24 year-old male, presented with multiple painful genital ulcers. Herpes or chanchroid? This is a question that came up during our most recent Core Didactics.
Take a look at the pictures. Which one is which?
Herpes – caused by Herpes Simplex Virus (picture on left)
- Presentation: Papules and vesicles on an erythematous base, erode in hours to days. Vesicles usually are uniform in size; some can have umbilicated center.
- 80% primary infections have prodromes of fever, headache, malaise, and/or painful inguinal lymphadenopathy.
- Recurrent infections are milder and heal in shorter time.
- Diagnosis: clinical. If uncertain, do Tzanck test (large intranuclear inclusions) or viral culture (negative result does not mean no HSV infection as the viral shedding is intermittent).
- Treatment: to hasten recovery, not to cure. Acyclovir 400mg tid x 7-10 days in first episode, 400mg bid x 5 days for recurrent episodes.
Chancroid – caused by Haemophilus ducreyi (gram-negative bacillus)
- Presentation: painful genital ulcers and lymphadenitis. Larger than Herpes, the erythematous papule is 1-2 cm in diameter with sharp margins. In 1-2 days, the lesion becomes ulcerated pustules (not vesicles). Multiple lesions and “kissing lesions” (infection of adjacent skin areas due to autoinoculation) are frequent. Painful inguinal lymphadenopathy develops 1- 2 weeks after primary infection.
- Diagnosis: clinical. Need to exclude other diseases (HSV, syphilis, and HIV as Chancroid is a cofactor for HIV transmission.). Can swab a lesion or bubo (suppurative lymph node) but sensitivity is low.
- Azithromycin 1g PO, or ceftriaxone 250 mg IM, or ciprofloxacin 500 mg bid x 3 days, or erythromycin base 500 mg PO qid x 7 days
- I&D or aspiration of buboes is considered routine for the prevention of fistulas and secondary ulcers.
- Partners should be treated if they have had sexual contact in the last 10 days, regardless of symptoms.
So the bottom line is – Herpes are small vesicles, usually multiple. Chancroid lesions are bigger ulcers, usually single.
Painless genital ulcers…is another story for another day.