Case and Research Letter
Polyarteritis Nodosa with a Systemic Inflammatory Response Pattern: Effectiveness of anti-TNF
Panarteritis nudosa con patrón de respuesta inflamatoria sistémica: respuesta a anti-TNF
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(b) Necrosis fibrinoide e infiltrado neutrofílico en los vasos de mediano calibre acompañado de infiltrado eosinofílico (hematoxilina-eosina, ×20). (c) Livedo residual en las piernas, tras inicio de tratamiento con infliximab.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "F. Tous-Romero, E. Rodríguez-Almaraz, J.L. Rodríguez-Peralto, C. Postigo-Llorente" "autores" => array:4 [ 0 => array:2 [ "nombre" => "F." "apellidos" => "Tous-Romero" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Rodríguez-Almaraz" ] 2 => array:2 [ "nombre" => "J.L." "apellidos" => "Rodríguez-Peralto" ] 3 => array:2 [ "nombre" => "C." 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Tous-Romero, E. Rodríguez-Almaraz, J.L. Rodríguez-Peralto, C. Postigo-Llorente" "autores" => array:4 [ 0 => array:4 [ "nombre" => "F." "apellidos" => "Tous-Romero" "email" => array:1 [ 0 => "fatimatousro@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" => "E." "apellidos" => "Rodríguez-Almaraz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J.L." "apellidos" => "Rodríguez-Peralto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "C." "apellidos" => "Postigo-Llorente" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Reumatología, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Panarteritis nudosa con patrón de respuesta inflamatoria sistémica: respuesta a anti-TNF" ] ] "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" => 1199 "Ancho" => 2333 "Tamanyo" => 451179 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Nodules beneath erythematous plaques with peripheral desquamation. B, In greater detail, showing the residual hyperpigmentation. C, Edema on the dorsum of the left foot. D, Skin biopsy showing a normal epidermis and dermis, with lesions in the subcutaneous cellular tissue. Inflammatory infiltrate in the septa. Hematoxylin and eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×4.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Polyarteritis nodosa (PAN) is a vasculitis that affects small and medium-sized vessel. It is traditionally divided into 2 forms. The cutaneous form is the variant in which the clinical manifestations are limited to the skin, though muscle pain and generalized joint pain may also be reported, and neuritis in areas close to the affected skin. Fever is detected in up to a third of cases. The systemic form affects internal organs, most commonly the kidney, liver, and central nervous system.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 50-year-old man was seen in our department for a 5-year history of outbreaks of nodular lesions, initially only affecting the legs, associated with widespread joint pain. In the last year, lesions had also appeared on his arms, and he had developed episodes of fever, weight loss, asthenia, and anorexia. He had been on follow-up at another hospital, where several biopsies had been performed with nonspecific results (a dermal neutrophilic infiltrate, stasis dermatitis, and, in the most recent biopsy, a predominantly lobular panniculitis). He had received no definitive diagnosis. Despite treatment with various drugs, control of his disease had not been achieved; throughout this whole period he had been administered oral corticosteroids, with intermittent courses of colchicine, azathioprine, methotrexate, and ciclosporin. Important blood test results included elevation of the acute phase reactants (AFRs), with elevation of C-reactive protein and erythrocyte sedimentation rate (which had risen to 120<span class="elsevierStyleHsp" style=""></span>mm/h in recent months). Other additional tests, including autoimmunity studies (antinuclear antibodies, extractable nuclear antigen, and antineutrophil cytoplasmic antibodies) and serology (HIV and hepatotropic viruses), were normal or negative.</p><p id="par0015" class="elsevierStylePara elsevierViewall">When the patient first came to our hospital, he presented erythematous plaques with peripheral desquamation, mainly on his lower limbs but also on his upper limbs. Nodules were present beneath the plaques. He also presented edema of the dorsum of the left foot and ankle (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>,<span class="elsevierStyleHsp" style=""></span>A-C). A biopsy was taken, which was consistent with septal panniculitis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Coinciding with tapering of the dose of prednisone, the patient presented a further outbreak at the same sites as the previous outbreak, with purpuric plaques that spread centrifugally, pain, bilateral ankle edema, and fever.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A further biopsy revealed a neutrophilic infiltrate in the small and medium-sized vessels, with fibrinoid necrosis, and a moderate eosinophilic infiltrate (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, A and<span class="elsevierStyleHsp" style=""></span>B). Based on these findings, we made a diagnosis of PAN. Given the absence of organ involvement, despite the marked elevation of the AFRs and alteration of the patient's general state of health, we considered this to be cutaneous PAN with an associated systemic inflammatory response.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">After increasing the dose of prednisone to 1<span class="elsevierStyleHsp" style=""></span>mg/kg/d and controlling the acute outbreak, treatment was started with cyclophosphamide and immunoglobulins. However, this did not enable us to reduce the dose of corticosteroids without renewed deterioration. Treatment was therefore commenced with infliximab at a dose of 5<span class="elsevierStyleHsp" style=""></span>mg/kg, which led to a very good response after the first infusion, with complete normalization of laboratory parameters. The dose of corticosteroids was progressively reduced until their withdrawal, with no further outbreaks of lesions in a year of follow-up, except for a residual livedo (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a><span class="elsevierStyleHsp" style=""></span>C); during this period the patient continued treatment with infliximab every 8 weeks.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The typical clinical manifestations of cutaneous PAN are characterized by outbreaks of painful nodular lesions that leave a residual livedo.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> In the first patient series, dating from 1974, the presence of a starburst pattern was described as a characteristic manifestation of this livedo, and was very similar to that observed in our patient, though we have found no similar descriptions in the recent literature.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Typically, histology reveals a focal panniculitis around affected arteries. However, if the inflammatory infiltrate is very intense, the panniculitis can be so pronounced that it masks the vasculitis.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Three subgroups of cutaneous PAN have been described based on the presentation, laboratory tests, and clinical course: class <span class="elsevierStyleSmallCaps">i</span>, in which the cutaneous manifestations are associated with slightly elevated AFRs; class <span class="elsevierStyleSmallCaps">ii</span>, in which constitutional symptoms are also present, with fever and marked elevation of the AFRs; and class <span class="elsevierStyleSmallCaps">iii</span>, in which the cutaneous form progresses to systemic forms of the disease.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> We classified our patient in the second subgroup.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In cutaneous PAN, patients with marked elevation of AFRs are more likely to present inflammatory plaques and edema of the lower limbs. Considering this association as a more severe form of the disease, it has been proposed that the initial management approach should be more aggressive to avoid progression to systemic forms.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Although the use of TNF inhibitors is not uncommon in the systemic forms of PAN, we have found very few reports in the literature in which this treatment has been required to control cutaneous forms (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion, we have presented a case of cutaneous PAN associated with a systemic inflammatory response and refractory to conventional treatments. It is essential to suspect this disease in patients with nodules beneath plaques showing centrifugal spread, even if histology does not initially support the diagnosis, particularly if there is an associated intense inflammatory reaction that could hide the vasculitis. Patients with cutaneous PAN with very high AFRs will often require management similar to the systemic forms, and TNF inhibitors are an option.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => 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: Tous-Romero F, Rodríguez-Almaraz E, Rodríguez-Peralto JL, Postigo-Llorente C. Panarteritis nudosa con patrón de respuesta inflamatoria sistémica: respuesta a anti-TNF. Actas Dermosifiliogr. 2017;108:787–790.</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" => 1199 "Ancho" => 2333 "Tamanyo" => 451179 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Nodules beneath erythematous plaques with peripheral desquamation. B, In greater detail, showing the residual hyperpigmentation. C, Edema on the dorsum of the left foot. D, Skin biopsy showing a normal epidermis and dermis, with lesions in the subcutaneous cellular tissue. Inflammatory infiltrate in the septa. Hematoxylin and eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×4.</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" => 1667 "Ancho" => 2000 "Tamanyo" => 782012 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Normal epidermis with lesions in the dermis and subcutaneous cellular tissue. Hematoxylin and eosin, original magnification ×4. B, Fibrinoid necrosis and a neutrophilic infiltrate in the medium-sized vessels, with an associated eosinophilic infiltrate. Hematoxylin and eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×20.<span class="elsevierStyleHsp" style=""></span>C, Residual livedo on the legs after starting treatment with infliximab.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: AZA, azathioprine; CsA, ciclosporin; CY, cyclophosphamide; DFPP, double filtration plasmapheresis; ETN, etanercept; IFX, infliximab; IVIG, intravenous immunoglobulin; MTX, methotrexate; NA, not available; OC, oral corticosteroid therapy; PE, plasma exchange; RTX, rituximab; SSZ, sulfasalazine; TAC, tacrolimus.</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"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Authors, Year, and Reference \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age, y \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Previous Treatments \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Duration of Previous Treatments, mo \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TNF Inhibitor, Dose \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Concomitant Immunosuppressant Treatment \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Follow-up, mo \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Outcome/Adverse Events \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">García-Porrua and Gonzalez-Gay,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> 2003 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Indomethacin, SSZ, MTX \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IFX, 5<span class="elsevierStyleHsp" style=""></span>mg/kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">MTX 15<span class="elsevierStyleHsp" style=""></span>mg/wk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Resolution/none \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vega Gutiérrez et al.,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> 2007 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">OC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IFX, 5<span class="elsevierStyleHsp" style=""></span>mg/kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Resolution/none \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bansal and Houghton,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> 2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">OC, CY, MTX, IVIG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IFX, 5<span class="elsevierStyleHsp" style=""></span>mg/kg first dose, followed by 10<span class="elsevierStyleHsp" style=""></span>mg/kg every 4 wk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">OC, MTX \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No response (corticosteroid dependence). Response to RTX and CY \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Zoshima et al.,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> 2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">OC, MTX, CsA, TAC, CY, AZA, colchicine, PE, DFPP<br>Lamivudine, adefovir \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">156 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ETN, 25<span class="elsevierStyleHsp" style=""></span>mg/wk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">OC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Resolution/none \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Campanilho-Marques et al.,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> 2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">OC, MTX, CY, RTX \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IFX, 5<span class="elsevierStyleHsp" style=""></span>mg/kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Resolution/none \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Valor et al.,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> 2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">OC, CY \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ETN, 25<span class="elsevierStyleHsp" style=""></span>mg/wk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Resolution/none \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1527679.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Treatment With TNF Inhibitors in Cutaneous Polyarteritis Nodosa.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cutaneous polyarteritis nodosa: A comprehensive review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 8 | 16 |
| 2024 October | 97 | 39 | 136 |
| 2024 September | 102 | 20 | 122 |
| 2024 August | 140 | 56 | 196 |
| 2024 July | 144 | 36 | 180 |
| 2024 June | 142 | 26 | 168 |
| 2024 May | 105 | 38 | 143 |
| 2024 April | 97 | 21 | 118 |
| 2024 March | 156 | 22 | 178 |
| 2024 February | 182 | 27 | 209 |
| 2024 January | 133 | 40 | 173 |
| 2023 December | 139 | 19 | 158 |
| 2023 November | 237 | 47 | 284 |
| 2023 October | 211 | 18 | 229 |
| 2023 September | 140 | 40 | 180 |
| 2023 August | 126 | 21 | 147 |
| 2023 July | 161 | 35 | 196 |
| 2023 June | 134 | 36 | 170 |
| 2023 May | 176 | 34 | 210 |
| 2023 April | 231 | 24 | 255 |
| 2023 March | 200 | 31 | 231 |
| 2023 February | 202 | 24 | 226 |
| 2023 January | 146 | 34 | 180 |
| 2022 December | 151 | 37 | 188 |
| 2022 November | 109 | 29 | 138 |
| 2022 October | 84 | 24 | 108 |
| 2022 September | 88 | 65 | 153 |
| 2022 August | 104 | 32 | 136 |
| 2022 July | 93 | 34 | 127 |
| 2022 June | 168 | 31 | 199 |
| 2022 May | 212 | 21 | 233 |
| 2022 April | 201 | 38 | 239 |
| 2022 March | 203 | 59 | 262 |
| 2022 February | 223 | 30 | 253 |
| 2022 January | 266 | 37 | 303 |
| 2021 December | 178 | 35 | 213 |
| 2021 November | 206 | 45 | 251 |
| 2021 October | 203 | 62 | 265 |
| 2021 September | 168 | 35 | 203 |
| 2021 August | 159 | 45 | 204 |
| 2021 July | 191 | 31 | 222 |
| 2021 June | 238 | 37 | 275 |
| 2021 May | 268 | 51 | 319 |
| 2021 April | 472 | 73 | 545 |
| 2021 March | 276 | 39 | 315 |
| 2021 February | 197 | 30 | 227 |
| 2021 January | 118 | 25 | 143 |
| 2020 December | 117 | 18 | 135 |
| 2020 November | 68 | 23 | 91 |
| 2020 October | 63 | 13 | 76 |
| 2020 September | 73 | 15 | 88 |
| 2020 August | 43 | 21 | 64 |
| 2020 July | 51 | 23 | 74 |
| 2020 June | 59 | 35 | 94 |
| 2020 May | 29 | 13 | 42 |
| 2020 April | 33 | 18 | 51 |
| 2020 March | 33 | 19 | 52 |
| 2020 February | 4 | 0 | 4 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 8 | 0 | 8 |
| 2019 November | 4 | 0 | 4 |
| 2019 September | 8 | 0 | 8 |
| 2019 August | 2 | 0 | 2 |
| 2019 July | 6 | 0 | 6 |
| 2019 June | 6 | 0 | 6 |
| 2019 May | 2 | 0 | 2 |
| 2019 April | 5 | 0 | 5 |
| 2019 March | 4 | 0 | 4 |
| 2019 January | 7 | 0 | 7 |
| 2018 December | 2 | 0 | 2 |
| 2018 November | 2 | 0 | 2 |
| 2018 October | 4 | 0 | 4 |
| 2018 September | 4 | 0 | 4 |
| 2018 June | 0 | 1 | 1 |
| 2018 February | 27 | 7 | 34 |
| 2018 January | 39 | 8 | 47 |
| 2017 December | 37 | 16 | 53 |
| 2017 November | 45 | 11 | 56 |
| 2017 October | 108 | 33 | 141 |
| 2017 September | 4 | 14 | 18 |
| 2017 August | 3 | 13 | 16 |
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