Chancroid: causes, symptoms, diagnosis, treatment

Shankroid (synonyms: the third venereal disease, mild chancroid, venereal ulcer) is found in Africa, Asia, and America. However, due to the growth of international relations and tourism, infection is possible.

Chancroid is endemic in some parts of the United States; there are also separate outbreaks of the disease. It was found that chancroid is a cofactor of HIV transmission, and a high incidence of HIV infection among patients with chancroid in the US and other countries was also reported. About 10% of patients with chancroid can be simultaneously infected with T. Pallidum and HSV.

Causes and pathogenesis of chancroid. The causative agent of chancroid is the streptobacillus Haemophilis Dukreu, described for the first time by Ferrary and simultaneously by OV Peterson in 1887, Ducrey in 1889, then N. Krefting in 1892, M. Unna in 892. Streptobacillus is a short (1 , 5-2 μm), thin (0.5-0.6 μm) in diameter with several rounded ends and a constriction in the middle of the stick. It is located singly or parallel transversely in the form of chains (5-25 rods), from which it was called streptobacillus. The causative agent in appearance looks like eight, dumbbells, rarely - a kind of cocci. At the initial stages of the disease, the rod is located extracellularly, and with late forms - intracellularly. Does not contain endotoxins and does not release toxins. The microbe quickly dies when heated (at a temperature of 50 ° C - for 5 minutes). In the pus chopsticks remain virulence up to 6-8 days at room temperature, up to 10 days - at a low temperature.

Epidemiology of the chancroid. Infection occurs through direct contact, solely with sexual intercourse. The causative agent is located on the genitals, rarely - on the inner surface of the thigh, perianal, rarely - on the cervix and vagina. Chancroid is described on the oral mucosa, fingers. Rarely the infection is transferred through objects. Men are more often ill, and women can be bacilli carriers. After the disease, immunity does not remain. The incubation period for men is 2-3 days, sometimes 2-3 pedules, for women - from 2-3 weeks to 3-5 months.

Symptoms of chancroid. At the site of the introduction of the microbe develops a small spot of bright red color. The next day a papule forms over the spot, then a bubble with transparent contents develops. The content of the bladder becomes turbid and a purulent liquid is formed. After 3-4 days, the pustule is opened and an ulcer is formed, somewhat uplifted above the level of healthy skin, prone to peripheral growth and reaching up to 1.0-1.5 cm. The ulcer is rounded, irregular, its edges are pitted, pitted, soft, with uneven soft bottom. The bottom is covered with a yellowish-gray coating. The edges of the ulcer are elevated and have an acute-inflammatory corolla. Palpator, the ulcer base has a soft consistency. Ulcers in the head groove as an exception are compacted. From the purulent discharge of the ulcer of the chancroid, streptobacilli are detected. In men, the ulcer is painful, and in women, soreness may be absent or insignificant. Ulcers can increase in number due to autoinoculation. Primary ulcer can be located in the center, and around form "child" soft ulcers. Progression stops after 2 4 weeks, purulent discharge, the number of ulcers and the inflammatory process gradually decrease, as a result of ulcers are granulated and scars are formed. Without complications, chancroid heals in 1-2 months.

In addition to the typical forms of chancroid, other atypical varieties are distinguished:

• elevated chancroid, in which the bottom of the ulcer is lifted by granulation, causing the ulcer to rise somewhat above the surface of the surrounding skin;
• serpentine chancroid, characterized by a slow peripheral growth of one of the edges of the ulcer;
• follicular chancroid, resulting from the penetration of the pathogen into the excretory ducts of the sebaceous glands or hair follicles, which leads to the formation of single and multiple nodules in the center of which are deep ulcers with a purulent discharge;
• funnel-shaped chancroid - rarely formed on the coronary furrow of the penis, it is limited, in the form of a cone with compaction, there is an ulcer in the base, and the apex penetrates into the subcutaneous tissue;
• diphtheritic chancroid, in which the ulcer is deep, the bottom is covered with a thick, dirty yellow fibrinoid bloom. It takes a long time;
• Impetigious chancroid, characterized by the appearance of vesicles, which persist for a long time. The contents are scraped, a crust is formed. After peeling off, a deep ulcer is exposed;
• Herpetic chancroid, clinically similar to simple bladderwort. Is intrinsic to autoinoculation. Develop inguinal lymphadenitis. The contents of the vesicles show streptobacilli;
• Nodular chancroid - in the base of the focus palpation of the seal;
• crack-like chancroid, characterized by the appearance of painful cracks with a pronounced reaction. It is localized on the folds of the skin;
• gangrenous chancroid, formed as a result of the penetration of anaerobic microbes and fusospirillosis. Ulcers at the same time grow peripherally, deep tissues disintegrate, resulting in ulcers with dented edges, and under them - deep strokes, which in men can lead to the destruction of cavernous bodies and, consequently, to amputation of the penis with heavy bleeding;
• phagadenic chancroid, different from gangrenous absence of the demarcation line, progression of gangrene inside and periphery. There is a chill, the body temperature rises, sometimes sepsis develops.
• mixed chancroid, which develops as a result of the penetration of streptobacillus and pale trepidemia simultaneously or sequentially. In this case, the shaikroide first appears, followed by syphilis. Education chancroid an ulcer occurs in 2-3 days, and a syphilitic ulcer - in 3-4 weeks. Detection of pathogens is important.

Complications of chancroid. Lymphangitis is a frequent complication of chancroid, as the lymphocytes of the penis back of men and labia in women are involved in the process. The vessel becomes in the form of a dense strand, not bound to the skin, going from the ulcer to the lymph nodes. The skin becomes hyperemic and swells, but dense nodules are formed. They can resolve or ulcerate.

Bubo. It is observed in 40-50% of patients. It occurs on 2-4 weeks after the penetration of streptobacillus into the regional lymph nodes, more often - into the inguinal lymph nodes. The development of bubo increases from physical exertion and from the use of cauterizing drugs. One or more lymph nodes are involved in the pathological process. With the development of periadenitis, lymph nodes can merge and form conglomerates. The skin above the node is hyperemic, edematous, morbidity is noted, the body temperature rises, and malaise occurs. Later the inflammation subsides, the center softens and the phenomena of fluctuations are formed. The skin is thinned and destroyed, a large amount of pus with an admixture of blood is released from the cavity formed, sometimes the cavity is granulated and a scar is formed. Often, the bubo turns into a large ulcer surrounded by often new screenings (chancroid bubo). At the part of victims the process proceeds sluggishly, with the formation of cold abscesses, deep, fistulous passages (a bubble bubo) are formed. After a few weeks or months after treatment, adenopathy may occur.

Phimosis. It develops due to the formation of multiple ulcers on the inner leaf of the foreskin or along its edge, which increases the penis due to swelling of the foreskin. The skin becomes hyperemic, the opening of the preputial sac narrows, with abundant purulent discharge, increased body temperature, and pain.

Paraphimosis. Develops rarely, there is a forcible wrapping of edematous foreskin for the head, which squeezes the penis in the head groove and leads to a violation of blood circulation. The head of the penis swells, increases in volume, the color becomes cyanotic, develops severe pain, necrosis of the head and foreskin can form.

Laboratory diagnostics. To detect streptobacillus, ulcers and a purulent discharge from the lymph nodes opened or unopened (buboes) are necessary. For this, the areas from which the material will be taken are applied, it is applied to the glass and stained using the Romanovsky Giemsa method or methylene blue, they are negative in Gram staining. The drug should be painted after a slight warming. With negative results, you can use the method of autoinoculation by applying pus or pieces that have been torn from ulcerative foci of necrotic tissues.

An accurate diagnosis of chancroid requires the isolation of a pure N. Ducreyi culture on a special medium that is not commercially available; even when using these media, the sensitivity of the method does not exceed 80%, and usually even lower. A probable diagnosis (for both treatment and surveillance services) can be made if one (or more) painful genital ulcer is detected in the patient, and a) there is no evidence of infection caused by T. Pallidum when examining a peptic ulcer in a dark field exudate or during serological tests for syphilis at least 7 days after the formation of the ulcer and b) the appearance and location of ulcers, as well as regional lymphadenopathy, if present, are typical for chancroid, and the test result for HSV is negative th. The combination of painful ulcers and painful palpation of lymph nodes in the groin (which are found in one third of patients) confirms the presence of chancroid, and if this combination is accompanied by suppuration of the lymph nodes, then it is almost pathognomonic. It is assumed that PCR will soon become a widely available method for the diagnosis of chancroid.

Treatment of chancroid. Use antibiotics and sulfonamide drugs. Assign azithromycin (azimed) 1.0 g orally single or ceftriaxone 250 mg IM once, or erythromycin 500 mg 4 times daily for 7 days, or ciprofloxacin 500 mg 2 times a day for 3 days.

Successful treatment of chancroid leads to cure, resolution of clinical symptoms and prevents transmission of infection to others. With extensive lesions, despite successful treatment, scars can form.

Recommended schemes

Azithromycin 1 g orally once

Or Ceftriaxone 250 mg intramuscularly (IM) once

Or Ciprofloxacin 500 mg orally 2 times a day for 3 days

Or Erythromycin basic 500 mg orally 4 times a day for 7 days

NOTE: Ciprofloxacin is contraindicated in pregnant and lactating women, as well as in persons under the age of 18.

All four schemes are effective for the treatment of chancroid in patients with HIV infection. Azithromycin and ceftriaxone have an advantage, since they can be used once. Data were obtained from different regions of the world on the isolation of several isolates with resistance to either ciprofloxacin or erythromycin.

Other observations on patient management

Treatment of HIV-infected patients and patients who have not been circumcised may be less effective than those who are not infected with HIV, or who have been circumcised. In the diagnosis of chancroid, simultaneous testing for HIV infection should be carried out. It is necessary to repeat the serological responses to syphilis and HIV infection after 3 months if the initial results of these studies were negative.

Follow-up

Patients should be re-examined 3-7 days after the start of therapy. With successful treatment, the condition of ulcers improves symptomatically within 3 days and objectively - within 7 days after the initiation of therapy. If the clinical improvement is not observed, the doctor should consider the following options: a) misdiagnosed, b) mixed infection with another STD, c) the patient is infected with HIV, d) the treatment regimen was not followed, or e) the H. Ducreyi strain, resistant to the prescribed drug. The time required for a complete cure depends on the size of the ulcer; It may take more than 2 weeks for treatment of a large ulcer. In addition, the healing process is slower in some men who have not undergone circumcision, in which the ulcer is located under the foreskin. Clinical resolution of fluctuating lymph nodes requires more time than for ulceration, and even with successful treatment, drainage may be required. Incision and draining of buboes may be a more preferable method than aspirating the contents with a syringe, because after drainage, less frequent use of any subsequent procedures is required, although aspiration is a simpler procedure.

Management of sexual partners

Persons who have had sex with patients with chancroid within 10 days before the clinical presentation of these patients should be examined and treated, even if they have no symptoms of the disease.

Special Remarks

Pregnancy

The safety of the use of azithromycin in pregnant and lactating women has not been established. Ciprofloxacin is contraindicated during pregnancy. No adverse outcome of pregnancy or development of pathology in the fetus with chancroid was reported.

HIV infection

Patients who are HIV-infected at the same time should be closely monitored. To treat such patients, longer courses of therapy may be required than those recommended in this manual. Healing of ulcers in HIV-infected patients can occur more slowly, and any treatment regimen may prove ineffective. Since the data on the therapeutic efficacy of the recommended treatment regimens for ceftriaxone and azithromycin in HIV-infected patients are limited, they can be used in such patients if there is a possibility of follow-up. Some experts suggest using a 7-day course of erythromycin to treat HIV-infected patients.

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