Chancroid

Chancroid (Kan-kroid) is also known as:
* soft chancre;
* venereal sore;

Chancroid ( human genital ulcer disease) is an STI caused by exposure to:
* Haemophilus ducreyi (a small gram-negative rod organism) which occurs mainly in developing countries, especially the African, Asian and Latin American nations;
* Infection from Chancroid related to Haemophilus ducreyi  is decreasing in many areas but increasing in infections related to Herpes simplex virus type-2 (HSV-2);
* Chancroid is a bacterial disease causing painful, irregularly shaped sores, but is a localized infection which can be treated and cured and has no long-term effects;
* Over 4,000 cases are reported annually occurring mainly in younger adults, although it can affect any age; 

Chancroid 
The size can vary from 1-2 millimeters to several centimeters but is usually 1-2 centimeters in diameter. 

The shape can be:
* irregular;
* oval;
* round;

Unlike the chancre of syphilis:
* the chancroid ulcer edge is soft;
* the ulcer changes shape when the edges are squeezed;

Symptoms

First signs of infection appear from 3-5 days and up to 2 weeks after contact, and usually a tender, raised bump develops where the bacteria entered the body:
* inside/outside the vagina or rectum;
* occasionally on hands, thighs or mouth;
* on the penis;

Within 1-4 days the bump transforms into one or more shallow sores which break open and deepen, becoming:
* filled with pus;
* inflamed;
* painful;
* ruptured;

The next stage may persist for several weeks and may result in:
* a painful open sore;
* purulent base of the ulcer;
* several lesions merging to form gigantic ulcers;

In over half of the untreated cases the chancroid bacteria infects the lymph glands in the groin. 

The lymph glands in the groin may:
* swell, creating a pus-filled bulge, known as a bubo ;
* enlarge until they burst through the skin;
* drain continuously;
* remain open;
* become infected by other bacteria;
* may be firm or fluctuant;
* may rupture or ulcerate;

The typical chancroid bubo:
* appears about 1-2 weeks after the ulcer forms;
* is unilateral, spherical, and painful;

In men:
* 1 - 4 sores on the penis may develop;
* Buboes appear in about 50% of male patients;
* The foreskin may swell;
The ulcers usually are found in:;
* the prepuce near the frenulum;
* coronal sulcus;
* glans; 

Rectal sores may:
* bleed; 
* cause pain when defecating;

In women:
* Buboes are uncommon in women; 
* Dyspareunia (painful sex); 
* Dysuria (painful urination); 
* Painless sores can develop on the cervix; 
* Several sores may develop around the vagina and rectum; 
* Vaginal discharge; 
The ulcers usually are found on the:
* Cervix; 
* Entrance of the vagina, particularly the fourchette; 
* Labia majora and minora;
* Peri-anal area; 
 
Rectal sores may: 
* bleed;
* cause pain when defecating;

Transmission

Chancroid is transmitted through the skin by direct sexual contact with an infected individual through:
* anal sex;
* vaginal sex;
* oral sex;

The infection is spread to other parts of the body by:
* minor abrasions;
* physical contact;
* rubbing;
* scratching;

Other
* An uncircumcised man is more likely to contract the disease than a circumcised man;
* Any sexually active person can be infected with chancroid;
* If a person does not practice personal hygiene it is easier for the infection to be transmitted;
* It is more commonly seen in men than in women;

Risk Factors
* Contact between scraped or broken infected skin increases the likelihood of transmission;
* Ejaculation is not necessary for the infection to be spread;
* Even if using a condom, sores may be present on areas not protected by the latex and can cause infection anywhere they contact receptive tissue;
* The bacteria are more likely to invade the sexual organs at the point of a pre-existing injury, such as a small cut or scratch;

More outbreaks occur in:
* drug users;
* people with STIs;
* prostitutes and their clients;

Re-infection can occur from: * ;
* minor abrasions;
* open wounds;

The disease is not  spread from person to person by casual contact such as:
* clothings;
* door knobs;
* eating ustansils;
* swimming pools;
* toilet seats;

and

* mothers do not pass it on to babies at birth;

Diagnosis

Chancroid is usually diagnosed by:
* Culture or biopsy;
* Gram Stain;
* Microscopic examination of a smear sample taken from the patient's sores;

Although the disease does not enter the bloodstream a blood sample is usually taken to check for the presence of other STIs.

Culture:
* Diagnosis requires culturing H ducreyi on special culture medium that is not always available;
* The sensitivity is not higher than 75%;
* The organism specimens should be checked out immediately at the clinic or sent rapidly (within 4 hours) to the laboratory;

Gram Stain
* Sensitivity range from 10-90%;
* The classic description of H ducreyi  is that of a 'school of fish' with small, pleomorphic, gram-negative rods;
* Has limitations in diagnosing chancroid;

Serology (blood test):
* Inability to distinguish acute from past exposure:
* Calcium alginate or plastic swabs should be used for collection of samples:
New techniques for diagnosis of chancroid are constantly being researched such as:;
* Antigen-detection techniques involving immuno-fluorescence or radio-isotopic probes;
* Detection of nucleic acid (DNA) by amplification techniques such as Polymerase Chain Reaction (PCR) which is 95% sensitive compared to a culture specimen;

Note
* The doctor or health professional should be advised if the patient has a history of HIV infection as HIV seropositivity can be responsible for an atypical presentation of chancroid;

HIV-infected patients have :
* a larger number of ulcers;
* atypical ulcers and extra-genital lesions;
* longer lasting ulcers;

Screening for other possible causes of genital ulcerative disease should be arranged, particularly the diagnosis of:
* Donovanosis (Granuloma inguinale);
* Herpes simplex virus (HSV);
* Lymphogranuloma venereum (LGV) caused by a virus and spread by sexual intercourse and contaminated articles;
* Treponema pallidum, the organism that causes syphilis;

Biopsy of lymph nodes may be required to exclude:
* Neoplasia (the presence of new growths or tumors);

Treatment

Buboes may need to be drained with a needle under local anesthetic.

Although treatment with antibiotics can cure the infection, strains are becoming more common that are resistant to:
* Ampicillin;
* Chloramphenicol;
* Penicillin;
* Tetracycline;

Conventional Treatment
Current treatment involves regular doses for up to two weeks of:
* Ciprofloxacin;
* Erythromycin;
* Trimethoprin;

or a single dose of:
* Azithromycin;
* Ceftriaxone;

Drug Information
Azithromycin (Zithromax) is used to treat:
* Chlamydial and Gonorrheal infections of the genital tract;
* Mild to moderately severe infections caused by susceptible strains of microorganisms;

Contraindications
* Concurrent Pimozide treatment (sudden death may occur);
* Hepatic impairment;
* Hypersensitivity ;

Interactions with other substances
Decreased effects if taking:
* Aluminum antacids ;
* Magnesium antacids;
Increased toxicity of:
* Digoxin;
* Theophylline;
* Warfarin;
If taking Cyclosporine there is an increased risk of:
* Nephrotoxicity;
* Neurotoxicity;

Side Effects
* Bacterial or fungal overgrowth with prolonged use;
* Cholestatic jaundice;
* May increase hepatic enzymes;
* Site reactions can occur with IV route;

Caution
Care should be used when dealing with patients:
* who are debilitated;
* who are geriatric;
*who are hospitalized;
* with with pneumonia;

During Pregnancy
It has not been established if it is safe for pregnant and lactating women

Ceftriaxone (Rocephin) is used to:
* Stop bacterial growth by binding to one or more penicillin-binding proteins;

Contraindications
Hypersensitivity

Interactions with other substances
Probenecid may increase levels of:
* Ceftriaxone;
* Nephrotoxicity increases if taking:
* Aminoglycosides;
* Ethacrynic Acid;
* Furosemide;

During Pregnancy
Thought to be safe but benefits must outweigh the risks

Caution
* Dosage should be adjusted in renal impairment;
* Should not be used by breastfeeding women;
* Should not be used if allergic to penicillin;

Erythromycin is used to inhibit:
* Bacterial growth;
* RNA-dependent protein synthesis;

Note
Erythromycin is used to treat patients allergic to:
* Cephalosporines;
* Quinolones;

Contraindications
* Hepatic impairment;
* Hypersensitivity;

Interactions with other substances
Increases toxicity of:
* Carbamazepine;
* Cyclosporine;
* Digoxin;
* Theophylline;

Anticoagulant effects potentiated of:
* warfarin;

Increased risk of Rhabdomyolysis if taking:
* Lovastatin;
* Simvastatin;

Side-Effects
* Adverse gastro-intestinal effects;
* Cholestatic jaundice may occur;

During Pregnancy
Thought to be safe but benefits must outweigh the risks

Caution
In liver disease
Discontinue if the following occurs:
* Abdominal colic;
* Fever;
* Malaise;
* Nausea;
* Vomiting;

Ciprofloxacin (Cipro) is a bactericidal antibiotic that is used to inhibit:
* Bacterial DNA synthesis and growth;

Contraindication:
* Hypersensitivity;
* Should not be used for children and adolescents under 18;

Interactions with other substances
Serum concentrations may be increased if taking:
* Probenecid;

Serum levels may be reduced if taking:
* Antacids;
* Iron Salts;
* Zinc Salts;

If taking Cimetidine it may interfere with the metabolism of:
* Fluoroquinolones:
Reduces the therapeutic effects of:
*Phenytoin;
Increases the toxicity of:
* Caffeine;
* Cyclosporine;
* Digoxin;
* Theophylline;

Note:
* Digoxin levels should always be monitored;
* If it is necessary to take antacids always have them 2-4 hours  before or after taking Fluoroquinolones;
* The effects of anticoagulants may be increased;

During Pregnancy
Ciprofloxacin is contraindicated for pregnant and lactating women

Caution
Dosage should be adjusted in renal function impairment * ;
* Superinfections may occur with prolonged or repeated therapy;
* The addition of proteolytic enzymes to antibiotic treatments has been shown to improve the effectiveness of the antibiotics;

Follow-up
An examination should be carried out 7 days after starting treatment.  If there is no obvious improvement several possibilities should be considered:
* Fluctuant lymphadenopathy (swelling and inflammation of the lymph glands) takes longer to heal than ulcers;
* Large ulcers take more  time to heal than small ulcers ;
* The course of antibiotics was not adhered to properly ;
* The H ducreyi strain may be resistant to the prescribed antibiotic;
* The person may have HIV making healing slower;
* The presence of another STI or illness;

In HIV-positive patients:
* Cure rates using standard antibiotic treatments are lower than in the general population;
* Longer treatment courses are usually necessary;

Naturopathic Treatments
* Abstinence from sexual activity while healing from the bacterial infection;
* To fortify the immune system to increase its ability to fight infection and heal;
* Direct, local anti-microbial applications;
* Chancroid can be difficult but not impossible to cure with natural treatments if you are consistent and patient;

Dietary Recommendations
Include:
* essential fatty acids, such as olive oil, nuts;
* fish and poultry;
* flax seed,  (linseed) oil;
* fresh fruits and vegetables;
* organic foods where possible;
* plenty of fresh water ( drink as much as possible);
* whole grains;

Avoid:
* alcohol;
* carbonated beverages;
* dairy products ;
* fruit juice;
* refined white flour, such as pasta, bread, desserts;
* sugar;

Nutritional Supplements
Proteolytic enzymes:
* Bromelain 400mg;
* Wobenzyme N five tablets three to four times a day away from meals;

and

* Vitamin C 1,000 mg three times a day with meals ;
* Zinc 30 mg daily;

Herbal Treatment
* Goldenseal (Hydrastis canadensis), strong infusion or poultice applied locally to sores;
* Goldenseal (Hydrastis)/Vitamin A suppository;

Other Treatments
* Warm sitz baths with several drops tea tree oil (Melaleuca alternifolia) added;
* Vaginal douche using one or both of the following herbs which have potent anti-microbial properties:
* Goldenseal (Hydrastis canadensis);
* Oregon Grape Root (Mahonia aqjuifolium);

Prevention

Risk Factors
* Douching or urinating after sex does not prevent STIs;
* Exposure of skin and mucus membranes with a high risk partner;
* If there are any signs or symptoms of chancroid abstain from sex until the infection is cured;

Help Factors
* Carefully washing the genitals with antibacterial soap immediately after sex;
* Limit one's sexual relationship to a single, uninfected partner;
* Practice safe sex;
* Use latex condoms or gloves put on before sex and disposed of responsibly immediately after sexual contact;

Other Precautions
* Notify all sexual contacts immediately so they can obtain examination and treatment;
* Patients should be tested for syphilis and retested 3 months later if initial test result is negative;
* Testing should be repeated 3 months later if initial test result is negative;
* Visit your local STI clinic, hospital,  doctor or urologist immediately if you have come in contact with chancroid;

Prognosis

Chancroid does not seem to have any adverse effects on pregnancy or the fetus

Complications
* Balanoposthitis, inflammation and partial loss of tissue, particularly of the glans, penis and prepuce, may occur ;
* Buboes may rupture  taking months to heal completely;
* Fistulous tracts, abnormal tube-like passages within the body tissues, may form;
* Phimosis, tightness of the foreskin;
* Scarring from extensive infection or from burst buboes may occur;
* Untreated chancroid often results in ulcers occurring on the genitals, which can persist for weeks or months;

Risk Factors
* People with open chancroid sores are especially vulnerable to other STIs;
* Re-infection can occur immediately after cure as the body does not build up any natural resistance;

In less than 10% of  cases sores may return and these may be caused by:
* Improper use of medication;
* Incomplete cure;
* Re-exposure to the bacteria through recently healed skin;
* Weakened immune system;

Note
It has been found that the genital ulcers of chancroid have:
* been associated with the sexual transmission of the HIV virus;
* occurred as outbreaks in populations with a high incidence of HIV-1 infection;

Related topics
* Sexual Health Advice & Leaflets