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Ulcus durum – The Hard Chancre of Syphilis

Ulcus durum is the painless genital ulcer that marks the primary stage of syphilis, caused by the bacterium Treponema pallidum. It is the first visible sign of a syphilis infection.

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Things worth knowing about "Ulcus durum"

Ulcus durum is the painless genital ulcer that marks the primary stage of syphilis, caused by the bacterium Treponema pallidum. It is the first visible sign of a syphilis infection.

What is Ulcus durum?

Ulcus durum, also known as a hard chancre, is a characteristic, painless ulcer of the skin or mucous membrane that appears during the primary stage of syphilis. It develops at the site of entry of the pathogen Treponema pallidum, a spiral-shaped bacterium (spirochete). The Latin term translates roughly to hard ulcer, referring to the firm, indurated consistency of the lesion.

Causes and Transmission

Ulcus durum results from infection with Treponema pallidum, the causative agent of syphilis. Transmission occurs primarily through direct mucous membrane contact during sexual intercourse. Less commonly, it can be transmitted through other forms of close physical contact or from mother to unborn child (congenital syphilis). Risk groups include individuals with multiple sexual partners and those who do not use condom protection.

Symptoms and Clinical Appearance

Ulcus durum typically appears 2 to 3 weeks after infection (incubation period: 10–90 days). It displays the following characteristic features:

Painless, round or oval ulceration with sharply defined edges
Firm, indurated (hardened) base and border
Diameter usually between 0.5 and 2 cm
Clean, often smooth ulcer floor with minimal exudate
Accompanying painless swelling of regional lymph nodes (bubo)

Common locations include the genitals (penis, vulva, vagina), the anal region, the oral cavity, and less frequently other body areas. The ulcer heals spontaneously within 3 to 6 weeks even without treatment; however, the infection persists and will progress without therapy.

Diagnosis

The diagnosis of ulcus durum is based on several approaches:

Clinical examination: Assessment of the typical morphology of the lesion
Darkfield microscopy: Direct detection of Treponema pallidum in a swab taken from the ulcer
Serological tests: Detection of specific antibodies in the blood (e.g., TPPA test, FTA-ABS test, VDRL test); these may still be negative in the early phase
PCR: Molecular direct detection of the pathogen

Important differential diagnoses include ulcus molle (soft chancre, caused by Haemophilus ducreyi, which is painful) and genital herpes lesions.

Treatment

The treatment of choice is penicillin G, typically administered as a single intramuscular injection of benzathine penicillin G. In cases of penicillin allergy, alternatives such as doxycycline or ceftriaxone are used. Early treatment prevents progression to the later, more dangerous stages of syphilis (secondary and tertiary stages). Sexual partners should also be examined and treated if necessary. Syphilis is a notifiable disease in many countries.

Prognosis and Complications

When treated promptly, the prognosis is excellent and complete recovery is possible. Without treatment, syphilis can progress through secondary and tertiary stages to neurosyphilis, leading to serious neurological and cardiovascular damage. Untreated syphilis during pregnancy can result in miscarriage, stillbirth, or severe illness in the newborn.

References

World Health Organization (WHO): Guidelines for the Treatment of Treponema pallidum (Syphilis). Geneva, 2016. Available at: https://www.who.int
Workowski KA, Bachmann LH et al.: Sexually Transmitted Infections Treatment Guidelines. MMWR Recomm Rep. 2021;70(4):1–187.
Hook EW: Syphilis. Lancet. 2017;389(10078):1550–1557.

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