical types have been described as follows :

1. Follicular chancroid.
2. Dwarf chancroid.
3. Transient chancroid(Chancre mou volant).
4. Papular chancroid(Ulcus molle elevatum).
5. Gaint chancroid.
6. Phagedenic chancroid.
7. Mixed chancroid

1.Follicular chancroid
- Lesions are very superficial.
- Originates in the hair follicles.
- At first may simulate pus –coccal folliculitis, but the
pustules soon ulcerate.
- Lesions may be seen on the vulva and on hairy surfaces
around the genitalia.

2.Dwarf chancroid
- Is a very small lesion.
- May resemble erosions of herpes genitalia.
- The lesion has an irregular floor and sharply-cut
haemorrhagic edges.
3.Transient chancroid –(Chancremou volant).

- Is a small lesion of typical chancroidal type, which resolves

rapidly in a few days.
- Typical inflammatory bubo developed in the groin with in 2
weeks.
- It has to be differentiated from the inguinal syndrome of
LGV.

4.papular chancroid : (Ulcus molle elevatum)

- Starts as an ulcer.
- Later becomes raised particularly around its edges.
- It may resemble the condyloma lata of secondary syphilis.
5.Gaint chancroid

- Starts as a small ulcer.

- Extends rapidly and form large ulcers.
- It is most likely to follow rupture of an inguinal abcess.
- The ulcer forming at the point of rupture may spread to
and to the thigh by autoinoculation(serpigenous) chancroid.

6.Phagedenic chancroid

- May commence as a small lesion.

- But becomes large and destructive with widespread necrosis
of tissue.
- External genitalia may be destroyed.
 - 7. Mixed chancroid- coinfection with treponema pallidum(or)HSV
may occur in upto 10% of patients.

SITES OF INVOLVEMENT : In the Male

Preputial orifice.
- Mucous surface of the prepuce.
- The frenum of the prepuce.
- External urinary meatus.
- Lesions may spread locally to the perineum.
Anus.
To the scrotum.
Thigh.
Lower abdomen.
In the female
Ulceration is most likely to be found.
- On the fourchette.
- In the vestibule.
- Round the urinary meatus.
- On the inner surface of the Labium minora.
- Perineum or anus may be involved.
- Occacianally vaginal or cervical ulceration may be seen.
Extragenital Lesions
- Hands
- Breasts.
- Mouth.
 COMPLICATIONS
1.Ingiunal adenitis (Inflammatory bubo)
- Is the commonest complication.
- 50% of the cases.
- It follows the primary lesion with in a few days to three weeks.
- Unilateral.
- Inguinal nodes become enlarged and tender and then matted
together.
- Unilocular abcess formation occurs in about half the cases.
- Single sinus formation occurs in untreated cases with rupture of
abcess.

2.Phimosis or para phimosis

- Result from lesions affecting the prepuce.
3.Urethral fistula
- Occur as the result of a destructive ulceration of the glans
penis.
- Urethral stricture may follow.

4.Associated infection
- With vincents organisms may enhance the severity and increase
the destructive character of the lesion.

DIAGNOSIS
1. Microscopic examination of smears.
2. Culture.
3. Intradermal test – Ito Reen stierna test.
4. Biopsy.

Microscopic examination of smears

- Smear taken from beneath the under mined edges of
chancroidal ulcers.
- Stained with : Gram’s stain
Wright’s stain
Cultures
- Good results have been obtained with cultures from chancroidal
ulcers (or) pus from buboes.
- A medium containing Defrbrinated rabbits blood.
Cystine
Dextrose and
Beef-infusion agar
Has proved particularly effective.
Other medias:- Gonococcal agar base
Mueller-Hinton agar
Columbia agar base
Protease peptone agar
Heart infusion agar
Intradermal test
- Method of producing a cutaneous reaction by intradermal
injection of a vaccine containing killed H.ducreyi in suspension.

- It was employed by Ito and later by Reenstierna, and is there

fore known as the Ito-Reenstierna test.

- PCR

- Antigen detection by immunofluorescence

- Antibody detection by serological tests

- Biopsy

DIFFERENCIAL DIAGNOSIS OF CHANCRIOD

1.Primary syphilis.
2.Herpes genitalia.
3.Septic scabies .
4.septic adenitis .
5.Lymphogranuloma venereum.
6.Granuloma inguinale.
7.Candidial balanitis
Non-STD’s 1. Traumatic ulcers
2. Fixed drug eruption
3. Carcinoma

TREATMENT
 Prior to the advent of antimicrobial agents, circumcision and
saline washes were standard therapy.

1.sulphonamides

- .Trimethoprim + sulphamethaxazole DS BID orally daily 10 days

2.Erythromycin

- Is effective therapy for patients with chancroid

Dose : 500mg four times orally daily for 7 days is relatively
inexpensive and effective.

3.Azithromycin
- 1gm single oral dose is also an effective.

4.Flouroquinolones
- Widely used for the treatment of chancroid and have given
excellent results.

Ciprofloxacin : A single dose of 500mg cures over 95 percent of

pts.
Fleroxacin, Enoxacin and other flouroquinolones are effective
therapeutic agents for chancroid.
5.Ceftriaxone : 250mg IM/IV single dose is effective

Other Regimens

6. Streptomycin 1gm IM Daily for 7-14 days.

7. Penicillin
- Penicillin is of little values in treatment unless associated
infection with vincent’s organisms is present.
-
8. Tetracycline and Oxytetracycline: 500mg Q.I.D Orally 10-14 days.

9. Kanamycin : 500mg IM B.I.D for 6-14 days.

10. Chloramphenicol : Orally it is effective but should not be used

because of its potentially severe toxic effects.

11. Amoxycillin + Clavulinic acid, IM STECTINOMYCIN have been

used successfully.
INGUINAL BUBO
- Aspiration of buboes has been the most effective
management.
- Effective antibacterial agents, incision and drainage is
appropriate treatment and usually more effective.
- HIV- CHANCROID:- Ulcers may present with atypical features
such as large size and numbers and extragenital localization.
- The ulcers may take longer duration to heel.

TREATMENT OF CHANCROID
IN HIV INFECTED PATIENTS
- Recommended regimens:-

- Azithromycin : 1gm orally in a single dose.

(or)
- Ceftriaxone : 250 mg IM in a single dose.
-
(or)
- Ciprofloxacin : 500 mg orally twice a day for 3 days.
-
(or)
- Erythromycin base 500mg orally 6th hrly for 7 days.
-

All four regimens are effective in the treatment of chancroid in

HIV patients.