Bilateral Nipple Enlargement as a Secondary Effect of Anabolic Drugs


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Smooth muscle hamartoma is usually solitary and congenital, may affect the genital area and nipples. Histopathologically, they are characterized by the presence of mature smooth muscle bundles. We present a 40-year-old male with bilateral nipple enlargement excised with clinical suspicion of bilateral leiomyoma. Skin biopsy shows mature, irregularly arranged smooth muscle bundles and lactiferous ducts between them. Immunohistochemistry is positive for smooth muscle actin, desmin, and fumarase but negative for estrogen and progestogen receptors. The presence of lactiferous ducts excludes bilateral leiomyomas. Even when, histopathologically, this can be interpreted as the nipple-type of muscular hamartoma of the breast, clinical history favors an anabolic drug-induced lesion. Bodybuilders present gynecomastia and nipple enlargement as frequent problems, but we have not found any histopathological description of these nipple lesions. We consider that dermatologists should be aware of the presence of them and dermatopathologists should know their histopathological features to avoid misdiagnosis as neoplasms.

1. Introduction

Smooth muscle hamartoma is usually a solitary and congenital lesion, mostly involving the back and lower limbs, although the mammary region may be affected [1].
Clinically, the commoner presentation is as a single skin-colored or hyperpigmented hairy lesion, even when it may present a gamut of appearances as morphea-like lesions, follicular spotted ones, vascular-like ones [2] or in a generalized pattern termed “Michelin tire baby” [3]. Histopathologically, it shows a disorganized proliferation of mature well-demarcated bundles of smooth muscle without spatial relation with hair follicles [4].

We present a bilateral enlargement of both nipples, histopathologically mimicking a smooth muscle hamartoma, but containing additionally lactiferous ducts.

2. Case Report

A 40-year-old male presented with progressive bilateral enlargement of both nipples excised due to cosmetic concerns. No medical relevant history, but intake of anabolic steroids to improve his physical performance.
Physical examination showed symmetrical, cylindrical, well-defined, and slightly indurated nipples of 10 mm diameter and 11 mm height, which were excised with the clinical diagnosis of bilateral leiomyomas (Figure 1).

3. Discussion

The main differential diagnosis in our case is bilateral leiomyoma of the nipple, a rarely reported problem [5,6]. Clinically, both entities appear as a progressive enlargement of the nipple. Histopathologically, in leiomyomas, interlacing bundles of smooth muscle fibers without necrosis, nuclear atypia, or mitosis and with no or minimal fibrous tissue and a complete absence of glandular elements are observed [7]. Thus, this diagnosis can be easily ruled out in our case as our patient presented numerous lactiferous ducts.

4. Conclusions

In conclusion, dermatopathologists, as other physicians, should also increase their awareness of problems associated with doping drugs like anabolic steroids and, even when these lesions are frequently excised due to cosmetic concerns, the histopathological study should be done to increase the knowledge on these lesions.


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Figure 1. Clinical picture. (A) Bilateral and quite symmetrical enlargement of both nipples. (B) Elastic consistency of a nipple with a length of 11 mm.
Screenshot (4425).png


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Figure 2. Histopathological picture. (A) The panoramic picture shows irregularly arranged smooth muscle bundles, a slightly papillomatous epidermis, and some dilated ducts in the deeper areas. (B) Close view of the irregularly arranged smooth muscle bundles. (C) Closer view of a lactiferous duct surrounded by myoepithelial layer. (D) HEx4 picture of the lesion stained with smooth muscle actin (SMA) shows the smooth muscle’s global distribution. A blue arrow shows myoepithelial cells.
Screenshot (4426).png

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