Rom J Morphol Embryol 2015, 56(2):569–574 ISSN (print) 1220–0522 ISSN (on-line) 2066–8279 CASE REPORT An immunocompetent young patient with tuberculosis of the penis: a challenging case MARIA ROTARU 1) , SORINA TĂBAN 2) , MONA ŢĂROI 3) , VIRGIL PĂTRAŞCU 4) , FLORINA-LIGIA POPA 5) 1) Department of Dermatology, “Victor Papilian” Faculty of Medicine, “Lucian Blaga” University of Sibiu, Romania 2) Department of Pathology, “Victor Babeş” University of Medicine and Pharmacy, Timisoara, Romania 3) Department of Dermatology, Emergency County Hospital, Sibiu, Romania 4) Department of Dermatology, University of Medicine and Pharmacy of Craiova, Romania 5) Department of Rehabilitation Medicine, “Victor Papilian” Faculty of Medicine, “Lucian Blaga” University of Sibiu, Romania Abstract Tuberculous chancre is an extremely rare form of cutaneous tuberculosis. The genital area is a possible site of presentation. We present a case of a young male with a persistent balanopreputial ulceration resembling a luetic chancre with negative serology for syphilis. The diagnosis was based on the specific pathologic features and the positive intradermal reaction to tuberculin. A successful treatment was achieved by combining antituberculosis treatment and surgical approach with circumcision. After six months of antituberculosis treatment, the patient developed paradoxical inguinal lymph node enlargement, which, after surgical excision and biopsy, was not followed by a relapse of the disease and needed no further therapy. Tuberculosis should be considered a potential diagnosis in the case of a persistent genital ulcer. Keywords: mucocutaneous tuberculosis, genital chancre, granuloma, penile ulcer, primary inoculation.  Introduction Skin tuberculosis, with its many clinical forms, repre- sents only 1–2% of the newly diagnosed cases of Koch bacillus infection [1]. Usually, the etiologic agent is Mycobacterium tuberculosis, but, exceptionally, it can be M. bovis or Calmette–Guérin bacillus [2]. Most commonly, skin tuberculosis is of endogenous origin, produced by blood or lymph dissemination or by direct extension from a latent or active infection [3]. In extremely rare cases, in individuals who have not previously contacted the disease, skin tuberculosis is produced by primary exo- genous inoculation on injured skin, thus creating the clinical picture of tuberculosis (TB) chancre [4]. There are many other diseases characterized by penile ulcer, and the most frequent is syphilis. In the present paper, we report an unusual case with giant penian chancre, initially suspected as being primary syphilis, but after several negative syphilis serology tests, a positive intradermal reaction to tuberculin and specific histopathological findings, it was later confirmed as a tuberculous chancre.  Case report A 17-year-old immunocompetent male has been admitted in the Department of Dermatology in May 2013, presenting a persistent and painful balanopreputial ulce- ration, which had occurred six weeks priorly. The current disease began as a group of three papular lesions localized on the ventral area of the penis, which gradually ulcerated and fused to form a unique large ulceration that destroyed the preputial frenulum. The serology for syphilis including VDRL (venereal disease research laboratory) test and TPHA (Treponema pallidum hemagglutination assay) was negative. Based on these data, the disease was originally considered to be a serological negative primary syphilis. The ultramicroscopy and PCR (polymerase chain reaction) for T. pallidum were not performed. Lacking any other investigations, the patient had previously been treated in the ambulatory, with Phenoxymethylpenicillinum 3× 1 g/day, for 10 days, and afterwards with Azithromycinum 500 mg/day for another seven days, as a chancroid. Both yielded no positive clinical results, with a rapid increasing in size of the penile ulcer. Dermatological examination showed a single large, painful and non-indurated ulceration on the ventral area of the penis, about 4/5 cm in diameter, with sharply demarcated irregular margins, and yellowish grey deposits on the base (Figure 1). Multiple painless mobile lymph node enlargements were found on both sides of the inguinal region, with the largest coming up to less than 1 cm in diameter. No other associate diseases or symptoms were detected during the general examination. Syphilis serology (VDRL and TPHA) tests came back negative on repeated occasions. Laboratory findings that included a complete blood count and liver and kidney function tests were normal. The HIV (human immuno- deficiency virus) serological test was also negative. Ulceration swabs were positive for Escherichia coli and Staphylococcus aureus, both sensitive to Ciprofloxacin on drug susceptibility testing (DST). The chest X-ray film revealed no pathological changes. Due to the presence of infection identified by a bacteriologic exam and to the rapid increase of the ulceration size, a systemic treatment with Ciprofloxacin 1 g/day for 10 days, combined with local disinfectant, was initiated. This did not trigger any improvements. Because R J M E Romanian Journal of Morphology & Embryology http://www.rjme.ro/