Case Report
Erythema Nodosum Leprosum and Reversal Reaction in 2 Cases of Imported Leprosy
Eritema nudoso leproso y reacción de reversión en 2 casos de lepra importada
A. Pulido-Pérez
, M.D. Mendoza-Cembranos, J.A. Avilés-Izquierdo, R. Suárez-Fernández
Corresponding author
Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
Read
16324
Timeswas read the article
4113
Total PDF
12211
Total HTML
Share statistics
array:24 [ "pii" => "S1578219013002424" "issn" => "15782190" "doi" => "10.1016/j.adengl.2012.09.024" "estado" => "S300" "fechaPublicacion" => "2013-12-01" "aid" => "738" "copyright" => "Elsevier España, S.L. and AEDV" "copyrightAnyo" => "2011" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2013;104:915-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 5640 "formatos" => array:3 [ "EPUB" => 69 "HTML" => 4406 "PDF" => 1165 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0001731012004553" "issn" => "00017310" "doi" => "10.1016/j.ad.2012.09.009" "estado" => "S300" "fechaPublicacion" => "2013-12-01" "aid" => "738" "copyright" => "Elsevier España, S.L. and AEDV" "documento" => "article" "crossmark" => 0 "subdocumento" => "sco" "cita" => "Actas Dermosifiliogr. 2013;104:915-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 9486 "formatos" => array:3 [ "EPUB" => 3 "HTML" => 7729 "PDF" => 1754 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Caso clínico</span>" "titulo" => "Eritema nudoso leproso y reacción de reversión en 2 casos de lepra importada" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "915" "paginaFinal" => "919" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Erythema Nodosum Leprosum and Reversal Reaction in 2 Cases of Imported Leprosy" ] ] "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" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 669 "Ancho" => 900 "Tamanyo" => 235916 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Infiltrado linfocítico, neutrofílico e histiocitario en dermis profunda en un eritema nudoso leproso (H-E, ×40).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Pulido-Pérez, M.D. Mendoza-Cembranos, J.A. Avilés-Izquierdo, R. Suárez-Fernández" "autores" => array:4 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Pulido-Pérez" ] 1 => array:2 [ "nombre" => "M.D." "apellidos" => "Mendoza-Cembranos" ] 2 => array:2 [ "nombre" => "J.A." "apellidos" => "Avilés-Izquierdo" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Suárez-Fernández" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1578219013002424" "doi" => "10.1016/j.adengl.2012.09.024" "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/S1578219013002424?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731012004553?idApp=UINPBA000044" "url" => "/00017310/0000010400000010/v1_201311281152/S0001731012004553/v1_201311281152/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S1578219013002436" "issn" => "15782190" "doi" => "10.1016/j.adengl.2012.07.037" "estado" => "S300" "fechaPublicacion" => "2013-12-01" "aid" => "697" "copyright" => "Elsevier España, S.L. and AEDV" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2013;104:920-3" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3919 "formatos" => array:3 [ "EPUB" => 51 "HTML" => 2859 "PDF" => 1009 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Foreign Body Granulomatous Reaction to Silica, Silicone, and Hyaluronic Acid in a Patient With Interferon-Induced Sarcoidosis" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "920" "paginaFinal" => "923" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reacción granulomatosa a cuerpo extraño a sílice, silicona y ácido hialurónico, en paciente con sarcoidosis inducida por interferon" ] ] "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" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 645 "Ancho" => 1750 "Tamanyo" => 337580 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A, Histopathology of the left axillary lymph node showing widespread sarcoid granulomas (hematoxylin and eosin, original magnification, ×200). B, The center of the node contains clear vacuoles in the extracellular space and in the cytoplasm of multinucleated giant cells. Note the refractile material within these vacuoles (hematoxylin and eosin, original magnification, ×400).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "R. Novoa, M.A. Barnadas, X. Torras, R. Curell, A. Alomar" "autores" => array:5 [ 0 => array:2 [ "nombre" => "R." "apellidos" => "Novoa" ] 1 => array:2 [ "nombre" => "M.A." "apellidos" => "Barnadas" ] 2 => array:2 [ "nombre" => "X." "apellidos" => "Torras" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Curell" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Alomar" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731012003535" "doi" => "10.1016/j.ad.2012.07.007" "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/S0001731012003535?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219013002436?idApp=UINPBA000044" "url" => "/15782190/0000010400000010/v1_201311281142/S1578219013002436/v1_201311281142/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1578219013002412" "issn" => "15782190" "doi" => "10.1016/j.adengl.2013.05.003" "estado" => "S300" "fechaPublicacion" => "2013-12-01" "aid" => "864" "copyright" => "Elsevier España, S.L. and AEDV" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Actas Dermosifiliogr. 2013;104:904-14" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3643 "formatos" => array:3 [ "EPUB" => 52 "HTML" => 3002 "PDF" => 589 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Retrospective Study of the Clinical, Histologic, and Immunologic Features of Epidermolysis Bullosa Acquisita in 9 Patients" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "904" "paginaFinal" => "914" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estudio retrospectivo de las características clínicas, histológicas e inmunológicas en una serie de de 9 pacientes con epidermólisis ampollosa adquirida" ] ] "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" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1099 "Ancho" => 1480 "Tamanyo" => 271510 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">A, Inflammatory epidermolysis bullosa acquisita. B, Subepidermal blister. Hematoxylin-eosin, original magnification ×40. C, Significant inflammatory infiltrate with predominance of neutrophils and scant eosinophils. Hematoxylin-eosin, original magnification ×100.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Barreiro-Capurro, J.M. Mascaró-Galy, P. Iranzo" "autores" => array:3 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Barreiro-Capurro" ] 1 => array:2 [ "nombre" => "J.M." "apellidos" => "Mascaró-Galy" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "Iranzo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731013002524" "doi" => "10.1016/j.ad.2013.05.005" "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/S0001731013002524?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219013002412?idApp=UINPBA000044" "url" => "/15782190/0000010400000010/v1_201311281142/S1578219013002412/v1_201311281142/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Erythema Nodosum Leprosum and Reversal Reaction in 2 Cases of Imported Leprosy" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "915" "paginaFinal" => "919" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Pulido-Pérez, M.D. Mendoza-Cembranos, J.A. Avilés-Izquierdo, R. Suárez-Fernández" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Pulido-Pérez" "email" => array:1 [ 0 => "ana.pulido@madrimasd.net" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M.D." "apellidos" => "Mendoza-Cembranos" ] 2 => array:2 [ "nombre" => "J.A." "apellidos" => "Avilés-Izquierdo" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Suárez-Fernández" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Eritema nudoso leproso y reacción de reversión en 2 casos de lepra importada" ] ] "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" => 669 "Ancho" => 900 "Tamanyo" => 257951 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Lymphocytic, neutrophilic, and histiocytic infiltrate in the deep dermis in a patient with erythema nodosum leprosum (hematoxylin-eosin, original magnification ×40).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Hansen disease, or leprosy, is uncommon in Spain. It is no longer considered a public health problem in our country<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> and most new cases are imported from leprosy-endemic areas in Southeast Asia, South America, and Africa.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The virtual absence of autochthonous cases and the added difficulty of evaluating dermatological conditions in patients from other racial groups complicate the early diagnosis of leprosy.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Leprosy is characterized by a wide spectrum of clinical manifestations that affect the skin, the mucosas, the eyes, the organs, and/or the nerves. On occasions, its cardinal signs or symptoms may be masked by sudden clinical changes known as leprosy reactions,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> which are triggered by changes in immune response.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> Multiple factors are involved in the development of leprosy reactions, but commencement of specific leprosy treatment is a factor in a considerable number of cases.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We describe 2 cases of type 1 and type 2 leprosy reactions in patients with previously undiagnosed leprosy that illustrate the diagnostic challenges in such cases.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Descriptions</span><p id="par0020" class="elsevierStylePara elsevierViewall">The first patient, a 25-year-old woman from Brazil who had been living in Spain for 6 months, visited the emergency department with high fever (up to 39<span class="elsevierStyleHsp" style=""></span>°C), general malaise, watery rhinorrhea, and painful, erythematous nodules located predominantly on the limbs (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The manifestations had started the previous week, but the patient had experienced similar lesions—which cleared spontaneously—on several occasions in the previous 3 months. Blood tests revealed a normocytic, normochromic anemia, leukocytosis with neutrophilia, mild elevation of the tranaminases, and considerably increased serum levels of immunoglobulin G. The ear, nose, and throat examination confirmed mucosal edema in the paranasal sinuses. The skin examination revealed multiple, asymptomatic brownish papules symmetrically distributed on the legs and the arches of the soles that were clinically diagnosed as lepromas. There were also purple nonulcerated papules on the distal third of the toes (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The path of the right common peroneal nerve was thickened and electromyography demonstrated a severe sensory-motor neuropathy. Biopsy of a nodule showed a diffuse inflammatory infiltrate in the deep dermis and subcutaneous tissue composed of lymphocytes, neutrophils and histiocytes with vacuolated cytoplasm (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The neutrophils exhibited marked tropism for the walls of the small dermal vessels but there was no evidence of fibrinoid necrosis. Ziehl-Neelsen staining showed acid-alcohol-fast bacilli (AAFB) within the histiocytes. A slit-skin smear taken from the earlobe, elbow, and a brownish papule on the leg showed 10 AAFB in one 100× microscope field (bacterial index, 3+). The diagnosis was erythema nodosum leprosum in a patient with subpolar lepromatous leprosy. Multiple drug therapy (MDT) was initiated following the regimen recommended by the World Health Organization for patients with multibacillary leprosy (rifampicin, clofazimine, and dapsone) in combination with oral corticosteroids (prednisone, 1<span class="elsevierStyleHsp" style=""></span>mg/kg/d). The nodules, fever, and general malaise all resolved. However, when the corticosteroid dose was reduced to 0.5<span class="elsevierStyleHsp" style=""></span>mg/kg/d, the patient experienced a new episode of nodules and fever that required treatment with thalidomide (150<span class="elsevierStyleHsp" style=""></span>mg/d). The response was complete.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The second patient was a 38-year-old man, born in the Philippine Islands and resident in Spain for 4 months, who visited the emergency department following the sudden worsening of annular skin lesions that had developed initially on the face and been treated in the patient's country of origin a year earlier. There was no fever or other systemic symptoms. The patient was questioned further but could not remember what treatment he had received or for how long. Physical examination showed erythematous, edematous plaques that were neither painful nor hot and were located on the lesions initially described by the patient (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). There was also a striking alteration of the nasal pyramid due to a road traffic accident. The neurological examination revealed moderate hypoesthesia in the area of a scaly plaque on the right leg. Two biopsies were taken: one from an erythematous, edematous plaque on the face and the other from the scaly plaque on the right leg. Multiple noncaseating granulomas surrounded by a crown of lymphocytes and located mainly around the nerves and the skin appendages were visible in both lesions, together with edema of the superficial and deep dermis. Skin-smear examination of a facial plaque showed a low bacillary load (2+) of AAFB. The diagnosis was a type 1 reaction in a patient with borderline leprosy. We initiated treatment with corticosteroids (prednisone, 0.5<span class="elsevierStyleHsp" style=""></span>mg/kg/d), which led to a gradual improvement, plus MDT (rifampicin, clofazimine, and dapsone) for 12 months in view of the little information available on previous treatments.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Leprosy reactions are sudden changes in the clinical condition of patients diagnosed with leprosy.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> They typically occur in patients with immunologically unstable forms of leprosy, but no clinical predictors have been identified to date. These clinical conditions, which are defined according to the Ridley-Jopling classification,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> fall within the spectrum of clinical, microbiologic, histologic, and immunologic manifestations that occur between the 2 extremes, or poles, of leprosy: at one end, tuberculoid or paucibacillary leprosy and at the other, lepromatous or multibacillary leprosy (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The factors involved in the development of these states disrupt the balance between the mycobacteria and the host's immune system. Examples of triggers that alter the immune state are adrenal gland insufficiency, stress, intercurrent infections, pregnancy, and, in particular, specific leprosy treatment.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Classically, there are 2 types of type 1 leprosy reactions: an upgrading, or reversal, reaction and a downgrading reaction.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Downgrading reactions are assumed to represent a shift towards the lepromatous (multibacillary) pole of the disease and are correlated with a decrease in cellular immune response. Reversal reactions, by contrast, are seen in patients who have received treatment and experience an increase in immune response. Type 1 reversal reactions are considered to be a delayed hypersensitivity reaction (or type IV reaction according to the Gell and Coombs classification), involving augmented type 1 helper T-cell response.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> Clinically, pre-existing lesions become inflamed and there is considerable exacerbation of neurological manifestations (polyneuritis with marked inflammation of the nerves). Patients may sometimes develop new lesions and general malaise, usually due to the sudden neurological deterioration. Treatment includes rest and systemic corticosteroids.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Type 2 leprosy reactions are essentially due to a type III hypersensitivity reaction, mediated by circulating immune complexes formed by antibodies binding to antigens. These complexes cannot be cleared by the kidneys or phagocytized by macrophages and therefore deposit on the vessel walls.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The release of inflammatory cytokines and the subsequent recruitment of neutrophils contribute to the development of characteristic clinical manifestations that vary according to the organ involved. When the skin is affected patients develop painful inflammatory nodules (a condition known as erythema nodosum leprosum as it is not an inflammatory process occurring within the septa of the subcutaneous tissue), necrotic areas (Lucio phenomenon), or plaques resembling erythema multiforme. Patients may also develop neuritis, with palpable, painful enlargement of the affected nerves.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Treatment includes rest, acetylsalicylic acid, pentoxifylline, systemic corticosteroids, and clofazimine. However, thalidomide (100-300<span class="elsevierStyleHsp" style=""></span>mg/d) remains the treatment of choice in recurrent cases because it is well tolerated and maintains prolonged remission.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a> Women of childbearing age receiving this drug must be warned to use effective contraception.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Early diagnosis of leprosy reactions is very important. While these reactions are uncommon in our setting, a late diagnosis can lead to irreversible nerve damage and severe functional impairment.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical Disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of humans and animals</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that no tests were carried out in humans or animals for the purpose of this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data appear in this article.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data appear in this article.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of Interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres295317" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec279238" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres295316" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec279237" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case Descriptions" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of humans and animals" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-12-08" "fechaAceptado" => "2012-09-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec279238" "palabras" => array:5 [ 0 => "Leprosy" 1 => "Hansen disease" 2 => "Vasculitis" 3 => "Thalidomide" 4 => "Neuropathy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec279237" "palabras" => array:5 [ 0 => "Lepra" 1 => "Enfermedad de Hansen" 2 => "Vasculitis" 3 => "Talidomida" 4 => "Neuropatía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Leprosy reactions, which are abrupt changes in the clinical condition of patients with immunologically unstable forms of the disease, can mask the cardinal signs of leprosy, delaying both diagnosis and treatment. The main complications that arise from delayed diagnosis reflect the characteristic features of the disease, involving impaired nerve function and both local (ulcers, pyogenic infection, osteomyelitis) and systemic compromise. Thorough clinical examination, sensory testing, and, where necessary, histopathology and microbiology, are essential when leprosy is suspected. Rapid initiation of anti-inflammatory treatment reduces the risk of functional impairment, the main concern in leprosy. We describe type 1 and type 2 leprosy reactions in 2 patients who had not yet been diagnosed with the disease.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las leprorreacciones suponen cambios clínicos de inicio súbito en los pacientes que presentan formas inmunológicamente inestables de la enfermedad de Hansen. Estos cuadros pueden enmascarar los signos cardinales de la misma y demorar así su diagnóstico y tratamiento. Las principales complicaciones derivadas de este retraso son las relacionadas con el compromiso neural, local (ulceraciones, piodermitis, osteomielitis…) y/o sistémico característico de estos cuadros. Ante su sospecha debe realizarse un minucioso examen clínico, exploración de la sensibilidad y, cuando se precise, estudio histopatológico y microbiológico. La instauración inmediata de tratamiento antiinflamatorio disminuye el riesgo de secuelas funcionales, principal causa de morbilidad en la lepra. A continuación, se presentan dos casos de leprorreacciones de tipo I y II en pacientes no diagnosticados hasta ese momento de enfermedad de Hansen.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pulido-Pérez A, Mendoza-Cembranos MD, Avilés-Izquierdo JA, Suárez-Fernández R. Eritema nudoso leproso y reacción de reversión en 2 casos de lepra importada. Actas Dermosifiliogr. 2013;104:915–919.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 796 "Ancho" => 900 "Tamanyo" => 100000 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Erythematous nodules affecting both thighs of a patient with erythema nodosum leprosum (type 2 leprosy reaction).</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" => 860 "Ancho" => 900 "Tamanyo" => 112305 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Distal purpuric lesions in a patient with erythema nodosum leprosum (type 2 leprosy reaction).</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" => 669 "Ancho" => 900 "Tamanyo" => 257951 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Lymphocytic, neutrophilic, and histiocytic infiltrate in the deep dermis in a patient with erythema nodosum leprosum (hematoxylin-eosin, original magnification ×40).</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" => 933 "Ancho" => 900 "Tamanyo" => 156609 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Erythematous, edematous facial plaques in a patient with a type 1 leprosy reaction.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: BB, mid-borderline leprosy; BL, borderline lepromatous leprosy; LL<span class="elsevierStyleInf">s</span>, subpolar lepromatous leprosy; NSAIDs, nonsteroidal anti-inflammatory drugs; TT<span class="elsevierStyleInf">s</span>, subpolar tuberculoid leprosy.</p>" "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"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Type 1 Reactions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Type 2 Reactions \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Immune response \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type 1 helper cells \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type 2 helper cells \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pathogenesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type IV (delayed cell-mediated) hypersensitivity reaction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type III hypersensitivity reaction (immune complex formation and deposition) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical subtypes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TT<span class="elsevierStyleInf">S</span>, BT, BB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BL, LL<span class="elsevierStyleInf">S</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Host \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Previous treatment (except in downgrading reactions) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Previous treatment or not \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Types \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reversal reactionDowngrading reaction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Erythema nodosum leprosumLucio phenomenonErythema multiforme-like reaction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cutaneous manifestations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Edema of previous lesionsIncrease in distal scalingNerve involvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NodulesNecrotic areasPolymorphous erythematous plaquesNerve involvement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Histopathology (changes with respect to conventional histologic findings) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tuberculoid granulomasDermal edema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neutrophilic infiltrate in the mid and deep dermis and subcutaneous cellular tissueLeukocytoclastic vasculitis of the small and medium vessels \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RestNSAIDsSystemic corticosteroids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RestAcetylsalicylic acid, pentoxifyllineSystemic corticosteroidsClofazimineThalidomide \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab430520.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Characteristics of Type 1 and 2 Leprosy<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15–17</span></a> Reactions.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Historia de la lepra en España" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.T. De las Aguas" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Piel" "fecha" => "2005" "volumen" => "20" "paginaInicial" => "485" "paginaFinal" => "497" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Factors contributing to the decline of leprosy in Spain in the second half of the twentieth century" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.L. Alfonso" 1 => "F.A. Vich" 2 => "J.J. Vilata" 3 => "J.T. de las Aguas" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Int J Lepr Other Mycobact Dis" "fecha" => "2005" "volumen" => "73" "paginaInicial" => "258" "paginaFinal" => "268" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16830635" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0015028207010308" "estado" => "S300" "issn" => "00150282" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Vigilancia de la lepra. Situación en el mundo y en España" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E. Rodríguez" 1 => "O. Díaz" 2 => "G. Hernández" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Bol Epidemiol Semanal" "fecha" => "2010" "volumen" => "18" "paginaInicial" => "201" "paginaFinal" => "212" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infecciones cutáneas por micobacterias" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P. Lázaro-Ochaita" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "Dermatología: texto y atlas" "paginaInicial" => "177" "paginaFinal" => "198" "serieFecha" => "2003" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The continuing challenges of leprosy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D.M. Scollard" 1 => "L.B. Adams" 2 => "T.P. Gillis" 3 => "J.L. Krahenbuhl" 4 => "R.W. Truman" 5 => "D.L. Williams" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1128/CMR.19.2.338-381.2006" "Revista" => array:6 [ "tituloSerie" => "Clin Microbiol Rev" "fecha" => "2006" "volumen" => "19" "paginaInicial" => "338" "paginaFinal" => "381" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16614253" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Imunopatologia da hanseníase: a complexidade dos mecanismos da resposta imune do hospedeiro ao Mycobacterium leprae" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "I.M. Goulart" 1 => "G.O. Penna" 2 => "G. Cunha" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Soc Bras Med Trop" "fecha" => "2002" "volumen" => "35" "paginaInicial" => "365" "paginaFinal" => "375" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12170333" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Features of the Ridley-Jopling classification and its application in the clinical field" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "S.K. Kundu" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Int J Lepr Other Mycobact Dis" "fecha" => "1979" "volumen" => "47" "paginaInicial" => "64" "paginaFinal" => "65" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/571855" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Association between leprosy reactions after treatment and bacterial load evaluated using anti PGL-I serology and bacilloscopy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.F. Brito" 1 => "R.A. Ximenes" 2 => "M.E. Gallo" 3 => "S. Bührer-Sékula" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Soc Bras Med Trop" "fecha" => "2008" "volumen" => "41" "paginaInicial" => "67" "paginaFinal" => "72" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19618079" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Leprosy type 1 (reversal) reactions and their management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.L. Walker" 1 => "D.N. Lockwood" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Lepr Rev" "fecha" => "2008" "volumen" => "79" "paginaInicial" => "372" "paginaFinal" => "386" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19274984" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Development of leprosy and type 1 leprosy reactions after treatment with infliximab: a report of 2 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D.M. Scollard" 1 => "M.P. Joyce" 2 => "T.P. Gillis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/505222" "Revista" => array:7 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2006" "volumen" => "43" "paginaInicial" => "e19" "paginaFinal" => "e22" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16779736" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0015028203011889" "estado" => "S300" "issn" => "00150282" ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Erythema nodosum leprosum: reactional leprosy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Cuevas" 1 => "J.L. Rodríguez-Peralto" 2 => "R. Carrillo" 3 => "F. Contreras" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.sder.2007.02.010" "Revista" => array:6 [ "tituloSerie" => "Semin Cutan Med Surg" "fecha" => "2007" "volumen" => "26" "paginaInicial" => "126" "paginaFinal" => "130" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17544965" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical course of erythema nodosum leprosum: an 11-year cohort study in Hyderabad, India" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Pocaterra" 1 => "S. Jain" 2 => "R. Reddy" 3 => "S. Muzaffarullah" 4 => "O. Torres" 5 => "S. Suneetha" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Trop Med Hyg" "fecha" => "2006" "volumen" => "74" "paginaInicial" => "868" "paginaFinal" => "879" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16687695" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Interventions for erythema nodosum leprosum. A Cochrane review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "N.H. Van Veen" 1 => "D.N. Lockwood" 2 => "W.H. Van Brakel" 3 => "J. Ramirez Jr." 4 => "J.H. Richardus" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Lepr Rev" "fecha" => "2009" "volumen" => "80" "paginaInicial" => "355" "paginaFinal" => "372" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20306635" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Nash J, editor. ILEP technical bulletin: Management of erythema nodosum leprosum. 18th Meeting of the ILEP Technical Commission; 2011, October 11; London: International Federation of Anti-Leprosy Associations; 2011." ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Langerhans cells in skin lesions of leprosy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "B. Azadeh" 1 => "S. Dabiri" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Iran J Med Sci" "fecha" => "2004" "volumen" => "29" "paginaInicial" => "51" "paginaFinal" => "55" ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multibacillary leprosy: lesions with macrophages positive for S100 protein and dendritic cells positive for Factor 13<span class="elsevierStyleSup">a</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Cuevas-Santos" 1 => "F. Contreras" 2 => "S. McNutt" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Cutan Pathol" "fecha" => "1998" "volumen" => "25" "paginaInicial" => "530" "paginaFinal" => "537" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9870671" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The histological diagnosis of leprosy type 1 reactions: identification of key variables and an analysis of the process of histological diagnosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "D.N. Lockwood" 1 => "S.B. Lucas" 2 => "K.V. Desikan" 3 => "G. Ebenezer" 4 => "S. Suneetha" 5 => "P. Nicholls" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/jcp.2007.053389" "Revista" => array:6 [ "tituloSerie" => "J Clin Pathol" "fecha" => "2008" "volumen" => "61" "paginaInicial" => "595" "paginaFinal" => "600" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18326022" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010400000010/v1_201311281142/S1578219013002424/v1_201311281142/en/main.assets" "Apartado" => array:4 [ "identificador" => "6183" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010400000010/v1_201311281142/S1578219013002424/v1_201311281142/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219013002424?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 13 | 27 |
| 2024 October | 142 | 179 | 321 |
| 2024 September | 175 | 42 | 217 |
| 2024 August | 221 | 71 | 292 |
| 2024 July | 200 | 54 | 254 |
| 2024 June | 176 | 45 | 221 |
| 2024 May | 206 | 50 | 256 |
| 2024 April | 161 | 47 | 208 |
| 2024 March | 204 | 33 | 237 |
| 2024 February | 185 | 38 | 223 |
| 2024 January | 124 | 44 | 168 |
| 2023 December | 149 | 35 | 184 |
| 2023 November | 170 | 44 | 214 |
| 2023 October | 121 | 40 | 161 |
| 2023 September | 122 | 43 | 165 |
| 2023 August | 116 | 70 | 186 |
| 2023 July | 128 | 106 | 234 |
| 2023 June | 146 | 44 | 190 |
| 2023 May | 188 | 56 | 244 |
| 2023 April | 174 | 46 | 220 |
| 2023 March | 170 | 38 | 208 |
| 2023 February | 177 | 40 | 217 |
| 2023 January | 149 | 45 | 194 |
| 2022 December | 132 | 32 | 164 |
| 2022 November | 112 | 45 | 157 |
| 2022 October | 89 | 56 | 145 |
| 2022 September | 69 | 54 | 123 |
| 2022 August | 49 | 51 | 100 |
| 2022 July | 78 | 49 | 127 |
| 2022 June | 65 | 28 | 93 |
| 2022 May | 177 | 69 | 246 |
| 2022 April | 207 | 87 | 294 |
| 2022 March | 172 | 87 | 259 |
| 2022 February | 158 | 70 | 228 |
| 2022 January | 193 | 100 | 293 |
| 2021 December | 151 | 90 | 241 |
| 2021 November | 132 | 68 | 200 |
| 2021 October | 178 | 85 | 263 |
| 2021 September | 136 | 58 | 194 |
| 2021 August | 128 | 50 | 178 |
| 2021 July | 183 | 82 | 265 |
| 2021 June | 182 | 64 | 246 |
| 2021 May | 175 | 55 | 230 |
| 2021 April | 397 | 61 | 458 |
| 2021 March | 186 | 50 | 236 |
| 2021 February | 144 | 35 | 179 |
| 2021 January | 106 | 45 | 151 |
| 2020 December | 87 | 28 | 115 |
| 2020 November | 73 | 22 | 95 |
| 2020 October | 79 | 25 | 104 |
| 2020 September | 65 | 17 | 82 |
| 2020 August | 53 | 26 | 79 |
| 2020 July | 54 | 19 | 73 |
| 2020 June | 57 | 30 | 87 |
| 2020 May | 55 | 35 | 90 |
| 2020 April | 36 | 23 | 59 |
| 2020 March | 24 | 22 | 46 |
| 2020 February | 6 | 8 | 14 |
| 2020 January | 0 | 7 | 7 |
| 2019 December | 0 | 8 | 8 |
| 2019 November | 0 | 5 | 5 |
| 2019 October | 0 | 6 | 6 |
| 2019 September | 0 | 10 | 10 |
| 2019 August | 0 | 8 | 8 |
| 2019 July | 0 | 15 | 15 |
| 2019 June | 0 | 20 | 20 |
| 2019 May | 1 | 35 | 36 |
| 2019 April | 0 | 66 | 66 |
| 2019 March | 0 | 11 | 11 |
| 2019 February | 1 | 9 | 10 |
| 2019 January | 5 | 7 | 12 |
| 2018 December | 0 | 9 | 9 |
| 2018 November | 3 | 7 | 10 |
| 2018 October | 4 | 0 | 4 |
| 2018 September | 9 | 2 | 11 |
| 2018 August | 0 | 15 | 15 |
| 2018 July | 0 | 17 | 17 |
| 2018 June | 0 | 26 | 26 |
| 2018 May | 0 | 9 | 9 |
| 2018 April | 0 | 1 | 1 |
| 2018 March | 4 | 3 | 7 |
| 2018 February | 141 | 25 | 166 |
| 2018 January | 134 | 25 | 159 |
| 2017 December | 162 | 27 | 189 |
| 2017 November | 120 | 21 | 141 |
| 2017 October | 89 | 17 | 106 |
| 2017 September | 95 | 19 | 114 |
| 2017 August | 133 | 27 | 160 |
| 2017 July | 120 | 17 | 137 |
| 2017 June | 147 | 50 | 197 |
| 2017 May | 129 | 31 | 160 |
| 2017 April | 107 | 24 | 131 |
| 2017 March | 92 | 25 | 117 |
| 2017 February | 95 | 24 | 119 |
| 2017 January | 81 | 18 | 99 |
| 2016 December | 107 | 13 | 120 |
| 2016 November | 176 | 22 | 198 |
| 2016 October | 215 | 22 | 237 |
| 2016 September | 300 | 26 | 326 |
| 2016 August | 262 | 25 | 287 |
| 2016 July | 113 | 18 | 131 |
| 2016 June | 9 | 15 | 24 |
| 2016 May | 7 | 20 | 27 |
| 2016 April | 3 | 2 | 5 |
| 2016 March | 10 | 14 | 24 |
| 2016 February | 15 | 22 | 37 |
| 2016 January | 7 | 1 | 8 |
| 2015 December | 5 | 14 | 19 |
| 2015 November | 9 | 2 | 11 |
| 2015 October | 6 | 29 | 35 |
| 2015 September | 7 | 2 | 9 |
| 2015 August | 5 | 2 | 7 |
| 2015 July | 144 | 13 | 157 |
| 2015 June | 91 | 12 | 103 |
| 2015 May | 76 | 27 | 103 |
| 2015 April | 56 | 12 | 68 |
| 2015 March | 113 | 16 | 129 |
| 2015 February | 118 | 14 | 132 |
| 2015 January | 71 | 11 | 82 |
| 2014 December | 60 | 27 | 87 |
| 2014 November | 71 | 4 | 75 |
| 2014 October | 69 | 7 | 76 |
| 2014 September | 44 | 8 | 52 |
| 2014 August | 49 | 13 | 62 |
| 2014 July | 77 | 17 | 94 |
| 2014 June | 73 | 17 | 90 |
| 2014 May | 61 | 16 | 77 |
| 2014 April | 48 | 9 | 57 |
| 2014 March | 73 | 15 | 88 |
| 2014 February | 51 | 8 | 59 |
| 2014 January | 98 | 8 | 106 |
| 2013 December | 34 | 15 | 49 |
Show all
