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Objectives: The goal of this study was to identify the causes and factors associated with genital ulcer disease (GUD) among patients attending a sexually transmitted disease (STD) clinic in Paris., Methods: This study was a prospective investigation of GUD cases. Data were collected from 1995 to 2005. In each case, a Dark Field Examination (DFE), Gram stain, inoculation onto Thayer Martin agar, Columbia agar and chocolate agar with 1% isovitalex and 20% fetal calf serum, PCR Chlamydia trachomatis (Amplicor Roche), culture for herpes simplex virus (HSV) on MRC 5 cells and PCR HSV (Argene Biosoft) were obtained from the ulceration. First Catch Urine (FCU) PCR for Chlamydia trachomatis and syphilis, HIV, HSV, and HBV serologies were also performed., Results: A total 278 cases of GUD were investigated, 244 (88%) in men and 34 (12%) in women. Primary syphilis accounted for 98 cases (35%), genital herpes for 74 (27%), chancroid for 8 (3%), other infections for 12 (5%). In 91 (32%) patients, no identifiable microorganism was documented. Primary syphilis was more prevalent in MSMs (P < 0.0001), while genital herpes and chancroid were significantly associated with heterosexuality (both P < 0.0001). A high level of HIV infection (27%) was found, particularly in patients with primary syphilis (33%). In the univariate analysis, no statistical difference was found between syphilis and herpes according to clinical presentation, pain being the only item slightly more frequent in herpes (P = 0.06). In the multivariable model syphilis was associated with being MSM (OR: 51.3 [95% CI: 14.7-178.7], P < 0.001) and with an ulceration diameter >10 mm (OR: 9.2 [95% CI: 2.9-30.7], P < 0.001). Genital herpes was associated with HIV infection in the subgroup of MSWs (OR: 24.4 [2.4-247.7], P = 0.007). We did not find significant differences in the clinical presentation of the ulcers according to HIV status., Conclusion: The profound changes of the epidemiology of GUD during the decade, due to disappearance of chancroid and reemergence of infectious syphilis have led to a new distribution of pathogens, genital herpes, primary syphilis and GUD from unknown origin, accounting each for one third of cases. No clinical characteristic is predictive of the etiology, underlining the importance of performing a thorough microbiologic evaluation. Close association with HIV is still a major public health problem.

Background: Naturally occurring chancroid is usually more prevalent in men than in women., Goal: To examine whether there were gender differences in susceptibility to Haemophilus ducreyi infection by analyzing the papule and pustule formation rates for men and women who were experimentally inoculated with Haemophilus ducreyi., Study Design: Ninety volunteers were included in the analysis. A total of 189 sites were available for estimation of the papule formation rate, and 166 sites for estimation of the pustule formation rates using logistic regression modeling., Results: Although there were no gender differences in papule formation rates, the women had significantly lower rates of pustule formation than the men after adjustment for the estimated delivered dose., Conclusions: In women the disease will resolve and not progress to the pustular stage of disease as often as in men. The high male-to-female ratio in naturally occurring chancroid may in part reflect biological differences in gender susceptibility to disease progression, although the mechanisms responsible for this difference are unclear.

Background and Objectives: Chancroid is endemic in sub-Saharan Africa and enhances the sexual transmission of the human immunodeficiency virus Type 1 (HIV-1). Azithromycin is an orally absorbed macrolide antibiotic that is active against Haemophilus ducreyi, the causative agent of chancroid, and has pharmacokinetic properties that are suitable for single dosing., Study Design: In a randomized single-blinded study of 127 men presenting to a referral STD clinic with culture proven chancroid, we compared the efficacy of azithromycin, administered as a single 1 g dose, with erythromycin 500 mg given 4 times daily for 7 days., Results: Cure rates were 89% (73 of 82) in the azithromycin group and 91% (41 of 45) in the erythromycin group. A failure to respond to treatment was associated with HIV-1 seropositivity and a lack of circumcision. Both regimens were well tolerated., Conclusions: Azithromycin, given as a single 1 g oral dose, is an effective treatment for chancroid in men, and offers major prescribing advantages over erythromycin.

Background and Objectives: A better knowledge of gross and microscopic features in chancroid are important in this increased frequency disease., Study Design: Two biopsies were taken from each one of 200 culture-proven cases of chancroid, and studied through different stains., Results: The ratio male/female was 15.7/1, and adenopathies were found in 87%. Biopsies showed edema, lymphohistiocytic inflammation and fibrinoid vasculitis, as well as the presence of numerous eosinophils and Russell bodies., Conclusion: Biopsy should be considered as an important tool for the diagnostic of chancroid.

Background and Objectives: Haemophilus ducreyi, the causative agent of chancroid is a fastidious organism difficult to culture and identify. Consequently, culture is an insensitive method for diagnosis. The polymerase chain reaction (PCR) offers a sensitive and specific nonculture method for the detection of bacterial pathogens., Study Design: A polymerase chain reaction (PCR) assay was developed to detect the presence of Haemophilus ducreyi. A pair of primers was selected from sequences of an anonymous fragment of DNA cloned from H. ducreyi. The primers were tested in amplification reactions with both purified DNA and lysed organisms for their ability to detect H. ducreyi, and with DNA from a variety of different bacteria for their specificity. The utility of the primers for the detection of H. ducreyi in samples taken from genital ulcers was also tested and compared with culture., Results: PCR was positive for 62% of the specimens that were culture-positive, however, PCR was also positive for 49% of the culture-negative specimens. Comparison of specimens that were dark field positive for T. pallidum and PCR-positive with those that were culture-positive for herpes simplex virus and PCR positive suggested that PCR was giving true and not random positive results. Additional studies demonstrated that the failure of PCR to detect H. ducreyi in all of the culture-positive specimens probably resulted from inhibitors of the Taq DNA polymerase that were present in the nucleic acids extracted from the clinical specimen., Conclusion: PCR should be a useful method for the detection of H. ducreyi in genital lesions, especially where culture sensitivity is poor. However, the presence of unidentified Taq polymerase inhibitors in some ulcers specimens require the development of improved methods for specimen handling.

Fifty patients with lesions characteristic of chancroid were enrolled in an open-label prospective study to examine the efficacy of a single 2-gm dose of spectinomycin for treatment of chancroid. Only those patients (41 men; aged 18 to 49 years) with positive culture results for Haemophilus ducreyi were included in the analysis. Patients each received a single 2-gm dose of spectinomycin intramuscularly. The recovery process began on the third day of follow-up, as evidenced by the occurrence of epithelialization and a decrease in inflammation. By the seventh day after treatment, only one patient had ulcers; 40 patients experienced eradication of all ulcers (P less than 0.0001). The condition of nodes affected by infection also indicated efficacy of treatment (P less than 0.01); only one patient still had a swollen node by the fourteenth day after treatment. Of the 41 patients, 37 (90%) had negative culture results for H. ducreyi on the third day after treatment. Only 4 patients (10%) required a second dose of spectinomycin on the seventh day to affect a cure. Treatment with spectinomycin resulted in a 98% cure rate 14 days after treatment. The minimum inhibitory concentration (MIC) of spectinomycin was 1 microgram/mL to 3 micrograms/mL in the 15 strains studied. The drug was well tolerated and no adverse reactions were reported. It is concluded that a single 2-gm dose of spectinomycin is a safe and effective alternative drug for treatment of chancroid.

Carriage of Haemophilus ducreyi has not been adequately investigated in men, and its role in urethritis is unknown. In this study 456 men with H. ducreyi-culture positive genital ulcers were investigated. Among these men, 16 (3.5%) had urethritis. H. ducreyi was isolated from the urethra of nine men (1.9%). Of 57 men who had chancroid but not urethritis, none had H. ducreyi isolated from the urethra. Of 106 patients presenting with only acute urethritis, H. ducreyi was found in one. We conclude that H. ducreyi is responsible for acute urethritis in men, but that it rarely, if ever, can be cultured from the urethra of men with chancroid who do not have symptomatic urethritis.

The rates of isolation of Haemophilus ducreyi from patients with presumed chancroid has been low, and improved cultural techniques are required. We determined the isolation rates of H. ducreyi from 38 patients with clinical chancroid and compared gonococcal agar supplemented with bovine hemoglobin to Mueller-Hinton agar supplemented with chocolated horse blood, each with and without 5% fetal calf serum. The rate of isolation and the qualitative and quantitative growth of strains was best on gonococcal agar with added fetal calf serum (GC-HgS). However, three strains were isolated only on Mueller-Hinton base (MH-base). GC-HgS was compared with MH-HB for the isolation of H. ducreyi from 201 patients with clinical chancroid. Seventy-one percent of cultures were positive on GC-HgS, and 61% were positive on MH-HB (P less than .005); however, 10% of cultures were positive only on MH-HB. The use of the two media together increased the yield of positive cultures to 81%. Thus maximal rates of isolation of H. ducreyi from clinical specimens requires the use of two media, GC-HgS and MH-HB.

In October 1982, penile ulcers were identified in 248 (19%) of 1282 men at Bangrak Hospital, Bangkok, Thailand. The etiology of the ulcers was determined for 120 (48%) of these patients. Haemophilus ducreyi was isolated from 45 (38%), herpes simplex virus from 14 (12%), and Neisseria gonorrhoeae from two (2%) of 120 patients. Syphilis was detected in one patient. Two patients had both H. ducreyi and herpes simplex virus isolated from the same ulcer. Thirty-five per cent of patients had a single ulcer, 56% had two to four ulcers, and 9% had more than four. Ulcers were located on the prepuce or coronal sulcus (69%), frenulum (18%), shaft (9%), and glans (4%). Inguinal adenopathy was present in only 11% of patients. H. ducreyi infection was diagnosed by gram stain in 28 (62%) of 45 patients from whom H. ducreyi was isolated and in only one of 75 patients from whom H. ducreyi was not isolated. Of the 45 isolates of H. ducreyi, 42 (93%) were isolated with use of media containing horse blood and 34 (76%) with use of media containing rabbit blood.

Haemophilus influenzae was isolated from the urethra of three of 85 men attending a sexually transmitted diseases clinic. These isolates of H. influenzae were nonencapsulated; one was biotype III, and two were biotype IV. Haemophilus parainfluenzae was isolated from the urethra or coronal sulcus of five men; three isolates were biotype II, and two were biotype III. Neither H. influenzae nor H. parainfluenzae was isolated from the genital secretions of 84 women. Haemophilus ducreyi and Haemophilus equigenitalis (contagious equine metritis bacterium) were not isolated from any of the 169 patients.

The authors conducted a double-blind randomized clinical trial comparing single-dose cefotaxime (1 g im) plus daily placebo injections with cefotaxime (1 g im on each of three days). Each regimen was given with probenicid (1 g orally) for the treatment of chancroid. Twenty Haemophilus ducreyi culture-positive men received the single-dose cefotaxime regimen; in eight patients ulcers or buboes failed to respond to therapy. Nineteen H. ducreyi culture-positive men received cefotaxime on each of three days; H. ducreyi was eradicated from all patients, but one had a continuing ulcer and another had a bubo that failed to respond. Thus cefotaxime (1 g im daily for three days) plus probenicid (1 g orally) is effective therapy for chancroid. The lack of efficacy for chancroid of the single-dose cefotaxime regimen is surprising, given the remarkable susceptibility of H. ducreyi to cefotaxime; presumably the half-life of cefotaxime is too short for predictable eradication of H. ducreyi from the ulcer with a single-dose regimen.