CASE OF THE MONTH
What is the probable cause of this genital ulcer? Alicia Quella, PhD, PA-C
CASE A 23-year-old man who works as a migrant farm worker presented at the ED with the chief complaint of a worsening sore on his penis. He reported a very painful lesion on the underside of his penis that started about 2 weeks ago, about 1 week after he had vaginal intercourse with a commercial sex worker. He has had two other female sexual partners in the last 6 months and did not use barrier protection regularly. The lesion started as a small group of bumps that ruptured and went on to ulcerate. The patient reported no tingling or pruritus around the lesions. He also reported tenderness and mild swelling in the right inguinal area. On review of systems he denied fever, chills, malaise, weight loss, urethral discharge, dysuria, and generalized rash. His past medical history was negative for genital ulcers, HIV, and other sexually transmitted infections (STIs). He denied illicit drug use and male sexual partners. On physical examination, the patient was a wellappearing male with a BP of 116/72 mm Hg, pulse of 70, and temperature of 98.6° F (37° C). He had an ulcerated, nonindurated 2 cm wide wet lesion with irregular borders on the underside of his external foreskin. The lesion was extremely tender to palpation. The base of the ulcer was covered with yellowish exudate and bled easily when scraped with a cotton-tipped swab. He had no urethral discharge. His right inguinal area had a lymph node that was enlarged, tender with mild surrounding erythema but no fluctuance on palpation. Bedside ultrasound of his inguinal area was negative for a fluid collection. He had no other rash, lesions, or oral thrush on examination. WHAT IS YOUR DIAGNOSIS? • syphilis • herpes simplex virus Alicia Quella is the Spokane, Wash., site director for the MEDEX Northwest PA program at the University of Washington School of Medicine. She practices emergency medicine in Spokane Valley, Wash. The author has disclosed no potential conflicts of interest, financial or otherwise. Adrian Banning, MMS, PA-C, department editor DOI: 10.1097/01.JAA.0000458871.39548.82 Copyright © 2015 American Academy of Physician Assistants
JAAPA Journal of the American Academy of Physician Assistants
Key points In the United States, genital ulcers typically are caused by herpes simplex virus, syphilis, or chancroid. Chancroid is rare in the United States but should be considered in the differential diagnosis of a genital ulcer. Coinfection with other STIs, typically syphilis or HIV, is common. Diagnostic testing for chancroid is expensive and not commonly available, but a probable diagnosis can be made based on clinical criteria.
• chancroid • methicillin-resistant Staphylococcus aureus (MRSA) OUTCOME The probable diagnosis is Haemophilus ducreyi, also called chancroid. No laboratory test was readily available for H. ducreyi and results of laboratory testing for syphilis and herpes take 48 hours. The patient was treated empirically with oral azithromycin to target H. ducreyi (a gram-negative bacillus) and IM benzathine penicillin G to treat possible syphilis. He was referred to the community health clinic for HIV testing, hepatitis B and C testing, repeat syphilis testing, and to receive follow-up and counseling. Two days later, the patient tested negative for syphilis by rapid plasma reagin, negative for herpes by polymerase chain reaction (PCR), and negative for chlamydia and gonorrhea by PCR. His superficial wound culture was negative as well. The patient was advised to abstain from sexual activity until his symptoms completely resolved. He was told to recheck with a local provider, to inform his sexual partners, and to use condoms. A recheck in the ED was suggested in 3 days but he did not return. A follow-up telephone call revealed that the lesion started to heal about 3 days after antibiotic therapy was started, and was completely resolved after about 10 days. Pain, swelling, and redness healed in the right inguinal area as well. The patient had scheduled an appointment at the community health clinic for follow-up and further STI testing, including HIV testing. www.JAAPA.com
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
63
CASE OF THE MONTH
DISCUSSION In the United States, the differential diagnosis of a genital ulcer in a patient with a history of high-risk sexual behavior is most commonly herpes, syphilis, or chancroid (although coinfections may occur). Chancroid is not commonly diagnosed in the United States and the true incidence is unknown. The CDC reported a decline in the incidence of chancroid since 1987; eight cases were reported in the United States in 2011.1 The CDC cautions that H. ducreyi is difficult to culture and most clinical settings lack the diagnostic tests for this infection.1 As a result, providers may not consider this infection in their differential diagnosis. Worldwide, chancroid is the third most common cause of genital ulceration after herpes and syphilis. The incidence appears to be declining in many parts of the developing world, including Southeast Asia and Africa.2 H. ducreyi has recently been recognized as a
About 50% of patients with chancroid develop painful, suppurative lymphadenopathy in one or both inguinal areas. causative agent of chronic skin ulceration (nonsexual, skin-to-skin transmission) in children in developing countries, specifically in the South Pacific.3 As an STI, H. ducreyi is transmitted by direct sexual contact from infectious lesions. Most patients develop one to three small papules within 4 to 7 days after exposure. These papules may progress into a pustular stage and then erode into one or more painful ulcers. Uncircumcised men tend to be more susceptible to infection.2 Ulcers are typically found on the foreskin but other parts of the penis also may be affected.2 In women, ulcers are usually located on the vulva but may be found on the cervix and perianal area.2,4 About 50% of patients with chancroid develop painful, suppurative lymphadenopathy in one or both inguinal areas.2,4 Formation of inguinal buboes may occur, requiring aspiration or incision and drainage to prevent spontaneous rupture.2,4,5 Complications of an untreated infection include scarring in the inguinal area, phimosis, and superinfection. Coinfection with other STIs is common, especially syphilis and HIV. The presence of a genital ulcer may facilitate the transmission of HIV.6 Diagnostic testing for chancroid is expensive and not commonly available. H. ducreyi may be isolated using 64
www.JAAPA.com
selective culture media under special conditions. PCR testing is more sensitive than culture but can only be performed by specialty laboratories.2,7 According to the CDC, the diagnosis of chancroid is definite if H. ducreyi has been isolated from the lesion. A probable diagnosis is made if all the following criteria are met: • The patient has one or more painful genital ulcers. • The patient has no evidence of Treponema pallidum infection by darkfield examination of ulcer exudate or by serologic testing (performed at least 7 days after onset of ulcers). • The clinical presentation is typical for chancroid. • A test for herpes performed on the ulcer exudate is negative.8 One of the following drugs may be used to treat chancroid: • azithromycin, 1 g orally in a single dose • ceftriaxone, 250 mg IM in a single dose • ciprofloxacin, 500 mg orally twice a day for 3 days (contraindicated for pregnant and lactating women) • erythromycin base, 500 mg orally three times a day for 7 days.8 CONCLUSION H. ducreyi is a rare infection in the United States, but clinicians should consider it in their differential diagnosis when evaluating a patient with a genital ulcer. Accurate diagnosis and management is important in order to monitor the prevalence of sexually transmitted illnesses and will ensure thorough reporting to the local public health department. JAAPA REFERENCES 1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2011. Atlanta, GA: US Department of Health and Human Services; 2012. 2. Lewis DA. Epidemiology, clinical features, diagnosis and treatment of Haemophilus ducreyi—a disappearing pathogen? Expert Rev Anti Infect Ther. 2014;12(6):687-696. 3. Roberts SA, Taylor SL. Haemophilus ducreyi: a newly recognised cause of chronic skin ulceration. Lancet Glob Health. 2014;2(4):e187-e188. 4. Lewis DA. Chancroid: clinical manifestations, diagnosis, and management. Sex Transm Infect. 2003;79(1):68-71. 5. Ernst AA, Marvez-Valls E, Martin DH. Incision and drainage versus aspiration of fluctuant buboes in the emergency department during an epidemic of chancroid. Sex Transm Dis. 1995; 22(4):217-220. 6. Mertz KJ, Trees D, Levine WC, et al. Etiology of genital ulcers and prevalence of human immunodeficiency virus coinfection in 10 US cities. The Genital Ulcer Disease Surveillance Group. J Infect Dis. 1998;178(6):1795-1798. 7. Bong CT, Bauer ME, Spinola SM. Haemophilus ducreyi: clinical features, epidemiology, and prospects for disease control. Microbes Infect. 2002;4(11):1141-1148. 8. Workowski KA, Berman S. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-110. Volume 28 • Number 1 • January 2015
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
What is the probable cause of this genital ulcer? Alicia Quella, PhD, PA-C
CASE A 23-year-old man who works as a migrant farm worker presented at the ED with the chief complaint of a worsening sore on his penis. He reported a very painful lesion on the underside of his penis that started about 2 weeks ago, about 1 week after he had vaginal intercourse with a commercial sex worker. He has had two other female sexual partners in the last 6 months and did not use barrier protection regularly. The lesion started as a small group of bumps that ruptured and went on to ulcerate. The patient reported no tingling or pruritus around the lesions. He also reported tenderness and mild swelling in the right inguinal area. On review of systems he denied fever, chills, malaise, weight loss, urethral discharge, dysuria, and generalized rash. His past medical history was negative for genital ulcers, HIV, and other sexually transmitted infections (STIs). He denied illicit drug use and male sexual partners. On physical examination, the patient was a wellappearing male with a BP of 116/72 mm Hg, pulse of 70, and temperature of 98.6° F (37° C). He had an ulcerated, nonindurated 2 cm wide wet lesion with irregular borders on the underside of his external foreskin. The lesion was extremely tender to palpation. The base of the ulcer was covered with yellowish exudate and bled easily when scraped with a cotton-tipped swab. He had no urethral discharge. His right inguinal area had a lymph node that was enlarged, tender with mild surrounding erythema but no fluctuance on palpation. Bedside ultrasound of his inguinal area was negative for a fluid collection. He had no other rash, lesions, or oral thrush on examination. WHAT IS YOUR DIAGNOSIS? • syphilis • herpes simplex virus Alicia Quella is the Spokane, Wash., site director for the MEDEX Northwest PA program at the University of Washington School of Medicine. She practices emergency medicine in Spokane Valley, Wash. The author has disclosed no potential conflicts of interest, financial or otherwise. Adrian Banning, MMS, PA-C, department editor DOI: 10.1097/01.JAA.0000458871.39548.82 Copyright © 2015 American Academy of Physician Assistants
JAAPA Journal of the American Academy of Physician Assistants
Key points In the United States, genital ulcers typically are caused by herpes simplex virus, syphilis, or chancroid. Chancroid is rare in the United States but should be considered in the differential diagnosis of a genital ulcer. Coinfection with other STIs, typically syphilis or HIV, is common. Diagnostic testing for chancroid is expensive and not commonly available, but a probable diagnosis can be made based on clinical criteria.
• chancroid • methicillin-resistant Staphylococcus aureus (MRSA) OUTCOME The probable diagnosis is Haemophilus ducreyi, also called chancroid. No laboratory test was readily available for H. ducreyi and results of laboratory testing for syphilis and herpes take 48 hours. The patient was treated empirically with oral azithromycin to target H. ducreyi (a gram-negative bacillus) and IM benzathine penicillin G to treat possible syphilis. He was referred to the community health clinic for HIV testing, hepatitis B and C testing, repeat syphilis testing, and to receive follow-up and counseling. Two days later, the patient tested negative for syphilis by rapid plasma reagin, negative for herpes by polymerase chain reaction (PCR), and negative for chlamydia and gonorrhea by PCR. His superficial wound culture was negative as well. The patient was advised to abstain from sexual activity until his symptoms completely resolved. He was told to recheck with a local provider, to inform his sexual partners, and to use condoms. A recheck in the ED was suggested in 3 days but he did not return. A follow-up telephone call revealed that the lesion started to heal about 3 days after antibiotic therapy was started, and was completely resolved after about 10 days. Pain, swelling, and redness healed in the right inguinal area as well. The patient had scheduled an appointment at the community health clinic for follow-up and further STI testing, including HIV testing. www.JAAPA.com
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
63
CASE OF THE MONTH
DISCUSSION In the United States, the differential diagnosis of a genital ulcer in a patient with a history of high-risk sexual behavior is most commonly herpes, syphilis, or chancroid (although coinfections may occur). Chancroid is not commonly diagnosed in the United States and the true incidence is unknown. The CDC reported a decline in the incidence of chancroid since 1987; eight cases were reported in the United States in 2011.1 The CDC cautions that H. ducreyi is difficult to culture and most clinical settings lack the diagnostic tests for this infection.1 As a result, providers may not consider this infection in their differential diagnosis. Worldwide, chancroid is the third most common cause of genital ulceration after herpes and syphilis. The incidence appears to be declining in many parts of the developing world, including Southeast Asia and Africa.2 H. ducreyi has recently been recognized as a
About 50% of patients with chancroid develop painful, suppurative lymphadenopathy in one or both inguinal areas. causative agent of chronic skin ulceration (nonsexual, skin-to-skin transmission) in children in developing countries, specifically in the South Pacific.3 As an STI, H. ducreyi is transmitted by direct sexual contact from infectious lesions. Most patients develop one to three small papules within 4 to 7 days after exposure. These papules may progress into a pustular stage and then erode into one or more painful ulcers. Uncircumcised men tend to be more susceptible to infection.2 Ulcers are typically found on the foreskin but other parts of the penis also may be affected.2 In women, ulcers are usually located on the vulva but may be found on the cervix and perianal area.2,4 About 50% of patients with chancroid develop painful, suppurative lymphadenopathy in one or both inguinal areas.2,4 Formation of inguinal buboes may occur, requiring aspiration or incision and drainage to prevent spontaneous rupture.2,4,5 Complications of an untreated infection include scarring in the inguinal area, phimosis, and superinfection. Coinfection with other STIs is common, especially syphilis and HIV. The presence of a genital ulcer may facilitate the transmission of HIV.6 Diagnostic testing for chancroid is expensive and not commonly available. H. ducreyi may be isolated using 64
www.JAAPA.com
selective culture media under special conditions. PCR testing is more sensitive than culture but can only be performed by specialty laboratories.2,7 According to the CDC, the diagnosis of chancroid is definite if H. ducreyi has been isolated from the lesion. A probable diagnosis is made if all the following criteria are met: • The patient has one or more painful genital ulcers. • The patient has no evidence of Treponema pallidum infection by darkfield examination of ulcer exudate or by serologic testing (performed at least 7 days after onset of ulcers). • The clinical presentation is typical for chancroid. • A test for herpes performed on the ulcer exudate is negative.8 One of the following drugs may be used to treat chancroid: • azithromycin, 1 g orally in a single dose • ceftriaxone, 250 mg IM in a single dose • ciprofloxacin, 500 mg orally twice a day for 3 days (contraindicated for pregnant and lactating women) • erythromycin base, 500 mg orally three times a day for 7 days.8 CONCLUSION H. ducreyi is a rare infection in the United States, but clinicians should consider it in their differential diagnosis when evaluating a patient with a genital ulcer. Accurate diagnosis and management is important in order to monitor the prevalence of sexually transmitted illnesses and will ensure thorough reporting to the local public health department. JAAPA REFERENCES 1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2011. Atlanta, GA: US Department of Health and Human Services; 2012. 2. Lewis DA. Epidemiology, clinical features, diagnosis and treatment of Haemophilus ducreyi—a disappearing pathogen? Expert Rev Anti Infect Ther. 2014;12(6):687-696. 3. Roberts SA, Taylor SL. Haemophilus ducreyi: a newly recognised cause of chronic skin ulceration. Lancet Glob Health. 2014;2(4):e187-e188. 4. Lewis DA. Chancroid: clinical manifestations, diagnosis, and management. Sex Transm Infect. 2003;79(1):68-71. 5. Ernst AA, Marvez-Valls E, Martin DH. Incision and drainage versus aspiration of fluctuant buboes in the emergency department during an epidemic of chancroid. Sex Transm Dis. 1995; 22(4):217-220. 6. Mertz KJ, Trees D, Levine WC, et al. Etiology of genital ulcers and prevalence of human immunodeficiency virus coinfection in 10 US cities. The Genital Ulcer Disease Surveillance Group. J Infect Dis. 1998;178(6):1795-1798. 7. Bong CT, Bauer ME, Spinola SM. Haemophilus ducreyi: clinical features, epidemiology, and prospects for disease control. Microbes Infect. 2002;4(11):1141-1148. 8. Workowski KA, Berman S. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-110. Volume 28 • Number 1 • January 2015
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
