The primary lesion of chanchroid appears within 4 to 7 days of inoculation. In male patients, the primary lesion is usually on the penis; in female patients, most lesions occur in the vagina or periurethral area. Over the course of several days, the surface of the primary lesion erodes to produce an irregular ulcer, which is more likely to be painful in males than in females. The regional lymph nodes, particularly in the inguinal region, become enlarged and tender in about 50% of cases within 1 to 2 weeks of the primary inoculation. In untreated cases, the inflamed and enlarged nodes (buboes) may erode the overlying skin to produce chronic, draining ulcers. A definitive diagnosis requires the identification of H. ducreyi on special culture media that are not widely available from commercial sources; even when such media are used, sensitivity is less than 80%. Therefore, the diagnosis often is based on clinical grounds alone.
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Granuloma inguinale is a chronic inflammatory disease caused by Calymmatobacterium granulomatis, a minute, encapsulated coccobacillus related to the Klebsiella genus. This disease is uncommon in the United States and Western Europe, but it is endemic in the rural parts of certain tropical and subtropical regions. When it occurs in urban settings, transmission of C. granulomatis typically is associated with a history of multiple sexual partners. Untreated cases are characterized by extensive scarring, often associated with lymphatic obstruction and lymphedema (elephantiasis) of the external genitalia. Culture of the organism is difficult, and PCR-based assays are not widely available.
MORPHOLOGYGranulomainguinalecausesgenitalulceration,accompaniedbythedevelopmentofabundantgranulationtissue.Disfiguringscarsmaydevelopinuntreatedcases,sometimesassociatedwithformationofurethral,vulvar,oranalstrictures.Incontrastwithchancroid,regionallymphnodestypicallyaresparedorshowonlynonspecificreactivechanges.
Microscopicexaminationofactivelesionsrevealsmarkedepithelialhyperplasiaatthebordersoftheulcer,sometimesmimickingcarcinoma(pseudoepitheliomatous hyperplasia). Amixtureofneutrophilsandmononuclearinflammatorycellsispresentatthebaseoftheulcerandbeneaththesurroundingepithelium.TheorganismsaredemonstrableinGiemsa-stainedsmearsoftheexudateasminutecoccobacilliwithinvacuolesinmacrophages(Donovan bodies). Silverstains(e.g.,theWarthin-Starrystain)alsomaybeusedtodemonstratetheorganism.
LYMPHOGRANULOMAVENEREUM,CHANCROID,ANDGRANULOMAINGUINALE
LGViscausedbyC.trachomatis serotypesthataredistinctfromthosethatcausenongonococcalurethritis.LGVisassociatedwithurethritis,ulcerativegenitallesions,lymphadenopathy,andinvolvementoftherectum.Thelesionsshowbothacuteandchronicinflammation;theyprogresstofibrosis,withconsequentlymphedemaandformationofrectalstrictures.Diagnosisismadebynucleicacidamplificationtestsandserology.
H. ducreyi infectioncausesanacutepainfululcerativegenitalinfectioncalledchancroid. Inguinalnodeinvolvementoccursinmanycasesandleadstotheirenlargementandulceration.Ulcersshowasuperficialareaofacuteinflammationandnecrosis,withanunderlyingzoneofgranulationtissueandmononuclearinfiltrate.Diagnosisispossiblebycultureoftheorganism.