Chancroid

　　Soft chancre is a sexually transmitted disease caused by Haemophilus ducreyi, characterized by acute, multiple, painful genital ulcers, with swelling, suppuration, and ulceration of nearby lymph nodes. This disease is found worldwide and is an important cause of genital ulcers, with contact with prostitutes being the main mode of transmission.

　　The root cause of soft chancre is infection with Haemophilus ducreyi, which has been found to be the causative agent of soft chancre. When through unclean sexual contact, Haemophilus ducreyi can often enter the inguinal lymph nodes through the skin and mucous membrane through minute lesions in the lymphatic vessels. And the Haemophilus ducreyi侵入人体后 can resist the phagocytosis, killing, and complement-mediated immune killing of leukocytes.

　　In real life, the main cause of soft chancre is unclean sexual contact.

　　Patients with soft chancre are not only prone to infection but also to various complications. If not discovered and treated in time, it often brings great pain to patients. So, what are the common complications of soft chancre?

　　1, Epididymo-orchitis: Also known as soft chancre orchitis or painful orchitis, 50% to 60% of patients may develop this complication within a few days to 3 weeks after onset. It is generally unilateral, with the left side more common, but it can also occur bilaterally. Initially, it presents as an inactive hard nodule the size of a broad bean, with red, swollen, and painful skin surface. It can involve multiple lymph nodes, which adhere to each other, forming large masses, with marked pain. Finally, it becomes suppurative, softens, has fluctuations, can spontaneously ulcerate, and the pus is thick, resembling cream. It is prone to溃破 forming erosive or perforating ulcers. In traditional Chinese medicine, it is called 'fish mouth'. Sinuses can form and drain spontaneously. Generally, it heals in about 2 to 4 weeks, leaving scars. Lymphadenitis is less common in female patients. Early treatment can reduce the occurrence of lymphadenitis. In recent years, due to effective treatment for the disease, this complication is rare.

　　2、炎性包茎或嵌顿包茎：因局部炎性水肿，可形成包茎，甚至造成嵌顿性包茎。

　　2, Inflammatory phimosis or phimosis: Due to local inflammatory edema, phimosis can occur, and even cause incarcerated phimosis.

　　3, Urethral fistula and urethral stricture: In the case of penile involvement, it can form destructive ulcers, and if the urethra is involved, urination can be painful, and even a urethral fistula and stricture can form.

　　5, Secondary infection by other pathogens: This disease can also be complicated with LGV, inguinal granuloma, genital herpes, etc. If there is a co-infection with Treponema pallidum, mixed chancroid can occur. At this time, chancroid occurs first, followed by the appearance of hard chancroid, usually 15-25 days after the occurrence of chancroid. In recent years, due to the widespread use of antibiotics, hard chancroid often does not occur and latent syphilis may develop. Therefore, chancroid patients should undergo syphilis serological tests 3 weeks after the onset of symptoms or 3 months after treatment. 4, Mixed chancroid: If there is a co-infection with Treponema pallidum, mixed chancroid can occur. At this time, chancroid occurs first, followed by the appearance of hard chancroid, usually 15-25 days after the occurrence of chancroid. In recent years, due to the widespread use of antibiotics, hard chancroid often does not occur and latent syphilis may develop. Therefore, chancroid patients should undergo syphilis serological tests 3 weeks after the onset of symptoms or 3 months after treatment.

　　Based on the sexual contact history before the onset of chancroid, especially the history of unclean sexual intercourse, the typical clinical manifestations and course, after a relatively short incubation period, soft and flat papules, pustules, and ulcers occur, with unilateral suppurative lymphadenitis. Direct microscopy and culture can detect Haemophilus ducreyi, and PCR can detect the DNA of Haemophilus ducreyi, thereby making a diagnosis. So, what are the typical symptoms of chancroid?

　　It initially appears as inflammatory papules in the external genitalia. After 24-48 hours, it rapidly forms pustules, and after 3-5 days, the pustules rupture to form ulcers with clear boundaries. The ulcers are round or elliptical, with jagged edges and erosion at the lower margin, and a red inflammatory halo around them. The bottom of the ulcer has a yellow lard-like pus scab, and is covered with a lot of purulent secretions. Removing the pus scab reveals bleeding, and the base of the ulcer shows abundant red gross tissue proliferation, with obvious pain and softness upon palpation, which is called chancroid.

　　The number of chancroid lesions at first is only 1-2, as they can be self-inoculated, new lesions can appear in the nearby and kissing areas. Most chancroid occurs in the external genitalia, with men more often in the coronal sulcus, prepuce, glans, and prepuce frenulum. Women often occur in the labia, vulva, posterior commissure, cervix, and vagina, but the latter's hidden location is not easy to be discovered. Lesions outside the vulva, such as fingers, lips, and tongue, can also be seen.

　　Lymphadenopathy at the site of the lesion can form ulcers within a few days to two weeks. It is more common in males. This is called a 'swelling'. Chancroid inguinal lymphadenitis is an acute suppurative condition, usually unilateral, but can also be seen bilaterally, with local redness, swelling, heat, and pain. After the swelling breaks, the ulcer presents with a fish-mouth-like outward flip, commonly known as 'fish mouth'. In recent years, due to the early use of effective treatment and the control of further infection, typical chancroid inguinal lymphadenitis has become rare.

　　Chancroid is another major sexually transmitted disease (STD) isolated from primary syphilis (hard chancre). Although the incidence of chancroid has decreased in modern times, the disease has not been eliminated. Chancroid used to be one of the top STDs, one of the three major STDs. How can we prevent chancroid in daily life? We should pay attention to the following 9 points.

　　1. The best way to prevent chancroid is not to use the same bathtub, use a separate shower; try to avoid using the sitting toilet in public restrooms; also, develop the habit of washing hands before using the toilet.

　　2. Practice safe sex by using condoms correctly.

　　3. Cultivate good hygiene habits: Keep the vulva clean and dry; wash underwear daily, using personal utensils for washing; even among family members, bath basins and towels should not be shared.

　　4. Avoid unclean sexual contact.

　　5. If there are suspicious red ulcerations around the vulva and anus, seek medical treatment promptly.

　　6. Within 10 days before the onset of symptoms, all sexual partners of chancroid patients, regardless of whether they have symptoms or not, must undergo examination and treatment.

　　7. The main method of prevention for chancroid, which is mainly transmitted through sexual behavior, is to maintain fidelity between couples, not to indulge in extramarital affairs, which can basically prevent infection.

　　8. Within 10 days before the onset of symptoms, all sexual partners of chancroid patients, regardless of whether they have symptoms or not, must undergo examination and treatment.

　　9. If there are suspicious red ulcerations around the vulva and anus, seek medical treatment promptly.

　　Patients with chancroid should undergo the following examinations:

　　1. Smear staining examination: Material can be obtained from the deep edge or base of the ulcer, first rinse the affected area with normal saline, and collect the exudate. If material is obtained by lymph node puncture, the needle should be inserted from a healthy skin area to avoid the formation of fistulas. When making a smear, the slide should be pushed from one end to the other to maintain the characteristic morphology of the bacteria. After the smear is fixed, it can be stained with Gram, Wright, Giemsa, or Pappenheim Saathof. Approximately 50% can be observed to have short, small bacilli with a blunt rounded end, about 1-2 cm long, showing diplococcal staining. Gram staining is negative, and they can be arranged in clusters or parallel groups along the mucous threads. The ulcer site often has contamination by short, small bacilli similar to Haemophilus ducreyi, but the contaminated bacteria do not have the 'school of fish' feature.

　　2.病原菌培养 可从横痃或溃疡损害处取材。常用培养基为淋球菌胎牛血清培养基、Mueller-Hinton巧克力培养基等。2h内接种，置于5％～10％二氧化碳和饱和湿度环境中，于33～34℃至少培养48h。Ducrey嗜血杆菌的菌落直径为2mm，呈光滑的半球形，黏性极强。

　　2. Pathogen culture: Materials can be taken from the chancre or ulcer lesions. Common culture media include gonococcal bovine serum broth, Mueller-Hinton chocolate broth, etc. Inoculation should be done within 2 hours, placed in an environment with 5% to 10% carbon dioxide and saturated humidity, and cultured at 33 to 34℃ for at least 48 hours. The colony diameter of Ducrey haemophilus is 2mm,呈光滑的半球形，黏性极强.

　　3. Identification test: Biochemical tests should be performed to identify the isolated Ducrey bacilli, including oxidative enzyme test and nitrate reduction test, etc.

　　4. Immunological examination: Indirect immunofluorescence test with monoclonal antibodies that react with the outer membrane components of Ducrey bacilli to detect smears of genital ulcer secretions. Enzyme immunoassay has a detection rate of 93% in patients with positive cultures, and can be used for mass screening and examination of the population.

　　Dietary taboos for patients with soft chancre

　　Reasonable health care measures are helpful for the early recovery of patients, so what should soft chancre patients pay attention to in their daily diet?Strengthen nutrition:

　　Eat more milk, eggs, fish, pork, bean products, etc., which are rich in protein and other nutritional elements, can help tissue repair, enhance the body's immunity, promote body recovery, and in addition, attention should be paid to the supplementation of vitamins and trace elements. Acute patients can also take vitamin C to enhance immunity and anti-inflammatory effects.

　　Dietary taboos:

　　Avoid spicy foods: Spicy foods include chili, ginger, scallion, garlic, etc. Excessive consumption can cause dryness and heat, causing internal organs to accumulate heat and toxins, leading to symptoms such as swollen gums, ulcers on the tongue, short and red urine, burning sensation around the anus, and itching and pain around the anus and vulva, thus aggravating the symptoms of the disease.

　　Avoid seafood: Seafood such as shrimps, mandarin fish, black fish, hairtail, yellow croaker, crabs, etc., can promote damp-heat, and eating them can worsen the itching of the vulva, which is not conducive to the regression of inflammation, so they should be avoided.

　　Avoid sweet and greasy foods: Greasy foods such as lard, pork fat, beef fat, mutton fat, butter, etc.; high-sugar foods such as candy, sweet pastries, chocolate, cream cakes, etc., these foods have the effect of promoting dampness and heat, which will increase the secretion of leukorrhea and affect the treatment effect.

　　The treatment principle of chancroid is timely, adequate, and regular medication; the sexual partners of the patients should receive examination and treatment at the same time; follow-up examination should be conducted after treatment. Sexual life should be prohibited during treatment. So, what are the common methods of Western medicine used to treat chancroid?

　　(1) General Treatment

　　1. Effective antibiotics include the erythromycin group: erythromycin, Lincocin, roxithromycin, azithromycin;

　　2. Cephalosporins: ceftriaxone sodium, etc., quinolones: ciprofloxacin, ofloxacin, moxifloxacin, etc;

　　3. Treatment Plan:

　　(1) Azithromycin 1g, single oral dose (pregnant and lactating women should use with caution).

　　(2) Ceftriaxone 250mg, single intramuscular injection.

　　(3) Ciprofloxacin 500mg, oral 2 times/d, course of treatment 3 days (not recommended for pregnant and lactating women and those of age

　　(4) 500mg erythromycin, oral 4 times/d, course of treatment 7 days.

　　(2) Local Treatment

　　1. Unbroken papules or nodules, apply ichthammol and erythromycin ointment externally.

　　2. Ulcers, flush with 1/5000 potassium permanganate or hydrogen peroxide, then apply erythromycin ointment externally. As chancre is prone to self-inoculation, local cleaning and disinfection should be done well.

　　3. Lymphadenitis; puncture should be inserted into the abscess cavity from the normal skin at a distance, and abscess fluid should be aspirated or drugs injected according to the condition.

　　(3) Management of HIV Infection

　　These patients have slower ulcer healing, a longer course of treatment is required, and short-term treatment often fails, requiring the use of two or more antibiotics in combination. When conditions permit, it is recommended to isolate Haemophilus ducreyi from the lesion for antibiotic sensitivity testing. After 3-7 days of treatment, the patient should be re-examined. If the treatment is effective, the symptoms of the ulcer will improve within 3 days, and the ulcer can be significantly healed within 7 days. Otherwise, consider: whether the diagnosis is correct, whether there is a simultaneous infection with another STD pathogen; whether there is a simultaneous HIV infection; or whether Haemophilus ducreyi is resistant to antibiotics. Generally, the healing time of ulcers is related to the size of the ulcers, and larger ulcers may take two weeks to heal.

　　(4) Surgical Treatment

　　For those with advanced stage with tissue destruction, scars, and deformities, surgical treatment can be performed. For phimosis patients, the above solution should be soaked or wetted first, and then circumcision should be performed after cure.