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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case presentation</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 53-year-old female patient with Fitzpatrick phototype III was seen for asymptomatic nail lesions on the second and third fingers of the dominant &#40;right&#41; hand that had appeared 4&#8211;5 years earlier and had grown progressively &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; She reported no personal or family history of melanoma or other skin cancers&#44; had no concomitant diseases&#44; and was not taking any medication&#46; She did not perform any manual tasks that could result in trauma either in work or in her leisure time&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed dark brown longitudinal striate melanonychia on the second and third fingers of the dominant &#40;right&#41; hand&#44; consisting of narrow bands of homogeneous color and thickness&#46; Hutchinson sign was absent&#46; The remaining nails on the right hand&#44; as well as those on the contralateral hand and the feet&#44; were unaffected &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A and B&#41;&#46; No mucosal pigmentation was observed&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In evaluations performed 3 and 6 months later the lesions remained stable&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Nail matrix biopsy confirmed the absence of significant melanocytic proliferations&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">When the patient was questioned further&#44; the only relevant medical history was carpal tunnel-release surgery&#44; which had been performed before the appearance of the nail lesions on the right hand and was repeated 2 years later due to recurrence&#46; An electroneurogram revealed moderate focal sensory&#8211;motor neuropathy of the median nerve in the wrist&#46; Currently&#44; the patient is awaiting another intervention for the same reason&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Diagnosis and comment</span><p id="par0030" class="elsevierStylePara elsevierViewall">Melanonychia is the presence of melanin in the nail plate&#46; If it acquires a linear morphology&#44; from the proximal to the distal nail fold&#44; it is known as longitudinal melanonychia&#46; This melanin comes from melanocytes located in the nail matrix&#44; most of which are in a quiescent inactive state&#46; When activated&#44; they can cause melanonychia through melanocytic activation or melanocytic hyperplasia&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The causes of melanonychia due to melanocytic activation are multiple&#44; and include physiological &#40;race&#44; pregnancy&#41;&#44; regional &#40;acute or repeated trauma&#44; tight shoes&#44; subungual foreign body&#44; post-inflammatory hyperpigmentation&#44; carpal tunnel syndrome&#41;&#44; dermatological &#40;psoriasis&#44; lichen planus&#41;&#44; systemic &#40;Cushing syndrome&#44; Addison syndrome&#41;&#44; and iatrogenic &#40;medication&#44; radiotherapy&#44; phototherapy&#41; causes&#44; as well as Laugier-Hunziker and Peutz-Jeghers syndromes&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> Causes of melanonychia due to melanocytic hyperplasia include lentigo&#44; nevus&#44; and melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In general&#44; traumatic melanonychia tends to affect the thumb and the second and third fingers of the dominant hand &#40;used for clamping and grasping&#41; and the first or fourth and fifth toes&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Carpal tunnel syndrome is the main cause of acroparesthesia of the arms&#44; which is bilateral in 50&#37; of cases&#46; It is more common in women aged 40&#8211;60 years&#46; It is caused by compression of the median nerve in the tunnel formed by the carpal bones and the transverse carpal ligament&#46; This nerve provides sensation and movement to the thumb and the index and middle fingers&#44; as well as part of the ring finger&#46; For this reason&#44; the most common signs include tingling in the innervated areas&#44; affecting mobility and sensitivity in advanced cases&#46; The frequently unilateral skin manifestations of carpal tunnel syndrome include necrotic ulcerations and sclerodermiform changes &#40;due to involvement of sensory and autonomic fibers&#41;&#46; The following nail alterations have been described&#58; hypertrophy of the cuticle&#44; changes in coloration&#44; Beau lines&#44; subungual hyperkeratosis&#44; onychomadesis&#44; and one case of melanonychia of unknown origin&#46; Cutaneous manifestations usually indicate serious involvement of the median nerve&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In the present case&#44; the fact that the melanonychia exhibited regular neat margins&#44; affected several fingers&#44; and remained stable over time was reassuring&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In the absence of these factors a confirmatory biopsy would be necessary&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">There are few published cases of longitudinal melanonychia in patients with carpal tunnel syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> which is considered an infrequent cause&#46; The etiology of these nail alterations is unknown and is thought to be multifactorial&#46; Microtrauma due to sensory denervation likely plays an important role&#46; We present a case of melanonychia associated with advanced and operated carpal tunnel syndrome in a patient in whom we excluded other causes of longitudinal melanonychia&#46; This is a rarely reported association&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case for Diagnosis
Longitudinal Melanonychia and Carpal Tunnel Syndrome: A Rarely Reported Association
Melanoniquia estriada y síndrome del túnel del carpo: una asociación escasamente reportada
R. García Castro
Corresponding author
, S. Blanco Barrios, A.M. González Pérez
Servicio de Dermatología, Hospital Clínico Universitario de Salamanca, Salamanca, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case presentation</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 53-year-old female patient with Fitzpatrick phototype III was seen for asymptomatic nail lesions on the second and third fingers of the dominant &#40;right&#41; hand that had appeared 4&#8211;5 years earlier and had grown progressively &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; She reported no personal or family history of melanoma or other skin cancers&#44; had no concomitant diseases&#44; and was not taking any medication&#46; She did not perform any manual tasks that could result in trauma either in work or in her leisure time&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed dark brown longitudinal striate melanonychia on the second and third fingers of the dominant &#40;right&#41; hand&#44; consisting of narrow bands of homogeneous color and thickness&#46; Hutchinson sign was absent&#46; The remaining nails on the right hand&#44; as well as those on the contralateral hand and the feet&#44; were unaffected &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A and B&#41;&#46; No mucosal pigmentation was observed&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In evaluations performed 3 and 6 months later the lesions remained stable&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Nail matrix biopsy confirmed the absence of significant melanocytic proliferations&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">When the patient was questioned further&#44; the only relevant medical history was carpal tunnel-release surgery&#44; which had been performed before the appearance of the nail lesions on the right hand and was repeated 2 years later due to recurrence&#46; An electroneurogram revealed moderate focal sensory&#8211;motor neuropathy of the median nerve in the wrist&#46; Currently&#44; the patient is awaiting another intervention for the same reason&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Diagnosis and comment</span><p id="par0030" class="elsevierStylePara elsevierViewall">Melanonychia is the presence of melanin in the nail plate&#46; If it acquires a linear morphology&#44; from the proximal to the distal nail fold&#44; it is known as longitudinal melanonychia&#46; This melanin comes from melanocytes located in the nail matrix&#44; most of which are in a quiescent inactive state&#46; When activated&#44; they can cause melanonychia through melanocytic activation or melanocytic hyperplasia&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The causes of melanonychia due to melanocytic activation are multiple&#44; and include physiological &#40;race&#44; pregnancy&#41;&#44; regional &#40;acute or repeated trauma&#44; tight shoes&#44; subungual foreign body&#44; post-inflammatory hyperpigmentation&#44; carpal tunnel syndrome&#41;&#44; dermatological &#40;psoriasis&#44; lichen planus&#41;&#44; systemic &#40;Cushing syndrome&#44; Addison syndrome&#41;&#44; and iatrogenic &#40;medication&#44; radiotherapy&#44; phototherapy&#41; causes&#44; as well as Laugier-Hunziker and Peutz-Jeghers syndromes&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> Causes of melanonychia due to melanocytic hyperplasia include lentigo&#44; nevus&#44; and melanoma&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In general&#44; traumatic melanonychia tends to affect the thumb and the second and third fingers of the dominant hand &#40;used for clamping and grasping&#41; and the first or fourth and fifth toes&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Carpal tunnel syndrome is the main cause of acroparesthesia of the arms&#44; which is bilateral in 50&#37; of cases&#46; It is more common in women aged 40&#8211;60 years&#46; It is caused by compression of the median nerve in the tunnel formed by the carpal bones and the transverse carpal ligament&#46; This nerve provides sensation and movement to the thumb and the index and middle fingers&#44; as well as part of the ring finger&#46; For this reason&#44; the most common signs include tingling in the innervated areas&#44; affecting mobility and sensitivity in advanced cases&#46; The frequently unilateral skin manifestations of carpal tunnel syndrome include necrotic ulcerations and sclerodermiform changes &#40;due to involvement of sensory and autonomic fibers&#41;&#46; The following nail alterations have been described&#58; hypertrophy of the cuticle&#44; changes in coloration&#44; Beau lines&#44; subungual hyperkeratosis&#44; onychomadesis&#44; and one case of melanonychia of unknown origin&#46; Cutaneous manifestations usually indicate serious involvement of the median nerve&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In the present case&#44; the fact that the melanonychia exhibited regular neat margins&#44; affected several fingers&#44; and remained stable over time was reassuring&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In the absence of these factors a confirmatory biopsy would be necessary&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">There are few published cases of longitudinal melanonychia in patients with carpal tunnel syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> which is considered an infrequent cause&#46; The etiology of these nail alterations is unknown and is thought to be multifactorial&#46; Microtrauma due to sensory denervation likely plays an important role&#46; We present a case of melanonychia associated with advanced and operated carpal tunnel syndrome in a patient in whom we excluded other causes of longitudinal melanonychia&#46; This is a rarely reported association&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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