Case and Research Letters
Contact allergy to aluminum following vaccination: A report of 3 cases
Alergia de contacto a aluminio tras vacunación: presentación de tres casos
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Tous Romero, S.I. Palencia Pérez, J.L. Rodríguez Peralto, F.J. Ortiz de Frutos" "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" => "S.I." "apellidos" => "Palencia Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J.L." "apellidos" => "Rodríguez Peralto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "F.J." "apellidos" => "Ortiz de Frutos" "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 Anatomía Patológica, Hospital Universitario 12 de Octubre, 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" => "Alergia de contacto a aluminio tras vacunación: presentación de tres casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 551 "Ancho" => 905 "Tamanyo" => 50803 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lesions on the right thigh in the form of excoriated erythematous macules clustered over a nodular lesion with hypertrichosis on the surface.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Vaccination is an essential measure in preventive medicine. However, it is not free from complications, since it can lead to adverse reactions, although these are mainly mild, transient, and self-limiting<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. The reactions are rarely persistent, with most cases involving a hypersensitivity reaction to aluminum<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the cases of 2 girls (age, 2 and 3 years) and a boy (8 years) who experienced persistent cutaneous reactions after vaccination (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). All 3 patients developed nodules at the injection site, and in 1 case, the reaction was accompanied by eczema and hypertrichosis, which had first appeared more than 1 year previously (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>)<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>. The vaccinations had been administered according to the corresponding schedule, and the clinical picture was associated with the vaccines included in the schedule. Given that the clinical suspicion included other conditions in 2 cases, diagnosis was based on skin biopsy, which revealed findings typical of this type of reaction (histiocytes with granular cytoplasm) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). All 3 patients underwent patch testing with aluminum chloride 2% in petrolatum (Chemotechnique), which yielded positive readings at 72 and 168 hours (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Aluminum compounds have been used as adjuvants in vaccines for more than 80 years to boost the immune response to the antigen. Administration of vaccines can lead to cutaneous lesions, mostly in the form of pruritus or subcutaneous nodules; areas of hypertrichosis or eczema are less common. The reactions persist in 0.5%–6% of cases, mainly because of a type IV hypersensitivity reaction to aluminum hydroxide. Patch testing with aluminium hydroxide 2% is positive in 77%–95% of children with persistent reactions, thus demonstrating the presence of contact allergy to the metal<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Various histologic patterns have been described (panniculitis, pseudolymphomatous, granuloma annulare–like), although the characteristic finding is histiocytes with a granular cytoplasm. Nevertheless, given the high sensitivity of patch testing, skin biopsy is not considered essential for diagnosis<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The lesions generally appear at 12–18 months of life, mostly after several vaccinations (usually after the third) and with subcutaneous vaccines. It is thought that, at the subcutaneous level, aluminum comes into contact with dendritic cells, thus triggering a hypersensitivity reaction. The reactions usually occur 2.5 months after the vaccination, although reports indicate that this interval can vary from 2 weeks to 13 months. The duration of symptoms also varies widely, from months to up to 10 years<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Children who are sensitized to aluminum can experience contact dermatitis when exposed to objects that contain it (e.g., deodorants, toothpaste, pigments used in tattoos). However, some studies show that contact allergy to aluminum can diminish or disappear over time, with negative results in up to 77% of cases 7 years after the initial positive patch test reading<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Aluminum-containing vaccines should be replaced by aluminum-free vaccines in patients with contact dermatitis to aluminum. However, since not all vaccines have an aluminum-free version, the patient should receive a deep intramuscular injection to reduce the risk of new lesions in cases where no substitute is available. In general terms, the benefits of vaccines outweigh potential complications; therefore, the appearance of the lesions does not justify nonadherence to the vaccination schedule. Similarly, given that aluminum is also a standard adjuvant in subcutaneous allergen-specific immunotherapy, contact allergy to aluminum is a relative contraindication.</p><p id="par0040" class="elsevierStylePara elsevierViewall">It is essential to be aware of the cutaneous complications associated with administration of vaccines. Consequently, in the case of a persistent reaction after administration, we should consider the presence of contact allergy to aluminum. A suggestive clinical history, together with positive patch tests results, should be sufficient to confirm the diagnosis. Early diagnosis will prevent parental anxiety and other, unnecessary and invasive procedures.</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: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, Palencia Pérez SI, Rodríguez Peralto JL, Ortiz de Frutos FJ. Alergia de contacto a aluminio tras vacunación: presentación de tres casos. Actas Dermosifiliogr. 2021;112:930–932.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 551 "Ancho" => 905 "Tamanyo" => 50803 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lesions on the right thigh in the form of excoriated erythematous macules clustered over a nodular lesion with hypertrichosis on the surface.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 980 "Ancho" => 2925 "Tamanyo" => 881572 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Skin biopsy from one of the case reports. A, Normal epidermis, with lesions mainly in the dermis and subcutaneous cellular tissue (hematoxylin-eosin, ×4). B, Areas of sclerosis, together with follicular lymphoid hyperplasia and histiocytic infiltrate (hematoxylin-eosin, ×4). C, Histiocytes with granular cytoplasm (hematoxylin-eosin, ×20).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1015 "Ancho" => 905 "Tamanyo" => 62799 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patch test readings at 168 h in one of the cases. Note the positive result to aluminum hydroxide 2% (++).</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: DPT, diphtheria, pertussis, tetanus; Hib: <span class="elsevierStyleItalic">Haemophilus influenzae</span> b; PCV, pneumococcal conjugate vaccine.</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="\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" scope="col" style="border-bottom: 2px solid black">Case \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Age, y \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Cutaneous Symptoms \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Associated Vaccine \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">No. of Aluminum-Containing vaccines \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Duration of Symptoms at the First Evaluation, mo \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \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">2 \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">Female \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">Nodules, eczema, and hypertrichosis \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">PCV13 \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">4 \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">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \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">3 \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">Female \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">Nodules \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">DTP, Hib \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">5 \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">18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \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 \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">Male \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">Nodules \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">DTP \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">6 \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">24 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2740428.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Summary of Cases of Contact Allergy to Aluminum.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cutaneous reactions to vaccinations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.E. Rosenblatt" 1 => "S.L. Stein" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Dermatol" "fecha" => "2015" "volumen" => "33" "paginaInicial" => "327" "paginaFinal" => "332" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aluminium Allergy in patients hyposensitized with aluminium precipited antigen extracts" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S. López" 1 => "A. Peláez" 2 => "A. Navarro" 3 => "E. Montesinos" 4 => "C. Morales" 5 => "C. Garde" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Contact Dematitis" "fecha" => "1994" "volumen" => "31" "paginaInicial" => "37" "paginaFinal" => "40" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Persistent subcutaneous nodules in patients hyposensitized with aluminum-containing allergen extracts" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "V. García-Patos" 1 => "R.M. Pujol" 2 => "A. Alomar" 3 => "A. Cisteró" 4 => "R. Curell" 5 => "M.T. 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Ortiz de Frutos" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Pediatr Dermatol" "fecha" => "2019" "volumen" => "36" "paginaInicial" => "145" "paginaFinal" => "146" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "How common are long-lasting, intensely itching vaccination granulomas and contact allergy to aluminium induced by currently used pediatric vaccines? A prospective cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "E. Bergfors" 1 => "G. Hermansson" 2 => "U. Nystrom Kronander" 3 => "L. Falk" 4 => "L. Valter" 5 => "B. Trollfors" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00431-014-2318-2" "Revista" => array:6 [ "tituloSerie" => "Eur J Pediatr" "fecha" => "2014" "volumen" => "173" "paginaInicial" => "1297" "paginaFinal" => "1307" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24752308" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Delayed–type hypersensitivity to vaccine aluminum adjuvant causing subcutaneous leg mass and urticaria in a child" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S.C. Gordon" 1 => "D.W. Bartenstein" 2 => "S.H. Tajmir" 3 => "J.S. Song" 4 => "E.B. Hawryluk" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Pediatr Dermatol" "fecha" => "2018" "volumen" => "00" "paginaInicial" => "1" "paginaFinal" => "3" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Unexpected loss of contact allergy to aluminium induced by vaccine" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Gente Lidholm" 1 => "E. Bergfors" 2 => "A. Inerot" 3 => "U. Blomgren" 4 => "M. Gillstedt" 5 => "B. Trollfors" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/cod.12053" "Revista" => array:6 [ "tituloSerie" => "Contact Dermatitis" "fecha" => "2013" "volumen" => "68" "paginaInicial" => "286" "paginaFinal" => "292" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23601064" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000011200000010/v1_202111080506/S1578219021002572/v1_202111080506/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/15782190/0000011200000010/v1_202111080506/S1578219021002572/v1_202111080506/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219021002572?idApp=UINPBA000044" ]
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