Chancroid

Diagnosis

Chancroid, caused by Haemophilus ducreyi, is the most common STI worldwide, affecting men three times more often than women. The initial lesion at the site of inoculation is a vesicopustule that deteriorates to form a painful, soft ulcer with a friable base covered with a gray or yellow purulent exudate and a shaggy, undetermined border. It is associated with inguinal adenopathy that is typically unilateral, tender, and erythematous that may become fluctuant and fistulize. Four criteria should be considered to corroborate the diagnosis of chancroid: (1) presence of one or more painful ulcers, (2) presence of regional lymphadenopathy, (3) a negative Treponema pallidum evaluation or negative serologies at least 1 week after symptoms begin, and (4) a negative HSV culture from the ulcer exudate.1 HIV and syphilis screening should be done at the time of diagnosis and 3 months after treatment if initially negative.

Culture for Haemophilus ducreyi is recommended by the CDC to confirm diagnosis, but requires special media that is not widely available. Gram-stain of a specimen from the undermined edge of the ulcer may identify the gram-negative streptobacilli. PCR assays, available through commercial agencies are sensitive and specific although no PCR test is currently FDA approved.

Treatment

Single-dose treatments consist of azithromycin 1 g orally or ceftriaxone 250 mg intramuscularly. Alternative regimens are listed in Table 25.2. Resistance to ciprofloxacin and erythromycin has been reported in some regions. Ciprofloxacin is contraindicated during pregnancy and lactation.

Subjective improvement should be noted within 3 days and ulcers generally heal completely in 1–2 weeks. Healing may be slower in uncircumcised men with ulcers below the foreskin and in patients with HIV.13 Patients should be reexamined in 5–7 days and sexual partners should be examined and treated if sexual relations were held within the 2 weeks prior to or during the eruption of the ulcer.Symptomatic relief of ingui-

Syphilis

Diagnosis

Syphilis is caused by a spirochete, Treponema pallidum. Primary syphilis is characterized by a single painless, indurated ulcer that appears about 3 weeks after inoculation and persists for 4–6 weeks. The ulcer is usually found on the glans, corona, or perianal area on men and on the labial or anal area on women. It is often associated with bilateral, nontender inguinal or regional lymphadenopathy. Because the ulcer and adenopathy are painless and spontaneously heal, primary syphilis often goes undetected.

Latent syphilis is defined as seroreactivity with no clinical evidence of disease. Early latent syphilis is latent syphilis acquired within the past year. All other latent syphilis is either referred to as late latent syphilis or latent syphilis of unknown duration.

Secondary syphilis usually develops 4–10 weeks after the ulcer but may present as long as 2 years later. Secondary syphilis manifests with mucocutaneous, constitutional and parenchymal signs and symptoms. Early manifestations frequently include a generalized nontender lymphadenopathy and maculopapular rash on the trunk and arms. After several days or weeks, a papular rash may accompany the primary rash. These papular lesions, commonly seen on the palms and soles, are associated with endarteritis and may become necrotic and pustular. The papules may enlarge and erode to produce condyloma lata which are exceptionally infectious.

Approximately one-third of untreated patients will develop tertiary syphilis. It is very rare in industrialized countries,except for occasional cases reported in HIV patients. Aortitis, meningitis, uveitis, optic neuritis, general paresis, tabe dorsalis, and gummas of the skin and skeleton are just some of the sequalae associated with tertiary syphilis.

Neurosyphilis can occur at any stage of syphilis. Syphilitic uveitis or other ocular manifestations are frequently associated with neurosyphilis.A patient with clinical suggestion of neurologic involvement should have a cerebrospinal fluid examination.

Dark-field microscopy and direct fluorescent antibody (DFA) tests can be performed on specimens obtained from primary or secondary lesions.