A 21-year-old woman with no relevant history consulted for the presence of a single, painless, oval, ulcerative genital lesion with indurated borders, located on the right lateral wall of the vaginal introitus (Fig. 1A). She did not report general malaise or any systemic symptoms, but did acknowledge having had unprotected unsafe sex. Based on clinical suspicion of a syphilitic chancre, a single dose of intramuscular benzathine penicillin was administered and additional tests were requested. Serology was negative for human immunodeficiency virus, hepatitis viruses B and C, and syphilis. Bacterial culture was positive for Neisseria gonorrhoeae and polymerase chain reaction for gonococcus was positive. A diagnosis of gonococcal infection was established and ceftriaxone monotherapy was prescribed based on the antibiogram results. An improvement in the lesion was observed 3 weeks after beginning treatment (Fig. 1B). A subsequent bacterial culture was negative for gonococcus. Serological tests for syphilis performed 5 weeks after the appearance of the ulcer were negative.

Figure 1

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A hard chancre at the site of inoculation is characteristic of primary syphilis, but is a rare presentation of gonorrhea. We describe a case of gonococcal infection that simulated primary syphilis, manifesting with a typical syphilitic chancre. This case underscores the importance of confirming the diagnosis. There are few descriptions in the literature of genital gonorrhea presenting as a hard chancre.