Chancroid in Sheffield. A report of 22 cases diagnosed by isolating Haemophilus ducreyi in a modified medium.

The causative organism of chancroid, Haemophilus ducreyi, is generally considered to be very fastidious and its isolation, maintenance, and detailed study very demanding. In this study a modified medium was developed, which allowed the organism to be isolated more frequently than previously would have been expected. Twenty-two cases of chancroid were confirmed by the isolation of H ducreyi in 160 patients with genital ulceration examined over a one-year period. The cases were apparently unrelated, and in only five was there a history of recent sexual contact abroad. Concurrent infection with other sexually transmitted diseases was present in 18 (81.8%) patients, and in 14 (63.6%) both H ducreyi and herpes simplex virus were isolated form the same genital ulcers. Thus, these findings indicate that chancroid is underdiagnosed in England and that H ducreyi may frequently occur as a secondary invader of damaged genital skin and mucosa.     

Etiology of nonvesicular genital ulcers in Winnipeg

Twenty-eight patients with recent onset of nonvesicular ulcerative genital lesions were studied prospectively to define the microbial etiology. Causative agents identified included herpes simplex virus (HSV), Chlamydia trachomatis, Haemophilus ducreyi, and Treponema pallidum. Three women and 25 men (seven of whom were homosexual) were studied. Ten patients did not have an etiology identified. Nine patients had syphilis, six had genital herpes, one had chancroid, one had granuloma inguinale, and one had a human bite injury. Six of seven homosexual men had syphilis, as compared with one of eight heterosexual men (P less than .002). Among heterosexual men, five had atypical HSV infections, three with extensive balanoposthitis and two with chancroidal ulcers. Of the clinical characteristics examined, induration of the ulcer base and tenderness on palpation were predictive of etiology, whereas numbers of ulcers and regional lymphadenopathy were not. H. ducreyi was not a common cause of genital ulcers in Winnipeg, and it was not found as a commensal or superinfecting organism in ulcers caused by other agents.     

Clinical efficacy of antimicrobial therapy in Haemophilus ducreyi infections

Ulcerative genital disease in the United States is commonly due to herpes simplex or syphilis. Until recently, chancroid, an infection caused by the gram-negative streptobacillus Haemophilus ducreyi, was infrequently diagnosed. Continuing immigration, however, has reintroduced the disease into this country, and urban outbreaks have been associated with contact with infected prostitutes. Extensive resistance has made previous antimicrobial agents ineffective. Evaluations of multiple antibiotics and varied dosing schedules have been undertaken in an effort to circumvent this resistance. Clinicians treating patients with genital ulcerations must be aware of this disease and its geographically variable antibiotic sensitivities. Recent evidence demonstrating an association between seropositivity for the human immunodeficiency virus and ulcerative genital disease places additional importance on the timely diagnosis and appropriate treatment of chancroidal ulcers.     

Pathogenic microbial flora of genital ulcers in Sheffield with particular reference to herpes simplex virus and Haemophilus ducreyi

The pathogenic microbial flora of genital ulcers in 161 (80 men and 81 women) unselected patients was studied prospectively. In only one case was Treponema pallidum responsible whereas herpes simplex virus was considered to be the cause of 130 (80.8%) genital ulcers. H ducreyi was isolated from 46 (28.6%) patients, most commonly as a secondary pathogen in herpetic lesions. Two or more pathogens were isolated from the ulcers in 67 (41.6%) patients, and in 21 (13%) patients no pathogens were isolated. Our results indicate an urgent need for antiviral treatment to reduce the local reservoir of genital herpes, challenge traditional concepts about the prevalence of H ducreyi in Britain, and call for a reappraisal of its role in the causation of genital ulcers.     

Pathogenic microbial flora of genital ulcers in Sheffield with particular reference to herpes simplex virus and Haemophilus ducreyi.

The pathogenic microbial flora of genital ulcers in 161 (80 men and 81 women) unselected patients was studied prospectively. In only one case was Treponema pallidum responsible whereas herpes simplex virus was considered to be the cause of 130 (80.8%) genital ulcers. H ducreyi was isolated from 46 (28.6%) patients, most commonly as a secondary pathogen in herpetic lesions. Two or more pathogens were isolated from the ulcers in 67 (41.6%) patients, and in 21 (13%) patients no pathogens were isolated. Our results indicate an urgent need for antiviral treatment to reduce the local reservoir of genital herpes, challenge traditional concepts about the prevalence of H ducreyi in Britain, and call for a reappraisal of its role in the causation of genital ulcers.     

The autoinoculation test. False-positive reactions caused by herpes simplex virus

The autoinoculation test has been used as a diagnostic procedure in patients with chancroid-suspected genital ulcerations. In four of 13 patients with a positive autoinoculation test, herpes simplex virus type 2 was isolated from the primary lesions. In two of the cases this virus was also isolated from the inoculation site, and one patient developed a recurrent herpetic eruption here. Two patients were proven to have chancroid. Three of the remaining seven patients developed recurrent herpes genitalis later. It is concluded that the autoinoculation test should be avoided as a diagnostic procedure because of lack of specificity and risk of inducing recurrent herpes simplex at the site of inoculation.     

Acquisition of concomitant oral and genital infection with herpes simplex virus type 2

Primary oral and genital infections caused by herpes simplex virus type 2 were diagnosed in an 18-year-old female. A history of sexual practices was critical in determining the anatomic sites of infection. Restriction endonuclease analysis of viral DNAs helped to identify the male sexual partner from whom the virus had been acquired. He had been infected recently by a previous sexual partner but had not yet developed lesions. Clinicians should obtain a history of sexual practices from patients with newly acquired genital herpes and should advise patients with genital herpes that transmission of virus to sexual partners can occur in the absence of overt lesions.     

The role of Haemophilus ducreyi in penile ulcers in Bangkok, Thailand

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.     

The microbial aetiology of genital ulcers in black men in Durban, South Africa.

The microbial aetiology of genital ulcers was assessed in 100 black men attending a sexually transmitted disease (STD) clinic in Durban, South Africa. Forty patients harboured Haemophilus ducreyi, one hepes simplex virus, and one Neisseria gonorrhoeae. Syphilis was diagnosed in 44 patients on the basis of dark field microscopy or positive syphilis serology test results, or both. Of these 44 patients, eight also harboured N ducreyi, one herpes simplex virus. Lymphogranuloma venereum was diagnosed in one patient. No cause of ulceration could be found in the remaining 16 patients.     

Incidence of herpes genitalis in Northern Ireland in 1973-83 and herpes simplex types 1 and 2 isolated in 1982-4.

During 1973 - 83 there was a pronounced rise in the number of new cases of herpes genitalis in Northern Ireland. This study of 127 patients with herpes genitalis shows that 30% had herpes simplex virus type 1 (HSV 1) and 70% had herpes simplex virus type 2 (HSV 2) infections. Of 41 sexual contacts who attended, only seven had herpes genitalis (caused in each case by HSV 2); another patient had a history of genital lesions, and one other of oral lesions, but HSV was not isolated from either patient. None of the other sexual contacts had a history of oral or genital infection. Of 31 women with herpes genitalis who consented to undergoing cervical cytology, five had atypical changes (all had primary herpes genitalis). Of these, four were infected with HSV 1 and one with HSV 2.     

Chancroid or chancroidal ulcers

1532 cases with genital ulcers were investigated, of whom 610 presented with features suggestive of chancroid; classic, multiple lesions of chancroid were observed in 312, while its other variants, i.e. dwarf, giant and phagedaenic chancroid were also seen. In addition, 162 cases had a conspicuous morphology characterised by a single ulcer which was well-defined, soft, tender, non-indurated and had weakening edges. These were termed chancroidal ulcers. The latter had a longer incubation period of 8-11 days. Absence of lymphadenopathy was prominent in these cases. The male/female ratio was 27/1. Persons of low socio-economic status in the sexually vulnerable age-group were predominantly affected. The prepuce, coronal sulcus and glans penis were the common sites of affliction in males, while the labia minora was frequently involved in females. Due to the limited value of gram-stained smears for the detection of H. ducreyi and lack of good culture media, chancroid and chancroidal ulcers should be differentiated clinically.     

Anaerobic bacteria and herpes simplex virus in genital ulceration.

Of 91 patients with genital ulceration, herpes simplex virus was isolated from 52 (57%) and Haemophilus ducreyi from 12 (13%); none had syphilis. The difference in incidence of other aerobes in patients and controls was not significant. Anaerobes, predominantly Bacteroides spp, were isolated from a large proportion (77%) of men and women patients with ulcers but from few control men. The most common anaerobic species were B asaccharolyticus and B ureolyticus, with fewer isolates of the melaninogenicus/oralis group. The bacterial flora of herpetic and non-herpetic ulcers were similar, but Candida albicans was isolated significantly more often from non-herpetic ulcers. Anaerobic bacteria may contribute to the pathogenesis of genital ulcers.     

Urethral infection with Haemophilus ducreyi in men

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.     

Purulent penile ulcers of patients in Singapore.

In 80 patients with painful purulent penile ulcers who attended the outpatient service of Middle Road Hospital in Singapore, Haemophilus ducreyi was isolated from 18 (22%), herpes simplex virus type 2 from nine (11%), and Neisseria gonorrhoeae from eight (10%). Primary pathogens were not isolated from 45 (57%) men. Painful purulent penile ulcers were more common in uncircumcised men, and patients had often acquired the disease after sexual intercourse with prostitutes in Singapore.     

Role of type specific herpes simplex virus serology in the diagnosis and management of genital herpes

OBJECTIVES: To investigate the indications for the use of a type specific antibody test for herpes simplex virus in a department of genitourinary medicine in the United Kingdom. METHOD: Retrospective analysis of case records of 127 patients who accepted the test during a 20 month period. RESULTS/CONCLUSION: The test contributed to patient management in 79% of patients with recurrent genital ulceration of unknown cause. It was also useful for counselling a number of patients with initial episodes of disease and the asymptomatic partners of some patients when the partners were shown to possess antibodies specific to herpes simplex virus type 2. When evaluating sexual partners, the test was difficult to interpret if an isolate from the index case had not been typed. Access to viral typing may therefore be a greater priority than serological testing. As adverse psychological sequelae may follow the identification of an asymptomatic chronic infection, guidelines for the use of a type specific serological test are proposed.


     

Increasing relative prevalence of HSV-2 infection among men with genital ulcers from a mining community in South Africa

OBJECTIVES: To determine the aetiology of genital ulcer disease (GUD) and its association with HIV infection in the mining community of Carletonville, South Africa, from two cross sectional surveys of consecutive men presenting with genital lesions during October 1993 to January 1994 and July to November 1998. METHODS: A multiplex polymerase chain reaction (M-PCR) assay combined with amplicon detection was used to identify DNA specific sequences of Treponema pallidum, herpes simplex virus (HSV), and Haemophilus ducreyi. A real time PCR assay was used to differentiate between HSV-1 and HSV-2. RESULTS: M-PCR detected T pallidum, HSV, and H ducreyi in 10.3%, 17.2%, and 69.4% of 232 GUD patients during 1993-4 and in 12.4%, 36.0%, and 50.5% of 186 GUD patients in 1998. The proportion of patients with more than one agent increased significantly from 7.3% (17/232) in 1993-4 to 16.7% (31/186) in 1998 (p <0.01). HSV-2 was detected in a higher proportion of ulcer specimens from HIV infected patients than in specimens from HIV uninfected patients during both time periods (1993-4: 26.2% v 6.7%, p <0.001; 1998: 42.1% v 29.6%, p >0.09). CONCLUSIONS: Based on two cross sectional surveys, 4 years apart, chancroid remained the leading cause of GUD in men who presented at the STD clinic with genital ulcers in the mining community of Carletonville, South Africa. The relative prevalence of primary syphilis has remained low. However, HSV-2 has emerged as a more significant cause of GUD and the proportion of GUD patients infected with more than one agent also increased significantly. HSV-2 DNA was detected in a significantly higher proportion of ulcer specimens from HIV positive patients than from HIV negative patients. No association was found between HIV infection status and the relative prevalence of chancroid or syphilis.     

Genital ulcers in Kenya. Clinical and laboratory study.

Of 97 patients with genital ulcers attending a special treatment clinic in Nairobi, Kenya, 60 harboured Haemophilus ducreyi, four herpes simplex virus, and five Neisseria gonorrhoeae. Eleven patients had serological evidence of syphilis; of these one case was confirmed by darkfield microscopy. In the remaining cases no aetiological agent was identified. An enriched chocolate agar with vancomycin and serum was a useful medium for primary isolation of H ducreyi. Tetracycline was generally ineffective in the treatment of ulcers, but sulfadimidine was successful in almost 80% of cases.     

Genital ulcers in Kenya. Clinical and laboratory study

Of 97 patients with genital ulcers attending a special treatment clinic in Nairobi, Kenya, 60 harboured Haemophilus ducreyi, four herpes simplex virus, and five Neisseria gonorrhoeae. Eleven patients had serological evidence of syphilis; of these one case was confirmed by darkfield microscopy. In the remaining cases no aetiological agent was identified. An enriched chocolate agar with vancomycin and serum was a useful medium for primary isolation of H ducreyi. Tetracycline was generally ineffective in the treatment of ulcers, but sulfadimidine was successful in almost 80% of cases.     

Inapparent genital herpes simplex infection in women attending a venereal disease clinic

The purpose of this study was to determine the prevalence of asymptomatic genital infection with herpes simplex virus in women attending a venereal disease clinic in Puerto Rico. Genital samples were obtained from 123 consecutively enrolled patients. Vero cells were used for viral isolation; isolates demonstrating cytopathic effect were stored at -70 C and were typed by use of monoclonal antibodies. Herpes simplex virus was isolated from six patients, three of whom were free of any possible complaint that might be associated with a genital herpes virus infection. One patient was diagnosed as having herpetic cervicitis, and the remaining two were clinically diagnosed as well as laboratory confirmed cases of genital herpes. Virus isolated from all six women was identified as herpes simplex virus type 2. Thus the prevalence of laboratory confirmed genital herpes infection in women attending this clinic was 4.9% (6/123). Inapparent virus infection was detected in 2.5% (3/120) of the patients.     

Recurrent genital herpes in a population attending a clinic for sexually transmitted diseases.

Patients with recurrent genital herpes attending a sexually transmitted disease clinic were studied and transmission of the infection was elucidated by evaluating serostatus in their partners. Of 84 patients attending for recurrent genital herpes, 94% had a herpes simplex virus type 2 (HSV-2) infection and only 6% (5 patients) a type 1 infection. The mean age of the patients was 36 years and the duration of their infection was up to 37 years (median 4 years). In most patients the number of recurrences had not decreased between the first year and the last year. About half had experienced a more severe first episode infection. Of the patients, 64% were not aware of asymptomatic shedding and the risk of sexual transmission without clinical symptoms. Of 67 steady partners of patients with genital HSV-2, 15% had a history of genital herpes. By HSV serology, HSV-2 antibodies (indicating subclinical genital herpes) were demonstrated in more than half of the partners. The duration of the relationship or condom use did not seem to influence the frequency of transmission to the partner, which may indicate an individual susceptibility for acquiring a genital HSV-2 infection. Eleven per cent of the patients were on suppressive antiviral therapy, while 39% had no experience of antiviral therapy. Type-specific HSV serology was found to be of value in counselling partners of patients with genital herpes.