J Cutan Pathol 2015: 42: 239–243 doi: 10.1111/cup.12491 John Wiley & Sons. Printed in Singapore
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Journal of Cutaneous Pathology
Cover Quizlet Sebastian Podlipnik MD, Priscila Giavedoni MD, Mercé Alsina MD, Adriana García-Herrera MD, Juan Ferrando MD, PhD and José M. Mascaró Jr MD, PhD Figures 1 and 2 are depicted on the journal cover.
Figure 3.
Figure 4.
Figure 5.
Figure 6.
Figure 7.
Figure 8.
Your diagnosis? Discussion follows on page 240
239
Cover Quizlet
An erythematous nodule on the nipple: An unusual presentation of primary syphilis Sebastian Podlipnik MD1 , Priscila Giavedoni MD1 , Mercé Alsina MD1 , Adriana García-Herrera MD2 , Juan Ferrando MD, PhD1 and José M. Mascaró Jr MD, PhD1 1
Departments of Dermatology, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain 2 Departments of Pathology, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain Jose M. Mascaró Jr, MD. PhD Department of Dermatology Hospital Clinic Universitat de Barcelona Calle Villarroel 170 Barcelona 08036, Spain E-mail: [email protected] Phone: (+34) 932279867 FAX: (+34) 932275438
Syphilis is a sexually transmitted disease caused by the spirochete bacterium Treponema pallidum. Humans are the only natural hosts, and transmission occurs through direct contact with an infectious mucocutaneous lesion.1 This is followed by spread of the treponemes to regional lymph nodes and hematogenous dissemination to other parts of the body, which causes the systemic symptoms of the disease.2 Acquired syphilis has four well-characterized stages (primary, secondary, latent, and tertiary), during which activity and latency alternate.3 In primary syphilis, a lesion (or chancre) appears at the site of initial inoculation of the spirochete, 9–90 days after exposure. It usually presents as an indurated and painless genital ulcer, but it may have an atypical presentation (painful, soft, multiple), especially at extragenital locations.2 Primary syphilis involving the nipple is a rare presentation. The first cases were reported in 2006 by Lee et al, who described two patients with nipple lesions manifest as solitary unilateral nodules.4 Since then, only five additional cases have been reported in the English language literature.5 – 9
240
Herein, we report the case of a 49-year-old white male with a past medical history of Addison disease, autoimmune thyroiditis, type II diabetes mellitus and dyslipidemia who was referred to our Dermatology department to evaluate a pruritic nodule on his left nipple (Figs. 1, 3). The patient was a man who has sex with men and who had had a stable partner for the last 8 years. Furthermore, he denied having sex outside his relationship. On physical examination, the nipple showed a well-demarcated erythematous eroded nodule that was firm and slightly painful to palpation. The rest of the mucocutaneous examination revealed no remarkable findings, and no palpable regional lymphadenopathy was identified. Complete blood cell count and basic biochemistry were within reference ranges. A punch biopsy of the nodule was performed. There was a pseudocarcinomatous epidermal hyperplasia and a lichenoid reaction pattern with a dense inflammatory infiltrate in the papillary and reticular dermis (Fig. 2, 4). The infiltrate was composed of lymphocytes, histiocytes and abundant plasma cells (Fig. 5). There was also prominent endothelial swelling with extravasated erythrocytes and hemo-
Cover Quizlet
Fig. 1. An erythematous eroded nodule involved the left nipple.
Fig. 2. Hematoxylin/eosin-stained sections of a biopsy demonstrate a lichenoid granulomatous infiltrate with plasma cells
siderophages. No ulcer or erosion could be seen. Immunohistochemical staining using a polyclonal rabbit antibody directed against T. pallidum showed the presence of spirochetes in the epidermis (Fig. 6), and a diagnosis of syphilis was rendered. At the next visit, further laboratory studies were ordered. This included a VDRL titer >1:1024 and a fluorescent treponemal antibody absorption (FTA-ABS) IgM test that was positive. Screening for other sexually-transmitted diseases, including human immunodeficiency virus (HIV) infection, was negative. The patient was treated with 2.4 million units benzathine penicillin intramuscularly and the nodule rapidly disappeared in follow-up visits. Three months later, the VDRL titer had decreased to 1:4. Moreover, we informed the patient in his first visit the importance of notifying his sexual partner, who was also tested positive for syphilis,
and the partner received proper treatment in another center. The clinical manifestations of primary extragenital syphilis can be quite diverse. Chancres are usually atypical and may vary in size, shape, morphology and color. Unlike genital lesions, they are often painful.10 Extragenital chancres occur mostly on the mouth, lips and anus but they can be seen at any mucocutaneous site exposed to infectious contact.11,12 They can also appear anywhere on the palate, face (cheeks and chin), conjunctiva, neck, breasts, abdomen, interscapular region, arms, palms, fingers, or thighs.10 In recent years, a few reports describing cases of primary syphilis involving the nipple have been published (Table 1). All of them occurred in males, and in many of them the lesions appeared shortly after the nipple was bitten during sexual intercourse with a prostitute or oral contact with an infected person.5 – 8 Lesions were described as unilateral nodules,4 ulcers,5 erosive and erythematous plaques 6,8 or crusted patches.7 One patient presented with bilateral involvement of the nipples with eczematoid-like lesions,9 while another had an overlap between primary and secondary syphilis at the same time.7 In our case, the clinical diagnosis of syphilis was not made, and it was histopathology that made the diagnosis possible. We posit that solitary eroded lesions of the nipple can pose significant diagnostic challenges to both clinicians and pathologists, and if the patient fails to inform about his sexual behavior, an unusual presentation of syphilis could be easily misdiagnosed as multiple other diseases.5 The most frequent differential diagnoses include Paget disease of the breast13 , nipple eczema14 and erosive adenomatosis of the nipple.15 Other differential diagnoses could include basal cell carcinoma,16 squamous cell carcinoma,17 leishmaniasis18 or cutaneous lymphoid hyperplasia.19 Our initial clinical suspicion was Paget disease, but the biopsy did not show the typical Paget cells in the epidermis. In addition, there were no epidermal atypical cells, ruling out other diagnoses such as basal cell or squamous cell carcinoma. Although the presence of dense a dermal infiltrate may be suggestive of cutaneous lymphoid hyperplasia, the infiltrate was composed of lymphocytes, histiocytes and plasma cells, a pattern different from that of cutaneous lymphoid hyperplasia. Erosive adenomatosis of the nipple typically shows glandular hyperplasia. Cutaneous leishmaniasis presents with a lymphohistiocytic infiltrate with plasma cells, but amastigotes are
241
242
1
1
1
1
1
1
Oh et al.5
Sim et al.6
Chiu et al.7
Yu et al.8
Zheng et al.9
Present report
NA
Bitten on the nipple
Bitten on the nipple
Bitten on the nipple
Bitten on the nipple
Bitten on the nipple
Bitten on the nipple
IM = Intramuscular; MU = million units; NA = not available.
Lee et al.
2
Patients
4
Reference
Mechanism of contagion
Asymptomatic scaly erythematous patches on both areolas with eroded nipples Well-demarcated erythematous eroded nodule
Asymptomatic erythematous, crusted and erosive patch with several pustules
Asymptomatic crusted plaque
Erythematous erosive patch with ipsilateral lymphadenopathy
Indolent ulcer covered with a crust
Patient 1: erosive lesion Patient 2: swelling of nipple
Clinical presentation
Table 1. Patients with primary syphilis involving the nipple
Eroded and focally ulcerated epidermis Focal smudged dermoepidermal junction Pseudoepitheliomatous epidermal hyperplasia
NA
Epidermal hyperplasia with focal ulceration
Epidermal hyperplasia
Parakeratosis, infiltration of small lymphocytes, neutrophils and vacuolar alteration of basal cells with scattered necrotic keratinocytes Focal parakeratosis, and partially damaged dermoepidermal junction
Epidermis Dense, superficial and deep perivascular and periadnexal infiltrate of lymphocytes, histiocytes, plasma cell and occasional neutrophils with an angioinvasive pattern Inflammatory infiltrate in the upper part of the dermis and periadnexal area. On high-power view lymphocytes, histiocytes, and many plasma cells around the blood vessels Dense perivascular and periadnexal infiltrate with a slightly nodular pattern. At high power, dense infiltration of lymphocytes and plasma cells Dense lichenoid infiltrate composed of lymphocytes plasma cells and histiocytes around the dermoepidermal junction and perivascular areas Interstitial inflammatory cell infiltration with prominent endothelial cell swelling, admixture of lymphocytes, histiocytes, neutrophils and plasma cells Diffuse and dense infiltrates composed of abundant lymphocytes, prominent plasma cells and sparse neutrophils Dense inflammatory infiltrate in superficial and reticular dermis, composed by lymphocytes, histiocytes and abundant plasma cells. Prominent endothelial swelling and focally extravasated erythrocytes and hemosiderophages
Dermis
Histopathology
Single IM injection of penicillin G benzathine 2.4 MU
3 weekly IM injections of penicillin G benzathine 2.4 MU
3 weekly IM injections of penicillin G benzathine 2.4 MU
2 weekly IM injections of penicillin G benzathine 2.4 MU
NA
3 weekly IM injections of penicillin G benzathine 2.4 MU
2 weekly IM injections of penicillin G benzathine 2.4 MU
Treatment
Resolution
Resolution
Resolution
Resolution
NA
Resolution
Resolution
Outcome
Cover Quizlet
Cover Quizlet usually observed, although they may be difficult to see. Finally, the combination of prominent epidermal hyperplasia, lichenoid tissue reaction with abundant plasma cells, and endothelial cell swelling were highly suggestive of syphilis. The diagnosis was then confirmed by immunohistochemistry. The typical histopathologic findings of a chancre include a central ulcerated area with necrosis at its base and an interstitial inflammatory cell infiltrate with a slightly nodular pattern in the dermis. At high magnification, the infiltrate is composed of lymphocytes, histiocytes, neutrophils, and, as a hallmark, abundant plasma cells. Prominent vascular endothelial cell proliferation and swelling are also characteristic. 8 There are at least two possible routes of infection in primary syphilis of the nipple. First, oral contact can be the cause of transmission. If the sexual partner has a chancre in the oral mucosa or tongue, it is possible that T. pallidum can be inoculated into a nibbling site of the nipple. Second, if a sexual partner has active or latent secondary syphilis, it is possible that minor trauma may have occurred in his/her oral mucous membrane, such that T. pallidum was released with blood and was inoculated onto the nipple mixed with saliva.5,8 According to Centers for Disease Control and Prevention (CDC) guidelines, benzathine penicillin G 2.4
million units IM in a single dose is the preferred regimen of treatment for primary syphilis.20 In summary, we report a case of primary syphilis presenting as a unilateral, solitary, erythematous nodule on the nipple of a male patient. Taking an exhaustive history can be an important diagnostic clue and in the case of an ulcer resulting from trauma during sexual intercourse, the possibility of syphilis should be suspected. Histopathologic examination can also be diagnostically crucial. Fig. 3. Both swelling and erythema of the left nipple were observed. Fig. 4. Routine staining with hematoxylin/ eosin demonstrated epidermal hyperplasia with a dense inflammatory infiltrate in the superficial, middle and deep dermis. Smooth muscle bundles, normal for this site, were also observed. Fig. 5. Acanthosis and a dense lichenoid infiltrate were observed. Figs. 6-7. At higher magnification, plasma cells were prominent within the lichenoid infiltrate Fig. 8. In an area similar to that depicted in Fig. 7, spirochetes were identifiable in the lower epidermis with specific immunohistochemical staining against T. pallidum.
References 1. French P. Syphilis. BMJ 2007; 334: 143. 2. Goh BT. Syphilis in adults. Sex Transm Infect 2005; 81: 448. 3. Cohen SE, Klausner JD, Engelman J, Philip S. Syphilis in the modern era: an update for physicians. Infect Dis Clin North Am 2013; 27: 705. 4. Lee JY-Y, Lin M-H, Jung Y-C. Extragenital syphilitic chancre manifesting as a solitary nodule of the nipple. J Eur Acad Dermatol Venereol 2006; 20: 886. 5. Oh Y, Ahn S, Hong SP, Bak H, Ahn SK. A case of extragenital chancre on a nipple from a human bite during sexual intercourse. Int J Dermatol 2008; 47: 978. 6. Sim JH, Lee MG, In SI, et al. Erythematous erosive patch on the left nipple--quiz case. Diagnosis: Extragenital syphilitic chancres. Arch Dermatol 2010; 146: 81. 7. Chiu H-Y, Tsai T-F. A crusted plaque on the right nipple. JAMA 2012; 308: 403. 8. Yu M, Lee HR, Ty H, Lee JH, Son SJ. A solitary erosive patch on the left nipple. Extragenital syphilitic chancres. Int J Dermatol 2012; 51: 27.
9. Zheng S, Liu J, Xu X-G, Gao X-H, Chen H-D. Primary Syphilis Presenting as Bilateral Nipple-areola Eczematoid Lesions. Acta Derm Venereol 2014; 94: 617. 10. Dourmishev LA, Dourmishev AL. Syphilis: uncommon presentations in adults. Clin Dermatol 2005; 23: 555. 11. Mindel A, Tovey SJ, Timmins DJ, Williams P. Primary and secondary syphilis, 20 years’ experience. 2. Clinical features. Genitourin Med 1989; 65: 1. 12. Chapel TA, Prasad P, Chapel J, Lekas N. Extragenital syphilitic chancres. J Am Acad Dermatol 1985; 13: 582. 13. Sandoval-Leon AC, Drews-Elger K, Gomez-Fernandez CR, Yepes MM, Lippman ME. Paget’s disease of the nipple. Breast Cancer Res Treat 2013; 141: 1. 14. Song HS, Jung S-E, Chan Kim Y, Lee E-S. Nipple Eczema, an Indicative Manifestation of Atopic Dermatitis? A Clinical, Histological, and Immunohistochemical Study. Am J Dermatopathol 2014 Jul 30. [Epub ahead of print]. 15. Cosechen MS, Wojcik AS d L, Piva FM, Werner B, Serafini SZ. Erosive adenomatosis of the nipple. An Bras Dermatol 2011; 86: S17.
16. Betti R, Martino P, Moneghini L, Vergani R, Tolomio E, Crosti C. Basal cell carcinomas of the areola-nipple complex: case reports and review of the literature. J Dermatol 2003; 30: 822. 17. Sofos SS, Tehrani H, Lymperopoulos N, Constantinides J, James MI. Primary squamous cell carcinoma of the nipple: a diagnosis of suspicion. J Plast Reconstr Aesthetic Surg JPRAS 2013; 66: e315. 18. Marsden PD, Almeida EA, Llanos-Cuentas EA, et al. Leishmania braziliensis braziliensis infection of the nipple. Br Med J Clin Res Ed 1985; 290: 433. 19. Boudova L, Kazakov DV, Sima R, et al. Cutaneous lymphoid hyperplasia and other lymphoid infiltrates of the breast nipple: a retrospective clinicopathologic study of fifty-six patients. Am J Dermatopathol 2005; 27: 375. 20. CDC - Diseases Characterized by Genital, Anal, or Perianal Ulcers - 2010 STD Treatment Guidelines [Internet]. [cited 2014 Sep 17]; Available from: http://www.cdc. gov/std/treatment/2010/genital-ulcers.htm #syphilis
243
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Journal of Cutaneous Pathology
Cover Quizlet Sebastian Podlipnik MD, Priscila Giavedoni MD, Mercé Alsina MD, Adriana García-Herrera MD, Juan Ferrando MD, PhD and José M. Mascaró Jr MD, PhD Figures 1 and 2 are depicted on the journal cover.
Figure 3.
Figure 4.
Figure 5.
Figure 6.
Figure 7.
Figure 8.
Your diagnosis? Discussion follows on page 240
239
Cover Quizlet
An erythematous nodule on the nipple: An unusual presentation of primary syphilis Sebastian Podlipnik MD1 , Priscila Giavedoni MD1 , Mercé Alsina MD1 , Adriana García-Herrera MD2 , Juan Ferrando MD, PhD1 and José M. Mascaró Jr MD, PhD1 1
Departments of Dermatology, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain 2 Departments of Pathology, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain Jose M. Mascaró Jr, MD. PhD Department of Dermatology Hospital Clinic Universitat de Barcelona Calle Villarroel 170 Barcelona 08036, Spain E-mail: [email protected] Phone: (+34) 932279867 FAX: (+34) 932275438
Syphilis is a sexually transmitted disease caused by the spirochete bacterium Treponema pallidum. Humans are the only natural hosts, and transmission occurs through direct contact with an infectious mucocutaneous lesion.1 This is followed by spread of the treponemes to regional lymph nodes and hematogenous dissemination to other parts of the body, which causes the systemic symptoms of the disease.2 Acquired syphilis has four well-characterized stages (primary, secondary, latent, and tertiary), during which activity and latency alternate.3 In primary syphilis, a lesion (or chancre) appears at the site of initial inoculation of the spirochete, 9–90 days after exposure. It usually presents as an indurated and painless genital ulcer, but it may have an atypical presentation (painful, soft, multiple), especially at extragenital locations.2 Primary syphilis involving the nipple is a rare presentation. The first cases were reported in 2006 by Lee et al, who described two patients with nipple lesions manifest as solitary unilateral nodules.4 Since then, only five additional cases have been reported in the English language literature.5 – 9
240
Herein, we report the case of a 49-year-old white male with a past medical history of Addison disease, autoimmune thyroiditis, type II diabetes mellitus and dyslipidemia who was referred to our Dermatology department to evaluate a pruritic nodule on his left nipple (Figs. 1, 3). The patient was a man who has sex with men and who had had a stable partner for the last 8 years. Furthermore, he denied having sex outside his relationship. On physical examination, the nipple showed a well-demarcated erythematous eroded nodule that was firm and slightly painful to palpation. The rest of the mucocutaneous examination revealed no remarkable findings, and no palpable regional lymphadenopathy was identified. Complete blood cell count and basic biochemistry were within reference ranges. A punch biopsy of the nodule was performed. There was a pseudocarcinomatous epidermal hyperplasia and a lichenoid reaction pattern with a dense inflammatory infiltrate in the papillary and reticular dermis (Fig. 2, 4). The infiltrate was composed of lymphocytes, histiocytes and abundant plasma cells (Fig. 5). There was also prominent endothelial swelling with extravasated erythrocytes and hemo-
Cover Quizlet
Fig. 1. An erythematous eroded nodule involved the left nipple.
Fig. 2. Hematoxylin/eosin-stained sections of a biopsy demonstrate a lichenoid granulomatous infiltrate with plasma cells
siderophages. No ulcer or erosion could be seen. Immunohistochemical staining using a polyclonal rabbit antibody directed against T. pallidum showed the presence of spirochetes in the epidermis (Fig. 6), and a diagnosis of syphilis was rendered. At the next visit, further laboratory studies were ordered. This included a VDRL titer >1:1024 and a fluorescent treponemal antibody absorption (FTA-ABS) IgM test that was positive. Screening for other sexually-transmitted diseases, including human immunodeficiency virus (HIV) infection, was negative. The patient was treated with 2.4 million units benzathine penicillin intramuscularly and the nodule rapidly disappeared in follow-up visits. Three months later, the VDRL titer had decreased to 1:4. Moreover, we informed the patient in his first visit the importance of notifying his sexual partner, who was also tested positive for syphilis,
and the partner received proper treatment in another center. The clinical manifestations of primary extragenital syphilis can be quite diverse. Chancres are usually atypical and may vary in size, shape, morphology and color. Unlike genital lesions, they are often painful.10 Extragenital chancres occur mostly on the mouth, lips and anus but they can be seen at any mucocutaneous site exposed to infectious contact.11,12 They can also appear anywhere on the palate, face (cheeks and chin), conjunctiva, neck, breasts, abdomen, interscapular region, arms, palms, fingers, or thighs.10 In recent years, a few reports describing cases of primary syphilis involving the nipple have been published (Table 1). All of them occurred in males, and in many of them the lesions appeared shortly after the nipple was bitten during sexual intercourse with a prostitute or oral contact with an infected person.5 – 8 Lesions were described as unilateral nodules,4 ulcers,5 erosive and erythematous plaques 6,8 or crusted patches.7 One patient presented with bilateral involvement of the nipples with eczematoid-like lesions,9 while another had an overlap between primary and secondary syphilis at the same time.7 In our case, the clinical diagnosis of syphilis was not made, and it was histopathology that made the diagnosis possible. We posit that solitary eroded lesions of the nipple can pose significant diagnostic challenges to both clinicians and pathologists, and if the patient fails to inform about his sexual behavior, an unusual presentation of syphilis could be easily misdiagnosed as multiple other diseases.5 The most frequent differential diagnoses include Paget disease of the breast13 , nipple eczema14 and erosive adenomatosis of the nipple.15 Other differential diagnoses could include basal cell carcinoma,16 squamous cell carcinoma,17 leishmaniasis18 or cutaneous lymphoid hyperplasia.19 Our initial clinical suspicion was Paget disease, but the biopsy did not show the typical Paget cells in the epidermis. In addition, there were no epidermal atypical cells, ruling out other diagnoses such as basal cell or squamous cell carcinoma. Although the presence of dense a dermal infiltrate may be suggestive of cutaneous lymphoid hyperplasia, the infiltrate was composed of lymphocytes, histiocytes and plasma cells, a pattern different from that of cutaneous lymphoid hyperplasia. Erosive adenomatosis of the nipple typically shows glandular hyperplasia. Cutaneous leishmaniasis presents with a lymphohistiocytic infiltrate with plasma cells, but amastigotes are
241
242
1
1
1
1
1
1
Oh et al.5
Sim et al.6
Chiu et al.7
Yu et al.8
Zheng et al.9
Present report
NA
Bitten on the nipple
Bitten on the nipple
Bitten on the nipple
Bitten on the nipple
Bitten on the nipple
Bitten on the nipple
IM = Intramuscular; MU = million units; NA = not available.
Lee et al.
2
Patients
4
Reference
Mechanism of contagion
Asymptomatic scaly erythematous patches on both areolas with eroded nipples Well-demarcated erythematous eroded nodule
Asymptomatic erythematous, crusted and erosive patch with several pustules
Asymptomatic crusted plaque
Erythematous erosive patch with ipsilateral lymphadenopathy
Indolent ulcer covered with a crust
Patient 1: erosive lesion Patient 2: swelling of nipple
Clinical presentation
Table 1. Patients with primary syphilis involving the nipple
Eroded and focally ulcerated epidermis Focal smudged dermoepidermal junction Pseudoepitheliomatous epidermal hyperplasia
NA
Epidermal hyperplasia with focal ulceration
Epidermal hyperplasia
Parakeratosis, infiltration of small lymphocytes, neutrophils and vacuolar alteration of basal cells with scattered necrotic keratinocytes Focal parakeratosis, and partially damaged dermoepidermal junction
Epidermis Dense, superficial and deep perivascular and periadnexal infiltrate of lymphocytes, histiocytes, plasma cell and occasional neutrophils with an angioinvasive pattern Inflammatory infiltrate in the upper part of the dermis and periadnexal area. On high-power view lymphocytes, histiocytes, and many plasma cells around the blood vessels Dense perivascular and periadnexal infiltrate with a slightly nodular pattern. At high power, dense infiltration of lymphocytes and plasma cells Dense lichenoid infiltrate composed of lymphocytes plasma cells and histiocytes around the dermoepidermal junction and perivascular areas Interstitial inflammatory cell infiltration with prominent endothelial cell swelling, admixture of lymphocytes, histiocytes, neutrophils and plasma cells Diffuse and dense infiltrates composed of abundant lymphocytes, prominent plasma cells and sparse neutrophils Dense inflammatory infiltrate in superficial and reticular dermis, composed by lymphocytes, histiocytes and abundant plasma cells. Prominent endothelial swelling and focally extravasated erythrocytes and hemosiderophages
Dermis
Histopathology
Single IM injection of penicillin G benzathine 2.4 MU
3 weekly IM injections of penicillin G benzathine 2.4 MU
3 weekly IM injections of penicillin G benzathine 2.4 MU
2 weekly IM injections of penicillin G benzathine 2.4 MU
NA
3 weekly IM injections of penicillin G benzathine 2.4 MU
2 weekly IM injections of penicillin G benzathine 2.4 MU
Treatment
Resolution
Resolution
Resolution
Resolution
NA
Resolution
Resolution
Outcome
Cover Quizlet
Cover Quizlet usually observed, although they may be difficult to see. Finally, the combination of prominent epidermal hyperplasia, lichenoid tissue reaction with abundant plasma cells, and endothelial cell swelling were highly suggestive of syphilis. The diagnosis was then confirmed by immunohistochemistry. The typical histopathologic findings of a chancre include a central ulcerated area with necrosis at its base and an interstitial inflammatory cell infiltrate with a slightly nodular pattern in the dermis. At high magnification, the infiltrate is composed of lymphocytes, histiocytes, neutrophils, and, as a hallmark, abundant plasma cells. Prominent vascular endothelial cell proliferation and swelling are also characteristic. 8 There are at least two possible routes of infection in primary syphilis of the nipple. First, oral contact can be the cause of transmission. If the sexual partner has a chancre in the oral mucosa or tongue, it is possible that T. pallidum can be inoculated into a nibbling site of the nipple. Second, if a sexual partner has active or latent secondary syphilis, it is possible that minor trauma may have occurred in his/her oral mucous membrane, such that T. pallidum was released with blood and was inoculated onto the nipple mixed with saliva.5,8 According to Centers for Disease Control and Prevention (CDC) guidelines, benzathine penicillin G 2.4
million units IM in a single dose is the preferred regimen of treatment for primary syphilis.20 In summary, we report a case of primary syphilis presenting as a unilateral, solitary, erythematous nodule on the nipple of a male patient. Taking an exhaustive history can be an important diagnostic clue and in the case of an ulcer resulting from trauma during sexual intercourse, the possibility of syphilis should be suspected. Histopathologic examination can also be diagnostically crucial. Fig. 3. Both swelling and erythema of the left nipple were observed. Fig. 4. Routine staining with hematoxylin/ eosin demonstrated epidermal hyperplasia with a dense inflammatory infiltrate in the superficial, middle and deep dermis. Smooth muscle bundles, normal for this site, were also observed. Fig. 5. Acanthosis and a dense lichenoid infiltrate were observed. Figs. 6-7. At higher magnification, plasma cells were prominent within the lichenoid infiltrate Fig. 8. In an area similar to that depicted in Fig. 7, spirochetes were identifiable in the lower epidermis with specific immunohistochemical staining against T. pallidum.
References 1. French P. Syphilis. BMJ 2007; 334: 143. 2. Goh BT. Syphilis in adults. Sex Transm Infect 2005; 81: 448. 3. Cohen SE, Klausner JD, Engelman J, Philip S. Syphilis in the modern era: an update for physicians. Infect Dis Clin North Am 2013; 27: 705. 4. Lee JY-Y, Lin M-H, Jung Y-C. Extragenital syphilitic chancre manifesting as a solitary nodule of the nipple. J Eur Acad Dermatol Venereol 2006; 20: 886. 5. Oh Y, Ahn S, Hong SP, Bak H, Ahn SK. A case of extragenital chancre on a nipple from a human bite during sexual intercourse. Int J Dermatol 2008; 47: 978. 6. Sim JH, Lee MG, In SI, et al. Erythematous erosive patch on the left nipple--quiz case. Diagnosis: Extragenital syphilitic chancres. Arch Dermatol 2010; 146: 81. 7. Chiu H-Y, Tsai T-F. A crusted plaque on the right nipple. JAMA 2012; 308: 403. 8. Yu M, Lee HR, Ty H, Lee JH, Son SJ. A solitary erosive patch on the left nipple. Extragenital syphilitic chancres. Int J Dermatol 2012; 51: 27.
9. Zheng S, Liu J, Xu X-G, Gao X-H, Chen H-D. Primary Syphilis Presenting as Bilateral Nipple-areola Eczematoid Lesions. Acta Derm Venereol 2014; 94: 617. 10. Dourmishev LA, Dourmishev AL. Syphilis: uncommon presentations in adults. Clin Dermatol 2005; 23: 555. 11. Mindel A, Tovey SJ, Timmins DJ, Williams P. Primary and secondary syphilis, 20 years’ experience. 2. Clinical features. Genitourin Med 1989; 65: 1. 12. Chapel TA, Prasad P, Chapel J, Lekas N. Extragenital syphilitic chancres. J Am Acad Dermatol 1985; 13: 582. 13. Sandoval-Leon AC, Drews-Elger K, Gomez-Fernandez CR, Yepes MM, Lippman ME. Paget’s disease of the nipple. Breast Cancer Res Treat 2013; 141: 1. 14. Song HS, Jung S-E, Chan Kim Y, Lee E-S. Nipple Eczema, an Indicative Manifestation of Atopic Dermatitis? A Clinical, Histological, and Immunohistochemical Study. Am J Dermatopathol 2014 Jul 30. [Epub ahead of print]. 15. Cosechen MS, Wojcik AS d L, Piva FM, Werner B, Serafini SZ. Erosive adenomatosis of the nipple. An Bras Dermatol 2011; 86: S17.
16. Betti R, Martino P, Moneghini L, Vergani R, Tolomio E, Crosti C. Basal cell carcinomas of the areola-nipple complex: case reports and review of the literature. J Dermatol 2003; 30: 822. 17. Sofos SS, Tehrani H, Lymperopoulos N, Constantinides J, James MI. Primary squamous cell carcinoma of the nipple: a diagnosis of suspicion. J Plast Reconstr Aesthetic Surg JPRAS 2013; 66: e315. 18. Marsden PD, Almeida EA, Llanos-Cuentas EA, et al. Leishmania braziliensis braziliensis infection of the nipple. Br Med J Clin Res Ed 1985; 290: 433. 19. Boudova L, Kazakov DV, Sima R, et al. Cutaneous lymphoid hyperplasia and other lymphoid infiltrates of the breast nipple: a retrospective clinicopathologic study of fifty-six patients. Am J Dermatopathol 2005; 27: 375. 20. CDC - Diseases Characterized by Genital, Anal, or Perianal Ulcers - 2010 STD Treatment Guidelines [Internet]. [cited 2014 Sep 17]; Available from: http://www.cdc. gov/std/treatment/2010/genital-ulcers.htm #syphilis
243
This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
