Dr.MOHAMED NASR Lecturer Of Dermatology & Venereology VENEREAL DISEASES; OTHER THAN GONORRHEA AND SYPHILIS

1.Chancroid (soft sore). 2.Lymphogranuloma venereum. 3.Granuloma inguinale. 4.Herpes genitalis.

Definition Incubation period Clinical picture Complications Diagnosis Treatment

CHANCROID (SOFT SORE) Chancroid is an acute infectious disease of the genitalia caused by a Gram- negative bacillus, Haemophilus ducreyi.

Incubation period: days

Clinical picture: One or more small red painful papules or pustules appear at the site of inoculation and rapidly break down to form multiple rounded or oval ulcers which are: 1- Painful and have ragged edges and sloughing bases. 2- Bleed easily on touch. 3- Soft and non indurated to touch and surrounded by a red areola.

One week after the appearance of ulcer; the inguinal lymph nodes in one or both groins become enlarged and tender. The nodes tend to become matted together forming an oval mass, which is called bubo. Suppuration commonly occurs and in untreated patient the skin will break down leading to sinus formation and discharging pus.

Complications: 1- Spreading gangrene of the external genitalia. 2- Hemorrhage from an ulcer. 3- Urethral stricture. 4- Fistula, phimosis and paraphimosis. 5- Sinus from lymph nodes discharging pus.

Diagnosis: 1- Clinical picture. 2- Gram-stained smears reveal small Gram- negative bacilli frequently arranged in chains or pairs giving the appearance of a "school of fish". 3- Culture, using selective media containing defibrinated rabbit’s blood as the organism needs haematin at temperature 33°C and high humidity. 4- Serological tests. 5- Skin biopsy.

Differential diagnosis: ChancroidChancre Causative organismHaemophilus ducreyiTreponema pallidum I.P.3-7 days9-90 days Number of lesionsUsually multipleUsually single ConsistencySoftHard BaseFlat and softRaised and indurated Regional lymph nodesEnlarged, painful, matted and suppurate Enlarged, not matted, not painful and do not suppurate. V.D.R.L.NegativePositive usually after days from its appearance. TreatmentAzithromycinPenicillin

Treatment: 1- Azithromycin 1 g orally in a single dose. 2- Or Ceftriaxone 250 mg intramuscularly (IM) in a single dose. 3- Or Ciprofloxacin 500 mg orally twice a day for 3 days. 4- Or Erythromycin base 500 mg orally three times a day for 7 days.

LYMPHOGRANULOMA VENEREUM Lymphogranuloma venereum is an infectious disease, caused by Chlamydia trachomatis types L1, L2, L3 and is usually transmitted by sexual contact. Chlamydia trachomatis is no longer considered as a virus. It is now considered as bacteria and belongs to the Rickettsiae family.

Incubation period: weeks.

Clinical picture: A small papulovesicle develops turning rapidly into a transient ulcer which heals rapidly. The inguinal syndrome: the inguinal lymph nodes become enlarged and tender, then they become matted together into a sausage-shaped mass (climatic bubo). The nodes eventually break down with abscess formation and rupture of the skin leads to multiple sinuses. The inguinal ligament and the groin fold divides the glands into upper and lower groups (groove sign). These inguinal manifestations are more common in men.

Complications: 1- Rectal syndrome (much more common in females): proctatitis, rectal stricture, peri- rectal abscess, rectovesical and rectovaginal fistulae. 2- Elephantiasis: induration and slowly developing enlargement of the penis and scrotum (saxophone penis). 3- Esthiomene: edema and enlargement of the vulva associated with ulceration, fistula and scarring of the buttocks and thighs. 4- Urethral stricture and fistulae.

Diagnosis: 1- Clinical picture 2- A smear stained with Micuvali or Geimsa stain. 3- Complement fixation test. Fluorescent antibody test is more specific 4- Culture on yolk sac or tissue cultre containing cyclohexaphosphamide.

Treatment: 1- Doxycycline 100 mg orally twice a day for 21 days. 2- Erythromycin base 500 mg orally four times a day for 21 days. 3- Aspiration of fluctuant lymph nodes to avoid rupture.

GRANULOMA INGUINALE It is a chronic progressive granulomatous disease affecting the skin and S.C. tissue of the genitalia, perineum and groins. It is caused by Donovan bodies or Donovania granulomatis which are believed to be bacteria related to the klebsiella group and are called Calymatobacterium granulomatis.

Incubation period: Uncertain, it is around 50 days and may range (8-80 days).

Clinical picture: A red painless papule appears on the genitalia, in the pubic or inguinal region. It is painless and grows slowly to produce a chronic granuloma. The lesions are beefy red in color and raised above the surface. The granuloma advances slowly destroying tissue lying in its course. The regional lymph nodes are not involved (pseudo- bubo).

Complications: 1- Secondary infection. 2- Rectovaginal fistula, urethral stricture, cystitis and marked scar formation. 3- Genital edema (due to infiltration or pressure on lymphatics by the granuloma).

Diagnosis: 1- Clinical picture 2- Stained smears with wright’s or Giemsa stain will show the organisms within mononuclear cells. They appear as encapsulated rods with pink capsule and bipolar condensation of chromatin material giving the appearance of a safety pin.

Treatment: 1- Doxycycline 100 mg orally twice a day for at least 3 weeks and until all lesions have completely healed. 2- Or Azithromycin 1 g orally once per week for at least 3 weeks and until all lesions have completely healed. 3- Or Ciprofloxacin 750 mg orally twice a day for at least 3 weeks and until all lesions have completely healed. 4- Or Erythromycin base 500 mg orally four times a day for at least 3 weeks and until all lesions have completely healed. 5- Or Trimethoprim-sulfamethoxazole one tablet (160 mg/800 mg) orally twice a day for at least 3 weeks and until all lesions have completely healed.

Herpes genitalis It is an acute inflammatory disease of the male and female genital tract due to infection with Herpes simplex virus (HSV-2).Herpes simplex virus

·Incubation period: 2-7 days (2-21 days).

Clinical picture: Initial manifestations: include local pain, tenderness, itching sensation, dysuria and in females, a profuse watery vaginal discharge. Initial lesions are papules on a red erythematous base but they rapidly develop into vesicles and later ulcers covered with a grayish exudate.vesicles · The manifestations of recurrent genital herpes are similar but less severe, and resolve faster.

Diagnosis: A clinical diagnosis. Laboratory approaches for the diagnosis of genital herpes include: –Cytologic examination multi-nucleated giant cells.multi-nucleated giant cells –Direct immune fluorescent

Treatment: First clinical episode: Acyclovir 400 mg orally three times a day for 7-10 days. Recurrent Genital Herpes: Acyclovir 400 mg orally three times a day for 5 days.