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Erosive Patches on Bilateral Nipples

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 19-year-old woman presented with erosions on both nipples. Pruritic skin lesions had formed gradually over 4 weeks after a bite during sexual intercourse and persisted for approximately 8 weeks. No significant change in size or morphologic characteristics of these lesions occurred during the 8 weeks. The lesions were painless; neither fever nor associated systemic symptoms were noted. Three months later, the patient presented with an asymptomatic skin eruption. Physical examination revealed erythematous erosive patches on both nipples (Figure, A and B) and pink macules on the trunk. Lymphadenopathy and mucosal lesions were absent. Punch biopsy specimens were obtained from both nipples for histopathologic analysis (Figure, C and D).

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C. Chancres of bilateral nipples

The skin biopsy specimen from both nipples showed the similar change. Epidermis showed parakeratosis, neutrophils, and pseudoepitheliomatous hyperplasia. Diffuse and dense infiltrates composed of abundant lymphocytes, plasma cells and sparse neutrophils, eosinophils, and hemorrhage could be observed in the dermis (Figure, C). Immunohistochemical analysis for Treponema pallidum was used, which demonstrated numerous spirochetes in the epidermis and dermis (Figure, D). A rapid plasma reagin (RPR) test result was positive, with a titer of at least 1:32, and a T pallidum particle agglutination assay was reactive. A diagnosis of chancres of bilateral nipples was made. A serologic test result for infection with the human immunodeficiency virus was negative. Both the nipple lesions and the pink macules gradually resolved after intramuscular injections of benzathine penicillin G, 2.4 MU weekly for 3 weeks. The titer of RPR was negative at the 9-month follow-up.

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Article Information

Corresponding Author: Jun Li, MD, Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College. No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, China, 100730 (lijun06321@pumch.cn).

Published Online: February 7, 2018. doi:10.1001/jamadermatol.2017.5640

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

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