Case for Diagnosis
Multiple Acquired Hypopigmented Nodules on the Anterior Chest
Nódulos múltiples hipopigmentados adquiridos en la cara anterior del tórax
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Quintana-Codina, G. Melé-Ninot, C. Santonja" "autores" => array:3 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Quintana-Codina" "email" => array:1 [ 0 => "mquintanacodina@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" => "Melé-Ninot" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Santonja" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitari Sagrat Cor, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario Fundación Jiménez Díaz, 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" => "Nódulos múltiples hipopigmentados adquiridos en la cara anterior del tórax" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 338 "Ancho" => 450 "Tamanyo" => 16708 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 52-year-old man with a personal history of vitiligo came to our clinic for assessment of multiple asymptomatic lesions on his upper chest that had first appeared 4 years earlier.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed 6 soft, oval, hypopigmented, subcutaneous lesions. No follicular component was present but mild friction-induced erythema, without induration, was observed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Additional Tests</span><p id="par0015" class="elsevierStylePara elsevierViewall">Dermoscopy showed only achromic macules coinciding with each of the nodules.</p><p id="par0020" class="elsevierStylePara elsevierViewall">High-frequency ultrasound imaging (18<span class="elsevierStyleHsp" style=""></span>MHz, Esaote MyLab<span class="elsevierStyleSup">TM</span>25Gold) of 2 contiguous lesions revealed 2 oval foci of thickening and decreased dermal echogenicity that had a solid appearance and were pushing up the epidermis. No sonographic abnormalities of the dermal surface were observed between the 2 foci (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Color Doppler ultrasound showed no sign of vascular flow in the lesions. The other lesions had a similar echostructure.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Histologic examination of a punch biopsy specimen revealed the absence of melanocytes in the basal layer of the epidermis and multiple thin fascicles of smooth muscle fibers oriented in various directions in the middle dermis (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">What Is Your Diagnosis?</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Multiple acquired smooth muscle hamartoma (SMH) with vitiligo hypopigmentation.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">One lesion was surgically removed at the patient's request. The other nodules have remained stable over time.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">SMH is a rare, benign entity that is slightly more common in men and typically presents as a single congenital lesion; the acquired form is exceptional.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Unlike congenital SMH, the acquired form often does not present hypertrichosis, hyperpigmentation, and pseudo Darier sign. Moreover, while congenital SMH tends to be located on the lumbosacral region and the proximal parts of the limbs, acquired SMH tends to appear on the trunk, neck, upper limbs, vulva, and scrotum.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">SMH is mainly diagnosed clinically, although histologic examination may be essential, especially when the clinical presentation is atypical, as in the case of our patient. Histologically, SMH is characterized by the proliferation in the dermis of bundles of smooth muscle oriented in various directions and intermixed with collagen bundles. These bundles, which may or may not be connected to hair follicles, are revealed by histochemical staining with Masson trichrome stain; immunohistochemical techniques such as smooth muscle actin and desmin may also give positive results. Epidermal changes such as acanthosis, papillomatosis, and hypermelanosis can be observed in some cases.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3,4</span></a> Koizumi et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> described CD34-positive dendritic cells in the vicinity of muscle cell bundles in the dermis and interpreted this as a characteristic finding with possible pathogenic implications.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The differential diagnosis is extensive and includes Becker nevus, solitary mastocytoma, connective tissue nevus, and eruptive leiomyoma, among other entities.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,4</span></a> Most authors consider Becker nevus and SMH to be polar forms of a spectrum of entities. At one end of the spectrum is Becker nevus, characterized by the predominance of epidermal changes such as hyperpigmentation and hypertrichosis, while at the other end is SMH, characterized by the predominance of smooth muscle cell proliferation over epidermal changes.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Ultrasound findings for this entity are nonspecific, so differential diagnosis must include other soft-tissue tumors with clinical and sonographic similarities, such as dermatofibroma, granuloma annulare, multiple piloleiomyoma, and spontaneous keloids, among other entities. In some cases, we may find differential characteristics that can point to a diagnosis, such as the peripheral hypoechoic lines in dermatofibromas and the hyperechoic linear fibrillar pattern in keloids. However, histopathologic information is often necessary in order to establish a definitive diagnosis.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion, we have presented an exceptional case of multiple acquired SMH with vitiligo hypopigmentation, probably caused by an isotopic phenomenon. The clinical presentation of SMH in our patient was atypical due to the hypopigmentation, the absence of hypertrichosis, and the multiple lesions, making it necessary to carry out a histopathologic study to confirm the clinical diagnosis. We have also described for the first time the sonographic characteristics of this rare entity. Soft-tissue tumors are a large, heterogeneous group of rare tumors—hence the paucity of information about their sonographic characteristics. We believe that computer-aided diagnostic systems will someday make it easier to distinguish between malignant and benign tumors using high-frequency ultrasound.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">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:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:3 [ "identificador" => "sec0015" "titulo" => "Additional Tests" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical Course and Treatment" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Comment" ] ] ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 4 => array:2 [ "identificador" => "xack370107" "titulo" => "Acknowledgments" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Quintana-Codina M, Melé-Ninot G, Santonja C. Nódulos múltiples hipopigmentados adquiridos en la cara anterior del tórax. Actas Dermosifiliogr. 2018;109:743–744.</p>" ] ] "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 338 "Ancho" => 450 "Tamanyo" => 16708 ] ] ] 1 => array:6 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 530 "Ancho" => 750 "Tamanyo" => 47646 ] ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 263 "Ancho" => 350 "Tamanyo" => 35318 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>40.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Non-congenital smooth muscle hamartoma: 3 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.P. 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"fecha" => "1999" "volumen" => "140" "paginaInicial" => "172" "paginaFinal" => "174" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10215795" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0060" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The computer-aided diagnosis of soft-tissue tumors using sonographic morphology and texture features" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "H.J. Chiou" 1 => "C.Y. Chen" 2 => "Y.H. Chou" 3 => "H.K. Chiang" 4 => "X. Wortsman" 5 => "G.B.E. Jemec" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:6 [ "titulo" => "Dermatologic ultrasound with clinical and histologic correlations" "fecha" => "2013" "paginaInicial" => "177" "paginaFinal" => "181" "editorial" => "Springer" "editorialLocalizacion" => "New York" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack370107" "titulo" => "Acknowledgments" "texto" => "<p id="par0075" class="elsevierStylePara elsevierViewall">We would like to thank Dr. Luis Requena Caballero of the dermatology department at Hospital Universitario Fundación Jiménez Díaz.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010900000008/v1_201810020631/S1578219018302610/v1_201810020631/en/main.assets" "Apartado" => array:4 [ "identificador" => "6154" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case for Diagnosis" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010900000008/v1_201810020631/S1578219018302610/v1_201810020631/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219018302610?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 9 | 17 |
| 2024 October | 64 | 45 | 109 |
| 2024 September | 79 | 27 | 106 |
| 2024 August | 95 | 51 | 146 |
| 2024 July | 82 | 36 | 118 |
| 2024 June | 81 | 28 | 109 |
| 2024 May | 82 | 37 | 119 |
| 2024 April | 77 | 34 | 111 |
| 2024 March | 99 | 28 | 127 |
| 2024 February | 83 | 32 | 115 |
| 2024 January | 66 | 38 | 104 |
| 2023 December | 73 | 17 | 90 |
| 2023 November | 95 | 21 | 116 |
| 2023 October | 82 | 26 | 108 |
| 2023 September | 71 | 38 | 109 |
| 2023 August | 41 | 18 | 59 |
| 2023 July | 69 | 33 | 102 |
| 2023 June | 57 | 27 | 84 |
| 2023 May | 58 | 28 | 86 |
| 2023 April | 79 | 25 | 104 |
| 2023 March | 66 | 31 | 97 |
| 2023 February | 44 | 42 | 86 |
| 2023 January | 43 | 33 | 76 |
| 2022 December | 53 | 51 | 104 |
| 2022 November | 22 | 28 | 50 |
| 2022 October | 25 | 29 | 54 |
| 2022 September | 24 | 32 | 56 |
| 2022 August | 29 | 31 | 60 |
| 2022 July | 30 | 40 | 70 |
| 2022 June | 24 | 33 | 57 |
| 2022 May | 26 | 37 | 63 |
| 2022 April | 67 | 39 | 106 |
| 2022 March | 57 | 52 | 109 |
| 2022 February | 49 | 27 | 76 |
| 2022 January | 71 | 54 | 125 |
| 2021 December | 43 | 45 | 88 |
| 2021 November | 55 | 46 | 101 |
| 2021 October | 39 | 57 | 96 |
| 2021 September | 35 | 40 | 75 |
| 2021 August | 74 | 43 | 117 |
| 2021 July | 84 | 39 | 123 |
| 2021 June | 35 | 27 | 62 |
| 2021 May | 48 | 50 | 98 |
| 2021 April | 158 | 87 | 245 |
| 2021 March | 56 | 54 | 110 |
| 2021 February | 68 | 42 | 110 |
| 2021 January | 46 | 44 | 90 |
| 2020 December | 41 | 47 | 88 |
| 2020 November | 45 | 35 | 80 |
| 2020 October | 22 | 19 | 41 |
| 2020 September | 45 | 25 | 70 |
| 2020 August | 40 | 21 | 61 |
| 2020 July | 22 | 21 | 43 |
| 2020 June | 38 | 38 | 76 |
| 2020 May | 23 | 29 | 52 |
| 2020 April | 20 | 9 | 29 |
| 2020 March | 19 | 12 | 31 |
| 2020 February | 1 | 0 | 1 |
| 2019 May | 0 | 0 | 0 |
| 2019 April | 1 | 0 | 1 |
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