Chancroid -- Massachusetts

From January 8, to September 30, 1985, 53 patients with culture-confirmed or clinically suspected chancroid were treated in Boston-area sexually transmitted diseases (STD) clinics (Figure 2). In the previous 2 years, only two chancroid cases had been diagnosed in Massachusetts. The outbreak was terminated by intensive surveillance efforts, contact tracing, and antimicrobial treatment of both symptomatic and asymptomatic sex partners.

The first presumed case of chancroid occurred in a man who had recently arrived from Florida and who denied having had sexual intercourse while in Massachusetts. He presented to the Boston City Hospital STD Clinic on January 8 with a tender penile ulcer on the foreskin that had been present for 2 weeks, accompanied by swollen, tender, right-sided inguinal lymph nodes. He was treated for presumed syphilis with 2.4 million units of benzathine penicillin, administered intramuscularly. On follow-up examination 1 week later, the ulcer was unchanged, but he had developed swollen, tender, left-sided inguinal lymph nodes. Chancroid was suspected, but the patient failed to respond to oral tetracycline, 500 mg four times a day. On January 24, therapy was changed to oral erythromycin, 500 mg four times a day, with subsequent improvement.

In March, five additional males with soft, penile ulcers and tender inguinal adenopathy were seen at the Boston City Hospital and New England Medical Center STD clinics. In these cases, serologic tests for syphilis were negative, as were cultures, direct fluorescent-antibody tests, and/or Tzanck smears for herpes simplex virus. The cases were presumptively diagnosed as chancroid and responded positively to erythromycin. In early April, the Division of Communicable and Venereal Diseases, Massachusetts Department of Public Health began enhanced surveillance and case investigation after four additional similar patients were seen. By September 30, 53 patients with presumed or culture-confirmed chancroid were identified. The epidemic peaked in April/May, when 32 (60%) of the 53 chancroid patients were seen. Only four cases have been diagnosed since August 1, and three of these appear to have been contracted outside Massachusetts.

Thirty-nine (74%) of the 53 cases were in males. All the males had one or more tender penile ulcers, often with ragged edges. Tender unilateral or bilateral inguinal adenopathy occurred in 33 (85%) men, and five men developed fluctuant buboes. All 14 women had ulcers; two (14%) had asymptomatic cervical ulcers that were found only on examination; six (43%) had only perianal ulcers; and the remaining six (43%) had symptomatic vulvar ulcers. Six of the women had tender inguinal adenopathy. Before chancroid was suspected, several patients underwent surgical procedures because of inguinal adenopathy (herniorrhaphy) and erosive anal lesions (hemorrhoidectomy).

The etiology was confirmed by isolation of Haemophilus ducreyi, serology, and exclusion by laboratory evidence of other recognized causes of genital ulcers. Of 28 patients whose ulcers were cultured for H. ducreyi, four (14%) were positive. However, indirect immunofluorescence of ulcer smears using a monoclonal antibody directed against H. ducreyi, identified rod-shaped organisms typical of H. ducreyi in 15 (54%) of 28 specimens, including three of four culture-positive cases. A dot-immunobinding serologic test for H. ducreyi antibody, using an H. ducreyi outer membrane preparation as antigen, yielded positive results in nine (32%) of 28 cases. All patients were serologically negative for syphilis. No patient tested for herpes simplex virus (by culture, direct fluorescent-antibody test, or Tzanck smear) or lymphogranuloma venereum (by serology) was positive.

Prostitution appeared important in transmitting the disease. Two-thirds of the male patients had recent sexual exposure to prostitutes. Of the 14 females, eight were prostitutes, and all frequented a distinct geographic area of the city. An additional three women had sexual exposure to men known to be sexually active with prostitutes in the same geographic area.

Control measures began in mid-April, immediately after the initial recognition of cases. The sexual partners of the chancroid patients and their sexual contacts were identified, interviewed, examined, and treated (whether lesions were present or not) with oral erythromycin, 500 mg four times a day, or trimethoprim/sulfamethoxazole, two tablets twice a day, each for 10 days. Intensive efforts were made to locate, examine, and treat all prostitutes from the identified Boston area. All were treated with prophylactic antimicrobial therapy. All Massachusetts STD clinics were notified of the outbreak, and all implemented clinical protocols. A medical advisory memorandum outlining the clinical and laboratory characteristics of chancroid were distributed to neighborhood health centers, infection-control nurses, hospital emergency rooms, and private physicians in the Boston area. Reported by LM Mofenson, MD, RS Cremo, TJ Rheaume, M Ed, CW Duncan, FR Meyers, E West, Div of Communicable and Venereal Diseases, B Carlson, State Diagnostic Laboratory, Massachusetts Dept of Public Health; Sexually Transmitted Diseases Laboratory Program, Center for Infectious Diseases, Div of Sexually Transmitted Diseases, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Chancroid is an uncommon disease in the United States. In 1983, 847 cases were reported, an incidence of 0.4/100,000 (1). Ninety percent of cases were reported by four states--Florida, New York, Georgia, and California--and CDC has investigated outbreaks in three of these states (Florida, New York, and California) during the last 3 years. Nevertheless, this episode demonstrates that outbreaks may occur elsewhere. Although the origin of this outbreak is unclear, it seems likely that an individual infected outside Massachusetts was the source. The fact that three of the four patients whose chancroid occurred after August 1 became infected outside Massachusetts reinforces this suspicion.

Chancroid must be differentiated from other sexually transmitted infectious diseases with genital ulceration (syphilis, genital herpes, lymphogranuloma venereum, granuloma inguinale), but differentiation on clinical grounds can be difficult. The culture of H. ducreyi is also difficult and requires special media and personnel experienced with growing H. ducreyi. Although laboratories experienced with growing H. ducreyi have reported isolation rates as high as 80% from clinically suspected cases (2), isolation rates far less than this are generally reported. Both the recent description of a dot-immunobinding serologic test and a means to detect H. ducreyi in ulcer material by immunofluorescence offer promising aids to diagnose chancroid where culture has been unsuccessful or impossible to perform (3).

Tetracycline was formerly a preferred treatment for chancroid. However, many strains of H. ducreyi are now tetracycline resistant (4). Similarly, in some areas of the world, including the United States, increased resistance to trimethoprim has recently been described (5,6), making treatment with the synergistic combination of trimethoprim/sulfamethoxazole less reliable than before (5-7). Yet, trimethoprim/sulfamethoxazole remains reliable in areas where such resistance has not been documented. As a consequence, oral erythromycin, 500 mg four times a day, or intramuscular ceftriaxone, 250 mg, once, have recently been recommended as the preferred drugs for the treatment of chancroid (8).

The apparent successful termination of this outbreak demonstrates how promptly implemented surveillance and intervention measures can be effective in controlling outbreaks of sexually transmitted diseases. With chancroid, because asymptomatic carriage of H. ducreyi in males and females has been described (5,9,10), aggressive tracing and treatment of sex partners, whether symptomatic or not, was an integral part of this strategy.

References

1. U.S. Public Health Service. Sexually transmitted disease statistics, 1983. U.S. Department of Health and Human Services, February, 1985; issue no. 133.

2. Ronald AR, Plummer FA. Chancroid and Haemophilus ducreyi. Ann Intern Med 1985;102:705-7.

3. Schalla WO, Sanders LL, Schmid GP, Tam MR, Morse SA. Investigation of clinically suspected cases of chancroid using a dot-immunobinding assay and immunofluorescence. J Infect Dis (in press).

4. Kraus SJ, Kaufman HW, Albritton WL, Thornsberry C, Biddle JW. Chancroid therapy: a review of cases confirmed by culture. Rev Infect Dis 1982;4(S):S848-56.

5. Taylor DN, Pitarangsi C, Echeverria P, Panikabutra K, Suvongse C. Comparative study of ceftriaxone and trimethoprim-sulfamethoxazole for the treatment of chancroid in Thailand. J Infect Dis 1985;152:1002-6.

6. Schmid GP. The treatment of chancroid. JAMA (in press).

7. Naamara W, Kunimoto D, Plummer F, et al. Treatment of chancroid with enoxacin. Brighton, England: The 6th international meeting of the international society for STD research, July 31-August 2, 1985.

8. CDC. 1985 STD treatment guidelines. MMWR 1985;34(suppl 4):76S-7S.

9. Kinghorn GR, Hafiz S, McEntegart MG. Oropharyngeal Haemophilus ducreyi infection. Br Med J 1983;287:650.

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