Case for Diagnosis
Slow-growing Scaly Erythematous Plaque on the Face and Scalp of an Elderly Woman
Placa eritematodescamativa de lento crecimiento en la cara y el cuero cabelludo de una mujer anciana
Y. Torres Garcia, B. Escutia Muñoz, R. Botella Estrada
Corresponding author
Departamento de Dermatología, Hospital Universitario La Fe, Valencia, Spain
Read
6706
Timeswas read the article
2273
Total PDF
4433
Total HTML
Share statistics
array:24 [ "pii" => "S1578219013001807" "issn" => "15782190" "doi" => "10.1016/j.adengl.2013.02.009" "estado" => "S300" "fechaPublicacion" => "2013-10-01" "aid" => "829" "copyright" => "Elsevier España, S.L. and AEDV" "copyrightAnyo" => "2012" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "cor" "cita" => "Actas Dermosifiliogr. 2013;104:715-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1768 "formatos" => array:3 [ "EPUB" => 47 "HTML" => 1352 "PDF" => 369 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0001731013001282" "issn" => "00017310" "doi" => "10.1016/j.ad.2013.02.012" "estado" => "S300" "fechaPublicacion" => "2013-10-01" "aid" => "829" "copyright" => "Elsevier España, S.L. y AEDV" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "cor" "cita" => "Actas Dermosifiliogr. 2013;104:715-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2337 "formatos" => array:3 [ "EPUB" => 1 "HTML" => 1597 "PDF" => 739 ] ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Casos para el diagnóstico</span>" "titulo" => "Placa eritematodescamativa de lento crecimiento en la cara y el cuero cabelludo de una mujer anciana" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "715" "paginaFinal" => "716" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Slow-growing Scaly Erythematous Plaque on the Face and Scalp of an Elderly Woman" ] ] "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" => 450 "Ancho" => 736 "Tamanyo" => 151268 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxilina-eosina × 40.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Y. Torres Garcia, B. Escutia Muñoz, R. Botella Estrada" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Y." "apellidos" => "Torres Garcia" ] 1 => array:2 [ "nombre" => "B." "apellidos" => "Escutia Muñoz" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Botella Estrada" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1578219013001807" "doi" => "10.1016/j.adengl.2013.02.009" "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/S1578219013001807?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731013001282?idApp=UINPBA000044" "url" => "/00017310/0000010400000008/v1_201309240051/S0001731013001282/v1_201309240051/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S1578219013001819" "issn" => "15782190" "doi" => "10.1016/j.adengl.2013.03.007" "estado" => "S300" "fechaPublicacion" => "2013-10-01" "aid" => "831" "copyright" => "Elsevier España, S.L. and AEDV" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "cor" "cita" => "Actas Dermosifiliogr. 2013;104:717-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2203 "formatos" => array:3 [ "EPUB" => 44 "HTML" => 1662 "PDF" => 497 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case for Diagnosis</span>" "titulo" => "Smoker With Raynaud Phenomenon and Painful Nodules on the Legs" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "717" "paginaFinal" => "718" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fumador con fenómeno de Raynaud y nódulos dolorosos en las piernas" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 500 "Ancho" => 666 "Tamanyo" => 54584 ] ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.U. Floristán, R. Almodovar, F.J. Salamanca" "autores" => array:3 [ 0 => array:2 [ "nombre" => "M.U." "apellidos" => "Floristán" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Almodovar" ] 2 => array:2 [ "nombre" => "F.J." "apellidos" => "Salamanca" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731013001300" "doi" => "10.1016/j.ad.2013.03.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731013001300?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219013001819?idApp=UINPBA000044" "url" => "/15782190/0000010400000008/v1_201309240048/S1578219013001819/v1_201309240048/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1578219013001790" "issn" => "15782190" "doi" => "10.1016/j.adengl.2012.04.025" "estado" => "S300" "fechaPublicacion" => "2013-10-01" "aid" => "645" "copyright" => "Elsevier España, S.L. and AEDV" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2013;104:710-3" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4295 "formatos" => array:3 [ "EPUB" => 54 "HTML" => 3151 "PDF" => 1090 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Capillary Malformation-Arteriovenous Malformation Syndrome: A Report of 2 Cases, Diagnostic Criteria, and Management" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "710" "paginaFinal" => "713" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome malformaciones capilares-malformaciones arteriovenosas: presentación de 2 casos, claves diagnósticas y manejo" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1632 "Ancho" => 2468 "Tamanyo" => 227848 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Clinical characteristics of family 1. A, Arteriovenous malformation on the left upper limb of a 4-year-old girl. B-E, Multiple atypical capillary malformations detected on the upper and lower limbs. F and G, Large capillary malformations on the right breast (F) and on the right thigh and buttock (G) of the patient's mother.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Català, E. Roé, M. Vikkula, E. Baselga" "autores" => array:4 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Català" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Roé" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Vikkula" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Baselga" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731012002293" "doi" => "10.1016/j.ad.2012.04.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731012002293?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219013001790?idApp=UINPBA000044" "url" => "/15782190/0000010400000008/v1_201309240048/S1578219013001790/v1_201309240048/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case for Diagnosis</span>" "titulo" => "Slow-growing Scaly Erythematous Plaque on the Face and Scalp of an Elderly Woman" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "715" "paginaFinal" => "716" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Y. Torres Garcia, B. Escutia Muñoz, R. Botella Estrada" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Y." "apellidos" => "Torres Garcia" ] 1 => array:2 [ "nombre" => "B." "apellidos" => "Escutia Muñoz" ] 2 => array:4 [ "nombre" => "R." "apellidos" => "Botella Estrada" "email" => array:1 [ 0 => "botella_rafest@gva.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Dermatología, Hospital Universitario La Fe, Valencia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Placa eritematodescamativa de lento crecimiento en la cara y el cuero cabelludo de una mujer anciana" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 450 "Ancho" => 600 "Tamanyo" => 108432 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, ×400.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">An 89-year-old female with no known relevant medical history presented with an asymptomatic, scaly, erythematous, infiltrated plaque on the scalp and part of the face. The lesion had appeared about a year earlier and had gradually grown to its size at the time of presentation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient reported no systemic symptoms.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed a large, scaly, erythematous plaque on the left frontal and temporal region extending down to the left malar area and cheek. Areas of yellowish discoloration were observed in some parts of the lesion. Exophytic and keratotic lesions were present on the upper left side. There was no evidence of mucosal involvement and the patient's general condition was normal.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">At low magnification, a biopsy specimen from the edge of the lesion showed a slightly acanthotic and ulcerated but otherwise unremarkable epidermis as well as a granulomatous inflammatory infiltrate throughout the full thickness of the dermis and subcutaneous tissue. The granulomas had a lymphocytic corona (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Higher magnification revealed basophilic dot-like structures in the cytoplasm of many histiocytes (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) and Giemsa staining showed these structures to be cytoplasmic inclusion bodies without capsules.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">What Is Your Diagnosis?</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Chronic cutaneous leishmaniasis.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical Course</span><p id="par0035" class="elsevierStylePara elsevierViewall">Additional tests to rule out systemic involvement included a complete blood count, liver and kidney biochemistry, blood coagulation panel, chest radiograph, abdominal ultrasound, electrocardiogram, and serum anti–<span class="elsevierStyleItalic">Leishmania</span> immunoglobulins M and G, as well as urinary leishmanial antigen. Results were all normal or negative.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Further tests were carried out to rule out immune deficiency beyond that of advanced old age. Lymphocyte subpopulations, proteins, immunoglobulins, and serum immunofixation showed no significant abnormalities.</p><p id="par0045" class="elsevierStylePara elsevierViewall">With a confirmed diagnosis of cutaneous leishmaniasis, the extent and degree of progression of the lesion as well as the patient's overall health status led to the choice of miltefosine therapy. Pending hospital authorization of this off-label treatment, the patient was started on intramuscular meglumine antimoniate, which had to be withdrawn when she developed signs of heart failure.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Ultimately, the patient and her family decided to forgo any further treatment. No clinical recurrence has been observed so far.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Leishmaniasis is a zoonotic disease caused by a kinetoplastid protozoan of the <span class="elsevierStyleItalic">Leishmania</span> genus. This organism acts as an intracellular parasite of the mononuclear phagocytic system, and mammals are its reservoir hosts. In the Old World, leishmaniasis is transmitted by the bite of the female <span class="elsevierStyleItalic">Phlebotomus</span> sand fly. It is endemic to the Mediterranean basin. Clinical presentation may be cutaneous, mucocutaneous, or visceral. Manifestations vary according to the species involved (<span class="elsevierStyleItalic">L infantum</span> in the Mediterranean region) and to the patient's immune status prior to infection. Cutaneous signs range from the typical form, which consists of a centrally ulcerated papule, to extensive lesions or diffuse forms resulting from lymphatic or systemic spread.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Extensive skin manifestations, such as the present case, may necessitate differential diagnosis with lupus vulgaris, cutaneous sarcoidosis, or granuloma faciale. Diagnosis is confirmed either by the presence of amastigotes (Leishman-Donovan bodies) in histiocyte cytoplasm or by polymerase chain reaction, used particularly in cases where few amastigotes are present.</p><p id="par0065" class="elsevierStylePara elsevierViewall">These atypical, extensive cutaneous forms of leishmaniasis should be considered in immunodeficient as well as older patients. In recent years a number of cases of atypical cutaneous involvement have been described in patients undergoing treatment with anti–tumor necrosis factor biologic agents. Dermatologists should therefore consider the possibility of leishmaniasis in such cases even if clinical presentation does not otherwise suggest this diagnosis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">New therapeutic options for leishmaniasis are now available,<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> including topical treatments, such as imiquimod<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and photodynamic therapy, and some systemic therapies, such as miltefosine. Miltefosine is as effective as standard antimonial treatments and is less toxic.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of Interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:3 [ "identificador" => "sec0010" "titulo" => "Physical Examination" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] ] ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Clinical Course" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of Interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Torres Garcia Y, et al. Placa eritematodescamativa de lento crecimiento en la cara y el cuero cabelludo de una mujer anciana. Actas Dermosifiliogr. 2013;104:715–6.</p>" ] ] "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1000 "Ancho" => 730 "Tamanyo" => 106347 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 448 "Ancho" => 736 "Tamanyo" => 143866 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, ×40.</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" => 450 "Ancho" => 600 "Tamanyo" => 108432 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, ×400.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Leishmaniasis cutánea" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D. García-Almagro" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Actas Dermosifiliogr" "fecha" => "2005" "volumen" => "96" "paginaInicial" => "1" "paginaFinal" => "24" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16476327" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cutaneous leishmaniasis: Advances in disease pathogenesis, diagnostics and therapeutics" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M. Ameen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2230.2010.03851.x" "Revista" => array:6 [ "tituloSerie" => "Clin Exp Dermatol" "fecha" => "2010" "volumen" => "35" "paginaInicial" => "699" "paginaFinal" => "705" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20831602" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tumor necrosing factor alpha antagonist drugs and leishmaniasis in Europe" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P. Zanger" 1 => "I. Kötter" 2 => "P.G. Kremsner" 3 => "S. Gabrysch" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1469-0691.2011.03674.x" "Revista" => array:6 [ "tituloSerie" => "Clin Microbiol Infect" "fecha" => "2012" "volumen" => "18" "paginaInicial" => "670" "paginaFinal" => "676" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21985586" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Designing and reporting clinical trials on treatments for cutaneous leishmaniasis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "U. González" 1 => "M. Pinart" 2 => "L. Reveiz" 3 => "M. Rengifo-Pardo" 4 => "J. Tweed" 5 => "A. Macaya" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/655134" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2010" "volumen" => "51" "paginaInicial" => "409" "paginaFinal" => "419" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20624067" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Advances in the treatment of cutaneous leishmaniasis in the new world in the last ten years: A systematic literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "O.L. Almeida" 1 => "J.B. Santos" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "An Bras Dermatol" "fecha" => "2011" "volumen" => "86" "paginaInicial" => "497" "paginaFinal" => "506" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21738967" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Old world Leishmania infantum cutaneous leishmaniasis unresponsive to liposomal amphotericin B treated with topical imiquimod" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.A. Hervás" 1 => "A. Martín-Santiago" 2 => "D. Hervás" 3 => "E. Rojo" 4 => "A. Mena" 5 => "V. Rocamora" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/INF.0b013e31822dfbf7" "Revista" => array:6 [ "tituloSerie" => "Pediatr Infect Dis J" "fecha" => "2012" "volumen" => "31" "paginaInicial" => "97" "paginaFinal" => "100" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21829140" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010400000008/v1_201309240048/S1578219013001807/v1_201309240048/en/main.assets" "Apartado" => array:4 [ "identificador" => "6171" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Cases for Diagnosis" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010400000008/v1_201309240048/S1578219013001807/v1_201309240048/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219013001807?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 16 | 7 | 23 |
| 2024 October | 87 | 43 | 130 |
| 2024 September | 65 | 24 | 89 |
| 2024 August | 97 | 75 | 172 |
| 2024 July | 82 | 33 | 115 |
| 2024 June | 93 | 38 | 131 |
| 2024 May | 69 | 38 | 107 |
| 2024 April | 80 | 32 | 112 |
| 2024 March | 77 | 39 | 116 |
| 2024 February | 100 | 34 | 134 |
| 2024 January | 77 | 36 | 113 |
| 2023 December | 73 | 36 | 109 |
| 2023 November | 75 | 35 | 110 |
| 2023 October | 104 | 27 | 131 |
| 2023 September | 70 | 41 | 111 |
| 2023 August | 43 | 25 | 68 |
| 2023 July | 70 | 43 | 113 |
| 2023 June | 69 | 21 | 90 |
| 2023 May | 86 | 50 | 136 |
| 2023 April | 62 | 26 | 88 |
| 2023 March | 93 | 20 | 113 |
| 2023 February | 50 | 23 | 73 |
| 2023 January | 43 | 61 | 104 |
| 2022 December | 61 | 45 | 106 |
| 2022 November | 38 | 36 | 74 |
| 2022 October | 22 | 19 | 41 |
| 2022 September | 24 | 33 | 57 |
| 2022 August | 21 | 36 | 57 |
| 2022 July | 20 | 40 | 60 |
| 2022 June | 25 | 17 | 42 |
| 2022 May | 39 | 41 | 80 |
| 2022 April | 61 | 31 | 92 |
| 2022 March | 62 | 50 | 112 |
| 2022 February | 50 | 30 | 80 |
| 2022 January | 80 | 35 | 115 |
| 2021 December | 41 | 45 | 86 |
| 2021 November | 41 | 42 | 83 |
| 2021 October | 54 | 57 | 111 |
| 2021 September | 47 | 50 | 97 |
| 2021 August | 58 | 30 | 88 |
| 2021 July | 38 | 33 | 71 |
| 2021 June | 43 | 35 | 78 |
| 2021 May | 53 | 56 | 109 |
| 2021 April | 64 | 74 | 138 |
| 2021 March | 76 | 33 | 109 |
| 2021 February | 79 | 26 | 105 |
| 2021 January | 45 | 17 | 62 |
| 2020 December | 29 | 14 | 43 |
| 2020 November | 32 | 24 | 56 |
| 2020 October | 25 | 7 | 32 |
| 2020 September | 26 | 15 | 41 |
| 2020 August | 27 | 22 | 49 |
| 2020 July | 24 | 18 | 42 |
| 2020 June | 28 | 27 | 55 |
| 2020 May | 16 | 16 | 32 |
| 2020 April | 27 | 21 | 48 |
| 2020 March | 22 | 20 | 42 |
| 2020 February | 3 | 4 | 7 |
| 2020 January | 0 | 2 | 2 |
| 2019 December | 4 | 11 | 15 |
| 2019 November | 0 | 1 | 1 |
| 2019 October | 0 | 1 | 1 |
| 2019 September | 4 | 6 | 10 |
| 2019 August | 0 | 1 | 1 |
| 2019 July | 0 | 5 | 5 |
| 2019 June | 2 | 6 | 8 |
| 2019 May | 0 | 38 | 38 |
| 2019 April | 0 | 10 | 10 |
| 2019 March | 2 | 7 | 9 |
| 2019 February | 0 | 3 | 3 |
| 2019 January | 2 | 0 | 2 |
| 2018 December | 1 | 0 | 1 |
| 2018 November | 1 | 0 | 1 |
| 2018 October | 2 | 0 | 2 |
| 2018 September | 4 | 0 | 4 |
| 2018 March | 5 | 1 | 6 |
| 2018 February | 35 | 7 | 42 |
| 2018 January | 35 | 3 | 38 |
| 2017 December | 35 | 6 | 41 |
| 2017 November | 24 | 4 | 28 |
| 2017 October | 29 | 7 | 36 |
| 2017 September | 28 | 5 | 33 |
| 2017 August | 47 | 7 | 54 |
| 2017 July | 50 | 7 | 57 |
| 2017 June | 57 | 19 | 76 |
| 2017 May | 39 | 12 | 51 |
| 2017 April | 38 | 5 | 43 |
| 2017 March | 27 | 12 | 39 |
| 2017 February | 25 | 11 | 36 |
| 2017 January | 18 | 7 | 25 |
| 2016 December | 41 | 15 | 56 |
| 2016 November | 45 | 9 | 54 |
| 2016 October | 41 | 17 | 58 |
| 2016 September | 53 | 3 | 56 |
| 2016 August | 50 | 4 | 54 |
| 2016 July | 38 | 2 | 40 |
| 2016 June | 7 | 5 | 12 |
| 2016 May | 6 | 8 | 14 |
| 2016 April | 7 | 3 | 10 |
| 2016 March | 5 | 0 | 5 |
| 2016 February | 8 | 1 | 9 |
| 2016 January | 8 | 1 | 9 |
| 2015 December | 18 | 3 | 21 |
| 2015 November | 4 | 0 | 4 |
| 2015 October | 4 | 4 | 8 |
| 2015 September | 4 | 3 | 7 |
| 2015 August | 3 | 4 | 7 |
| 2015 July | 40 | 2 | 42 |
| 2015 June | 35 | 1 | 36 |
| 2015 May | 45 | 4 | 49 |
| 2015 April | 29 | 3 | 32 |
| 2015 March | 25 | 4 | 29 |
| 2015 February | 23 | 4 | 27 |
| 2015 January | 14 | 4 | 18 |
| 2014 December | 24 | 4 | 28 |
| 2014 November | 19 | 4 | 23 |
| 2014 October | 26 | 5 | 31 |
| 2014 September | 21 | 2 | 23 |
| 2014 August | 18 | 7 | 25 |
| 2014 July | 20 | 7 | 27 |
| 2014 June | 27 | 3 | 30 |
| 2014 May | 25 | 7 | 32 |
| 2014 April | 26 | 6 | 32 |
| 2014 March | 24 | 2 | 26 |
| 2014 February | 15 | 4 | 19 |
| 2014 January | 20 | 2 | 22 |
| 2013 December | 16 | 3 | 19 |
| 2013 November | 1 | 2 | 3 |
| 2013 October | 2 | 1 | 3 |
Show all
