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Chancroid
Stephan Lautenschlager
Taxonomy
H. ducreyi is a Gram-negative, facultative anaerobic coccobacillus that requires hemin (X factor) for
growth. The organism is small, nonmotile, and nonspore-forming and shows typically streptobacillary
chaining, especially in culture. The exact taxonomy
is still controversial. The current classifications list
H. ducreyi as a true Haemophilus species. However,
studies of DNA homology and chemotaxonomy
demonstrate substantial differences between H. ducreyi and Haemophilus species. H. ducreyi will likely
be reclassified in the future, but this issue awaits
further studies.23,24
Biochemistry
H. ducreyi has few distinguishing biochemical
features. Nitrate reduction is a characteristic of the
genus. All reported strains are oxidase-positive
and catalase-negative and have a broad range of
phosphatase activity. The alkaline phosphatase
reaction is used in its identification.23 Differentiation
from other hemin-requiring strains of Haemophilus
is made by the lack of requirement for nicotinamide
adenine dinucleotide (NAD, V factor) and its failure
to produce hydrogen sulfide, catalase, or indole.23,25
Growth Requirements
H. ducreyi is a fastidious bacillus. In order to get
optimal rates of positive cultures, Nszane et al26 recommend the use of two media simultaneously: (1)
gonococcal agar supplemented with bovine hemoglobin and (2) Mueller-Hinton agar supplemented
with chocolate horse blood, each with 5% fetal calf
serum and vancomycin. Growth is best at 30C33C
(86F91.4F) in a water-saturated atmosphere.
LABORATORY TESTS
Bacterial culture of H. ducreyi currently remains
the main tool for the diagnosis of chancroid in
the clinical setting. However, the advent of more
sensitive DNA amplification techniques has demonstrated that the sensitivity of culture of H. ducreyi
reaches only 75% at the best.3537 The bacillus will
survive only 24 hours on a swab unless refrigerated. Swabs from the purulent ulcer base should be
inoculated directly to appropriate culture medium
since no satisfactory transport system is available.38
The simultaneous use of two primary isolation
media from a nutritionally rich agar base supplemented with hemoglobin and serum are recommended for high culture sensitivity.26 Small, nonmucoid, yellowgray, translucent colonies appear in
24 days after inoculation. Typically, these colonies
remain intact when they are pushed across the agar
surface. The identification of H. ducreyi is performed
following the recommendations of Lubwama,39
demonstration of hemin requirement, oxidase and
catalase test, -lactamase test, hydrogen sulfide
(H2S), and indole activity. Testing of antibiotic
susceptibility is recommended because clinically
significant antimicrobial resistance of H. ducreyi has
become common.
Direct examination of clinical material by Gram or
Giemsa stain may be helpful, but reported sensitivity and specificity values are low, 10%63% and
51%99%, respectively.40 The bacilli are usually
found in small clusters or parallel chains of two or
three organisms streaming along strands of mucus.
This pattern has been described as a school-of-fish
or railroad-track appearance (eFig. 202-4.1). This
arrangement, said to be characteristic of H. ducreyi,
is nevertheless not pathognomonic, because most
genital ulcers have a polymicrobial flora. Cotton
or calcium-alginate swabs are recommended for
specimen collection. Some authors do not recommend direct microscopy in the routine diagnosis of
chancroid.23,37,40