Abstract
A 64 year old cisgender man attended to our genito-urinary clinic with a 1 week history of a painful genital ulcer after travelling to Madagascar. On physical examination, we observed two small ulcers, each with a fibrinous base and erythematous borders, without associated lymphadenopathy. The initial diagnosis was a genital herpes outbreak. Thus, a seven-day course of Valaciclovir 500 mg twice daily orally was prescribed. An ulcer sample was collected for NAATs including C. trachomatis L1-L3, Herpes simplex virus 1 and 2, Varicella-zoster virus, Treponema pallidum and Haemophilus ducreyi. The ulcer NAATs was positive for H. ducreyi. Considering the result and the epidemiological background, diagnosis confirmed chancroid. Ceftriaxone 1 g STAT intramuscular was administered with subsequent improvement. Chancroid, caused by H. ducreyi is very rare in Europe. Its prevalence in STI clinics has varied from 0% to 0.5%. It must be suspected, especially in travellers to endemic countries in the first days of their return due to its short incubation period.
Clinical case
A 64-year-old cisgender man attended our genito-urinary clinic with a one week history of a painful genital ulcer. He had a past medical history of psoriasis treated with topical corticosteroids and a documented allergy to doxycycline. He is a man who has sex with women, with frequent trips to Madagascar where he has multiple sexual partners. In the last 3 months he reported more than ten sexual partners without consistent condom use for vaginal intercourse.
During his last trip to Madagascar, an ulcered lesion appeared on the dorsal balanopreputial region one day before returning to Spain. He attended our clinic one week later. On physical examination, we observed two small ulcers, each with a fibrinous base and erythematous borders, without associated lymphadenopathy (see Figure 1). No other cutaneous lesions were detected. Chancroid photography.
The initial diagnosis was a genital herpes outbreak. Thus, a seven-day course of valaciclovir 500 mg twice daily orally was prescribed. An ulcer sample was collected for NAATs including C. trachomatis L1-L3, Herpes simplex virus 1 and 2, Varicella-zoster virus, Treponema pallidum and Haemophilus ducreyi. Blood analysis for HIV and syphilis and urine NAATs for N. gonorrhoeae and C. trachomatis were also performed.
Follow-up and confirmation diagnosis
One week later, having completed his course of valaciclovir he re-attended for review. The two lesions still persisted with no signs of improvement. HIV and syphilis serologies were negative as were urine NAATs. The ulcer NAAT was positive for H. ducreyi. Considering the result and the epidemiological background, the diagnosis confirmed chancroid. Ceftriaxone 1 g STAT intramuscular was administered after two further confirmatory samples were taken, due to the rarity of chancroid in our setting. Both were positive for H. ducreyi. One week after treatment all lesions had resolved with no sequelae.
Discussion
Chancroid, caused by H. ducreyi is very rare in Europe. The last outbreak described was in Barcelona in 1982, during the Football World Cup. 1
More recent cases in Spain cannot be excluded, as its notification is not compulsory. Globally, a decrease in its prevalence has been observed due to syndromic genital ulcer treatment implementation. In Europe, chancroid prevalence in STI clinics has varied from 0% to 0.5% since 1990 until 2011 in six countries. 2
Chancroid must be suspected in cases of genital ulceration, especially in travellers to endemic countries in the first days of their return due to its short incubation period (three to seven days). 3
Differential diagnoses include other ulcerative sexually transmitted infections. Chancroid differs from Herpes simplex because its ulcers tend to be deeper and with an exudative base. In comparison with syphilis, chancroid is usually painful and without indurated borders; hence, why it is called a soft chancre. Lymphadenopathies are common (approximately 50% of cases), and can evolve into fistulous buboes. 3
Diagnosis is based in molecular tests (NAATs). In our setting H. ducreyi is included in a multiplex ulcer NAAT in order to avoid missing diagnoses in cases of gential ulceration. Culture is not routinely available, and antimicrobial resistances are not well known, but treatment failures to ciprofloxacin and erythromycin have been described. First line therapies are ceftriaxone and azithromycin. 3
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
