DIAGNOSIS AND TREATMENT OF CHANCROID
by Major M. P. Vora
Indian Journal of Medical Sciences
Volume No – 3, Number. 10 of October 1949.
Page No. 604 to 606.
Paper read before the Medical Congress held at Bombay, November 1948.
From the Department of Venereology, St. George’s Hospital, Bombay.
Immediate diagnosis of a chancroid or a soft sore by a clinical examination is impracticable. It is dangerous and at times disastrous. Diagnosis of a chancroid is arrived at by a process of exclusion and it usually takes a period of three months, which is required to exclude the possibility of syphilitic infection. In the meantime, a genital ulcer or ulcers are labelled as N.Y.D.V.S. (not yet diagnosed venereal sore), and investigations are carried out for the accurate diagnosis. Venereal sores are given topical application of normal or hypertonic saline and are subjected repeatedly to darkfield examinations for Tr. pallidum for three days. Patients are given, as a routine, two tablets of sulphathiozol O.SG. each, four to five times a day, at four hourly intervals, and copious fluids to assure normal output of urine. Blood is taken at regular intervals for serologic tests for syphilis till three months’ period has elapsed for that is the incubation time for syphilis. In chancroids, incubation period of one to three days, superficiality and multiplicity of lesions, undermined and irregular edge, loss of tissue, painless, tendency to bleed easily, absence of induration, enlarged, tender and painful inguinal lymph glands etc. are points of some value but they are not always available and are often subjected to alteration by the presence of other factors; hence they are not of material help in reaching an early diagnosis. They allow only of “presumptive diagnosis” but a definite opinion could never be expressed in any case until the twelfth week has been reached. The diagnosis of chancroid is usually based on negative results of dark-field examinations for Tr. pallidum, clinical improvement following trial of sulpha drugs and continued negativity of serologic tests for syphilis Skin tests (Auto- inoculation and Reinstierna’s test of intracutaneous injection of 0.2 c.c. of the dead suspension of Ducrey bacillus) and smears do not yield a positive diagnosis. In an effort to establish more valid criteria for identification of the disease, Heyman, Beason and Sheldon compared various diagnostic methods in 125 cases and a diagnosis of chancroid was established in 60 cases by culture, by biopsy or by both methods. Though non-specific, microscopic changes in chancroid have a histological pattern so constant that biopsy appears to be the most efficient single diagnostic procedure. A histologic diagnosis of chancroid was made in 45 of 59 cases in which biopsy was done and was confirmed by culture in 35 cases. A 3 mm. fragment of tissue from the ulcer is taken with a Gaylors forceps and the examination of sections shows three distinct zones. The surface zone or the base of the ulcer is shallow, consisting of polymorphonuclear leucocytes, fibrin, red blood cells and necrotic tissue. Below this is a fairly wide layer of edematous tissue containing chiefly endothelial cells in various stages of proliferation, many newly-formed blood vessels showing palisading and an occasional area of degeneration or thrombosis. Finally, the deeper zone shows dense infiltration by plasma cells and lymphocytes. Ducrey bacilli are at times seen. Biopsy is feasible and efficient in more advanced lesions, in which cultures or smears give poor results.
In cases of small early primary lesions, diagnosis by culture and smear is most likely to be successful. Cultures are made of all genital lesions or aspirated material from buboes on whole defibrinated rabbit blood media, and the stained smears made from the cultures after 24 to 48 hours’ incubation, are examined for Ducrey bacillus. The procedure revealed Ducrey organisms in 50 cases. Old and secondarily infected lesions often give negative cultures and smears.
Skin testing with Ducrey vaccine is of limited value. It becomes positive after about eight days of infection and remains so indefinitely. The validity of skin tests is diminished by the persistence of cutaneous hypersensitivity for years the after acute infection. One cannot be certain, therefore, whether a positive test represents the existing infection or a previous one. Positive skin tests were found in only 46 of the 60 proved cases of chancroid thus giving a percentage rate of 77.
Autoinoculation yielded 20 positive cases in 36 of the 60 proved cases of chancroid. A loopful of exudate is rubbed into a scarified area on the patient’s arm, and the area is kept covered for 48 hours. A positive reaction is shown by an appearance of small pustules or ulcers in which Ducrey bacilli could be identified and cultured from the autoinoculations. This procedure has several disadvantages and has a limited value as a method of diagnosis. Hence it cannot be recommended for general use. Besides, such a procedure is bound to cause some delay in the institution of treatment.
Smears were positive in 50% of the cases. Diagnosis of chancroid by means of direct smears is based on certain characteristics of morphology, staining and arrangement of bacilli. Positive smears usually show only a few organisms particularly in early cases. In advanced cases especially in women identification is well nigh impossible. Ducrey bacilli are characteristically short, plump, gram-negative bacilli with rounded ends, with a “closed safety pin” appearance in Pappenheim preparations due to bipolar staining. They are sometimes intracellular but more often seen outside the cells, singly or in clusters. At times alignment in long chains is noted.
Although no one method is applicable in all instances, a chancroid can be diagnosed by proper combination of diagnostic procedures in a high percentage of cases. Small early primary lesions should be submitted for culture and smear examinations. This is most likely to be helpful. In advanced lesions, biopsy and section examinations seem to be most effective. The importance of negative darkfield examination for Tr. pallidum and negative serologic test need not be stressed.
Rest in bed is to be preferred specially where the lesion has a tendency to spread and give rise to adenitis or become phagedenous. Tropical application of saline to the chancroid is both effective and useful; it not only aids healing but also facilitates detection of Tr. pallida, and early diagnosis of syphilis. Experience has proved the usefulness of administration of sulphathiozole 20 to 25 gms. in five days in chancroids, and 28 to 35 gms. in seven days in cases where buboes co-exist. Routine administration of sulphathiozole helps the lesion to heal more quickly, lessen the chances of inguinal adenitis, and reduces considerably average duration of illness and hospitalization. Local pain and tension in adenitis are relieved by frequent application of dry heat to the groin. Softened buboes are aspirated if necessary often. Incision is contra-indicated. Occasionally, 1, 2, or 3 intravenous injections of chancroid or T.A.B. (1 in 20) Vaccine, on alternate days, ½ to 2 cc, according to the individual reaction come handy in stimulating and accelerating the process of resolution and healing. Penicillin either locally or parenterally must not be used as it is likely to mask early signs of syphilis and make early diagnosis difficult or impossible.
POST-TREATMENT SURVEILLENCE- all cases should have serologic tests for syphilis at regular intervals over a period of three months. Quantitative methods of serum testing are to be preferred. Rise in the titre of the reaction suggests the presence of syphilis.