172: Chancroid

Question 1

What is the typical incubation period for chancroid?

Answer 1

The incubation period (IP) for chancroid is typically 3 to 7 days, rarely exceeding 10 days.

Question 2

What are the common clinical findings associated with chancroid ulcers?

Answer 2

Chancroid ulcers typically begin as a soft papule with surrounding erythema. After 24-48 hours, they progress to pustular, then eroded, and finally ulcerated. The edges are ragged and undermined, covered by a necrotic, yellow-gray exudate, and are usually tender and/or painful.

Question 3

What factors are associated with the transmission of chancroid?

Answer 3

Factors associated with the transmission of chancroid include:
1. Lower-class prostitutes as reservoirs in outbreaks.
2. Male circumcision is associated with a reduced risk of contracting chancroid.
3. Chancroid ulcer is an important risk factor for the heterosexual spread of HIV.
4. Transmission rate from males to females is approximately 70% per sex act.

Question 4

What are the classic etiologic agents for genital ulceration?

Answer 4

The three classic etiologic agents for genital ulceration are:
1. H. ducreyi
2. Treponema pallidum
3. Herpes simplex

Question 5

What is the significance of painful inguinal adenitis (bubo) in chancroid?

Answer 5

Painful inguinal adenitis (bubo) occurs in up to 50% of patients within a few days to 2 weeks after the onset of the primary lesion. It is typically unilateral, with erythema of the overlying skin, and can become fluctuant and may rupture spontaneously. The pus of the bubo is usually thick and creamy and is less common in females.

Question 6

A female sex worker in West Africa is asymptomatic but tests positive for H. ducreyi. What is the significance of this finding?

Answer 6

Asymptomatic carriage of H. ducreyi in female sex workers is significant because it can contribute to the spread of chancroid. Approximately 2% of female sex workers in West Africa carry the organism asymptomatically.

Question 7

A patient presents with a single genital ulcer that is tender, non-indurated, and covered by a necrotic yellow-gray exudate. What is the most likely diagnosis?

Answer 7

The most likely diagnosis is chancroid. The ulcer’s characteristics, including tenderness, non-induration, and necrotic yellow-gray exudate, are typical of chancroid.

Question 8

A patient with chancroid has systemic symptoms. Is this common, and what should be considered?

Answer 8

Systemic symptoms are rare in chancroid. If present, consider the possibility of co-infection or another underlying condition.

Question 9

A patient with chancroid has a lesion on the vulva. What are the common sites for chancroid lesions in females?

Answer 9

In females, chancroid lesions are most commonly localized on the vulva, especially on the fourchette, the labia minora, and the vestibule.

Question 10

A patient with chancroid has a lesion that has spread to the groin. What is this phenomenon called?

Answer 10

The phenomenon of chancroid lesions spreading to the groin is referred to as ‘kissing ulcers’ or serpiginous ulcers.

Question 11

A patient with chancroid has a lesion on the penis shaft. Is this a common site for chancroid lesions in males?

Answer 11

The shaft of the penis is less frequently involved in chancroid lesions compared to other sites like the prepuce, frenulum, or glans.

Question 12

A patient with chancroid has a lesion localized in the urethra. What additional symptom might be observed?

Answer 12

If the chancroid lesion is localized in the urethra, purulent urethritis may be observed.

Question 13

A patient with chancroid has a lesion that bleeds easily on manipulation. What does this indicate about the ulcer’s base?

Answer 13

The ulcer’s base is composed of granulation tissue that bleeds easily on manipulation, which is characteristic of chancroid.

Question 14

A patient has a lesion with ragged and undermined edges on the genital area. What does this suggest about the ulcer?

Answer 14

Ragged and undermined edges are characteristic of chancroid ulcers.

Question 15

A patient with chancroid has a lesion covered by a necrotic yellow-gray exudate. What does this indicate?

Answer 15

The necrotic yellow-gray exudate covering the lesion is a typical feature of chancroid ulcers.

Question 16

A patient with chancroid has a lesion that is tender and painful. How does this differ from syphilitic ulcers?

Answer 16

Chancroid ulcers are tender and painful, whereas syphilitic ulcers are typically non-tender and indurated.

Question 17

A patient with chancroid has a lesion with a diameter of 2 cm. Is this within the typical size range for chancroid ulcers?

Answer 17

Yes, chancroid ulcers typically have a diameter ranging from 1 mm to 2 cm.

Question 18

A patient with chancroid has a single ulcer. Is this common in males?

Answer 18

Yes, half of the males with chancroid present with a single ulcer.

Question 19

A patient with chancroid has a lesion on the glans penis. Is this a common site for chancroid lesions in males?

Answer 19

Yes, the glans penis is a common site for chancroid lesions in males.

Question 20

A patient with chancroid has a lesion on the anus. Is this a common site for chancroid lesions?

Answer 20

The anus is less frequently involved in chancroid lesions.

Question 21

A patient with chancroid has a lesion on the breast. What does this suggest about the mode of transmission?

Answer 21

A lesion on the breast suggests extragenital transmission, possibly due to trauma or abrasion.

Question 22

A patient with chancroid has a lesion inside the mouth. What does this suggest about the mode of transmission?

Answer 22

A lesion inside the mouth suggests extragenital transmission, possibly due to trauma or abrasion.

Question 23

A patient with chancroid has painful inguinal adenitis. How common is this symptom?

Answer 23

Painful inguinal adenitis occurs in up to 50% of patients with chancroid.

Question 24

A patient with chancroid has unilateral inguinal adenitis. Is this typical?

Answer 24

Yes, inguinal adenitis in chancroid is unilateral in most patients.

Question 25

A patient with chancroid has erythema of the overlying skin. What does this indicate about the adenitis?

Answer 25

Erythema of the overlying skin is typical of inguinal adenitis in chancroid.

Question 26

A patient with chancroid has fluctuant inguinal adenitis. What is the risk if left untreated?

Answer 26

If left untreated, fluctuant inguinal adenitis may rupture spontaneously.

Question 27

A patient with chancroid has thick and creamy pus from a ruptured bubo. Is this typical?

Answer 27

Yes, the pus from a ruptured bubo in chancroid is usually thick and creamy.

Question 28

A patient with chancroid has mild systemic symptoms. Is this common?

Answer 28

Mild systemic symptoms are rare in chancroid.

Question 29

What is the significance of male circumcision in relation to chancroid risk?

Answer 29

Male circumcision is associated with a **reduced risk** of contracting chancroid.

Question 30

Describe the progression of a chancre in chancroid after 24-48 hours.

Answer 30

After **24-48 hours**, from a papule with surrounding erythema, a chancre progresses to: 1. **Pustular** 2. **Eroded** 3. **Ulcerated** Vesicles are not seen, and the edges are **ragged and undermined**.

Question 31

What are the common locations for lesions in males with chancroid?

Answer 31

In males, lesions are commonly found on: - The external or internal surface of the **prepuce** - The **frenulum** - The **glans** Half of the males present with a single ulcer.

Question 32

What is the typical presentation of painful inguinal adenitis (bubo) in chancroid?

Answer 32

Painful inguinal adenitis (bubo) occurs in up to **50%** of patients within a few days to **2 weeks** after the onset of the primary lesion. It is typically: - **Unilateral** in most cases - Characterized by **erythema** of the overlying skin - Can become **fluctuant** and may rupture spontaneously - The pus is usually **thick and creamy**.

Question 33

What is the transmission rate of chancroid from males to females?

Answer 33

The transmission rate of chancroid from males to females is approximately **70%** per sexual act.

Question 34

What are the common extragenital sites for chancroid lesions in females?

Answer 34

In females, extragenital lesions of chancroid have been reported on: - The **breasts** - **Fingers** - **Thighs** - Inside the **mouth** Trauma and abrasion may be important factors in these cases.

Question 35

What is the duration of infectivity for women with chancroid in the absence of treatment?

Answer 35

The duration of infectivity for women with chancroid in the absence of treatment is **45 days**.

Question 36

What are the characteristics of ulcers in chancroid?

Answer 36

Ulcers in chancroid are typically: - **Tender and/or painful** - **Not indurated** (in contrast to syphilis) - Covered by a **necrotic, yellow-gray exudate** - The base is composed of **granulation tissue** that bleeds easily on manipulation.

Question 37

What is the primary cause of isolated painful chancres in industrialized countries?

Answer 37

Isolated painful chancres are most likely caused by **herpes simplex virus**.

Question 38

What is required for the definitive diagnosis of H. ducreyi?

Answer 38

Definitive diagnosis requires **identification of H. ducreyi on culture media**. The sensitivity of culture reaches only 75% at best, which is particularly important when testing for antimicrobial susceptibility patterns.

Question 39

What are the most active drugs against H. ducreyi?

Answer 39

The most active drugs against H. ducreyi are **azithromycin, ceftriaxone, ciprofloxacin, and erythromycin**.

Question 40

What should be considered if no clinical improvement is evident one week after starting therapy for H. ducreyi infection?

Answer 40

Consider the following if no clinical improvement is evident: 1. Incorrect diagnosis 2. Coinfection with another STI 3. Concomitant HIV infection 4. Poor compliance 5. A resistant strain of H. ducreyi

Question 41

What are the consequences of treatment delay for H. ducreyi infections?

Answer 41

Consequences of treatment delay can include: - Spontaneous resolution without complications in half of untreated patients - Potential for persistent genital ulcer and inguinal abscess for years - Local pain as the most frequent complaint.

Question 42

A patient presents with a painful genital ulcer and unilateral inguinal adenitis. What steps should you take to confirm a diagnosis of chancroid?

Answer 42

To confirm a diagnosis of chancroid, collect a specimen from the ulcer for culture or nucleic acid amplification techniques. Microscopy is not routinely recommended due to low sensitivity and specificity.

Question 43

A patient with chancroid has a fluctuant bubo. What is the recommended management for this condition?

Answer 43

Fluctuant buboes should not be incised. Instead, they can be punctured with a large syringe laterally through normal skin to prevent spontaneous rupture and sinus tract formation.

Question 44

A patient with chancroid is pregnant. What is the preferred treatment?

Answer 44

The preferred treatment for a pregnant patient with chancroid is ceftriaxone, although azithromycin can also be used.

Question 45

A patient with chancroid has a lesion that resolved spontaneously. How common is this outcome?

Answer 45

Spontaneous resolution without complications occurs in half of untreated patients with chancroid.

Question 46

A patient with chancroid has a lesion that persisted for years. Is this typical?

Answer 46

While rare, genital ulcers and inguinal abscesses in chancroid can persist for years without treatment.

Question 47

What is the primary cause of isolated painful chancres in industrialized countries?

Answer 47

Isolated painful chancres in industrialized countries are most likely caused by **herpes simplex virus**.

Question 48

What is the significance of identifying H. ducreyi in culture media for diagnosis?

Answer 48

Identifying **H. ducreyi** in culture media is crucial because the sensitivity of culture reaches only **75% at best**, which is particularly important when testing for antimicrobial susceptibility patterns in cases of therapeutic failure.

Question 49

What are the most active drugs against H. ducreyi?

Answer 49

The most active drugs against **H. ducreyi** are **azithromycin, ceftriaxone, ciprofloxacin, and erythromycin**.

Question 50

What is the prognosis for untreated chancroid?

Answer 50

The prognosis for untreated chancroid is that the disease is usually **self-limited**, but without treatment, genital ulcers and inguinal abscesses can persist for years, with **local pain** being the most frequent complaint.

Question 51

What is the importance of bedside inoculation of culture plates in diagnosing H. ducreyi?

Answer 51

Bedside inoculation of culture plates is important because it involves using **2 different selective, enriched culture media** followed by immediate incubation to reduce the loss of viable bacteria during transport.

Question 52

What is the clinical significance of reinfections in patients treated for chancroid?

Answer 52

Reinfections are possible in patients treated for chancroid, highlighting the importance of instructing patients to use **condoms properly** to avoid reinfections.

Question 53

What is the recommended treatment for patients with phimosis related to chancroid?

Answer 53

For patients with phimosis related to chancroid, **circumcision may be necessary**.

Question 54

Are reinfections with chancroid possible after treatment or spontaneous resolution?

Answer 54

Reinfections are possible, highlighting the importance of instructing patients to use condoms properly to avoid reinfections.

Question 55

What is the recommended treatment for patients with phimosis related to chancroid?

Answer 55

Circumcision may be necessary when all active lesions have healed.

Question 56

What is the relationship between HIV infection and chancroid?

Answer 56

Effective treatment of genital ulcers has been shown to reduce the incidence of HIV. Concomitant HIV infection significantly affects the course of chancroid disease.

Question 57

What preventive measures should be taken to avoid chancroid?

Answer 57

Patients should abstain from sexual activity until all clinical lesions have cleared. Sexual contacts should be examined and treated within 10 days of symptom presentation, regardless of symptoms.

Question 58

What should be done if a patient presents with an isolated small ulcer and painful matted gland?

Answer 58

The patient should be treated for lymphogranuloma venereum, chancroid, and syphilis. (SLC)

Question 59

What management approach should be followed for a patient with a history of recent blisters and a small genital ulcer?

Answer 59

Herpes management should be followed.

Question 60

What infections should be treated for a patient with a painful matted gland and an isolated small ulcer?

Answer 60

Lymphogranuloma venereum, chancroid, and syphilis should be treated.

Question 61

Why is it important for patients with chancroid to abstain from sexual activity?

Answer 61

To prevent the spread of the infection until all clinical lesions have cleared.

Question 62

What preventive measures can be taken to avoid reinfection in patients with chancroid?

Answer 62

Patients should use condoms properly, and sexual contacts within 10 days of symptom presentation should be examined and treated.

Question 63

What is the likely cause of recurrence in a patient with chancroid?

Answer 63

Reinfection by an untreated sexual partner.

Question 64

What alternative treatment should be considered for a patient with chancroid not responding to single-dose therapy?

Answer 64

A multiday regimen should be considered, especially in HIV-seropositive patients.

Question 65

What should be done if a patient presents with small blisters or an ulcer with a history of recent blisters?

Answer 65

Herpes management should be followed.

Question 66

What should patients with chancroid be tested for?

Answer 66

Patients should be tested for HIV antibodies.

Question 67

What is recommended for sexual contacts of a patient with chancroid?

Answer 67

Sexual contacts should be examined and treated within 10 days of symptom presentation, regardless of whether symptoms are present.

Question 68

What is the significance of azithromycin in the treatment of chancroid?

Answer 68

A single dose of azithromycin may provide protection from reinfection and lasts as long as 2 months after treatment.

Question 69

What is the most frequent complaint associated with chancroid?

Answer 69

The most frequent complaint is local pain.

Question 70

What is the association between HIV-1 seropositivity and treatment failure in chancroid?

Answer 70

Failure of single-dose or short-course therapy for chancroid in men is associated with HIV-1 seropositivity.

Question 71

What is the recommended approach for HIV-seropositive patients with chancroid?

Answer 71

HIV-seropositive patients should be monitored closely and treated with a multiday regimen.

Question 72

What is the potential for asymptomatic carriage of H. ducreyi?

Answer 72

Asymptomatic carriage of H. ducreyi is possible, and sexual contacts should be treated regardless of symptoms.

Question 73

What is the reservoir for H. ducreyi cutaneous infection?

Answer 73

The reservoir for H. ducreyi cutaneous infection remains to be elucidated.

Question 74

What is the clinical picture of chancroid in HIV-infected patients?

Answer 74

There is a wide variation of the clinical picture in these patients.

Question 75

If only an ulcer is present, the patient should be treated for what diseases?

Answer 75

If only an ulcer is present, syphilis and chancroid should be treated.

Question 76

What is the implication of chronic limb ulcers in adults and children?

Answer 76

H. ducreyi should be considered as a cause of chronic limb ulcers in adults and especially in children.

Question 77

How should the patient with chancroid be monitored?

Answer 77

Patients should be monitored closely, especially if they are HIV-seropositive.

Question 78

What is the treatment approach for fluctuating buboes in chancroid?

Answer 78

Fluctuating buboes are entered by a large syringe through normal skin for treatment.

Question 79

What is the clinical significance of treating sexual partners of patients with chancroid?

Answer 79

Treating sexual partners is crucial to prevent reinfection and further spread of the disease.

Question 80

What factors appear to be associated with increased likelihood of H. ducreyi infection and treatment failure?

Answer 80

Lack of circumcision and HIV infection.

Question 81

What is the recommended action if relapse occurs in chancroid treatment?

Answer 81

If relapse occurs (5%), treatment with original regimen is required.

Question 82

What is the clinical implication of the variation in the clinical picture of chancroid in HIV-infected patients?

Answer 82

The variation indicates the need for careful assessment and tailored treatment for HIV-infected patients with chancroid.

Question 83

What is the role of antibiotics in preventing reinfection of chancroid?

Answer 83

Antibiotics may provide some protection from reinfection after treatment.

Question 84

What is the microscopic morphology of Haemophilus ducreyi?

Answer 84

Small gram-negative rods

Question 85

What are the different antibiotic regimens for the treatment of chancroid?

Answer 85