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Dermoscopic Findings of Jellyfish Stings Caused by Pelagia noctiluca
Dermatoscopia de las picaduras de medusa causadas por Pelagia noctiluca
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(A) Epidermal necrosis with vesicle formation. Melanin is found dispersed into the debris and remnants of pigmented keratinocytes (black arrows). Dermal inflammation with oedema, vasodilatation and erythrocyte extravasation is shown (H&E 100×). (B) Fragments of the tubules of nematocysts are seen in the stratum corneum (yellow arrows) (H&E 200×).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L.J. del Pozo, N. Knöpfel, A. Martín-Santiago, M.M. Escudero-Góngora, C. Saus, N. Izquierdo-Herce, A. Bauzà-Alonso" "autores" => array:7 [ 0 => array:2 [ "nombre" => "L.J." "apellidos" => "del Pozo" ] 1 => array:2 [ "nombre" => "N." "apellidos" => "Knöpfel" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Martín-Santiago" ] 3 => array:2 [ "nombre" => "M.M." "apellidos" => "Escudero-Góngora" ] 4 => array:2 [ "nombre" => "C." "apellidos" => "Saus" ] 5 => array:2 [ "nombre" => "N." "apellidos" => "Izquierdo-Herce" ] 6 => array:2 [ "nombre" => "A." "apellidos" => "Bauzà-Alonso" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0001731016000843" "doi" => "10.1016/j.ad.2016.02.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731016000843?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016301275?idApp=UINPBA000044" "url" => "/15782190/0000010700000006/v2_201704050141/S1578219016301275/v2_201704050141/en/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S0001731016000703" "issn" => "00017310" "doi" => "10.1016/j.ad.2015.09.022" "estado" => "S300" "fechaPublicacion" => "2016-07-01" "aid" => "1357" "copyright" => "AEDV" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2016;107:e39-45" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 437 "formatos" => array:3 [ "EPUB" => 3 "HTML" => 313 "PDF" => 121 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">E-casos clínicos</span>" "titulo" => "Dermatitis anular liquenoide de la infancia. Descripción de 2 casos y revisión de la literatura" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e39" "paginaFinal" => "e45" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Annular Lichenoid Dermatitis of Youth: A Report of 2 Cases and a Review of the Literature" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figura 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1256 "Ancho" => 1674 "Tamanyo" => 597094 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A. H-E<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>100. Biopsia del borde de una de las lesiones que muestra hiperqueratosis en cestillo, edema en la dermis papilar y un infiltrado inflamatorio linfocitario de tipo liquenoide, localizado principalmente en el techo de las papilas dérmicas. B. H-E<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>200. A mayor aumento vemos el edema en la dermis papilar y la localización de los linfocitos en las papilas dérmicas. C. El estudio inmunohistoquímico demuestra un infiltrado formado por linfocitos CD3 positivos (×<span class="elsevierStyleHsp" style=""></span>40). D. Linfocitos CD4 positivos (×<span class="elsevierStyleHsp" style=""></span>100).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "I. Vázquez-Osorio, M. González-Sabín, P. Gonzalvo-Rodríguez, E. Rodríguez-Díaz" "autores" => array:4 [ 0 => array:2 [ "nombre" => "I." "apellidos" => "Vázquez-Osorio" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "González-Sabín" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "Gonzalvo-Rodríguez" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Rodríguez-Díaz" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1578219016300701" "doi" => "10.1016/j.adengl.2016.05.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016300701?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731016000703?idApp=UINPBA000044" "url" => "/00017310/0000010700000006/v1_201606280028/S0001731016000703/v1_201606280028/es/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S000173101630028X" "issn" => "00017310" "doi" => "10.1016/j.ad.2016.03.004" "estado" => "S300" "fechaPublicacion" => "2016-07-01" "aid" => "1393" "copyright" => "AEDV" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Actas Dermosifiliogr. 2016;107:498-508" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 284 "formatos" => array:3 [ "EPUB" => 3 "HTML" => 211 "PDF" => 70 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">ORIGINAL</span>" "titulo" => "Análisis de coste-efectividad y coste-utilidad de ingenol mebutato versus diclofenaco 3% e imiquimod 5% en el tratamiento de la queratosis actínica en España" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "498" "paginaFinal" => "508" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Cost-Effectiveness and Cost-Utility Analysis of Ingenol Mebutate Versus Diclofenac 3% and Imiquimod 5% in the Treatment of Actinic Keratosis in Spain" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1212 "Ancho" => 1628 "Tamanyo" => 154876 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Análisis de sensibilidad probabilístico de ingenol mebutato vs. diclofenaco 3% en la cara y el cuero cabelludo, y el tronco y las extremidades.</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">AVAC: años de vida ajustados por calidad.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "I. Elías, N. Ortega-Joaquín, P. de la Cueva, L.J. del Pozo, D. Moreno-Ramírez, A. Boada, M. Aguilar, A. Mirada, E. Mosquera, C. Gibbons, I. Oyagüez" "autores" => array:11 [ 0 => array:2 [ "nombre" => "I." "apellidos" => "Elías" ] 1 => array:2 [ "nombre" => "N." "apellidos" => "Ortega-Joaquín" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "de la Cueva" ] 3 => array:2 [ "nombre" => "L.J." "apellidos" => "del Pozo" ] 4 => array:2 [ "nombre" => "D." "apellidos" => "Moreno-Ramírez" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Boada" ] 6 => array:2 [ "nombre" => "M." "apellidos" => "Aguilar" ] 7 => array:2 [ "nombre" => "A." "apellidos" => "Mirada" ] 8 => array:2 [ "nombre" => "E." "apellidos" => "Mosquera" ] 9 => array:2 [ "nombre" => "C." "apellidos" => "Gibbons" ] 10 => array:2 [ "nombre" => "I." "apellidos" => "Oyagüez" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S157821901630097X" "doi" => "10.1016/j.adengl.2016.05.022" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157821901630097X?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S000173101630028X?idApp=UINPBA000044" "url" => "/00017310/0000010700000006/v1_201606280028/S000173101630028X/v1_201606280028/es/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Dermoscopic Findings of Jellyfish Stings Caused by <span class="elsevierStyleItalic">Pelagia noctiluca</span>" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "509" "paginaFinal" => "515" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "L.J. del Pozo, N. Knöpfel, A. Martín-Santiago, M.M. Escudero-Góngora, C. Saus, N. Izquierdo-Herce, A. Bauzà-Alonso" "autores" => array:7 [ 0 => array:4 [ "nombre" => "L.J." "apellidos" => "del Pozo" "email" => array:2 [ 0 => "luis.javier.del.pozo.hernando@gmail.com" 1 => "lpozoh@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "N." "apellidos" => "Knöpfel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Martín-Santiago" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "M.M." "apellidos" => "Escudero-Góngora" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "C." "apellidos" => "Saus" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "N." "apellidos" => "Izquierdo-Herce" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "A." "apellidos" => "Bauzà-Alonso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitari Son Espases, Palma de Mallorca, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitari Son Espases, Palma de Mallorca, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Dermatoscopia de las picaduras de medusa causadas por <span class="elsevierStyleItalic">Pelagia noctiluca</span>" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 712 "Ancho" => 950 "Tamanyo" => 81427 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Dermoscopic findings in <span class="elsevierStyleItalic">Pelagia noctiluca</span> stings. Brown “Chinese characters” pattern. Brown dots appear connected by lines (*) composed of a fine light brown granular pigment, resembling Chinese letters. Clinical presentation corresponded to linear vesicles regularly spaced due to the contact with the “warts” contained in the oral arms of <span class="elsevierStyleItalic">Pelagia noctiluca</span>.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Jellyfish are free-living members of the phylum Cnidaria with whom they share a highly specialized cell type of mechanoreceptor, the cnidocyte or cnidoblast, each containing an intracellular organelle, the nematocyst. Nematocysts are formed and used only by cnidarians to capture and immobilize preys and to defense against predators. Following an appropriate stimulus, either chemical or mechanical, the cnidocyte discharges its nematocysts and injects the venom into the victim.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> The venom of jellyfish is composed of potent proteinaceous porins, neurotoxic peptides, bioactive lipids and other small molecules that are responsible for its cytotoxic, cytolytic, haemolytic and antigenic properties.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> Jellyfish stings produce direct immediate toxicity, either local (pain, oedema, inflammation and necrosis) or systemic. In a small number of patients, they may also trigger an immune response such as anaphylaxis, pruritus, erythema nodosum,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> lichen-planus like eruption<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a> and persistent or recurrent cutaneous reactions.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> Long-term complications including granulomatous reactions, keloids, retractile scars, pigmentary changes (hyper- or hypopigmentation) or fat atrophy may also occur.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The diagnosis of jellyfish stings is straightforward and is based on the clinical manifestations and personal history of contact with the Cnidarian. When a clear history of contact with jellyfish is lacking, the lesions may be confused with herpes, impetigo, phytophotodermatitis, stings from other marine animals or with other dermatosis following a whiplash pattern.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1,5–9</span></a> In these doubtful cases, the microscopic examination of a sticky tape applied to the sting site or the visualization of skin scrapings suspended in saline solution, may reveal the presence of nematocysts adhered to the corneal layer and should allow the identification of the species that caused the sting.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> Also, nematocysts remain attached to the victim's skin from hours to days, and can be detected in a cutaneous biopsy.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1,10</span></a> Dermoscopy is a rapid non-invasive technique that has been used for the diagnosis of infestations such as scabies, pediculosis, cutaneous larva migrans, ticks and <span class="elsevierStyleItalic">Trombicula</span> bites among others.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> In a previous study, we evaluated the dermoscopic findings of jellyfish stings in 8 patients and only 3 patients were able to identify the jellyfish species, that corresponded to <span class="elsevierStyleItalic">Pelagia noctiluca</span>.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> The aim of the present work is to study the dermoscopic findings of jellyfish stings in a larger group of patients in The Island of Majorca.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">We retrospectively reviewed the clinical and dermoscopic images of jellyfish stings evaluated in our department during the last seven years (from May 2009 to October 2015). To avoid misdiagnosis, only patients who had identified the jellyfish in close contact with the skin or in the vicinity were included. The identification of the jellyfish was made by the patient or his companions at the time of the sting and was confirmed at the time of consultation by means of a slideshow with pictures that included the most frequent jellyfish found in the Mediterranean Sea.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a> These pictures were downloaded from internet, mainly from “<a id="intr0005" class="elsevierStyleInterRef" href="https://www.wikipedia.org/">https://www.wikipedia.org</a>”.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The following data were collected for each episode: age and sex, location, morphology of the sting (lines, patch or both), date when the sting occurred and if biopsy was performed. Dermoscopic evaluation included the following features: pigmentation pattern, vascular pattern and presence of ulceration, crusting or scaling. To check if dermoscopic signs changed over time, we classified jellyfish stings in acute (up to 48<span class="elsevierStyleHsp" style=""></span>h) and subacute-chronic (between 48<span class="elsevierStyleHsp" style=""></span>h and 30 days), based on the course of experimental jellyfish stings where the erythema during the acute phase disappeared in 2–3 days.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Statistical analysis was performed using SPSS version 21.0 (IBM Corporation). Pearson's chi square test was used to compare percentages. When indicated, Yates's correction of continuity was applied. <span class="elsevierStyleItalic">P</span>-value cutoff was set at 0.05.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">We included 25 episodes of jellyfish sting in 22 patients, 11 females and 11 males. Age ranged from 2 to 74 years (mean 42, median 46.5). All stings occurred between May and October and 63.7% between June and August. In our series, the only jellyfish species that our patients identified as responsible for the sting was <span class="elsevierStyleItalic">P. noctiluca</span>; so eventually only stings by this species were included. Three cases had already been included in our previous series.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> Lesions were found in the upper limb (40.7%), lower limb (18.8%), trunk (31.3%) and head/neck (9.3%). Three patients presented two episodes of jellyfish sting. In 5 patients, lesions affected simultaneously two body areas and in one patient, three body areas were affected. Eleven jellyfish stings (44%) presented with linear lesions (including the whiplash pattern), 9 (36%) as circular patches (single or multiple), and 5 (19%) presented a combination of both. In three of these 5 cases, the complete shape of the jellyfish was drawn on the skin. Jellyfish sting duration at time of consultation ranged from 1<span class="elsevierStyleHsp" style=""></span>h to 30 days (mean 4.9 days, median 2 days). Thirteen stings (52%) were classified as acute, and 12 stings (48%) as subacute-chronic.</p><p id="par0035" class="elsevierStylePara elsevierViewall">We found the following dermoscopic features (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1–4</a>): brown dots (84.0%), pinkish hue (56.0%), pinpoint brown crusts (44.0%), scale-crust (40.0%), brown “Chinese character” pattern (32.0%), “serpentine” ulceration (28.0%), linear purpura (20.0%), and whitish-yellow crusts (15.0%). When vascular pattern was present, vessels were mainly dotted (36.0%) or reticular (16.0%). In <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, the frequency of dermoscopic features is summarized according to the time since the sting occurred. Scale-crust, serpentine ulceration and pinkish hue were significantly more frequent in lesions older than 2 days. Circular milky-red areas were observed in only one case of persistent chronic reaction. Linear purpura and reticular telangiectasia were no longer observed after 7 days. Histopathological study was performed in a jellyfish sting 18<span class="elsevierStyleHsp" style=""></span>h duration, from a selected area containing brown dots dermoscopically (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Jellyfish stings are very common among sea bathers in the Balearic Islands. In the summer of 2014, sea lifeguards attended 12,860 swimmers in the Balearic beaches, and of these, 209 were treated for jellyfish stings.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a> However, jellyfish stings are not a frequent cause of dermatologic consultation since most cutaneous lesions are mild and transient.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2,15</span></a> Several species in the Mediterranean sea, including <span class="elsevierStyleItalic">P. noctiluca</span> (mauve stinger), <span class="elsevierStyleItalic">Rhizostoma pulmo</span> (barrel jellyfish), <span class="elsevierStyleItalic">Chrysaora hysoscella</span> (compass jellyfish), <span class="elsevierStyleItalic">Caribdaea marsupialis</span> (sea wasp), <span class="elsevierStyleItalic">Rhopilema nomadica</span> and possibly, <span class="elsevierStyleItalic">Aurelia aurita</span> (moon jellyfish) are considered potentially harmful to humans.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">7,16</span></a> According to reports from a network of observers, the only toxic jellyfish species found in the Balearic beaches are <span class="elsevierStyleItalic">P. noctiluca</span> and less frequently, <span class="elsevierStyleItalic">A. aurita.</span><a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a><span class="elsevierStyleItalic">P. noctiluca</span> is by far the most common jellyfish found in the Mediterranean Sea<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">7,16,18</span></a> and this could explain that it was the only identified species in our series.</p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">P. noctiluca</span> has four thick oral arms and a bell or exumbrella of 4–13<span class="elsevierStyleHsp" style=""></span>cm in diameter with eight thin tentacles hanging from it which can reach up to 3 or more metres in length.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> Their nematocysts are arranged in characteristic clusters called “warts” distributed over its entire surface, which makes the whole body, including the bell, potentially toxic.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2,15</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Contact with <span class="elsevierStyleItalic">P. noctiluca</span> causes immediate pain, burning and erythematous-edematous vesicular lesions, that follow a linear or whiplash distribution if the contact is established with its tentacles.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2,15</span></a> Sometimes, it is possible to see the “print” of the bell on the skin, which appears as a circular patch; and less frequently the complete silhouette of the jellyfish is observed.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">15,19</span></a> Lesions usually resolve in 1–2 weeks and may leave a scar or pigmentary changes.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">15,20</span></a> Recurrent skin eruptions have been described,<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2,21</span></a> and in our series, only one patient developed a recurrent eruption. Dermoscopy in this case revealed the presence of circular, confluent, milky-red areas reminiscent of the jellyfish's warts (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>B).</p><p id="par0055" class="elsevierStylePara elsevierViewall">Similar to other series,<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">15,16</span></a> lesions were located mainly on the extremities and in contrast to previous studies no male predilection was found. This finding may reflect an inclusion bias.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The results of our study reveal 4 dermoscopic features that may represent the contact with the nematocysts of <span class="elsevierStyleItalic">P. noctiluca</span>: brown dots, brown “Chinese character pattern”, pinpoint brown crusts and whitish-yellow crusts. These features were observed in jellyfish stings from unidentified species,<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> suggesting that <span class="elsevierStyleItalic">P. noctiluca</span> may have been the causative species, although further studies are needed to support this assumption.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Histological examination of jellyfish stings reveal nematocysts above the stratum corneum and fine thread-like tubules penetrating the epidermis.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> We performed selected skin biopsy from dermoscopic brown dots in a sting of 18<span class="elsevierStyleHsp" style=""></span>h duration and observed dermoepidermal necrosis and fragments of fine refractile threads of the nematocysts in the epidermis (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). Dermoscopic-pathological correlation of this single case suggests that “brown dots” may represent the entry point of the nematocyst into the skin (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). We used the term “pinpoint brown crusts” (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) in larger lesions that may correspond to deeper dermal penetration of the nematocyst, with more necrosis and central crusting. When no pigment was observed, the term “whitish-yellow crusts” was used.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The exumbrella and oral arms of <span class="elsevierStyleItalic">P. noctiluca</span> have brown pigment of melanic nature mainly located on the “warts”.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a> We could speculate that this exogenous pigment could penetrate the skin through the puncture<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a> contributing to the brown colour observed on dermoscopy. However, the more probable explanation is that the brown colour is due to epidermal melanin dispersed in the necrotic content of the vesicles, as observed in the histology (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>A). When the vesicles observed histologically merge, the resulting dermoscopic image is a combination of dots and lines that do not follow the normal skin marks. Because are reminiscent of the Chinese alphabet letters, we termed this pattern brown “Chinese characters” (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Interestingly, at least one of the dermoscopic brown structures described was present in 23 episodes (88%) and these findings may be a characteristic dermoscopic feature of <span class="elsevierStyleItalic">P. noctiluca</span> stings. Although less common than the brown dots, the brown “Chinese characters” pattern, to our knowledge, has not been described in any other disease yet. All of these dermoscopic features disappeared over time, and were no longer perceptible after 4 weeks (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). These findings may help us in the differential diagnosis with post-inflammatory pigmentation due to the jellyfish sting,<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">15,20</span></a> which shows blue or grey granules on dermoscopy, corresponding to melanin in the papillary dermis.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Histological analysis of jellyfish stings often show extravasation of erythrocytes<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>) and we believe that clinical visualization of linear purpura (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B) is most probably caused by direct toxicity of the vascular endothelium from the <span class="elsevierStyleItalic">P. noctiluca</span> venom.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> Dermoscopic vascular features such as pinkish hue and red dots (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A) were more frequent in chronic lesions. The red dots may be due to toxic or immunologic damage of the venom to the vessels. Circular milky-red areas were observed in only one case of persistent chronic reaction (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>B). The dermoscopic image of serpentine ulceration (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>A) may be explained by the cytotoxic and dermonecrotic properties of the venom.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> The feature of serpentine ulceration together with brown dots would be very suggestive of contact with the tentacles of <span class="elsevierStyleItalic">P. noctiluca</span>.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Although visual recognition of the jellyfish is the usual method to identify the jellyfish species in field studies,<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">17,18</span></a> this method may involve species misclassification. In our series, all patients were residents and had no difficulty in recognizing the jellyfish when the pictures were shown. The second most frequent jellyfish that regularly arrives at the Balearic beaches is <span class="elsevierStyleItalic">A. aurita</span>,<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> easily distinguishable from <span class="elsevierStyleItalic">P. noctiluca</span>. Misrecognition with <span class="elsevierStyleItalic">C. hysoscella</span> (compass jellyfish) or <span class="elsevierStyleItalic">Chrysaora quinquecirrha</span> (sea nettle) is possible, but both are much less common than <span class="elsevierStyleItalic">P. noctiluca</span> in our beaches.<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">16,17</span></a> Another limitation of our study is that our findings are limited to an unique jellyfish species. Further studies are needed to evaluate these dermoscopic features in jellyfish stings caused by species other than <span class="elsevierStyleItalic">P. noctiluca</span>.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In conclusion, this study of the dermoscopic spectrum of jellyfish stings identifies 4 dermoscopic features that may represent the penetration of <span class="elsevierStyleItalic">P. noctiluca</span> nematocysts: brown dots, brown “Chinese characters” pattern, pinpoint brown crusts and whitish-yellow crusts. We believe that our study provides further knowledge in an unexplored field of dermoscopy. The recognition of these dermoscopic findings in typical cases of <span class="elsevierStyleItalic">P. noctiluca</span> stings may help us to establish the diagnosis when a clear history of contact with the cnidarian is lacking.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Protection of human and animal subjects</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Right to privacy and informed consent</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Confidentiality of data</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres678414" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions and limitations" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec684450" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres678413" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones y limitaciones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec684449" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-10-27" "fechaAceptado" => "2016-02-17" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec684450" "palabras" => array:3 [ 0 => "Jellyfish stings" 1 => "<span class="elsevierStyleItalic">Pelagia noctiluca</span>" 2 => "Dermoscopy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec684449" "palabras" => array:3 [ 0 => "Picadura de medusa" 1 => "<span class="elsevierStyleItalic">Pelagia noctiluca</span>" 2 => "Dermatoscopia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Jellyfish are free-living members of the phylum Cnidaria who share a specialized stinging cell, the cnidocyte. <span class="elsevierStyleItalic">Pelagia noctiluca</span> is the most frequent and toxic jellyfish species found in the Balearic beaches and cnidocytes are arranged in pigmented clusters called “warts”. Dermoscopy continues to expand its use much beyond the pigmentary lesions and to date, there is no data regarding dermoscopic findings in jellyfish stings. The aim of the present work was to study the dermoscopic findings of jellyfish stings in the island of Mallorca.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We retrospectively reviewed the clinical and dermoscopic images of 25 episodes of jellyfish stings caused by <span class="elsevierStyleItalic">P. noctiluca</span> that occurred between 2009 and 2015.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Overall, the following dermoscopic features were found: brown dots (84%), pinkish hue (56%), pinpoint brown crusts (44%), scale-crust (40%), brown “Chinese characters pattern” (32%), “serpentine” ulceration (28%), linear purpura (20%), and whitish-yellow crusts (15%). Vessels were mainly dotted (36%) or reticular (16%). Scale-crust, serpentine ulceration and pinkish hue were significantly more frequent in lesions older than 2 days.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions and limitations</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Our study identifies 4 dermoscopic features that may represent the contact with <span class="elsevierStyleItalic">P. noctiluca</span> cnidocytes: brown dots, brown “Chinese characters pattern”, pinpoint brown crusts and whitish-yellow crusts. A peculiar finding of “serpentine ulceration” with brown dots would be very suggestive of <span class="elsevierStyleItalic">P. noctiluca</span> sting. We believe dermoscopy is a valuable tool in the diagnosis of jellyfish stings when a clear history of contact is lacking. Further studies are needed to validate our findings in other jellyfish species.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions and limitations" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción y objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Las medusas son miembros del phylum Cnidaria que comparten una célula urticante especializada, el cnidiocito. En Baleares, <span class="elsevierStyleItalic">Pelagia noctiluca</span> es la medusa más frecuente y tóxica. En ella los cnidiocitos se encuentran en agrupaciones pigmentadas llamadas «verrugas». La dermatoscopia continúa ampliando su uso más allá de las lesiones pigmentadas, pero hasta la fecha no se ha utilizado en el diagnóstico de las picaduras de medusa. El objetivo del presente trabajo es estudiar los hallazgos dermatoscópicos en esta patología en la isla de Mallorca.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Revisamos retrospectivamente las imágenes clínicas y dermatoscópicas de 25 episodios de picaduras de medusa por <span class="elsevierStyleItalic">P. noctiluca</span> entre 2009 y 2015.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se encontraron las siguientes imágenes: puntos marrones (84%), tono rosado (56%), costras marrones puntiformes (44%), escamocostra (40%), patrón en «letras chinas» marrones (32%), ulceración «en serpentina» (28%), púrpura lineal (20%) y costras blancoamarillentas (15%). Los vasos fueron puntiformes (36%) o reticulares (16%). La escamocostra, la ulceración en serpentina y el tono rosado fueron significativamente más frecuentes en las lesiones de más de 2<span class="elsevierStyleHsp" style=""></span>días de duración.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones y limitaciones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Nuestro estudio identificó 4 imágenes dermatoscópicas debidas al contacto con los cnidiocitos: puntos marrones, patrón en «letras chinas» marrones, costras marrones puntiformes y costras blancoamarillentas. La combinación de ulceración «en serpentina» y puntos marrones sería muy sugestiva de picadura por <span class="elsevierStyleItalic">P. noctiluca.</span> La dermatoscopia es una herramienta útil en el diagnóstico de las picaduras de medusas, en ausencia del antecedente de contacto con ellas. Se necesitan más estudios para validar estos hallazgos en picaduras por otras especies de medusa.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones y limitaciones" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1129 "Ancho" => 1500 "Tamanyo" => 170607 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Dermoscopic findings in <span class="elsevierStyleItalic">Pelagia noctiluca</span> stings. Brown dots. (A) Brown dots of 0.1<span class="elsevierStyleHsp" style=""></span>mm diameter in a sting of 1-week duration. (B) The same lesion at 21 days showing complete disappearance of brown dots.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 712 "Ancho" => 950 "Tamanyo" => 81427 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Dermoscopic findings in <span class="elsevierStyleItalic">Pelagia noctiluca</span> stings. Brown “Chinese characters” pattern. Brown dots appear connected by lines (*) composed of a fine light brown granular pigment, resembling Chinese letters. Clinical presentation corresponded to linear vesicles regularly spaced due to the contact with the “warts” contained in the oral arms of <span class="elsevierStyleItalic">Pelagia noctiluca</span>.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1121 "Ancho" => 1500 "Tamanyo" => 164764 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Dermoscopic findings in <span class="elsevierStyleItalic">Pelagia noctiluca</span> stings. Brownish crust and Linear purpura. (A) Pinpoint brownish crusts (black arrows) and red dots (orange arrows) in a pinkish hue background. (B) “Linear purpura”: linear bands composed of red dots regularly spaced in a tabby pattern.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1129 "Ancho" => 1500 "Tamanyo" => 166989 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Dermoscopic findings in <span class="elsevierStyleItalic">Pelagia noctiluca</span> stings. Serpentine ulceration and circular milky-red areas. (A) Superficial linear ulceration presents as a winding road due to the contact with the tentacles of the jellyfish (“serpentine ulceration”). The edges of the ulcer are delimited by scales and contain brown dots. Linear purpura is shown inside the ulcer. (B) Distinctive “circular milky-red areas” on a recurrent, persistent, inflammatory reaction to jellyfish sting. The configuration of these circular milky-red areas match with the “warts” morphology of the jellyfish.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1400 "Ancho" => 975 "Tamanyo" => 342837 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Dermoscopic-pathological correlation of brown dots. (A) Epidermal necrosis with vesicle formation. Melanin is found dispersed into the debris and remnants of pigmented keratinocytes (black arrows). Dermal inflammation with oedema, vasodilatation and erythrocyte extravasation is shown (H&E 100×). (B) Fragments of the tubules of nematocysts are seen in the stratum corneum (yellow arrows) (H&E 200×).</p>" ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Dermoscopic feature \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Duration of the sting</th><th class="td" title="table-head " align="left" valign="top" scope="col">Total<br><span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>25 (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">P</span> value \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Acute (to 48<span class="elsevierStyleHsp" style=""></span>h)<br><span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>13 (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Subacute-chronic (>48<span class="elsevierStyleHsp" style=""></span>h)<br><span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>12 (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Brown dots \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (92.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (75.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 (84.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N.S \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Brown “Chinese characters” pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (38.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (25.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (32.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N.S \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Brown pinpoint crusts \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (38.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (50.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (44.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N.S \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Whitish-yellow crusts \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (32.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (8.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (15.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N.S \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Linear purpura \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (30.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (8.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (20.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N.S \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Scale-crust \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (15.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (66.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (40.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.02<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">§</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dotted vessels \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (38.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (33.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (36.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N.S \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Reticular telangiectasia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (15.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (16.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (16.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">N.S \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pinkish hue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (30.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (83.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (56.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.008 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Serpentine ulceration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (7.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (50.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (28.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.05<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">§</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1113382.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "§" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">After applying the correction for continuity.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Dermoscopic findings in 25 episodes of <span class="elsevierStyleItalic">Pelagia noctiluca</span> stings.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Venomous and poisonous marine animals: a medical and biological handbook" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 44 | 40 | 84 |
| 2024 September | 106 | 56 | 162 |
| 2024 August | 175 | 72 | 247 |
| 2024 July | 200 | 51 | 251 |
| 2024 June | 133 | 39 | 172 |
| 2024 May | 90 | 41 | 131 |
| 2024 April | 71 | 28 | 99 |
| 2024 March | 76 | 37 | 113 |
| 2024 February | 46 | 36 | 82 |
| 2024 January | 58 | 31 | 89 |
| 2023 December | 61 | 20 | 81 |
| 2023 November | 83 | 37 | 120 |
| 2023 October | 88 | 46 | 134 |
| 2023 September | 121 | 41 | 162 |
| 2023 August | 119 | 23 | 142 |
| 2023 July | 145 | 32 | 177 |
| 2023 June | 125 | 29 | 154 |
| 2023 May | 190 | 29 | 219 |
| 2023 April | 60 | 17 | 77 |
| 2023 March | 67 | 26 | 93 |
| 2023 February | 79 | 28 | 107 |
| 2023 January | 62 | 62 | 124 |
| 2022 December | 87 | 50 | 137 |
| 2022 November | 90 | 41 | 131 |
| 2022 October | 115 | 37 | 152 |
| 2022 September | 165 | 58 | 223 |
| 2022 August | 256 | 44 | 300 |
| 2022 July | 282 | 59 | 341 |
| 2022 June | 286 | 37 | 323 |
| 2022 May | 203 | 47 | 250 |
| 2022 April | 148 | 40 | 188 |
| 2022 March | 143 | 70 | 213 |
| 2022 February | 147 | 55 | 202 |
| 2022 January | 147 | 72 | 219 |
| 2021 December | 99 | 60 | 159 |
| 2021 November | 99 | 51 | 150 |
| 2021 October | 168 | 68 | 236 |
| 2021 September | 149 | 69 | 218 |
| 2021 August | 225 | 41 | 266 |
| 2021 July | 188 | 50 | 238 |
| 2021 June | 98 | 45 | 143 |
| 2021 May | 74 | 47 | 121 |
| 2021 April | 194 | 82 | 276 |
| 2021 March | 100 | 43 | 143 |
| 2021 February | 100 | 32 | 132 |
| 2021 January | 77 | 20 | 97 |
| 2020 December | 65 | 24 | 89 |
| 2020 November | 51 | 25 | 76 |
| 2020 October | 60 | 30 | 90 |
| 2020 September | 62 | 27 | 89 |
| 2020 August | 45 | 28 | 73 |
| 2020 July | 83 | 18 | 101 |
| 2020 June | 45 | 46 | 91 |
| 2020 May | 43 | 18 | 61 |
| 2020 April | 46 | 20 | 66 |
| 2020 March | 35 | 21 | 56 |
| 2020 February | 9 | 0 | 9 |
| 2020 January | 5 | 0 | 5 |
| 2019 December | 4 | 0 | 4 |
| 2019 November | 6 | 0 | 6 |
| 2019 October | 3 | 0 | 3 |
| 2019 September | 4 | 0 | 4 |
| 2019 August | 3 | 2 | 5 |
| 2019 July | 10 | 0 | 10 |
| 2019 June | 3 | 0 | 3 |
| 2019 May | 6 | 0 | 6 |
| 2019 April | 4 | 2 | 6 |
| 2019 March | 0 | 3 | 3 |
| 2019 February | 4 | 0 | 4 |
| 2019 January | 2 | 2 | 4 |
| 2018 November | 5 | 0 | 5 |
| 2018 October | 3 | 0 | 3 |
| 2018 September | 1 | 0 | 1 |
| 2018 July | 1 | 0 | 1 |
| 2018 February | 6 | 4 | 10 |
| 2018 January | 20 | 10 | 30 |
| 2017 December | 11 | 12 | 23 |
| 2017 November | 8 | 8 | 16 |
| 2017 October | 5 | 8 | 13 |
| 2017 September | 15 | 11 | 26 |
| 2017 August | 18 | 9 | 27 |
| 2017 July | 15 | 6 | 21 |
| 2017 June | 13 | 12 | 25 |
| 2017 May | 12 | 16 | 28 |
| 2017 April | 19 | 14 | 33 |
| 2017 March | 14 | 15 | 29 |
| 2017 February | 8 | 10 | 18 |
| 2017 January | 6 | 7 | 13 |
| 2016 December | 15 | 28 | 43 |
| 2016 November | 11 | 25 | 36 |
| 2016 October | 10 | 30 | 40 |
| 2016 September | 3 | 4 | 7 |
| 2016 August | 5 | 6 | 11 |
| 2016 July | 6 | 22 | 28 |
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