Infantile
Gynecomastia
With Bloody
Nipple
Discharge
By laik Olcay and Aytaq Giik6z
A dana, Turkey and Ankara, Turkey l Gynecomastia and bloody nipple discharge are very rare in childhood. In this report, a case of infantile gynecomastia together with bloody nipple discharge is presented. A hemorrhagic discharge was expressible from the mammary gland. Endocrinologic findings were within the normal limits. Because of persisting bleeding, a subcutaneous mastectomy was performed. The specimen was reported as gynecomastia. This boy is the first reported prepubetial gynecomastia with bloody nipple discharge in the medical literature. Copyright 1~)1992 by W. B. Saunders Company
INDEX WORDS:
Nipple discharge; gynecomastia,
infantile.
B
REAST enlargement is commonly seen in fullterm infants of either sex.’ This condition is often associated with clear or milky nipple discharge. Maternal hormones, including estrogens, progesterone, and prolactin, and fetal hormones such as prolactin appear to influence the hypertrophy and the secretion.’ In contrast, gynecomastia and bloody nipple discharge are each very rare in children? A Z-year-old boy with bloody nipple discharge due to gynecomastia is reported.
In the microscopic examination, eosinophilic amorphous material, and lipid- and hemosiderin-laden histiocytes were seen in the ducts; periductal and stromal fibrous tissue proliferation and edema were encountered (Fig 2). Lipid- and hemosiderin-laden histiocytes were also observed in the periductal area (Fig 3). With these morphological findings, the case is reported as gynecomastia.
DISCUSSION
Although bloody nipple discharge is very rare in childhood, there are some interesting reports concerning this clinical sign. In 1964 Simpson and Barson” and in 1987, Kucukaydin et al’ reported two cases of intraductal papillomas as the cause of bloody nipple discharge in two girls. In the reports by Berkowitz and Inkelis,i Fenster,” and Stringel et al’ the cause of the bleeding was unclear and the condition resolved
CASE REPORT A 2-year-old boy was admitted with a history of bloody nipple discharge from the right breast for 3 months (Fig 1). Physical examination showed a hypertrophied mammary gland 1 cm in diameter. A hemorrhagic discharge was expressible from the gland. T,, T,. TSH, and progesterone levels were within normal limits and x-ray showed a normal sella. Because of the persistent bleeding, a subcutaneus mastectomy was performed. He recovered uneventfully.
Fig 2. Proliferation of the ductal epithelium and periductal fibrous tissue (H&E, original magnification x 100).
Fig 1. A Z-year-old boy with bloody nipple discharge.
Jourffafof
Pedtatric
.Surgery,
Vol 27, No 1 (January), 1992: pp 103-104
From the Department of Pediatric Surgery. Cukurova Uni~~ersity, Faculty of Medicine, Adana. Turkey, and the Deparrment of Pathology, Hacettepe University, FaculQ of Medicine. Ankara, Turkey. Address reprint requests to Aytag Giiktiz, MD. Professor of Pathology, Hacettepe University. Faculty of Medicine, Ankara, Turkey. Copyright o 1992 by W.B. Saunders Compattj 0022.3468192/2701-0029$03,OOjO 103
OLCAY AND GOKOZ
the youngest children with prepubertal gynecomastia without hormonal imbalance. None of the children reported with prepubertal gynecomastia had bloody nipple discharge.3 The present patient is the first reported case of prepubertal gynecomastia with bloody nipple discharge in the medical literature. Obviously, it is not easy to explain the bleeding with the histopathologic findings of gynecomastia. In this patient, although the presence of the hemosiderin- and lipid-laden macrophages correlate with nipple discharge, it is still difficult to explain the etiology of the bleeding with the morphologic changes. REFERENCES
Fig 3. Ductal epithelial proliferation; lipid- and hemosiderin-laden histiocytes in the ducts and periductal area (H&E, original magnification x375).
spontaneously. Stringel et al’ also reported a 3-yearold boy with bloody nipple discharge due to mammary duct ectasia. Chronic cystic mastitis has been mentioned by Ravitch’ as a possible cause of bloody nipple discharge in childhood. Gynecomastia is a common condition after the age of 12,10-‘2whereas prepubertal gynecomastia is very rare.3 In 1983, Haibach and Rosenholtz3 collected 41 cases from the literature and added one of their own. The youngest patients in this group were three children who were 1 and 2 years of age. Only one of these three children had no hormonal imbalance. From this point of view, the present patient is one of
1. Dewhurst J: Breast disorders in children and adolescents. Pediatr Clin North Am 28:287-307, 1981 2. McKiernan JF, Hull D: Breast development in the newborn. Arch Dis Child 56:525-X9, 1981 3. Haibach H, Rosenholtz MS: Prepubertal gynecomastia with lobules and acini: Case report and review of the literature. Am J Clin Pathol80:252-255, 1983 4. Berkowitz CD, Inkelis SH: Bloody nipple discharge in infancy. J Pediatr 103:755-756, 1983 5. Fenster DL: Bloody nipple discharge. J Pediatr 104:640,1984 6. Simpson JS, Barson AJ: Breast tumors in infants and children. Can Med Assoc J lOl:lOO-102,1969 7. Kucukaydin M, Okten T, Okur H, et al: Intraductal papilloma in children. J Erciyes Univ Med Fat 9:547-550, 1987 (Turkish with English abstract) 8. Stringel G, Perelman A, Jaminez C: Infantile mammary duct ectasia: A cause of bloody nipple discharge. J Pediatr Surg 21:671-674, 1986 9. Ravitch MM: The breast, in Ravitch MM, Welch KJ, Benson CD, et al (eds): Pediatric Surgery. Chicago, IL, Year Book, 1979, pp 401-406Carlson HE: Current concepts: Gynecomastia. N Engl J Med 303:795-799,1986 10. Carlson HE: Current concepts: Gynecomastia. N Engl J Med 303:795-799,1986 11. Williams MJ: Gynecomastia: Its incidence, recognition and host characterization in 447 autopsy cases. Am J Med 34:103-112, 1963 12. Nydick M, Bustos J, Dale JH, et al: Gynecomastia adolescent boys. JAMA 178:449-451, 1961
in
Gynecomastia
With Bloody
Nipple
Discharge
By laik Olcay and Aytaq Giik6z
A dana, Turkey and Ankara, Turkey l Gynecomastia and bloody nipple discharge are very rare in childhood. In this report, a case of infantile gynecomastia together with bloody nipple discharge is presented. A hemorrhagic discharge was expressible from the mammary gland. Endocrinologic findings were within the normal limits. Because of persisting bleeding, a subcutaneous mastectomy was performed. The specimen was reported as gynecomastia. This boy is the first reported prepubetial gynecomastia with bloody nipple discharge in the medical literature. Copyright 1~)1992 by W. B. Saunders Company
INDEX WORDS:
Nipple discharge; gynecomastia,
infantile.
B
REAST enlargement is commonly seen in fullterm infants of either sex.’ This condition is often associated with clear or milky nipple discharge. Maternal hormones, including estrogens, progesterone, and prolactin, and fetal hormones such as prolactin appear to influence the hypertrophy and the secretion.’ In contrast, gynecomastia and bloody nipple discharge are each very rare in children? A Z-year-old boy with bloody nipple discharge due to gynecomastia is reported.
In the microscopic examination, eosinophilic amorphous material, and lipid- and hemosiderin-laden histiocytes were seen in the ducts; periductal and stromal fibrous tissue proliferation and edema were encountered (Fig 2). Lipid- and hemosiderin-laden histiocytes were also observed in the periductal area (Fig 3). With these morphological findings, the case is reported as gynecomastia.
DISCUSSION
Although bloody nipple discharge is very rare in childhood, there are some interesting reports concerning this clinical sign. In 1964 Simpson and Barson” and in 1987, Kucukaydin et al’ reported two cases of intraductal papillomas as the cause of bloody nipple discharge in two girls. In the reports by Berkowitz and Inkelis,i Fenster,” and Stringel et al’ the cause of the bleeding was unclear and the condition resolved
CASE REPORT A 2-year-old boy was admitted with a history of bloody nipple discharge from the right breast for 3 months (Fig 1). Physical examination showed a hypertrophied mammary gland 1 cm in diameter. A hemorrhagic discharge was expressible from the gland. T,, T,. TSH, and progesterone levels were within normal limits and x-ray showed a normal sella. Because of the persistent bleeding, a subcutaneus mastectomy was performed. He recovered uneventfully.
Fig 2. Proliferation of the ductal epithelium and periductal fibrous tissue (H&E, original magnification x 100).
Fig 1. A Z-year-old boy with bloody nipple discharge.
Jourffafof
Pedtatric
.Surgery,
Vol 27, No 1 (January), 1992: pp 103-104
From the Department of Pediatric Surgery. Cukurova Uni~~ersity, Faculty of Medicine, Adana. Turkey, and the Deparrment of Pathology, Hacettepe University, FaculQ of Medicine. Ankara, Turkey. Address reprint requests to Aytag Giiktiz, MD. Professor of Pathology, Hacettepe University. Faculty of Medicine, Ankara, Turkey. Copyright o 1992 by W.B. Saunders Compattj 0022.3468192/2701-0029$03,OOjO 103
OLCAY AND GOKOZ
the youngest children with prepubertal gynecomastia without hormonal imbalance. None of the children reported with prepubertal gynecomastia had bloody nipple discharge.3 The present patient is the first reported case of prepubertal gynecomastia with bloody nipple discharge in the medical literature. Obviously, it is not easy to explain the bleeding with the histopathologic findings of gynecomastia. In this patient, although the presence of the hemosiderin- and lipid-laden macrophages correlate with nipple discharge, it is still difficult to explain the etiology of the bleeding with the morphologic changes. REFERENCES
Fig 3. Ductal epithelial proliferation; lipid- and hemosiderin-laden histiocytes in the ducts and periductal area (H&E, original magnification x375).
spontaneously. Stringel et al’ also reported a 3-yearold boy with bloody nipple discharge due to mammary duct ectasia. Chronic cystic mastitis has been mentioned by Ravitch’ as a possible cause of bloody nipple discharge in childhood. Gynecomastia is a common condition after the age of 12,10-‘2whereas prepubertal gynecomastia is very rare.3 In 1983, Haibach and Rosenholtz3 collected 41 cases from the literature and added one of their own. The youngest patients in this group were three children who were 1 and 2 years of age. Only one of these three children had no hormonal imbalance. From this point of view, the present patient is one of
1. Dewhurst J: Breast disorders in children and adolescents. Pediatr Clin North Am 28:287-307, 1981 2. McKiernan JF, Hull D: Breast development in the newborn. Arch Dis Child 56:525-X9, 1981 3. Haibach H, Rosenholtz MS: Prepubertal gynecomastia with lobules and acini: Case report and review of the literature. Am J Clin Pathol80:252-255, 1983 4. Berkowitz CD, Inkelis SH: Bloody nipple discharge in infancy. J Pediatr 103:755-756, 1983 5. Fenster DL: Bloody nipple discharge. J Pediatr 104:640,1984 6. Simpson JS, Barson AJ: Breast tumors in infants and children. Can Med Assoc J lOl:lOO-102,1969 7. Kucukaydin M, Okten T, Okur H, et al: Intraductal papilloma in children. J Erciyes Univ Med Fat 9:547-550, 1987 (Turkish with English abstract) 8. Stringel G, Perelman A, Jaminez C: Infantile mammary duct ectasia: A cause of bloody nipple discharge. J Pediatr Surg 21:671-674, 1986 9. Ravitch MM: The breast, in Ravitch MM, Welch KJ, Benson CD, et al (eds): Pediatric Surgery. Chicago, IL, Year Book, 1979, pp 401-406Carlson HE: Current concepts: Gynecomastia. N Engl J Med 303:795-799,1986 10. Carlson HE: Current concepts: Gynecomastia. N Engl J Med 303:795-799,1986 11. Williams MJ: Gynecomastia: Its incidence, recognition and host characterization in 447 autopsy cases. Am J Med 34:103-112, 1963 12. Nydick M, Bustos J, Dale JH, et al: Gynecomastia adolescent boys. JAMA 178:449-451, 1961
in
