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JAMA Clinical Challenge |

A Crusted Plaque on the Right Nipple

Hsien-Yi Chiu, MD; Tsen-Fang Tsai, MD
JAMA. 2012;308(4):403-404. doi:10.1001/jama.2012.7538.
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A healthy 27-year-old heterosexual man presents with a crusted plaque on his right nipple. The lesion formed gradually over a week after a bite during sexual intercourse and has persisted for a month. The patient reports that over the following 2 to 3 weeks, no significant change in size or morphology of this lesion occurred. The lesion is not painful; neither fever nor associated systemic symptoms are noted. Now, 1 month later, the patient presents with a generalized asymptomatic skin eruption. Physical examination reveals generalized pink macules on the trunk and extremities (Figure 1A). A crusted, erythematous plaque is noted over the enlarged right nipple (Figure 1B).

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Figure 1. A, Crusted plaque on the right nipple with generalized erythematous macular eruption. B, Close-up view of the right nipple.
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Figure 2. A, Skin biopsy showed a dense, lichenoid infiltrate of lymphocytes and plasma cells in the superficial dermis (hematoxylin-eosin, original magnification ×40). B, Many spirochetes (brown) in the epidermis demonstrated by immunohistochemical stain with horseradish peroxidase detection (3,3′-diaminobenzidine chromogen and hematoxylin counterstain, original magnification ×400).
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