A healthy young male patient was referred to the department of dermatology for evaluation of a solitary painful scrotal ulceration that developed rapidly 48 hours before consultation. One week before he had been diagnosed with acute tonsillitis and fever (temperature up to 38 °C), which were treated with oral amoxicillin and clavulanic acid. No history of a traumatic event, insect bites, genital or oral ulcers, sexual risk contacts, application of topical products, or other drug treatments was recorded.

Physical examination revealed a well-circumscribed, round ulceration 15 mm in diameter with central black eschar localized on the right side of the scrotum (Figure 1A). Leukocytosis with neutrophilia was detected in an initial workup. The rest of the physical examination revealed bilateral tonsillitis and enlarged cervical lymph nodes. No inguinal lymphadenopathies were palpated. A 4-mm punch biopsy from the edge of the lesion was obtained. Representative histopathological features are shown in Figure 1B. Staining for periodic acid–Schiff, periodic acid–Schiff with diastase, and Gram failed to detect microorganisms. Immunohistochemical techniques for Treponema pallidum, cytomegalovirus (CMV), and Epstein-Barr virus (EBV) were negative.