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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">El lupus eritematoso cut&#225;neo &#40;LEC&#41; de tipo necr&#243;lisis epid&#233;rmica t&#243;xica &#40;NET&#41; es una manifestaci&#243;n rara y potencialmente letal del LEC<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a>&#46; Su diagn&#243;stico es dif&#237;cil y no existe consenso sobre sus criterios diagn&#243;sticos&#46; Los diagn&#243;sticos diferenciales incluyen reacciones farmacol&#243;gicas adversas graves&#44; infecciones&#44; trastornos ampollosos autoinmunes &#40;AIBD&#41; y otras enfermedades vesiculobulosas asociadas con el lupus eritematoso &#40;LE&#41;&#44; tales como el s&#237;ndrome de Rowell y el LE sist&#233;mico buloso<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a>&#46; La inmunofluorescencia indirecta &#40;IFI&#41; puede ser extremadamente &#250;til para el diagn&#243;stico del AIBD<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a>&#44; aunque no existen reportes de su uso en el LE de tipo NET&#46; Presentamos el caso de una paciente con LE cut&#225;neo agudo de tipo NET &#40;LECA de tipo NET&#41; en el que la IFI fue crucial para el diagn&#243;stico&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Una mujer de 81 a&#241;os&#44; por lo dem&#225;s sana&#44; con antecedentes de alergia a penicilina y proca&#237;na acudi&#243; con astenia y lesiones cut&#225;neas dolorosas en t&#243;rax y espalda desde hac&#237;a tres d&#237;as&#44; que se extendieron a brazos y piernas&#46; No report&#243; fiebre&#44; tos ni artralgia&#46; Quince d&#237;as antes de la consulta hab&#237;a recibido tratamiento de doxilamina&#44; y hab&#237;a sido vacunada contra la gripe&#46; La paciente no recib&#237;a ninguna otra medicaci&#243;n&#46; El reconocimiento f&#237;sico revel&#243; m&#225;culas&#44; erosiones eritematosas poco definidas y coalescentes&#44; as&#237; como descamaci&#243;n de la piel en el t&#243;rax&#44; espalda <span class="elsevierStyleBold">&#40;</span><a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41; y extremidades&#46; El signo de Nikolsky fue positivo&#46; Se observaron erosiones m&#237;nimas en la lengua y el paladar duro&#44; no vi&#233;ndose afectada ninguna otra mucosa&#46; El examen histol&#243;gico revel&#243; necrosis epid&#233;rmica&#44; estrato c&#243;rneo normal e infiltrado linfoc&#237;tico perianexal y perivascular leve &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>A&#41;&#46; La inmunofluorescencia fue negativa&#46; Se realiz&#243; IFI utilizando es&#243;fago de mono y vejiga de rata para descartar p&#233;nfigo paraneopl&#225;sico&#46; El examen de vejiga de rata fue negativo y la IFI en es&#243;fago de mono no mostr&#243; tinci&#243;n de los espacios intercelulares o la membrana basal&#44; pero para nuestra sorpresa&#44; se hallaron anticuerpos antinucleares &#40;ANA&#41; IgG &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>B&#41;&#46; Estos resultados fueron posteriormente confirmados utilizando c&#233;lulas Hep2 que demostraron positividad para ANA con t&#237;tulos 1&#58;320&#46; Se realiz&#243; un panel completo para lupus que mostr&#243; positividad anti-Ro&#44; con resultados negativos para el resto de los ant&#237;genos &#40;dsDNA&#44; Sm&#44; La&#44; RNP&#41;&#46; El recuento sangu&#237;neo completo&#44; los par&#225;metros bioqu&#237;micos y las pruebas serol&#243;gicas para <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span> fueron normales o negativos&#46; Sobre la base de los hallazgos cl&#237;nicos&#44; histopatol&#243;gicos&#44; de laboratorio e IFI se diagnostic&#243; LE cut&#225;neo agudo de tipo NET&#46; La paciente no cumpli&#243; los criterios de clasificaci&#243;n del <span class="elsevierStyleItalic">American College of Rheumatology</span> para LE sist&#233;mico&#46; Fue ingresada inici&#225;ndose tratamiento con pomada t&#243;pica de triamcinolona al 0&#44;1&#37; con respuesta cl&#237;nica completa durante la semana siguiente&#46; Se realiz&#243; la prueba de parche con doxilamina &#40;concentraci&#243;n al 10 y 30&#37;&#59; veh&#237;culo&#58; vaselina&#41; transcurridos seis meses&#44; con resultados negativos&#46; La paciente permaneci&#243; sin lesiones cut&#225;neas durante los tres a&#241;os de seguimiento&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">La diferenciaci&#243;n entre LEC de tipo NET y AIBD es dif&#237;cil&#46; La incidencia de NET se incrementa en los pacientes de LE<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a>&#44; siendo LE o LEC la primera manifestaci&#243;n cl&#237;nica en el 35&#37; de los individuos con LEC de tipo NET<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a>&#46; El diagn&#243;stico de LEC de tipo NET se realiza muy frecuentemente de manera retrospectiva&#44; dada la complejidad de integrar los hallazgos cl&#237;nicos&#44; histol&#243;gicos y de laboratorio<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a>&#46; La presencia de lesiones fotodistribuidas&#44; compromiso mucoso m&#237;nimo&#44; ausencia de fiebre y mejor pron&#243;stico<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4&#44;5</span></a>&#44; junto con presencia histol&#243;gica de mucina&#44; infiltrado linfoc&#237;tico perivascular y perianexal&#44; presencia variable de melan&#243;fagos y dermatitis interfase vacuolar pueden sugerir un diagn&#243;stico de LECA de tipo NET<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2&#44;4</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#44; aunque estos hallazgos no se observan en todos los casos<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Las t&#233;cnicas de inmunofluorescencia son el criterio de referencia para el diagn&#243;stico de AIBD&#46; La IFI es un procedimiento complejo de dos pasos que detecta los anticuerpos en circulaci&#243;n en la sangre del paciente que utiliza piel humana normal&#44; piel con t&#233;cnica <span class="elsevierStyleItalic">salt-split</span>&#44; es&#243;fago de mono u otros sustratos &#40;vejiga de rata para p&#233;nfigo paraneopl&#225;sico&#41;&#44; dependiendo del diagn&#243;stico cl&#237;nico sospechado<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a>&#46; En el caso de nuestra paciente&#44; IFI descart&#243; p&#233;nfigo paraneopl&#225;sico y revel&#243; la presencia de ANA&#44; permiti&#233;ndonos realizar un diagn&#243;stico muy dif&#237;cil&#46; No hemos encontrado otros reportes acerca del uso de IFI en LEC de tipo NET&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">El diagn&#243;stico de LEC de tipo NET es dif&#237;cil&#46; La IFI puede resultar &#250;til para descartar AIBD y demostrar los ANA circulantes&#46;</p></span>"
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                  \t\t\t\t">IgM&#44; IgG y&#47;o IgA y dep&#243;sitos del complemento &#40;C3&#41; en la uni&#243;n dermoepid&#233;rmica&#46;&nbsp;\t\t\t\t\t\t\n
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CARTA CIENTÍFICO-CLÍNICA
Hallazgos de inmunofluorescencia indirecta en una paciente con lupus eritematoso cutáneo de tipo necrólisis epidérmica tóxica
Indirect Immunofluorescence Findings in a Patient with Toxic Epidermal Necrolysis-like Cutaneous Lupus Erythematosus
D. Morgado-Carrasco, J.M. Mascaró Jr
Corresponding author
jmmascaro_galy@ub.edu

Autor para correspondencia.
Departamento de Dermatología, Hospital Clínic, Universidad de Barcelona, Barcelona, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">El lupus eritematoso cut&#225;neo &#40;LEC&#41; de tipo necr&#243;lisis epid&#233;rmica t&#243;xica &#40;NET&#41; es una manifestaci&#243;n rara y potencialmente letal del LEC<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a>&#46; Su diagn&#243;stico es dif&#237;cil y no existe consenso sobre sus criterios diagn&#243;sticos&#46; Los diagn&#243;sticos diferenciales incluyen reacciones farmacol&#243;gicas adversas graves&#44; infecciones&#44; trastornos ampollosos autoinmunes &#40;AIBD&#41; y otras enfermedades vesiculobulosas asociadas con el lupus eritematoso &#40;LE&#41;&#44; tales como el s&#237;ndrome de Rowell y el LE sist&#233;mico buloso<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a>&#46; La inmunofluorescencia indirecta &#40;IFI&#41; puede ser extremadamente &#250;til para el diagn&#243;stico del AIBD<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a>&#44; aunque no existen reportes de su uso en el LE de tipo NET&#46; Presentamos el caso de una paciente con LE cut&#225;neo agudo de tipo NET &#40;LECA de tipo NET&#41; en el que la IFI fue crucial para el diagn&#243;stico&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Una mujer de 81 a&#241;os&#44; por lo dem&#225;s sana&#44; con antecedentes de alergia a penicilina y proca&#237;na acudi&#243; con astenia y lesiones cut&#225;neas dolorosas en t&#243;rax y espalda desde hac&#237;a tres d&#237;as&#44; que se extendieron a brazos y piernas&#46; No report&#243; fiebre&#44; tos ni artralgia&#46; Quince d&#237;as antes de la consulta hab&#237;a recibido tratamiento de doxilamina&#44; y hab&#237;a sido vacunada contra la gripe&#46; La paciente no recib&#237;a ninguna otra medicaci&#243;n&#46; El reconocimiento f&#237;sico revel&#243; m&#225;culas&#44; erosiones eritematosas poco definidas y coalescentes&#44; as&#237; como descamaci&#243;n de la piel en el t&#243;rax&#44; espalda <span class="elsevierStyleBold">&#40;</span><a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41; y extremidades&#46; El signo de Nikolsky fue positivo&#46; Se observaron erosiones m&#237;nimas en la lengua y el paladar duro&#44; no vi&#233;ndose afectada ninguna otra mucosa&#46; El examen histol&#243;gico revel&#243; necrosis epid&#233;rmica&#44; estrato c&#243;rneo normal e infiltrado linfoc&#237;tico perianexal y perivascular leve &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>A&#41;&#46; La inmunofluorescencia fue negativa&#46; Se realiz&#243; IFI utilizando es&#243;fago de mono y vejiga de rata para descartar p&#233;nfigo paraneopl&#225;sico&#46; El examen de vejiga de rata fue negativo y la IFI en es&#243;fago de mono no mostr&#243; tinci&#243;n de los espacios intercelulares o la membrana basal&#44; pero para nuestra sorpresa&#44; se hallaron anticuerpos antinucleares &#40;ANA&#41; IgG &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>B&#41;&#46; Estos resultados fueron posteriormente confirmados utilizando c&#233;lulas Hep2 que demostraron positividad para ANA con t&#237;tulos 1&#58;320&#46; Se realiz&#243; un panel completo para lupus que mostr&#243; positividad anti-Ro&#44; con resultados negativos para el resto de los ant&#237;genos &#40;dsDNA&#44; Sm&#44; La&#44; RNP&#41;&#46; El recuento sangu&#237;neo completo&#44; los par&#225;metros bioqu&#237;micos y las pruebas serol&#243;gicas para <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span> fueron normales o negativos&#46; Sobre la base de los hallazgos cl&#237;nicos&#44; histopatol&#243;gicos&#44; de laboratorio e IFI se diagnostic&#243; LE cut&#225;neo agudo de tipo NET&#46; La paciente no cumpli&#243; los criterios de clasificaci&#243;n del <span class="elsevierStyleItalic">American College of Rheumatology</span> para LE sist&#233;mico&#46; Fue ingresada inici&#225;ndose tratamiento con pomada t&#243;pica de triamcinolona al 0&#44;1&#37; con respuesta cl&#237;nica completa durante la semana siguiente&#46; Se realiz&#243; la prueba de parche con doxilamina &#40;concentraci&#243;n al 10 y 30&#37;&#59; veh&#237;culo&#58; vaselina&#41; transcurridos seis meses&#44; con resultados negativos&#46; La paciente permaneci&#243; sin lesiones cut&#225;neas durante los tres a&#241;os de seguimiento&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">La diferenciaci&#243;n entre LEC de tipo NET y AIBD es dif&#237;cil&#46; La incidencia de NET se incrementa en los pacientes de LE<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a>&#44; siendo LE o LEC la primera manifestaci&#243;n cl&#237;nica en el 35&#37; de los individuos con LEC de tipo NET<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a>&#46; El diagn&#243;stico de LEC de tipo NET se realiza muy frecuentemente de manera retrospectiva&#44; dada la complejidad de integrar los hallazgos cl&#237;nicos&#44; histol&#243;gicos y de laboratorio<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a>&#46; La presencia de lesiones fotodistribuidas&#44; compromiso mucoso m&#237;nimo&#44; ausencia de fiebre y mejor pron&#243;stico<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4&#44;5</span></a>&#44; junto con presencia histol&#243;gica de mucina&#44; infiltrado linfoc&#237;tico perivascular y perianexal&#44; presencia variable de melan&#243;fagos y dermatitis interfase vacuolar pueden sugerir un diagn&#243;stico de LECA de tipo NET<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2&#44;4</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#44; aunque estos hallazgos no se observan en todos los casos<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Las t&#233;cnicas de inmunofluorescencia son el criterio de referencia para el diagn&#243;stico de AIBD&#46; La IFI es un procedimiento complejo de dos pasos que detecta los anticuerpos en circulaci&#243;n en la sangre del paciente que utiliza piel humana normal&#44; piel con t&#233;cnica <span class="elsevierStyleItalic">salt-split</span>&#44; es&#243;fago de mono u otros sustratos &#40;vejiga de rata para p&#233;nfigo paraneopl&#225;sico&#41;&#44; dependiendo del diagn&#243;stico cl&#237;nico sospechado<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a>&#46; En el caso de nuestra paciente&#44; IFI descart&#243; p&#233;nfigo paraneopl&#225;sico y revel&#243; la presencia de ANA&#44; permiti&#233;ndonos realizar un diagn&#243;stico muy dif&#237;cil&#46; No hemos encontrado otros reportes acerca del uso de IFI en LEC de tipo NET&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">El diagn&#243;stico de LEC de tipo NET es dif&#237;cil&#46; La IFI puede resultar &#250;til para descartar AIBD y demostrar los ANA circulantes&#46;</p></span>"
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                  \t\t\t\t">IgM&#44; IgG y&#47;o IgA y dep&#243;sitos del complemento &#40;C3&#41; en la uni&#243;n dermoepid&#233;rmica&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">Inmunofluorescencia indirecta&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#191;Anticuerpos antinucleares IgG&#63;&nbsp;\t\t\t\t\t\t\n
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ISSN: 00017310
Original language: Spanish
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