Editing Chancroid

{{Hatnote|Not to be confused with [[carcinoid]]. Compare with [[chancre#Similarities with chancroid|chancre]].}}
{{Short description|Sexually transmitted bacterial infection in humans}}
{{Infobox medical condition (new)
| name            = Chancroid
| image           = Haemophilus_ducreyi_01.jpg |
| caption         = Chancroid stained with [[gentian violet]]
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| synonyms        =  '''Soft chancre'''<ref name="Andrews">{{cite book |author=James, William D. |author2=Berger, Timothy G. |title=Andrews' Diseases of the Skin: clinical Dermatology |publisher=Saunders Elsevier |year=2006 |isbn=978-0-7216-2921-6 |pages=274|display-authors=etal}}</ref> and '''Ulcus molle'''<ref name="Bolognia">{{cite book |author=Rapini, Ronald P. |author2=Bolognia, Jean L. |author3=Jorizzo, Joseph L. |title=Dermatology: 2-Volume Set |publisher=Mosby |location=St. Louis |year=2007 |isbn=978-1-4160-2999-1 }}</ref>
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'''Chancroid''' ({{IPAc-en|ˈ|ʃ|æ|ŋ|k|r|ɔɪ|d}} {{respell|SHANG|kroyd}}) 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. However, there have been reports of accidental infection through the hand.<ref name="Waugh 410">{{Cite journal|last=Waugh|first=M.|date=1983-12-01|title=Diagnosis and treatment of sexually transmitted diseases|journal=Sexually Transmitted Infections|volume=59|issue=6|pages=410|doi=10.1136/sti.59.6.410-a|issn=1368-4973|doi-access=free}}</ref>

==Signs and symptoms==
[[File:Haemophilus ducreyi 5811 lores.jpg|thumb|Buboes in a male]]
These are only local and no systemic manifestations are present.<ref>{{cite book|title=Medical Microbiology: The Big Picture|publisher=McGraw Hill Professional|isbn=9780071476614|pages=243|date=2008-08-05}}</ref> The ulcer characteristically:
* Ranges in size dramatically from 3 to 50&nbsp;mm (1/8&nbsp;inch to 2 inches) across
* Is painful
* Has sharply defined, undermined borders
* Has irregular or ragged borders, ''described as saucer-shaped''.
* Has a base that is covered with a gray or yellowish-gray material
* Has a base that bleeds easily if traumatized or scraped
* Painful [[lymphadenopathy|swollen lymph nodes]] occur in 30–60% of patients.
* [[Dysuria]] (pain with urination) and [[dyspareunia]] (pain with intercourse) in females

About half of infected men have only a single ulcer. Women frequently have four or more ulcers, with fewer symptoms. The ulcers are typically confined to the genital region most of the time.<ref name="Waugh 410"/>

The initial ulcer may be mistaken as a "hard" [[chancre]], the typical sore of primary [[syphilis]], as opposed to the "soft chancre" of chancroid.{{citation needed|date=May 2021}}

Approximately one-third of the infected individuals will develop enlargements of the [[inguinal lymph node]]s, the nodes located in the fold between the leg and the lower abdomen.{{citation needed|date=May 2021}}

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]].{{citation needed|date=May 2021}}

===Complications===
* Extensive lymph node inflammation may develop.
* Large inguinal [[abscess]]es may develop and rupture to form draining [[Sinus (anatomy)|sinus]] or giant ulcer.
* [[Superinfection]] by ''[[Fusarium]]'' and ''[[Bacteroides]]''. These later require debridement and may result in disfiguring scars.
* [[Phimosis]] can develop in long-standing lesion by scarring and thickening of foreskin, which may subsequently require [[circumcision]].

=== Sites for chancroid lesions ===

==== Males ====
* Internal and external surface of [[Foreskin|prepuce]].
* [[Coronal sulcus]]
* [[Penile frenulum|Frenulum]]
* [[Body of penis|Shaft of penis]]
* Prepucial orifice
* [[External urethral orifice|Urethral meatus]]
* [[Glans penis]]
* Perineum area

==== Females ====
* [[Labia majora]] is the most common site. "Kissing ulcers" may develop. These are ulcers that occur on opposing surfaces of the labia.
* [[Labia minora]]
* [[Frenulum labiorum pudendi|Fourchette]]
* [[Vulval vestibule|Vestibule]]
* [[Clitoris]]
* [[perineum|Perineal]] area
* Inner thighs

==Causes==
Chancroid is a [[bacteria]]l [[infection]] caused by the [[Growth medium|fastidious]] [[Gram-negative]] streptobacillus ''[[Haemophilus ducreyi]]''. This pathogen is highly infectious<ref name="Waugh 410"/>''.'' It is a disease found primarily in [[developing countries]], most prevalent in low socioeconomic groups, associated with commercial sex workers.<ref>{{cite web |url=https://www.lecturio.com/concepts/chancroid/| title=Chancroid|website=The Lecturio Medical Concept Library |access-date= 7 July 2021}}</ref>

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 [[sexually transmitted infection]] (STI) clinics in Memphis and Chicago.<ref>{{cite web|url=http://pathmicro.med.sc.edu/infectious+disease/sexually+transmitted+diseases.htm|title=Error 404 - Page Not Found|website=pathmicro.med.sc.edu|access-date=19 April 2018}}{{Dead link|date=November 2023 |bot=InternetArchiveBot |fix-attempted=yes }}</ref>

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|date=August 2010}} 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|date=August 2010}}

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.<ref>{{cite journal |last1=Lewis |first1= D A |date=2003 |title=Chancroid: clinical manifestations, diagnosis, and management  |url= https://sti.bmj.com/content/79/1/68|journal=The BMJ |volume=79 |issue=1 |pages=68–71 |doi=10.1136/sti.79.1.68 |pmid= 12576620 |access-date= 7 July 2021|pmc=1744597 }}</ref>

==Pathogenesis==
''[[Haemophilus ducreyi]]'' enters skin through [[microabrasion]]s incurred during sexual intercourse. The incubation period of the infection is 10 to 14 days, after which there is progression of the disease.<ref name="Waugh 410"/> A local tissue reaction leads to development of erythematous [[Cutaneous conditions#Primary lesions|papule]], which progresses to [[Cutaneous conditions#Primary lesions|pustule]] in 4–7 days. It then undergoes central [[necrosis]] to ulcerate.<ref name=cur>{{cite book|title=CURRENT Diagnosis & Treatment of Sexually Transmitted Diseases|year=2007|publisher=McGraw-Hill Companies, Inc.|isbn=9780071509619|pages=69–74}}</ref>

==Diagnosis==

===Variants===
Some of clinical variants are as follows.<ref name=cur />
{|class="wikitable sortable sorted"
|-
! Variant!! Characteristics
|-
|Dwarf chancroid|| Small, superficial, relatively painless ulcer.
|-
|Giant chancroid|| Large granulomatous ulcer at the site of a ruptured inguinal bubo, extending beyond its margins.
|-
|Follicular chancroid|| Seen in females in association with hair follicles of the labia majora and [[Mons pubis|pubis]]; initial follicular pustule evolves into a classic ulcer at the site.
|-
|Transient chancroid|| Superficial ulcers that may heal rapidly, followed by a typical inguinal [[bubo]].
|-
|Serpiginous chancroid|| Multiple ulcers that coalesce to form a serpiginous pattern.
|-
|Mixed chancroid|| Nonindurated tender ulcers of chancroid appearing together with an indurated nontender ulcer of syphilis having an incubation period of 10 to 90 days.
|-
|Phagedenic chancroid|| Ulceration that causes extensive destruction of genitalia following secondary or [[superinfection]] by anaerobes such as [[Fusobacterium]] or [[Bacteroides]].
|-
|Chancroidal ulcer|| Most often a [[tenderness (medicine)|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 using special culture media; however, there is a <80% sensitivity. PCR-based identification of the organisms is available, but none in the United States are FDA-cleared.<ref name=":0">{{Cite web|url=https://www.cdc.gov/std/tg2015/default.htm|title=2015 STD Treatment Guidelines|date=2019-05-08|website=www.cdc.gov|language=en-us|access-date=2019-08-02}}</ref> Simple, rapid, sensitive and inexpensive antigen detection methods for ''H. ducreyi'' identification are also popular. Serologic detection of ''H. ducreyi'' uses [[Virulence-related outer membrane protein family|outer membrane protein]] and [[lipooligosaccharide]]. ''Most of the time, the diagnosis is based on presumptive approach using the symptomatology which in this case includes multiple painful genital ulcers''<ref name="Waugh 410"/>''.''

===Differential diagnosis===
{{Quote box
|title = [[Centers for Disease Control and Prevention|CDC]]'s standard clinical definition for a probable case of chancroid|
|quote =
# 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.
# No evidence of ''[[Treponema pallidum]]'' infection by [[darkfield microscopy|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
# 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:{{cn|date=May 2021}}
* [[Primary syphilis]]
* [[Genital herpes]]
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.{{citation needed|date=May 2021}}

==== Comparison with syphilis ====
There are many differences and similarities between the conditions syphilitic [[chancre]] and chancroid:<ref>{{cite journal |last1=Lewis |first1= D A |date=2003 |title=Chancroid: clinical manifestations, diagnosis, and management  |url= https://sti.bmj.com/content/79/1/68|journal=The BMJ |volume=79 |issue=1 |pages=68–71 |doi=10.1136/sti.79.1.68 |pmid= 12576620 |access-date= 7 July 2021|pmc=1744597 }}</ref>

;Similarities
* Both originate as [[pustule]]s at the site of inoculation, and progress to [[Ulcer (dermatology)|ulcerated]] lesions
* Both lesions are typically 1–2&nbsp;cm in diameter
* Both lesions are caused by sexually transmissible organisms
* Both lesions typically appear on the genitals of infected individuals
* Both lesions can be present at multiple sites and with multiple lesions

;Differences
* Chancre is a lesion typical of infection with the bacterium that causes syphilis, [[Treponema pallidum|''Treponema pallidum'']]
* Chancroid is a lesion typical of infection with the bacterium [[Haemophilus ducreyi|''Haemophilus ducreyi'']]
* Chancres are typically painless, whereas chancroid are typically painful
* Chancres are typically non-exudative, whereas chancroid typically have a grey or yellow purulent [[exudate]]
* Chancres have a hard (indurated) edge, whereas chancroid have a soft edge
* Chancres heal spontaneously within three to six weeks, even in the absence of treatment
* Chancres can occur in the [[pharynx]] as well as on the genitals

==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]].<ref name=cur /> Also, treatment of sexual partners is advocated whether they develop symptoms or not as long as there was unprotected sexual intercourse with the patient within 10 days of developing the symptoms.<ref name="Waugh 410"/>

==Treatment==
For the initial stages of the lesion, cleaning with soapy solution is recommended and [[sitz bath]] may be beneficial. Fluctuant nodules may require aspiration.<ref name="Waugh 410"/> Treatment may include more than one prescribed medication.<ref>{{cite journal |last1=Lewis |first1= D A |date=2003 |title=Chancroid: clinical manifestations, diagnosis, and management  |url= https://sti.bmj.com/content/79/1/68|journal=The BMJ |volume=79 |issue=1 |pages=68–71 |doi=10.1136/sti.79.1.68 |pmid= 12576620 |access-date= 7 July 2021|pmc=1744597 }}</ref>

=== Antibiotics ===
[[Macrolide]]s are often used to treat chancroid. The [[Centers for Disease Control and Prevention|CDC]] recommendation is either a single oral dose (1 gram) of [[azithromycin]], a single IM dose (250&nbsp;mg) of [[ceftriaxone]], oral (500&nbsp;mg) of [[erythromycin]] three times a day for seven days, or oral (500&nbsp;mg) of [[ciprofloxacin]] twice a day for three days.<ref name=":0" /> Due to a paucity of reliable empirical evidence it is not clear whether macrolides are actually more effective and/or better tolerated than other antibiotics when treating chancroid.<ref>{{cite journal |last1=Romero |first1=L |last2=Huerfano |first2=C |last3=Grillo-Ardila |first3=CF |title=Macrolides for treatment of Haemophilus ducreyi infection in sexually active adults. |journal=The Cochrane Database of Systematic Reviews |date=11 December 2017 |volume=2017 |issue=12 |pages=CD012492 |doi=10.1002/14651858.CD012492.pub2 |pmid=29226307|pmc=6486275 }}</ref> Data is limited, but there have been reports of ciprofloxacin and erythromycin resistance.{{Citation needed|date=July 2020}}

[[Aminoglycoside]]s such as [[gentamicin]], [[streptomycin]], and [[Kanamycin A|kanamycin]] has been used to successfully treat chancroid; however aminoglycoside-resistant strain of ''H. ducreyi'' have been observed in both laboratory and clinical settings.<sup>[[Chancroid#cite note-7|[7]]]</sup> Treatment with aminoglycosides should be considered as only a supplement to a primary treatment.{{Citation needed|date=July 2020}}

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.{{Citation needed|date=July 2020}}

==Prognosis==
Prognosis is excellent with proper treatment. Treating sexual contacts of affected individual helps break cycle of infection.{{Citation needed|date=July 2020}}

=== Follow-up ===
Within 3–7 days after commencing treatment, patients should be re-examined to determine whether the treatment was successful. Within 3 days, symptoms of ulcers should improve. Healing time of the ulcer depends mainly on size and can take more than two weeks for larger ulcers. In uncircumcised men, healing is slower if the ulcer is under the foreskin. Sometimes, needle aspiration or incision and drainage are necessary.<ref name=":0" />

== Epidemiology ==
Although the prevalence of chancroid has decreased in the United States and worldwide, sporadic outbreaks can still occur in regions of the Caribbean and Africa. Like other sexually transmitted infections, having chancroid increases the risk of transmitting and acquiring HIV.<ref name=":0" />

==History==
Chancroid has been known to humans since time of ancient Greeks.<ref name=std>{{cite book|title=Sexually Transmitted Diseases|edition=4th|year=2007|publisher=McGraw Hill Professional|isbn=9780071417488|pages=689–698}}</ref> Some of important events on historical timeline of chancre are:
{| class="wikitable"
|-
! Year !! Event
|-
| 1852|| Leon Bassereau distinguished chancroid from syphilis (i.e. soft chancre from hard chancre)
|-
| 1890s || Augusto Ducrey identified ''H. ducreyi''
|-
| 1900|| Benzacon and colleagues isolated ''H. ducreyi''
|-
| 1970s|| G. W. Hammond and colleagues developed selective media
|}

==References==
{{Reflist}}

== External links ==
{{Medical resources
|   DiseasesDB     = 5563
|   ICD11          = {{ICD11|1A90}}
|   ICD10          = {{ICD10|A|57||a|50}}
|   ICD9           = {{ICD9|099.0}}
|   ICDO           =
|   OMIM           =
|   MedlinePlus    = 000635
|   eMedicineSubj  = emerg
|   eMedicineTopic = 95
|   MeshID         = D002602
}}

{{STD/STI}}
{{Bacterial cutaneous infections}}
{{Bacterial diseases}}
{{Authority control}}

[[Category:Infections with a predominantly sexual mode of transmission]]
[[Category:Bacterium-related cutaneous conditions]]