Chancroid is a sexually transmitted infectious disease, less often ‒ with contact and household interactions. Pathognomonic symptoms are considered painful, soft genital or extragenital ulcers, as well as damage to regional lymph nodes. Diagnostic methods for detecting the pathogen are bacterioscopic, cultural, molecular genetic studies. Therapeutic measures for chancroid are reduced to the appointment of antibacterial agents as etiotropic therapy, pathogenetic and symptomatic treatment.
Chancroid (venereal ulcer, mild chancre, third venereal disease) is a bacterial infection. The first description of the disease in 1887 was made by the Russian scientist O. Peterson, a more detailed description of the soft chancre belongs to dermatologists A. Ducray and P. Unna (1889-1892). The infection has become widespread in Asia, Africa, Latin America; imported cases are registered in Europe and the USA. Mostly men are affected, women act rather as asymptomatic carriers. It has been proven that infection with chancroid increases the risk of HIV infection.
Causes of chancroid
The causative agent of the disease is the bacterium Haemophilus ducreyi (Ducrey’s wand). The source of infectious agents is a sick person, or a carrier. The ways of transmission are sexual (all types of sexual contacts), contact and household, usually implemented in unfavorable living conditions. Additionally, autoinfection may occur in persons with an asymptomatic course if the rules of intimate hygiene are not followed, and treatment is refused.
Homosexuals, commercial sex workers, pregnant women, and children from dysfunctional families are highly likely to be infected. The main risk factors of chancroid:
- casual sex without the use of barrier contraception
- uncircumcised foreskin in men
- concomitant symptoms of genital infection
- allergic reactions on the skin or mucous
- membranes local administration of medications that cause irritation of the integument.
Upon contact with the skin or mucous membrane, the pathogen penetrates into fibroblasts and keratinocytes, can form extracellular colonies. Due to surface proteins and pathogenicity factors produced, bacteria attract B-, T-lymphocytes to the focus, contributing to their apoptosis. During the development process, a granulomatous infiltrate is formed from pathogens and leukocyte masses, which eventually turns into an ulcerative defect.
Spreading lymphogenically, the bacteria penetrate into regional lymph nodes, usually inguinal. Periadenitis develops, lymph nodes are soldered together. The base of the ulcer is represented by necrosis with perivascular infiltration of polymorphonuclear leukocytes, erythrocytes, fibrin. The infiltrate located deeper consists of plasma cells and newly formed blood vessels with endothelial proliferation, microthrombs.
Symptoms of chancroid
The incubation period differs among the sexes: in men it takes about 7-10 days, in women – up to three weeks. The period of absence of symptoms may be reduced if there is an immune deficiency of any nature, damage to the integumentary apparatus. Most often, the chancre is located on the genitals, but can be found in the perineum, on the inner surface of the thighs, anus, perianal region, limbs, lips, breasts and eyelids. There can be several elements.
The first signal is the appearance of a pinkish spot and edema, a slight increase and sensitivity of regional lymph nodes. Intoxication symptoms are minimal, fever is absent. A few days later, a painful nodule appears on the spot, turning into a purulent bubble, after opening which a sharply painful ulcer with high edges and purulent discharge (soft chancre) is formed. On palpation, the formation is sharply painful.
Depending on the localization, the symptoms of chancroid may include pain during urination, defecation, sexual intercourse, swelling of the labia and scrotum. Frequent purulent inflammation of the inguinal lymph nodes is accompanied by their increase, the appearance of soldered conglomerates, cyanosis of the skin and sharp soreness, chills, fever. Sometimes there is extensive destruction of the tissues of the penis with a high probability of self-amputation.
A frequent complication of chancroid is the symptoms of purulent inflammation of the lymph nodes (lymphadenitis) or blood vessels (lymphangiitis). Often there is the formation of fistulas with the release of necrotic masses. With severe edema of the foreskin in men, phimosis occurs, in which it is impossible to release the head of the penis and the outpouring of pus. Compression of the head with edematous foreskin – paraphimosis – causes gangrene with prolonged course.
The addition of other bacterial flora leads to the appearance of symptoms of urethritis, balanitis, balanoposthitis. In the case of a long period of untreated chancroid, ascending infection with Ducray bacillus together with other pathological agents can cause cystitis and pyelonephritis. In pregnant women, premature onset of labor is possible if the chancre is located in the vagina, on the cervix.
Diagnosis and treatment of chancroid is mainly carried out by dermatovenerologists. Doctors of other specialties are involved in the presence of indications. It is mandatory to examine all sexual partners of the patient, especially if there are unprotected sexual contacts, as well as persons living with the patient. Basic laboratory-instrumental and clinical data of pathology:
- Physical examination. With an objective examination, the general condition is usually not changed. The most common localization of chancre in men is the foreskin, scrotum, coronal furrow, trunk and glans penis, in women – the vestibule of the vagina, labia, clitoris. The element is a soft, painful ulcer of a rounded shape, with covered soft edges, a narrow erythematous rim along the periphery, the bottom – with a necrotic fetid exudate.
- Laboratory tests. The addition of urethritis or purulent lymphadenitis demonstrates leukocytosis, a shift of the formula to the left, acceleration of ESR, leukocyturia and erythrocyturia in general clinical samples, an increase in the concentration of CRP in a biochemical test. If a chancroid is suspected, it is recommended to conduct a blood test for the presence of antibodies to HIV, the causative agent of syphilis, as well as PCR studies for the genital herpes virus.
- Identification of infectious agents. Bacterioscopic analysis of the ulcerative contents is carried out, the biological substrate is seeded on nutrient media. The most accurate and fastest result is detected during PCR diagnostics. Serological methods are uninformative due to possible cross-reactions with other bacteria of the Haemophilus family. Histological examination of the biopsy of ulcerative edges is rarely used.
- Instrumental methods. For the purpose of differential diagnosis, radiography, computer or magnetic resonance imaging of the chest organs is performed. According to the indications, ultrasound of the bladder, scrotum, kidneys, abdominal cavity, pelvis, soft tissues and lymph nodes is prescribed. In some cases, colposcopy, colonoscopy, biopsy of affected tissues, irrigoscopy are recommended.
Differential diagnosis of chancroid is carried out with the following pathologies:
- primary syphilis (solid chancre painless);
- genital herpes, in which bubbles and erosions form;
- acute ulcer of the vulva of Chapin-Lipschutz, accompanied by severe fever, intoxication, multiple ulcers on the labia minora without enlargement of the lymph nodes;
- tuberculosis of the skin, where the elements are painless and can be on the face, trunk, accompanied by lymphadenopathy.
Treatment of chancroid
Treatment is carried out on an outpatient basis, with complications requiring surgical intervention or decompensation of chronic diseases, hospitalization is indicated. A general regime is prescribed, with severe pain – bed rest. Dietary recommendations are reduced to limiting fatty, fried foods, alcohol, increased water load in the absence of contraindications. Strict observance of hygiene rules is necessary.
Treatment with chancroid usually does not exceed 3-7 days. Since simultaneous infection with other sexually transmitted diseases often occurs, the treatment regimen includes broad-spectrum drugs. Sexual partners also receive therapeutic drugs if sexual contacts were less than 10 days before the appearance of the chancre. It is recommended to give up sexual activity for the duration of treatment. Therapy is a combination of:
- Etiotropic treatment. Antibacterial agents active against the causative agent of chancroid are drugs of the group of cephalosporins and macrolides (first line), or fluoroquinolones. However, erythromycin is recommended to be used with caution due to toxic effects.
- Pathogenetic measures. Detoxification infusion solutions, glucocorticosteroids are used in case of severe intoxication, edema. Applications with enzyme–containing ointments may be prescribed, with prolonged torpid flow – provocation by pyrogens.
- Symptomatic therapy. This includes painkillers, sedatives, desensitizing and other means. In case of attachment of a fungal or viral agent, appropriate drugs are used, with exacerbation of chronic pathologies, their symptoms are stopped.
External therapy is necessary to reduce pain, and the use of antibacterial ointments accelerates healing. Most often, chlorhexidine bigluconate, a low-concentration dimexide solution, is used in the form of lotions. In some situations, warm baths with potassium permanganate (1:5000) are allowed, as well as a helium-neon laser for rapid resorption of infiltrate, prevention of rough scarring.
Russian recommendations sometimes include physiotherapy methods aimed mainly at improving local blood flow, stimulating cellular immunity. Treatment is carried out in the absence of fever. Such procedures include microwave therapy, inductothermy, laser therapy. The use of immunostimulants and adaptogens in the treatment of chancroid symptoms is questionable and has no proven effectiveness.
40-50% of patients with chancroid have symptoms of purulent lymphadenitis at the end of the first month of the disease. Abscessed lymph nodes are opened with the subsequent installation of drains or aspirated with a syringe. With phimosis, the edematous foreskin is excised with the removal of purulent masses. Necrotizing lesions caused by the causative agent of chancroid undergo necrectomy, in advanced cases – amputation.
Studies of the effect of essential oils of cinnamon, thyme and cloves on the pathogens of chancroid in vitro have revealed a powerful bactericidal effect of these plants. Scientists consider oils to be a promising alternative to antibiotics due to their low cytotoxicity, the absence of a negative effect on microflora, in particular, lactobacilli, and the growing antibiotic resistance of microorganisms.
Prognosis and prevention
With timely detection and treatment of chancroid, the prognosis of the disease is favorable. Specific prevention (vaccination) is under active development. Non-specific measures of protection are: the presence of a permanent sexual partner, the refusal of casual sexual relations, the use of a condom, compliance with the rules of personal hygiene. Doctors should use disposable gloves when examining patients with symptoms of chancroid.