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Chapter 202

Chancroid
Stephan Lautenschlager

ETIOLOGY AND PATHOGENESIS


Historical Aspects
Chancroid, or soft chancre (ulcus molle), was first
distinguished from syphilis by Basserau in France
in 1842. The causative bacillus was discovered and
described by Ducrey in 1889, a bacteriologist at the
University of Naples. Unna described the histology
of the chancroidal ulcer and found the chains of
Gram-negative rods in the lesion. It is still unclear
who was the first to culture Haemophilus ducreyi. In
his review, Albritton23 credited Himmel (1901) with
the first convincing isolation of H. ducreyi, but other
authors in the same period also claimed priority.

Taxonomy
H. ducreyi is a Gram-negative, facultative anaerobic coccobacillus that requires hemin (X factor) for
growth. The organism is small, nonmotile, and nonspore-forming and shows typically streptobacillary
chaining, especially in culture. The exact taxonomy
is still controversial. The current classifications list
H. ducreyi as a true Haemophilus species. However,
studies of DNA homology and chemotaxonomy
demonstrate substantial differences between H. ducreyi and Haemophilus species. H. ducreyi will likely
be reclassified in the future, but this issue awaits
further studies.23,24

Biochemistry
H. ducreyi has few distinguishing biochemical
features. Nitrate reduction is a characteristic of the
genus. All reported strains are oxidase-positive
and catalase-negative and have a broad range of
phosphatase activity. The alkaline phosphatase
reaction is used in its identification.23 Differentiation
from other hemin-requiring strains of Haemophilus
is made by the lack of requirement for nicotinamide
adenine dinucleotide (NAD, V factor) and its failure
to produce hydrogen sulfide, catalase, or indole.23,25

Growth Requirements
H. ducreyi is a fastidious bacillus. In order to get
optimal rates of positive cultures, Nszane et al26 recommend the use of two media simultaneously: (1)
gonococcal agar supplemented with bovine hemoglobin and (2) Mueller-Hinton agar supplemented
with chocolate horse blood, each with 5% fetal calf
serum and vancomycin. Growth is best at 30C33C
(86F91.4F) in a water-saturated atmosphere.

Genetics and Virulence


The H. ducreyi genome is being cloned. H. ducreyi
shares a significant gene pool with members of
the Pasteurellaceae and the Enterobacteriae. The
core plasmid conferring ampicillin resistance in H.
ducreyi is found in other species of Haemophilus
and Neisseria.23 -Lactamase production is mediated by plasmids (5,000 and 5,700 kDa) identical to
the two types of Neisseria gonorrhoeae -lactamase
plasmid. A 3,000- and 3,200-kDa plasmid mediating
-lactamase production has also been reported.27
The reassortment of the different plasmids in
various isolates can be used as a partial typing
system. Isogenic mutants of H. ducreyi now can be
constructed and the virulence properties of specific
mutants can be determined. An isogenic hemoglobin receptor-deficient mutant of H. ducreyi was
reported that showed an attenuated infection in a
human model.28
Three major problems seem to be important in
the still incompletely understood pathogenesis of H.
ducreyi infection: (1) the adherence to the epithelial
surface, (2) the rate of exotoxins (e.g., cytolethal distending toxin),29 and (3) the resistance to the host
defense mechanism. Various other virulence factors
(e.g., fibrinogen-binding lipoprotein and other
binding proteins) are described.30,31 Many questions
about pathogenesis are still unclear, but a human
model of H. ducreyi infection has provided more
detailed experimental analyses of the interactions
between humans and H. ducreyi than is available for
most bacterial infections.32

LABORATORY TESTS
Bacterial culture of H. ducreyi currently remains
the main tool for the diagnosis of chancroid in
the clinical setting. However, the advent of more
sensitive DNA amplification techniques has demonstrated that the sensitivity of culture of H. ducreyi
reaches only 75% at the best.3537 The bacillus will

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298 Chapter 202: Chancroid

survive only 24 hours on a swab unless refrigerated. Swabs from the purulent ulcer base should be
inoculated directly to appropriate culture medium
since no satisfactory transport system is available.38
The simultaneous use of two primary isolation
media from a nutritionally rich agar base supplemented with hemoglobin and serum are recommended for high culture sensitivity.26 Small, nonmucoid, yellowgray, translucent colonies appear in
24 days after inoculation. Typically, these colonies
remain intact when they are pushed across the agar
surface. The identification of H. ducreyi is performed
following the recommendations of Lubwama,39
demonstration of hemin requirement, oxidase and
catalase test, -lactamase test, hydrogen sulfide
(H2S), and indole activity. Testing of antibiotic
susceptibility is recommended because clinically
significant antimicrobial resistance of H. ducreyi has
become common.
Direct examination of clinical material by Gram or
Giemsa stain may be helpful, but reported sensitivity and specificity values are low, 10%63% and
51%99%, respectively.40 The bacilli are usually
found in small clusters or parallel chains of two or
three organisms streaming along strands of mucus.
This pattern has been described as a school-of-fish
or railroad-track appearance (eFig. 202-4.1). This
arrangement, said to be characteristic of H. ducreyi,
is nevertheless not pathognomonic, because most
genital ulcers have a polymicrobial flora. Cotton
or calcium-alginate swabs are recommended for
specimen collection. Some authors do not recommend direct microscopy in the routine diagnosis of
chancroid.23,37,40

Polymerase chain reaction (PCR) procedures with


different primers showed superior sensitivity for
the diagnosis of chancroid compared to bacterial
culture.40 A multiplex PCR (M-PCR) assay has been
developed by Roche Products for the simultaneous
amplification of DNA targets from H. ducreyi, Treponema pallidum, and herpes simplex types 1 and 2,43
which seems to be a particularly attractive diagnostic tool in the investigation of patients presenting
with genital ulcers. M-PCR has a resolved sensitivity
and specificity for H. ducreyi of 98.4% and 99.6%,
respectively.43 Recently, a multiplex real-time PCR
provided sensitive, rapid, and reproducible results
in a trial in a rural African field site.44 None of these
PCR-based methods are commercially available yet,
but such testing can be performed by commercial
laboratories that have developed their own PCR
test. In resource poor settings where diagnostic
facilities are not readily available, the World Health
Organization advocates the use of a syndromic
management approach for patients with genital
ulcer disease.

Characteristic histological features with three


vertical arranged zones (superficial necrotic zone,
beneath a zone of new blood vessel formation, and
a deep zone consisting of dense lymphocytic and
plasma cell infiltrate) have been described in chancroid,41 although tissue biopsy is not a recommended diagnostic method. Histological examination
may be useful as a means to exclude malignancy in
nonhealing or atypical ulcers.40
Many attempts have been made to develop serological tests for chancroid. Due to limited sensitivities for detection of circulating antibodies to H.
ducreyi, serology has currently limited usefulness
in the routine diagnosis of chancroid infection but
may be useful in population-based epidemiological research as a screening method for past infection.40,42

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