Case and Research Letter
Lichenoid Graft-vs-Host Disease With Exclusively Cutaneous Involvement After Liver Transplant
Enfermedad injerto contra huésped liquenoide tras trasplante hepático con afectación exclusivamente cutánea
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Placas eritematovioláceas liquenoides distribuidas sobre los miembros inferiores. B). Detalle de placas liquenoides con componente necrótico en el dorso del pie. C). Pápulas blanquecinas dispuestas en empedrado en la mucosa yugal.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Sanz-Bueno, G. Pérez-Rial, M. Castellanos, F. Vanaclocha" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Sanz-Bueno" ] 1 => array:2 [ "nombre" => "G." "apellidos" => "Pérez-Rial" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Castellanos" ] 3 => array:2 [ "nombre" => "F." 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Recurrence of psoriasis 30 weeks after initiation of ustekinumab (PASI, 9.8). B, Patient 1. PASI 75 after combining 17 sessions of narrowband UV-B therapy (12.9<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span>) with ustekinumab (PASI, 2.1). PASI indicates Psoriasis Area and Severity Index.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Soro Martínez, I. Belinchón Romero, M.P. Arribas Granados" "autores" => array:3 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Soro Martínez" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Belinchón Romero" ] 2 => array:2 [ "nombre" => "M.P." 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Respuesta al tratamiento combinado con crioterapia y terbinafina" ] ] "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" => 650 "Ancho" => 976 "Tamanyo" => 81953 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Firm contiguous plaques with crusted areas on a erythematous base and a larger area with a scar-like appearance.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Bassas-Vila, M.J. Fuente, R. Guinovart, C. Ferrándiz" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Bassas-Vila" ] 1 => array:2 [ "nombre" => "M.J." "apellidos" => "Fuente" ] 2 => array:2 [ "nombre" => "R." 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Sanz-Bueno, G. Pérez-Rial, M. Castellanos, F. Vanaclocha" "autores" => array:4 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Sanz-Bueno" "email" => array:1 [ 0 => "jsanzbueno@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "G." "apellidos" => "Pérez-Rial" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Castellanos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "F." "apellidos" => "Vanaclocha" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina del Aparato Digestivo, Hospital Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Enfermedad injerto contra huésped liquenoide tras trasplante hepático con afectación exclusivamente cutánea" ] ] "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" => 1050 "Ancho" => 1400 "Tamanyo" => 529635 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Hyperkeratosis with parakeratosis, vacuolization of the basal layer of the epidermis, necrosis of keratinocytes and lymphocytic infiltrate in the dermis (hematoxylin-eosin, original magnification ×10). B, Detail of histologic image showing hair follicle with keratinocyte necrosis (hematoxylin-eosin, original magnification ×40).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">While graft-vs-host disease (GVHD) is a common complication in bone marrow transplantation, it is rare in liver transplantation, with an estimated incidence of around 1% or 2%.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Since GVHD was first described in a liver-transplant recipient in 1988,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> approximately 80 cases have been reported and the vast majority of these have been acute cases. We present a case of chronic lichenoid GVHD in a liver-transplant recipient that presented with exclusively cutaneous involvement and mixed chimerism observed in skin but not peripheral blood samples.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient, a 70-year-old man, had undergone a cadaveric liver transplant for cirrhosis due to hepatitis C virus infection. The crossmatch results were negative. The HLA of the donor was *1 A*68 B*39 B*39 DRB1*17 DRB1 *17 while that of the recipient was A*1 A*1 B*35 B*78 DRB1*13 DRB1*13. The patient was started on immunosuppressive treatment with tacrolimus and prednisone and was also prescribed ranitidine for gastric protection. On day 16 posttransplant, he developed an asymptomatic centrifugal maculopapular rash. The blood test results were normal and serology for cytomegalovirus, Epstein-Barr virus, and parvovirus B19 were negative for acute infection. A drug-induced reaction was therefore suspected and the skin biopsy findings were consistent with this hypothesis. Ranitidine was identified as the most probable cause and withdrawn; prednisone doses were increased to 1<span class="elsevierStyleHsp" style=""></span>mg/kg/d, but no improvement was observed. A liver biopsy showed nonspecific inflammation and there was no evidence of rejection or GVHD. The patient's condition continued to worsen over the weeks. On day 122, multiple lichenoid plaques with a necrotic component covered a large area of his body (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B) and there were also whitish papules in a cobblestone pattern on the oral mucosa (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). Repeated skin biopsies showed interface dermatitis, a perivascular infiltrate in the dermis, and necrosis of keratinocytes in the epidermis and hair follicle (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Analysis of peripheral blood was negative for chimerism, but mixed chimerism (90% donor cells) was detected in the affected skin. Following the diagnosis of GVHD, immunosuppressive therapy was intensified; the patient was administered prednisone 1.5<span class="elsevierStyleHsp" style=""></span>mg/kg/d and tacrolimus to maintain blood levels at 10-12<span class="elsevierStyleHsp" style=""></span>ng/mL, but lesions continue to appear. The patient did not develop diarrhea, cytopenia, or any other systemic symptoms during the course of the disease, and we therefore did not test for GVHD in other organs. On day 180, the patient died of disseminated invasive aspergillosis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Chronic GVHD typically appears either de novo or following recovery from acute GVHD. Only Yilmaz et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> described a similar case to ours, in which acute GVHD progressed to chronic GVHD without a quiescent phase. It is difficult to determine the incidence of acute and chronic GVHD as their clinical and histologic findings overlap<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and the chronological criterion that establishes that acute GVHD occurs within 100 days of transplantation and that chronic GVHD occurs afterwards is insufficient. Lymphoid cells in the transplanted liver are responsible for the immune attack on the host's tissues. The skin, bone marrow, and digestive system are the most common targets. Unlike the situation with hematopoietic cell transplantation, the liver is not a target in this case as it is the engrafted organ. The lymphocytes reach peak levels a week after transplantation, but then become undetectable in the recipient's blood.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The coexistence of donor and host cell populations is known as mixed chimerism and it has been associated with the development of GVHD. Chimerism is detected by polymerase chain reaction, which is a highly sensitive method that can detect donor polymorphisms in host tissue with a sensitivity of up to 0.1%.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In our patient, we tested peripheral blood for chimerism on 2 separate occasions, but the results were negative. We did, however, observe a high rate of donor lymphocytes in lesional skin, suggesting an attack by the immune system. To our knowledge, this is the first time these cells have been described in target tissue without also being present in peripheral blood. We do not know if earlier tests would have detected lymphocytes in peripheral blood, that is, before they had reached the tissues. Cutaneous involvement has been reported in most cases of chronic GVHD in the literature (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), but only 3 of these described a lichenoid pattern.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4,7</span></a> Chimerism in the skin was not tested in any of the cases. Diagnosis of GVHD after liver transplantation is frequently delayed because the condition is rare and has nonspecific signs and symptoms that may be confused with those seen in drug-induced reactions or viral infections. Furthermore, the histology findings are practically indistinguishable from those seen in drug-induced reactions, particularly in the early stages of disease. We would like to stress that chimerism testing in both peripheral blood and affected tissue is a valuable diagnostic tool in GVHD, a potentially fatal disease.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sanz-Bueno J, Pérez-Rial G, Castellanos M, Vanaclocha F. Enfermedad injerto contra huésped liquenoide tras trasplante hepático con afectación exclusivamente cutánea. Actas Dermosifiliogr. 2014;105:198–200.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 896 "Ancho" => 1300 "Tamanyo" => 262076 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Erythematous violaceous lichenoid plaques covering the patient's legs. B, Detail of lichenoid plaques with a necrotic component on the dorsal aspect of the foot. C, Whitish papules arranged in a cobblestone pattern on the oral mucosa.</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" => 1050 "Ancho" => 1400 "Tamanyo" => 529635 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Hyperkeratosis with parakeratosis, vacuolization of the basal layer of the epidermis, necrosis of keratinocytes and lymphocytic infiltrate in the dermis (hematoxylin-eosin, original magnification ×10). B, Detail of histologic image showing hair follicle with keratinocyte necrosis (hematoxylin-eosin, original magnification ×40).</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: F, female; M, male; PB, peripheral blood.</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">Age \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">Sex \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">Onset \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">Clinical Manifestations \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">Chimerism \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">Course \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">Whitington et al.,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> 1996 \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">9 mo \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">F \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">+<span class="elsevierStyleHsp" style=""></span>60 d \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">Hematologic, cutaneous \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">Yes, PB \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">Chronic \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">Pinna et al.,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> 1999 \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">8 mo \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">F \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">+<span class="elsevierStyleHsp" style=""></span>330 d \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">Intestinal \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">Yes, PB \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">Recovery \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">8 mo \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">M \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">+<span class="elsevierStyleHsp" style=""></span>230 d \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">FeverIntestinalHematologicCutaneous \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">Yes, PB \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">Recovery \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">Dunn et al.,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> 2001 \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">10 mo \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">F \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">+<span class="elsevierStyleHsp" style=""></span>6 y \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">IntestinalCutaneous \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">Yes, PB \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">Recovery \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">Nemoto et al.,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> 2003 \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">50 y \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">F \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">+<span class="elsevierStyleHsp" style=""></span>114 d \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">Cutaneous \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">Yes, PB \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">Recovery \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">Walling et al.,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> 2004 \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">60 y \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">M \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">+<span class="elsevierStyleHsp" style=""></span>70 d \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">Cutaneous \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">Yes, PB \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">Recovery \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">Yilmaz et al.,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> 2012 \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">49 y \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">M \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">+<span class="elsevierStyleHsp" style=""></span>50 d \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">CutaneousFeverIntestinalHematologic \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">Not tested \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">Deceased \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab465402.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Characteristics of Chronic Graft-vs-Host Disease After Liver Transplantation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Graft vs host disease after liver transplantation: A new approach is needed" "autores" => 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 12 | 23 |
| 2024 October | 80 | 41 | 121 |
| 2024 September | 87 | 27 | 114 |
| 2024 August | 122 | 52 | 174 |
| 2024 July | 78 | 48 | 126 |
| 2024 June | 79 | 36 | 115 |
| 2024 May | 65 | 41 | 106 |
| 2024 April | 85 | 16 | 101 |
| 2024 March | 77 | 36 | 113 |
| 2024 February | 80 | 27 | 107 |
| 2024 January | 41 | 25 | 66 |
| 2023 December | 72 | 21 | 93 |
| 2023 November | 69 | 26 | 95 |
| 2023 October | 80 | 22 | 102 |
| 2023 September | 83 | 35 | 118 |
| 2023 August | 48 | 20 | 68 |
| 2023 July | 74 | 35 | 109 |
| 2023 June | 60 | 25 | 85 |
| 2023 May | 54 | 29 | 83 |
| 2023 April | 55 | 22 | 77 |
| 2023 March | 44 | 27 | 71 |
| 2023 February | 36 | 28 | 64 |
| 2023 January | 44 | 36 | 80 |
| 2022 December | 49 | 35 | 84 |
| 2022 November | 22 | 32 | 54 |
| 2022 October | 25 | 20 | 45 |
| 2022 September | 38 | 38 | 76 |
| 2022 August | 18 | 45 | 63 |
| 2022 July | 34 | 35 | 69 |
| 2022 June | 28 | 24 | 52 |
| 2022 May | 37 | 34 | 71 |
| 2022 April | 44 | 35 | 79 |
| 2022 March | 59 | 51 | 110 |
| 2022 February | 46 | 27 | 73 |
| 2022 January | 69 | 38 | 107 |
| 2021 December | 43 | 32 | 75 |
| 2021 November | 40 | 47 | 87 |
| 2021 October | 39 | 50 | 89 |
| 2021 September | 44 | 42 | 86 |
| 2021 August | 34 | 42 | 76 |
| 2021 July | 38 | 30 | 68 |
| 2021 June | 32 | 35 | 67 |
| 2021 May | 41 | 34 | 75 |
| 2021 April | 92 | 24 | 116 |
| 2021 March | 46 | 18 | 64 |
| 2021 February | 86 | 30 | 116 |
| 2021 January | 39 | 13 | 52 |
| 2020 December | 55 | 12 | 67 |
| 2020 November | 32 | 17 | 49 |
| 2020 October | 33 | 17 | 50 |
| 2020 September | 38 | 12 | 50 |
| 2020 August | 29 | 11 | 40 |
| 2020 July | 34 | 15 | 49 |
| 2020 June | 56 | 24 | 80 |
| 2020 May | 28 | 18 | 46 |
| 2020 April | 32 | 16 | 48 |
| 2020 March | 34 | 18 | 52 |
| 2020 February | 4 | 2 | 6 |
| 2020 January | 4 | 2 | 6 |
| 2019 December | 8 | 3 | 11 |
| 2019 November | 4 | 2 | 6 |
| 2019 October | 0 | 2 | 2 |
| 2019 September | 8 | 0 | 8 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 6 | 25 | 31 |
| 2019 May | 4 | 7 | 11 |
| 2019 April | 2 | 5 | 7 |
| 2019 March | 2 | 6 | 8 |
| 2019 February | 2 | 2 | 4 |
| 2019 January | 15 | 2 | 17 |
| 2018 December | 0 | 2 | 2 |
| 2018 November | 3 | 2 | 5 |
| 2018 October | 3 | 1 | 4 |
| 2018 September | 3 | 0 | 3 |
| 2018 March | 1 | 0 | 1 |
| 2018 February | 33 | 3 | 36 |
| 2018 January | 44 | 5 | 49 |
| 2017 December | 44 | 6 | 50 |
| 2017 November | 34 | 3 | 37 |
| 2017 October | 33 | 4 | 37 |
| 2017 September | 37 | 2 | 39 |
| 2017 August | 53 | 4 | 57 |
| 2017 July | 52 | 11 | 63 |
| 2017 June | 57 | 13 | 70 |
| 2017 May | 55 | 8 | 63 |
| 2017 April | 56 | 12 | 68 |
| 2017 March | 46 | 15 | 61 |
| 2017 February | 33 | 7 | 40 |
| 2017 January | 35 | 4 | 39 |
| 2016 December | 42 | 13 | 55 |
| 2016 November | 66 | 7 | 73 |
| 2016 October | 92 | 7 | 99 |
| 2016 September | 157 | 10 | 167 |
| 2016 August | 51 | 5 | 56 |
| 2016 July | 36 | 6 | 42 |
| 2016 June | 15 | 6 | 21 |
| 2016 May | 6 | 6 | 12 |
| 2016 April | 3 | 2 | 5 |
| 2016 March | 2 | 0 | 2 |
| 2016 February | 8 | 1 | 9 |
| 2016 January | 10 | 1 | 11 |
| 2015 December | 5 | 2 | 7 |
| 2015 November | 5 | 2 | 7 |
| 2015 October | 11 | 1 | 12 |
| 2015 September | 8 | 0 | 8 |
| 2015 August | 6 | 1 | 7 |
| 2015 July | 90 | 9 | 99 |
| 2015 June | 40 | 3 | 43 |
| 2015 May | 61 | 6 | 67 |
| 2015 April | 28 | 3 | 31 |
| 2015 March | 58 | 0 | 58 |
| 2015 February | 44 | 2 | 46 |
| 2015 January | 29 | 3 | 32 |
| 2014 December | 36 | 2 | 38 |
| 2014 November | 38 | 4 | 42 |
| 2014 October | 35 | 1 | 36 |
| 2014 September | 32 | 2 | 34 |
| 2014 August | 25 | 2 | 27 |
| 2014 July | 33 | 5 | 38 |
| 2014 June | 40 | 4 | 44 |
| 2014 May | 39 | 6 | 45 |
| 2014 April | 40 | 8 | 48 |
| 2014 March | 13 | 4 | 17 |
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