Case and Research Letters
Pustular Secondary Cutaneous Aspergillosis in an Immunosuppressed Patient
Aspergilosis cutánea secundaria pustulosa en paciente inmunosuprimido
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array:24 [ "pii" => "S1578219018300131" "issn" => "15782190" "doi" => "10.1016/j.adengl.2018.02.011" "estado" => "S300" "fechaPublicacion" => "2018-04-01" "aid" => "1759" "copyright" => "Elsevier España, S.L.U. and AEDV" "copyrightAnyo" => "2017" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2018;109:287-90" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 62 "HTML" => 62 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0001731017303873" "issn" => "00017310" "doi" => "10.1016/j.ad.2017.07.004" "estado" => "S300" "fechaPublicacion" => "2018-04-01" "aid" => "1759" "copyright" => "AEDV" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2018;109:287-90" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 150 "formatos" => array:2 [ "HTML" => 106 "PDF" => 44 ] ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta científico-clínica</span>" "titulo" => "Aspergilosis cutánea secundaria pustulosa en paciente inmunosuprimido" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "287" "paginaFinal" => "290" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Pustular Secondary Cutaneous Aspergillosis in an Immunosuppressed Patient" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1311 "Ancho" => 1744 "Tamanyo" => 550780 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio histológico de la pústula por biopsia incisional. A. Gran ampolla subepidérmica con gran destrucción tisular subyacente abarcando la dermis y el tejido celular subcutáneo (tinción de hematoxilina y eosina ×<span class="elsevierStyleHsp" style=""></span>2, magnificación ×<span class="elsevierStyleHsp" style=""></span>20). B. Se observa un infiltrado neutrofílico denso con destrucción del colágeno dérmico y vasculitis asociada (tinción de hematoxilina y eosina ×<span class="elsevierStyleHsp" style=""></span>10, magnificación ×<span class="elsevierStyleHsp" style=""></span>100). C. Detalle en el que se observan neutrófilos infiltrando densamente la dermis y rodeando estructuras filamentosas discretamente perceptibles (tinción de hematoxilina y eosina ×<span class="elsevierStyleHsp" style=""></span>20, magnificación ×<span class="elsevierStyleHsp" style=""></span>200). D. A mayor detalle y con tinción de PAS se visualizan estructuras lineales tabicadas y en ángulo agudo compatible con el diagnóstico clínico y microbiológico de aspergilosis cutánea (tinción de PAS ×<span class="elsevierStyleHsp" style=""></span>40 magnificación ×<span class="elsevierStyleHsp" style=""></span>400).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Fonda-Pascual, P. Fernández-González, O.M. Moreno-Arrones, L. Miguel-Gómez" "autores" => array:4 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Fonda-Pascual" ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Fernández-González" ] 2 => array:2 [ "nombre" => "O.M." "apellidos" => "Moreno-Arrones" ] 3 => array:2 [ "nombre" => "L." 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Erythema and desquamation at the level of the face and intermammary area sparing the retroauricular area and base of the neck fold.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Giácaman-von der Weth, A. Pérez-Ferriols, C. Sierra-Talamantes, V. Zaragoza-Ninet" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Giácaman-von der Weth" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Pérez-Ferriols" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Sierra-Talamantes" ] 3 => array:2 [ "nombre" => "V." 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Pereira, I. Raposo, F. Nery, T. Torres" "autores" => array:4 [ 0 => array:2 [ "nombre" => "R." "apellidos" => "Pereira" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Raposo" ] 2 => array:2 [ "nombre" => "F." "apellidos" => "Nery" ] 3 => array:2 [ "nombre" => "T." 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Fonda-Pascual, P. Fernández-González, O.M. Moreno-Arrones, L. Miguel-Gómez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "Fonda-Pascual" "email" => array:1 [ 0 => "pfondap@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "P." "apellidos" => "Fernández-González" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "O.M." "apellidos" => "Moreno-Arrones" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Miguel-Gómez" "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 Ramón y Cajal , Madrid, España" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Grupo de Dermatología Experimental y Biología Cutánea, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal, Madrid, España" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Aspergilosis cutánea secundaria pustulosa en paciente inmunosuprimido" ] ] "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" => 695 "Ancho" => 1500 "Tamanyo" => 117460 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical presentation. A, Painless erythematous nonfluctuant nodule on the left abdominal flank. B, Pustule containing blood-stained pus with a fluid level on an indurated erythematous base.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The growing use of immunosuppressive agents in procedures such as kidney transplantation and in intensive polychemotherapy regimens for different types of cancer has led to a notable increase in opportunistic fungal infections.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a><span class="elsevierStyleItalic">Aspergillus</span> species are ubiquitous, opportunistic, filamentous fungi often found in soil, decaying organic matter, and even in food remains.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> They tend to multiply in environments with high levels of dust dispersal and are particularly common in hospitals during building or maintenance work.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Care should therefore be taken to protect immunocompromised patients or patients with a greater risk of infection from exposure to building work or damp environments. <span class="elsevierStyleItalic">Aspergillus</span> species can cause serious primary or secondary skin infections.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> We present a case of pustular cutaneous aspergillosis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 56-year-old man with type IgA multiple myeloma was evaluated for painless skin nodules measuring over 1<span class="elsevierStyleHsp" style=""></span>cm and a large blister of recent onset on his left elbow. The patient had stage IIIA disease and had been under follow-up for 4 years. He had received several treatments, including 4 cycles of chemotherapy with bortezomib 1.3<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span> every 4 days, 4 cycles separated by a week of cyclophosphamide 500<span class="elsevierStyleHsp" style=""></span>mg once a day for 3 days, and dexamethasone 40<span class="elsevierStyleHsp" style=""></span>mg every 2 days for 12 days. He had also received radiation therapy and undergone hematopoietic stem cell transplantation. Following a relapse in 2015, it was decided to attempt mini-allogenic transplantation with reduced-intensity FluMel-ATG conditioning (70<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span> melphalan, fludarabine 30<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span>/d, bortezomib 1.3<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span>, and anti-thymocyte globulin 2<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span>) and an increase in melphalan infusion dose to 150<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Forty days after the transplantation, the patient was evaluated by a dermatologist as he suddenly developed painless erythematous subcutaneous nodules measuring approximately 3<span class="elsevierStyleHsp" style=""></span>cm on the anterior surface of both thighs and on the left abdominal flank (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). One of the lesions on the lateral surface of his left elbow was a tense 1.5-cm blister containing blood-stained pus with a fluid level (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). The patient reported no other symptoms. The onset of these lesions coincided with a progressive increase in serum galactomannan levels, which rose from previously undetectable levels to a level of 0.9.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In view of the patient's condition and the general clinical picture, skin biopsy samples were taken for histology and microbial culture. Histologic examination of the elbow lesion showed a purulent subepidermal blister and an underlying infiltrate composed of abundant polymorphonuclear leukocytes that caused notable tissue destruction, with weakened structures, collagen bundles with an unstructured appearance, and effacement of adnexal structures (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Higher magnification and periodic acid-Schiff (PAS) staining showed septate linear structures with dichotomous acute-angle (45°) branching throughout the dermis and extending into the more superficial areas of the subcutaneous tissue. These structures had an approximate diameter of 3<span class="elsevierStyleHsp" style=""></span>μm and a length of up to 80<span class="elsevierStyleHsp" style=""></span>μm in some sections and were consistent with hyalohyphomycosis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). Culture in Sabouraud agar produced <span class="elsevierStyleItalic">Aspergillus flavus</span>, which was sensitive to voriconazole and echinocandins in the ETEST (Biomérieux).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Intensive antifungal treatment was initiated with voriconazole (loading dose of 400<span class="elsevierStyleHsp" style=""></span>mg followed by a maintenance dose of 200<span class="elsevierStyleHsp" style=""></span>m/12<span class="elsevierStyleHsp" style=""></span>h) and intravenous anidulafungin (loading dose of 200<span class="elsevierStyleHsp" style=""></span>mg followed by 100<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h). Three days later, the patient developed right hemiparesis. In the staging study, the chest computed tomography (CT) scan showed previously undetected cavitated lesions in the right upper lobe of the lung (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A). The brain CT scan showed 2 nonvascular frontal lesions consistent with a stroke secondary to infection (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B). We decided to escalate the treatment to intravenous amphotericin B (400<span class="elsevierStyleHsp" style=""></span>mg every 24<span class="elsevierStyleHsp" style=""></span>h adjusted to the patient's weight). After 7 days, however, the patent developed severe dyspnea requiring oxygen support, aphasia, and general deterioration of health. A second brain scan showed multiple lesions similar to the lesions on the first scan but involving the entire brain parenchyma. The patient died as a result 2 days later. The family did not agree to an autopsy and we were therefore unable to collect brain tissue for microbiologic analysis.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Aspergillus</span> species are members of the eumycetes and are widely distributed in the environment. They are opportunistic pathogens that pose a particular threat to immunosuppressed individuals,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a> particularly those with neutropenia.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> The most common species are <span class="elsevierStyleItalic">Aspergillus fumigatus</span> and <span class="elsevierStyleItalic">A flavus.</span><a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleItalic">Aspergillus</span> species are ubiquitous in soil and vegetation.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Although aspergillosis mainly affects the lungs,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> it can also affect the liver, brain, and skin.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Between 5% and 27% of invasive aspergillosis cases involve the skin.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,6</span></a> Cutaneous aspergillosis can be primary or secondary,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,7</span></a> and these forms can be distinguished by the location and extension of lesions, which are widespread in secondary infections.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3,7</span></a> Secondary cutaneous aspergillosis generally originates from the lungs,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> but it can also originate from the paranasal sinuses or the upper respiratory tract, although these forms are much less common. Primary aspergillosis is generally caused by direct skin inoculation through wounds from contaminated objects, intravenous lines<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> at venipuncture sites on the arms, or even through dressings covering areas of macerated skin or catheters in patients requiring invasive procedures.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Clinically, aspergillosis manifests as erythematous papules and macules that progress to nodules<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> and eventually to ulcers with areas of central necrosis.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,7</span></a> Blisters are uncommon and may, as in our case, contain pus.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Standard diagnostic procedures are the potassium hydroxide technique (or similar) and an incisional skin biopsy with sufficient depth.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,7</span></a> Histology shows septate hyphae measuring 3 to 5<span class="elsevierStyleHsp" style=""></span>μm in diameter and 50 to 100<span class="elsevierStyleHsp" style=""></span>μm in length, 45° branching, absence of blistering with PAS or Gomori methenamine silver stains, and abundant polymorphonuclear cells involving the entire wall, with angiocentric necrosis in many cases.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Serum galactomannan levels should always be tested when aspergillosis is suspected.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> A progressive increase to a level over 0.5 in serial measurements points to a diagnosis of invasive bronchopulmonary or systemic aspergillosis, particularly in immunosuppressed patients.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleItalic">Aspergillus</span> infection is confirmed by polymerase chain reaction. Treatment consists of amphotericin B (5<span class="elsevierStyleHsp" style=""></span>mg/kg/ 24<span class="elsevierStyleHsp" style=""></span>h), combined with echinocandins (50-100<span class="elsevierStyleHsp" style=""></span>mg/d) or voriconazole (200<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h).<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> Debridement of necrotic lesions and rapid restoration of immunity are important.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">We have presented a case of pustular cutaneous aspergillosis in an immunosuppressed patient.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:2 [ "identificador" => "xack341081" "titulo" => "Acknowledgments" ] 2 => 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: Fonda-Pascual P, Fernández-González P, Moreno-Arrones OM, Miguel-Gómez L. Aspergilosis cutánea secundaria pustulosa en paciente inmunosuprimido. Actas Dermosifiliogr. 2018;109:287–290.</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" => 695 "Ancho" => 1500 "Tamanyo" => 117460 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical presentation. A, Painless erythematous nonfluctuant nodule on the left abdominal flank. B, Pustule containing blood-stained pus with a fluid level on an indurated erythematous base.</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" => 1128 "Ancho" => 1500 "Tamanyo" => 466505 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histologic features of the pustule following incisional biopsy. A, Large subepidermal blister with major underlying tissue destruction affecting the entire dermis and subcutaneous tissue (hematoxylin-eosin staining, original magnification ×<span class="elsevierStyleHsp" style=""></span>20). B, Dense neutrophilic infiltration with destruction of dermal collagen and associated vasculitis (hematoxylin-eosin original magnification ×100). C, Detail showing dense neutrophil infiltration in the dermis and around barely perceivable filamentous structures (hematoxylin-eosin, original magnification ×200). D, Higher magnification and periodic acid-Schiff (PAS) staining showing septate linear structures with acute-angle branching consistent with the clinical and microbiologic diagnosis of cutaneous aspergillosis (PAS ×40, original magnification ×400).</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" => 655 "Ancho" => 1500 "Tamanyo" => 86926 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Radiologic study after 3 days. A, Cranial computed tomography (CT) scan showing a nonvascular lesion in the right parasagittal-parietal region with internal spots of bleeding and a considerable intracranial mass consistent with cerebritis (*). B, CT scan of the chest area showing a cavitated nodule in the anterior segment of the right upper lobe, consistent with aspergilloma (+).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cutaneous aspergillosis as a first manifestation of systemic infection in allogeneic haematopoietic stem cell transplantation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K.U. Hashmi" 1 => "P. Ahmed" 2 => "T.M. Satti" 3 => "S. Raza" 4 => "Q.U. Chaudhry" 5 => "A. 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Ullmann" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1185/030079903125001884" "Revista" => array:6 [ "tituloSerie" => "Curr Med Res Opin" "fecha" => "2003" "volumen" => "19" "paginaInicial" => "263" "paginaFinal" => "271" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12841918" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack341081" "titulo" => "Acknowledgments" "texto" => "<p id="par0050" class="elsevierStylePara elsevierViewall">We thank Dr Carmen Moreno from the Pathology Laboratory and the Radiodiagnostic Unit at Hospital Ramón y Cajal.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010900000003/v1_201804020430/S1578219018300131/v1_201804020430/en/main.assets" "Apartado" => array:4 [ "identificador" => "6157" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case and Research Letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010900000003/v1_201804020430/S1578219018300131/v1_201804020430/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219018300131?idApp=UINPBA000044" ]
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