Chancroid Detected by Polymerase Chain Reaction -- Jackson, Mississippi, 1994-1995

Chancroid is a sexually transmitted disease (STD) caused by infection with Haemophilus ducreyi and is characterized by genital ulceration. Chancroid is underreported in the United States (1), reflecting, in part, difficulties in diagnosis because of clinical similarities between chancroid and other ulcerative STDs. In addition, laboratory confirmation by culture is 53%-84% sensitive and often is unavailable in clinical settings (2). In September 1994, clinicians at the District V STD clinic of the Mississippi State Department of Health (MSDH) in Jackson reported examining patients with genital ulcers characteristic of chancroid but lacked capacity to confirm the diagnosis. To determine the cause of the ulcers, MSDH, in conjunction with CDC, conducted an investigation of all patients with genital ulcers examined at the Jackson STD clinic during October 20, 1994-February 1, 1995. This report summarizes the findings of the investigation.

Swab specimens were obtained from the genital ulcers of all patients examined at the Jackson STD clinic. Specimens were tested at an independent laboratory using a research prototype multiplex polymerase chain reaction (PCR) assay that can amplify and subsequently detect DNA from H. ducreyi, Treponema pallidum, and herpes simplex virus (HSV) from a single swab specimen (3). All positive PCR results were confirmed by additional PCR research assays that amplify and detect different gene sequences. Serologic testing included standard human immunodeficiency virus (HIV) testing at the Mississippi State Public Health Laboratory.

During October 20, 1994-February 1, 1995, a total of 81 patients with genital ulcers were examined at the clinic. Of these, 66 (82%) were male. The median age was 33 years (range: 16 years-81 years). Of the 81 patients, 41 (51%) had H. ducreyi infection confirmed by PCR. For 33 patients, DNA sequences from H. ducreyi only were identified; for seven, DNA sequences from H. ducreyi and one other organism were identified; and for one, DNA sequences from H. ducreyi and two other organisms were identified (Table_1, page 573). For 12 (15%) patients, no etiology was identified. Of 79 patients tested for HIV antibody, eight (10%) were positive.

Because this investigation confirmed a high prevalence of chancroid among persons with genital ulcers, MSDH now recommends presumptive treatment for both syphilis and chancroid for all patients in Jackson with nonherpetic genital ulcers and for their sex partners. In March 1995, MSDH initiated statewide surveillance for genital ulcers by requesting 25 public clinics and emergency departments to record information about every patient with a genital ulcer. In addition, a case-control study is under way in Jackson to assess risk factors for chancroid, syphilis, and genital herpes. MSDH plans to examine risk and health-seeking behaviors of persons with genital ulcers and to provide additional HIV-prevention services to these persons. Reported by: RM Webb, MD, R Hotchkiss, MD, Div of Community Health Svcs, M Currier, MD, State Epidemiologist, Mississippi State Dept of Health; D Grillo, MD, P Byers, MD, D Jones, V Grant, District V Health Dept, Jackson. JB Weiss, PhD, KA Orle, MS, Roche Molecular Systems, Alameda, California. Epidemiology and Surveillance Br, Behavioral Research and Intervention Br, and Program Development and Support Br, Div of Sexually Transmitted Disease Prevention, National Center for Prevention Svcs; Treponemal Pathogenesis and Immunology Br, Div of Sexually Transmitted Diseases Laboratory Research, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: In the United States, H. ducreyi accounts for a small proportion of genital ulcers. Although the number of reported cases of chancroid has decreased every year since 1987, cases are still reported from some large urban areas. In 1994, a total of 773 cases of chancroid were reported to CDC, including 357 from New York City, 201 from New Orleans, 38 from Houston, and 36 from Chicago (CDC, unpublished data, 1995). The investigation in Jackson, Mississippi, suggests that a substantially greater number of cases of chancroid occur than are reported. Based on sensitive PCR testing, approximately half the cases of genital ulcers were found to involve chancroid. Because chancroid is difficult to diagnose by clinical and traditional laboratory means, it probably is underdiagnosed and undertreated in many set-tings (1).

Identification of chancroid is particularly important because it is the STD most strongly associated with an increased risk for HIV transmission (4,5). Without proper treatment, ulcers require longer periods to heal, thereby prolonging for patients their susceptibility to or risk for HIV transmission or acquisition.

Chancroid should be considered in the differential diagnosis of genital ulcers. Clinicians who suspect chancroid should confirm the diagnosis by culture. Assistance can be obtained from state and territorial public health laboratories or STD programs, which also can contact CDC's Division of Sexually Transmitted Diseases Laboratory Research, National Center for Infectious Diseases (fax {404} 639-3976), or Epidemiology and Surveillance Branch, Division of Sexually Transmitted Disease Prevention, National Center for Prevention Services (fax {404} 639-8610). In communities in which the prevalence of chancroid is high, patients with genital ulcers should be treated presumptively for both chancroid and syphilis, as recommended in the 1993 Sexually Transmitted Diseases Treatment Guidelines (6).

Syphilis and genital herpes, the two most common ulcerative STDs in the United States, also have been associated with an increased risk for HIV infection (7). In Jackson, a high proportion of all patients with genital ulcers tested positive for HIV antibodies. This finding underscores the need for health-care personnel in other areas to evaluate the occurrence of HIV infection among patients with genital ulcers and to target HIV-prevention services toward persons and populations with or at risk for ulcerative STDs.

References

1. Schulte JM, Martich FA, Schmid GP. Chancroid in the United States, 1981-1990: evidence for underreporting of cases. MMWR 1992;41(no. SS-3):57-61.

2. Morse SA. Chancroid and Haemophilus ducreyi. Clin Microbiol Rev 1989;2:137-57.

3. Orle KA, Martin DH, Gates CA, Johnson SR, Morse SA, Weiss JB. Multiplex PCR detection of Haemophilus ducreyi, Treponema pallidum, and herpes simplex viruses types -1 and -2, from genital ulcers {Abstract no. C-437}. In: Abstracts of the 94th general meeting of the American Society for Microbiology. Washington, DC: American Society for Microbiology, 1994.

4. Jessamine PG, Plummer FA, Achola JON, et al. Human immunodeficiency virus, genital ulcers, and the male foreskin: synergism in HIV-1 transmission. Scand J Infect Dis 1990;69(suppl):181-6.

5. Telzak EE, Chiasson MA, Bevier PJ, Stoneburner RL, Castro KG, Jaffe HW. HIV-1 seroconversion in patients with and without genital ulcer disease. Ann Intern Med 1993;119:1181-6.

6. CDC. 1993 Sexually transmitted diseases treatment guidelines. MMWR 1993;42(no. RR-14).

7. Wasserheit JN. Epidemiological synergy: interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sex Transm Dis 1992;19:61-77.

TABLE 1. Etiology of genital ulcers among patients examined at the
Mississippi State Department of Health sexually transmitted disease
clinic -- Jackson, Mississippi, October 20, 1994-February 1, 1995 *
====================================================================
Etiology by PCR                       No.     (%)
--------------------------------------------------------------------
Single infection
  Haemophilus ducreyi                  33    ( 41)
  Treponema pallidum                    8    ( 10)
  Herpes simplex virus (HSV)           18    ( 22)

Multiple infections
  H. ducreyi, T. pallidum               7    (  9)
  T. pallidum, HSV                      2    (  2)
  H. ducreyi, T. pallidum, and HSV      1    (  1)

Other
  No etiology identified               12    ( 15)

Total                                  81    (100)
--------------------------------------------------------------------
* All specimens were analyzed at an independent laboratory using
  a research prototype multiplex polymerase chain reaction (PCR)
  assay that can amplify and subsequently detect DNA from H. ducreyi,
  Treponema pallidum, and herpes simplex virus (HSV) from a single
  swab specimen (3).
====================================================================

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