array:24 [
  "pii" => "S1578219015003194"
  "issn" => "15782190"
  "doi" => "10.1016/j.adengl.2015.11.010"
  "estado" => "S300"
  "fechaPublicacion" => "2016-01-01"
  "aid" => "1123"
  "copyright" => "Elsevier España, S.L.U. and AEDV"
  "copyrightAnyo" => "2014"
  "documento" => "simple-article"
  "crossmark" => 1
  "subdocumento" => "crp"
  "cita" => "Actas Dermosifiliogr. 2016;107:e1-5"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 4263
    "formatos" => array:3 [
      "EPUB" => 43
      "HTML" => 3863
      "PDF" => 357
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S0001731015000502"
      "issn" => "00017310"
      "doi" => "10.1016/j.ad.2015.01.003"
      "estado" => "S300"
      "fechaPublicacion" => "2016-01-01"
      "aid" => "1123"
      "copyright" => "Elsevier España, S.L.U. y AEDV"
      "documento" => "simple-article"
      "crossmark" => 1
      "subdocumento" => "crp"
      "cita" => "Actas Dermosifiliogr. 2016;107:e1-5"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 3155
        "formatos" => array:3 [
          "EPUB" => 3
          "HTML" => 707
          "PDF" => 2445
        ]
      ]
      "es" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Caso cl&#237;nico</span>"
        "titulo" => "Cinco casos de urticaria multiforme y revisi&#243;n de la literatura"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "tieneResumen" => array:2 [
          0 => "es"
          1 => "en"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "e1"
            "paginaFinal" => "e5"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Urticaria multiforme&#58; A report of 5 cases and a review of the literature"
          ]
        ]
        "contieneResumen" => array:2 [
          "es" => true
          "en" => true
        ]
        "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" => 949
                "Ancho" => 1500
                "Tamanyo" => 162049
              ]
            ]
            "descripcion" => array:1 [
              "es" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Lesiones urticariformes peque&#241;as que crecen centr&#237;fugamente dejando una zona equim&#243;tica central en pierna y pie &#40;a&#41;&#44; cara anterior del tronco &#40;b&#41; y en dorso confluyendo hasta ocupar casi toda la espalda &#40;c&#41;&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "L&#46; Sempau, E&#46; Mart&#237;n-S&#225;ez, C&#46; Guti&#233;rrez-Rodr&#237;guez, M&#46;C&#46; Guti&#233;rrez-Ortega"
            "autores" => array:4 [
              0 => array:2 [
                "nombre" => "L&#46;"
                "apellidos" => "Sempau"
              ]
              1 => array:2 [
                "nombre" => "E&#46;"
                "apellidos" => "Mart&#237;n-S&#225;ez"
              ]
              2 => array:2 [
                "nombre" => "C&#46;"
                "apellidos" => "Guti&#233;rrez-Rodr&#237;guez"
              ]
              3 => array:2 [
                "nombre" => "M&#46;C&#46;"
                "apellidos" => "Guti&#233;rrez-Ortega"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S1578219015003194"
          "doi" => "10.1016/j.adengl.2015.11.010"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219015003194?idApp=UINPBA000044"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731015000502?idApp=UINPBA000044"
      "url" => "/00017310/0000010700000001/v1_201512300105/S0001731015000502/v1_201512300105/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S1578219015003182"
    "issn" => "15782190"
    "doi" => "10.1016/j.adengl.2015.11.009"
    "estado" => "S300"
    "fechaPublicacion" => "2016-01-01"
    "aid" => "1191"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and AEDV"
    "documento" => "simple-article"
    "crossmark" => 1
    "subdocumento" => "crp"
    "cita" => "Actas Dermosifiliogr. 2016;107:63-4"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 996
      "formatos" => array:3 [
        "EPUB" => 40
        "HTML" => 710
        "PDF" => 246
      ]
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Case for Diagnosis</span>"
      "titulo" => "Erythematous Abdominal Papule"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "63"
          "paginaFinal" => "64"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "P&#225;pula eritematosa abdominal"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0010"
          "etiqueta" => "Figure 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 732
              "Ancho" => 976
              "Tamanyo" => 271174
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin&#44; original magnification &#215;<span class="elsevierStyleHsp" style=""></span>200&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "T&#46; Fern&#225;ndez-Morano, I&#46; Fern&#225;ndez-Canedo, R&#46; F&#250;nez-Li&#233;bana"
          "autores" => array:3 [
            0 => array:2 [
              "nombre" => "T&#46;"
              "apellidos" => "Fern&#225;ndez-Morano"
            ]
            1 => array:2 [
              "nombre" => "I&#46;"
              "apellidos" => "Fern&#225;ndez-Canedo"
            ]
            2 => array:2 [
              "nombre" => "R&#46;"
              "apellidos" => "F&#250;nez-Li&#233;bana"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0001731015002215"
        "doi" => "10.1016/j.ad.2015.02.017"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731015002215?idApp=UINPBA000044"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219015003182?idApp=UINPBA000044"
    "url" => "/15782190/0000010700000001/v2_201704190205/S1578219015003182/v2_201704190205/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S1578219015003200"
    "issn" => "15782190"
    "doi" => "10.1016/j.adengl.2015.11.011"
    "estado" => "S300"
    "fechaPublicacion" => "2016-01-01"
    "aid" => "1269"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and AEDV"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "fla"
    "cita" => "Actas Dermosifiliogr. 2016;107:55-61"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 798
      "formatos" => array:3 [
        "EPUB" => 52
        "HTML" => 504
        "PDF" => 242
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>"
      "titulo" => "Yield of Computed Tomography at Baseline Staging of Melanoma"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "55"
          "paginaFinal" => "61"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Rendimiento de la tomograf&#237;a computarizada en la estadificaci&#243;n basal del paciente con melanoma"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0010"
          "etiqueta" => "Figure 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 699
              "Ancho" => 950
              "Tamanyo" => 91032
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Initial computed tomography staging of a man with primary cutaneous melanoma &#40;stage T3a&#41; on his back&#46; The white arrow indicates the presence of a hypodense space-occupying lesion in the liver parenchyma that was confirmed as being metastatic after resection and histopathology&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "L&#46; Ferr&#225;ndiz, M&#46; Silla-Pr&#243;sper, A&#46; Garc&#237;a-de-la-Oliva, F&#46;M&#46; Mendon&#231;a, T&#46; Ojeda-Vila, D&#46; Moreno-Ram&#237;rez"
          "autores" => array:6 [
            0 => array:2 [
              "nombre" => "L&#46;"
              "apellidos" => "Ferr&#225;ndiz"
            ]
            1 => array:2 [
              "nombre" => "M&#46;"
              "apellidos" => "Silla-Pr&#243;sper"
            ]
            2 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Garc&#237;a-de-la-Oliva"
            ]
            3 => array:2 [
              "nombre" => "F&#46;M&#46;"
              "apellidos" => "Mendon&#231;a"
            ]
            4 => array:2 [
              "nombre" => "T&#46;"
              "apellidos" => "Ojeda-Vila"
            ]
            5 => array:2 [
              "nombre" => "D&#46;"
              "apellidos" => "Moreno-Ram&#237;rez"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0001731015004275"
        "doi" => "10.1016/j.ad.2015.09.011"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731015004275?idApp=UINPBA000044"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219015003200?idApp=UINPBA000044"
    "url" => "/15782190/0000010700000001/v2_201704190205/S1578219015003200/v2_201704190205/en/main.assets"
  ]
  "en" => array:20 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">E-Case Report</span>"
    "titulo" => "Urticaria Multiforme&#58; A Report of 5 Cases and a Review of the Literature"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "e1"
        "paginaFinal" => "e5"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "L&#46; Sempau, E&#46; Mart&#237;n-S&#225;ez, C&#46; Guti&#233;rrez-Rodr&#237;guez, M&#46;C&#46; Guti&#233;rrez-Ortega"
        "autores" => array:4 [
          0 => array:4 [
            "nombre" => "L&#46;"
            "apellidos" => "Sempau"
            "email" => array:1 [
              0 => "leticiasempau&#64;gmail&#46;com"
            ]
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:2 [
            "nombre" => "E&#46;"
            "apellidos" => "Mart&#237;n-S&#225;ez"
          ]
          2 => array:2 [
            "nombre" => "C&#46;"
            "apellidos" => "Guti&#233;rrez-Rodr&#237;guez"
          ]
          3 => array:2 [
            "nombre" => "M&#46;C&#46;"
            "apellidos" => "Guti&#233;rrez-Ortega"
          ]
        ]
        "afiliaciones" => array:1 [
          0 => array:2 [
            "entidad" => "Servicio de Dermatolog&#237;a&#44; Hospital Universitario de Burgos&#44; Burgos&#44; Spain"
            "identificador" => "aff0005"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Cinco casos de urticaria multiforme y revisi&#243;n de la literatura"
      ]
    ]
    "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" => 1105
            "Ancho" => 1500
            "Tamanyo" => 181480
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Coalescing annular and archiform plaques with a violaceous center on the trunk &#40;A and B&#41;&#44; face &#40;D&#41;&#44; and limbs &#40;C and E&#41;&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Urticaria multiforme &#40;UM&#41; is a benign&#44; self-resolving cutaneous disorder that affects children between 4 months and 4 years of age&#46; It is characterized by the appearance of large annular and archiform erythematous plaques with a violaceous center and is very frequently accompanied by fever&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Descriptions</span><p id="par0010" class="elsevierStylePara elsevierViewall">We present 5 cases of UM seen in our hospital between December 2012 and June 2013&#46; Case data are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The patients&#8212;4 boys and 1 girl between the ages of 8 and 22 months&#8212;were brought to our emergency department following the appearance of extensive urticarial lesions on the face&#44; trunk&#44; and limbs&#46; The lesions had a violaceous center and were associated with edema of the hands and feet &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; Despite the striking clinical appearance of the skin&#44; the patients were in good general health&#46; Fever was a variable finding&#46; The mean duration of the skin lesions was 5 days&#44; during which time oral antihistamines or corticosteroids were administered to alleviate the lesions&#44; but new lesions continued to appear&#46; The first 2 patients seen were admitted to the hospital&#44; whereas the last 3 only required ambulatory follow-up&#46; All patients had received oral amoxicillin during the course of the disease or shortly before the skin lesions appeared&#59; 3 underwent amoxicillin allergy tests&#44; with negative results&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">UM is an acute skin disorder that typically affects infants and very small children and tends to be accompanied by fever and good general health&#46; The typical lesions are initially small urticarial lesions that spread outward and coalesce into large archiform plaques with polycyclic borders and a violaceous center&#46; The individual lesions have a duration of less than 24<span class="elsevierStyleHsp" style=""></span>hours&#44; can affect any part of the body&#44; and tend to be associated with edema of the face&#44; hands&#44; and feet&#46; The lesions disappear spontaneously in 6 to 10 days without leaving any residual pigmentation&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">UM was first described in 1997 by Tamayo-S&#225;nchez et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> who observed 34 patients with a rash that they called acute annular urticaria and which they proposed differentiating from acute urticaria&#46; Ten years later&#44; Shah et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> reported a new series of 19 cases and proposed the term <span class="elsevierStyleItalic">urticaria multiforme</span> because of the similarity of the entity to erythema multiforme&#46; Unlike Tamayo-S&#225;nchez et al&#46;&#44; Shah et al&#46; considered the disorder to be a subtype of urticaria because they found that the patients presented dermographism and pruritus&#44; whereas Tamayo-S&#225;nchez et al&#46; had doubted whether pruritus was present because they did not find scratch lesions on any of their patients&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The clinical diagnostic criteria that both authors agree on are as follows&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8211;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Large annular plaques with a transient ecchymotic center&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8211;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Individual lesions with a duration of less than 24<span class="elsevierStyleHsp" style=""></span>hours&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8211;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Associated episode of fever&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8211;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Total duration of disease&#58; less than 10 days&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8211;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Edema of the limbs&#46;</p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall">The etiology of UM is unknown&#46; In the few reported cases in which the infectious agent was investigated&#44; micoplasm&#44;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2&#44;3</span></a> adenovirus&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleItalic">Streptococcus</span> organisms&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> herpes virus 6&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> and the Epstein-Barr virus<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> were detected&#46; However&#44; most reports indicate the medications that the patient had been receiving before the appearance of the lesions &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1&#44;2&#44;5&#8211;10</span></a> Common medications include amoxicillin and furazolidone &#40;an antibiotic used in the treatment of giardiasis in Mexico&#41;&#44; which had been administered in 19 of the 34 cases reported by Tamayo-S&#225;nchez&#46; Likewise&#44; vaccination in the days prior to symptom onset is frequently reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2&#44;9&#44;10</span></a> In our series&#44; all 5 patients had been taking amoxicillin at the time the lesions appeared or up to 3 days before the appearance of the lesions&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Histologic studies have been carried out in only 3 cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1&#44;5</span></a> In these patients&#44; histology revealed dermal edema with a perivascular lymphocytic infiltrate and a few eosinophils&#44; but no epidermal involvement&#46; On the basis of these findings&#44; UM can be differentiated from erythema multiforme &#40;which is usually associated with epidermal necrosis&#41; and from acute urticaria &#40;which is not normally associated with perivascular lymphocytic infiltrate&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The only treatment proposal put forth by Tamayo-S&#225;nchez et al&#46; is the introduction of antipyretics if fever is present and the suspension of suspicious medications&#44; whereas Shah et al&#46; recommend the use of antihistamines on the grounds that UM is a type of urticaria&#46; All other authors propose the use of antihistamines for symptom relief&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">5&#44;6&#44;8&#8211;10</span></a> Our 5 patients initially received treatment with antihistamines&#44; and oral corticosteroids were added when symptoms persisted&#46; Both treatments alleviated the existing skin lesions but neither prevented the appearance of new lesions&#59; we therefore doubt the utility of oral corticosteroids in UM&#46; Like Tamayo-S&#225;nchez et al&#46;&#44; we observed no signs of scratching in our patients&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The differential diagnosis of UM includes other annular lesions<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">11&#44;12</span></a> such as acute urticaria &#40;which is usually associated with intense pruritus but not with fever and lacks central bluish pigmentation&#41;&#44; erythema multiforme&#44; and urticarial vasculitis &#40;in which the individual lesions usually persist for several days and leave residual lesions&#46; Facial and acral edema may require differential diagnosis with a drug-induced serum sickness&#8211;like reaction that is typically &#40;but not exclusively&#41; associated with the administration of cefaclor and vaccines&#46; This type of reaction appears around 7 to 10 days after the start of treatment and presents as urticarial lesions with a dark center&#46; In contrast to UM&#44; however&#44; the lesions do not have day-to-day fluctuation and tend to be associated with general malaise&#44; arthralgia&#44; and enlarged lymph nodes&#46; Finally&#44; it is important to differentiate UM from acute hemorrhagic edema of infancy&#44; which also appears in children under 24 months of age in association with low-grade fever and has little impact on general health&#46; Unlike UM&#44; in acute hemorrhagic edema of infancy purpuric plaques appear and spread outward&#44; forming annular&#44; targetoid lesions&#44; occasionally with a necrotic or bullous center&#44; which last several days and leave residual pigmentation&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0075" class="elsevierStylePara elsevierViewall">The 5 cases described in this article were seen over the course of 18 months&#44; suggesting that UM is a relatively frequent entity in routine clinical practice&#46; In all 5 cases&#44; the patient had a history of upper respiratory tract infection and had been receiving amoxicillin in the days before the lesions appeared&#8212;a finding reported in practically all cases described in the literature&#46; Because UM has an alarming appearance but a benign course&#44; it is important that physicians be able to recognize it in order to reassure the family and avoid unnecessary hospital admissions and diagnostic tests&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical Disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of persons and animals</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for the purpose of this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they followed their hospitals&#8217; regulations regarding the publication of patient information&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data appear in this article&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of Interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:11 [
        0 => array:3 [
          "identificador" => "xres830112"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec826076"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres830113"
          "titulo" => "Resumen"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec826075"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Case Descriptions"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Discussion"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Conclusions"
        ]
        8 => array:3 [
          "identificador" => "sec0025"
          "titulo" => "Ethical Disclosures"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Protection of persons and animals"
            ]
            1 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Confidentiality of data"
            ]
            2 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Right to privacy"
            ]
          ]
        ]
        9 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Conflicts of Interest"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2014-09-02"
    "fechaAceptado" => "2015-01-10"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec826076"
          "palabras" => array:3 [
            0 => "Urticaria"
            1 => "Infant"
            2 => "Erythema multiforme"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec826075"
          "palabras" => array:3 [
            0 => "Urticaria"
            1 => "Ni&#241;o"
            2 => "Eritema multiforme"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Urticaria multiforme is a cutaneous disorder that affects infants and small children&#46; It is characterized by large&#44; annular urticarial plaques with a violaceous center and is frequently accompanied by fever&#46; Urticaria multiforme follows a benign&#44; self-limiting course&#44; but the striking appearance of the lesions can cause alarm and considerable anxiety among parents&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We present 5 cases of urticaria multiforme seen in our hospital over a period of 18 months&#46; All the cases were preceded by an infection of the upper airways or otitis&#44; and they were all empirically with amoxicillin&#46; It is important to be familiar with this condition to reassure parents and avoid unnecessary hospital admissions and tests&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La urticaria multiforme es un cuadro cut&#225;neo&#44; propio de lactantes y ni&#241;os peque&#241;os&#44; caracterizado por la aparici&#243;n de grandes placas anulares urticariformes de centro viol&#225;ceo frecuentemente asociado a un proceso febril&#46; Tiene un curso benigno y autolimitado&#44; pero el llamativo aspecto de las lesiones puede ser alarmante y generar gran ansiedad en los padres&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Presentamos 5 casos de urticaria multiforme vistos en nuestro hospital a lo largo de 18 meses&#46; El antecedente com&#250;n a todos ellos fue una infecci&#243;n de v&#237;as respiratorias altas u otitis por la que fueron tratados emp&#237;ricamente con amoxicilina&#46; Es importante saber reconocer esta entidad para tranquilizar a los padres&#44; ahorrar el ingreso hospitalario y evitar la realizaci&#243;n de pruebas diagn&#243;sticas innecesarias&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Sempau L&#44; Mart&#237;n-S&#225;ez E&#44; Guti&#233;rrez-Rodr&#237;guez C&#44; Guti&#233;rrez-Ortega MC&#46; Cinco casos de urticaria multiforme y revisi&#243;n de la literatura&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;e1&#8211;e5&#46;</p>"
      ]
    ]
    "multimedia" => array:4 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1105
            "Ancho" => 1500
            "Tamanyo" => 181480
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Coalescing annular and archiform plaques with a violaceous center on the trunk &#40;A and B&#41;&#44; face &#40;D&#41;&#44; and limbs &#40;C and E&#41;&#46;</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" => 949
            "Ancho" => 1500
            "Tamanyo" => 164298
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Small urticarial lesions that spread outward leaving an ecchymotic center on the leg and foot &#40;A&#41;&#44; anterior aspect of the trunk &#40;B&#41;&#44; and posterior aspect of the trunk &#40;C&#41;&#44; coalescing until they occupy nearly the entire back&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; A&#44; patient was taking medication when the cutaneous signs appeared&#59; B&#44; patient was taking usual medication&#59; C&#44; patient had been taking medication in the days prior to the appearance of urticaria multiforme&#46;</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="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\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">Case 1&nbsp;\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">Case 2&nbsp;\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">Case 3&nbsp;\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">Case 4&nbsp;\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">Case 5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age&#44; mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Medical history&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Upper respiratory tract infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Upper respiratory tract infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Otitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Upper respiratory tract infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Otitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Medication history<br>and timing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Salbutamol&#44; B<br>Amoxicillin&#44; A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Montelukast&#44; B<br>Fluticasone&#44; B<br>Amoxicillin&#44; C &#40;2 d&#41;<br>Dextromethorphan&#44; C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Amoxicillin&#44; A<br>Paracetamol&#44; A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Amoxicillin&#44; A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Amoxicillin&#44; C &#40;2 d&#41;<br>Salbutamol&#44; A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Timing of<br>fever and skin rash&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fever began 2 d after rash appeared&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fever began 6<span class="elsevierStyleHsp" style=""></span>h before rash appeared&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fever until 1 d before rash appeared<br>No fever while rash was present&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low-grade fever while rash was present&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fever until 3 d before rash appeared<br>No fever while rash was present&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Duration of rash&#44; d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6<br>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">General health&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Edema of hands and feet&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Facial involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Annular plaques&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Edema of the eyelids<br>Annular plaques&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Annular plaques&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Edema of the eyelids<br>Annular plaques&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Annular plaques&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hospitalization&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hydroxyzine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Metamizole<br>Hydroxyzine<br>Prednisolone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hydroxyzine Prednisolone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hydroxyzine<br>Prednisolone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hydroxyzine<br>Prednisolone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Tests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Antinuclear antibodies&#44; negative<br><span class="elsevierStyleItalic">Mycoplasma</span>&#44; negative<br>Complete blood count&#44; no abnormalities<br>Biochemistry&#44; no abnormalities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pharyngeal exudate&#44; no abnormalities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Leukocytosis<br>Biochemistry&#44; no abnormalities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Allergy tests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative for<br>amoxicillin and<br>dextromethorphan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative for<br>amoxicillin and<br>paracetamol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative for amoxicillin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1396743.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Summary of Patient History in Our 5 Cases&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "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">Drug&nbsp;\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">Article&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Furazolidone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tamayo-S&#225;nchez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> &#40;&#215;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Amoxicillin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Shah et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> &#40;&#215;5&#41;<br>Emer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a><br>Donnelly and Tackett<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a><br>Authried et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a><br>Guerrier et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a><br>Sempau &#40;&#215;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Amoxicillin&#8211;clavulanic acid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Shah et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Palivizumab &#40;Synagis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Shah et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Varicella vaccine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Shah et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Unknown vaccine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Shah et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Albuterol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Shah et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Topiramate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Shah et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Nitrofurantoin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Shah et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Aspirin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Guerrier et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Vaccine against rotavirus&#44; <span class="elsevierStyleItalic">Haemophilus influenzae</span>&#44; diphtheria&#44; tetanus&#44; and pertussis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Starnes et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pyrazolone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tamayo-S&#225;nchez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Mesalamine<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>6-mercaptopurine<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>omeprazole&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Shah et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Naproxen<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>tetanus vaccine<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>human papillomavirus vaccine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fung et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1396742.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Drugs and Vaccines Associated With Urticaria Multiforme in the Literature&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:12 [
            0 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acute annular urticaria in infants and children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "L&#46; Tamayo-S&#225;nchez"
                            1 => "R&#46; Ruiz-Maldonado"
                            2 => "A&#46; Laterza"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Dermatol"
                        "fecha" => "1997"
                        "volumen" => "14"
                        "paginaInicial" => "231"
                        "paginaFinal" => "234"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9192421"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Urticaria multiforme&#58; A case series and review of acute annular urticarial hypersensitivity syndromes in children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "K&#46;N&#46; Shah"
                            1 => "P&#46;J&#46; Honig"
                            2 => "A&#46;C&#46; Yan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1542/peds.2006-1553"
                      "Revista" => array:7 [
                        "tituloSerie" => "Pediatrics"
                        "fecha" => "2007"
                        "volumen" => "119"
                        "paginaInicial" => "e1177"
                        "paginaFinal" => "e1183"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17470565"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0735109714063633"
                          "estado" => "S300"
                          "issn" => "07351097"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Picture of the month--quiz case&#46; Pneumonia with associated urticarial multiforme rash"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "S&#46;R&#46; Myers"
                            1 => "J&#46; Lavelle"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archpediatrics.2009.221-a"
                      "Revista" => array:5 [
                        "tituloSerie" => "Arch Pediatr Adolesc Med"
                        "fecha" => "2009"
                        "volumen" => "163"
                        "paginaInicial" => "1157"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19996054"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Human herpesvirus 6 associated neonatal urticaria multiforme"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46; Borghesi"
                            1 => "P&#46; Cipelletti"
                            2 => "R&#46; Maragliano"
                            3 => "P&#46; Manzoni"
                            4 => "M&#46; Stronati"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/archdischild-2012-301995"
                      "Revista" => array:5 [
                        "tituloSerie" => "Arch Dis Child Fetal Neonatal Ed"
                        "fecha" => "2013"
                        "volumen" => "98"
                        "paginaInicial" => "F450"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22684162"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Urticaria multiforme"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46;J&#46; Emer"
                            1 => "S&#46;G&#46; Bernardo"
                            2 => "O&#46; Kovalerchik"
                            3 => "M&#46; Ahmad"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Aesthet Dermatol"
                        "fecha" => "2013"
                        "volumen" => "6"
                        "paginaInicial" => "34"
                        "paginaFinal" => "39"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23556035"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "What is your diagnosis&#63; Urticaria multiforme"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46;F&#46; Donnelly"
                            1 => "B&#46; Tackett"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Cutis"
                        "fecha" => "2012"
                        "volumen" => "89"
                        "paginaInicial" => "262"
                        "paginaFinal" => "263"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Urticaria multiforme is a variation of urticaria&#44; which imitates erythema multiforme"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "G&#46; Authried"
                            1 => "L&#46; Bracher"
                            2 => "A&#46; Bygum"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ugeskr Laeger"
                        "fecha" => "2013"
                        "volumen" => "175"
                        "paginaInicial" => "436"
                        "paginaFinal" => "437"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23402256"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Unusual presentation of acute annular urticaria&#58; A case report"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "G&#46; Guerrier"
                            1 => "J&#46;M&#46; Daronat"
                            2 => "R&#46; Deltour"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1155/2011/604390"
                      "Revista" => array:5 [
                        "tituloSerie" => "Case Rep Dermatol Med"
                        "fecha" => "2011"
                        "volumen" => "2011"
                        "paginaInicial" => "604390"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23198178"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Urticaria multiforme--a case report"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "L&#46; Starnes"
                            1 => "T&#46; Patel"
                            2 => "R&#46;B&#46; Skinner"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1525-1470.2011.01311.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Dermatol"
                        "fecha" => "2011"
                        "volumen" => "28"
                        "paginaInicial" => "436"
                        "paginaFinal" => "438"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21793883"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Urticaria multiforme in an 18-year-old girl"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "I&#46;N&#46; Fung"
                            1 => "E&#46;M&#46; Berger"
                            2 => "L&#46; Castelo-Soccio"
                            3 => "T&#46;F&#46; Brown-Whitehorn"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Allergy Clin Immunol Pract"
                        "fecha" => "2013"
                        "volumen" => "1"
                        "paginaInicial" => "520"
                        "paginaFinal" => "521"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Annular erythema of infancy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "F&#46; Toledo-Alberola"
                            1 => "I&#46; Betlloch-Mas"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Actas Dermosifiliogr"
                        "fecha" => "2010"
                        "volumen" => "101"
                        "paginaInicial" => "473"
                        "paginaFinal" => "484"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20738966"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Urticaria mimickers in children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46;N&#46; Mathur"
                            1 => "E&#46;F&#46; Mathes"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/dth.12103"
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatol Ther"
                        "fecha" => "2013"
                        "volumen" => "26"
                        "paginaInicial" => "467"
                        "paginaFinal" => "475"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24552410"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/15782190/0000010700000001/v2_201704190205/S1578219015003194/v2_201704190205/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "34944"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "e- Case Report"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010700000001/v2_201704190205/S1578219015003194/v2_201704190205/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219015003194?idApp=UINPBA000044"
]
Share
Journal Information
Vol. 107. Issue 1.
Pages e1-e5 (January - February 2016)
Visits
13355
Vol. 107. Issue 1.
Pages e1-e5 (January - February 2016)
E-Case Report
Full text access
Urticaria Multiforme: A Report of 5 Cases and a Review of the Literature
Cinco casos de urticaria multiforme y revisión de la literatura
Visits
13355
L. Sempau
Corresponding author
leticiasempau@gmail.com

Corresponding author.
, E. Martín-Sáez, C. Gutiérrez-Rodríguez, M.C. Gutiérrez-Ortega
Servicio de Dermatología, Hospital Universitario de Burgos, Burgos, Spain
This item has received
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Figures (2)
Tables (2)
Table 1. Summary of Patient History in Our 5 Cases.
Table 2. Drugs and Vaccines Associated With Urticaria Multiforme in the Literature.
Show moreShow less
Abstract

Urticaria multiforme is a cutaneous disorder that affects infants and small children. It is characterized by large, annular urticarial plaques with a violaceous center and is frequently accompanied by fever. Urticaria multiforme follows a benign, self-limiting course, but the striking appearance of the lesions can cause alarm and considerable anxiety among parents.

We present 5 cases of urticaria multiforme seen in our hospital over a period of 18 months. All the cases were preceded by an infection of the upper airways or otitis, and they were all empirically with amoxicillin. It is important to be familiar with this condition to reassure parents and avoid unnecessary hospital admissions and tests.

Keywords:
Urticaria
Infant
Erythema multiforme
Resumen

La urticaria multiforme es un cuadro cutáneo, propio de lactantes y niños pequeños, caracterizado por la aparición de grandes placas anulares urticariformes de centro violáceo frecuentemente asociado a un proceso febril. Tiene un curso benigno y autolimitado, pero el llamativo aspecto de las lesiones puede ser alarmante y generar gran ansiedad en los padres.

Presentamos 5 casos de urticaria multiforme vistos en nuestro hospital a lo largo de 18 meses. El antecedente común a todos ellos fue una infección de vías respiratorias altas u otitis por la que fueron tratados empíricamente con amoxicilina. Es importante saber reconocer esta entidad para tranquilizar a los padres, ahorrar el ingreso hospitalario y evitar la realización de pruebas diagnósticas innecesarias.

Palabras clave:
Urticaria
Niño
Eritema multiforme
Full Text
Introduction

Urticaria multiforme (UM) is a benign, self-resolving cutaneous disorder that affects children between 4 months and 4 years of age. It is characterized by the appearance of large annular and archiform erythematous plaques with a violaceous center and is very frequently accompanied by fever.

Case Descriptions

We present 5 cases of UM seen in our hospital between December 2012 and June 2013. Case data are summarized in Table 1. The patients—4 boys and 1 girl between the ages of 8 and 22 months—were brought to our emergency department following the appearance of extensive urticarial lesions on the face, trunk, and limbs. The lesions had a violaceous center and were associated with edema of the hands and feet (Figs. 1 and 2). Despite the striking clinical appearance of the skin, the patients were in good general health. Fever was a variable finding. The mean duration of the skin lesions was 5 days, during which time oral antihistamines or corticosteroids were administered to alleviate the lesions, but new lesions continued to appear. The first 2 patients seen were admitted to the hospital, whereas the last 3 only required ambulatory follow-up. All patients had received oral amoxicillin during the course of the disease or shortly before the skin lesions appeared; 3 underwent amoxicillin allergy tests, with negative results.

Table 1.

Summary of Patient History in Our 5 Cases.

  Case 1  Case 2  Case 3  Case 4  Case 5 
Age, mo  22  13  16  15 
Sex  Male  Male  Male  Male  Female 
Medical history  Upper respiratory tract infection  Upper respiratory tract infection  Otitis  Upper respiratory tract infection  Otitis 
Medication history
and timing 
Salbutamol, B
Amoxicillin, A 
Montelukast, B
Fluticasone, B
Amoxicillin, C (2 d)
Dextromethorphan, C 
Amoxicillin, A
Paracetamol, A 
Amoxicillin, A  Amoxicillin, C (2 d)
Salbutamol, A 
Timing of
fever and skin rash 
Fever began 2 d after rash appeared  Fever began 6h before rash appeared  Fever until 1 d before rash appeared
No fever while rash was present 
Low-grade fever while rash was present  Fever until 3 d before rash appeared
No fever while rash was present 
Duration of rash, d  6
 
General health  Good  Good  Good  Good  Good 
Edema of hands and feet  Yes  Yes  Yes  Yes  Yes 
Facial involvement  Annular plaques  Edema of the eyelids
Annular plaques 
Annular plaques  Edema of the eyelids
Annular plaques 
Annular plaques 
Hospitalization  Yes  Yes  No  No  No 
Treatment  Hydroxyzine  Metamizole
Hydroxyzine
Prednisolone 
Hydroxyzine Prednisolone  Hydroxyzine
Prednisolone 
Hydroxyzine
Prednisolone 
Tests  Antinuclear antibodies, negative
Mycoplasma, negative
Complete blood count, no abnormalities
Biochemistry, no abnormalities 
Pharyngeal exudate, no abnormalities  None  Leukocytosis
Biochemistry, no abnormalities 
None 
Allergy tests  None  Negative for
amoxicillin and
dextromethorphan 
Negative for
amoxicillin and
paracetamol 
Negative for amoxicillin  None 

Abbreviations: A, patient was taking medication when the cutaneous signs appeared; B, patient was taking usual medication; C, patient had been taking medication in the days prior to the appearance of urticaria multiforme.

Figure 1.

Coalescing annular and archiform plaques with a violaceous center on the trunk (A and B), face (D), and limbs (C and E).

(0.17MB).
Figure 2.

Small urticarial lesions that spread outward leaving an ecchymotic center on the leg and foot (A), anterior aspect of the trunk (B), and posterior aspect of the trunk (C), coalescing until they occupy nearly the entire back.

(0.16MB).
Discussion

UM is an acute skin disorder that typically affects infants and very small children and tends to be accompanied by fever and good general health. The typical lesions are initially small urticarial lesions that spread outward and coalesce into large archiform plaques with polycyclic borders and a violaceous center. The individual lesions have a duration of less than 24hours, can affect any part of the body, and tend to be associated with edema of the face, hands, and feet. The lesions disappear spontaneously in 6 to 10 days without leaving any residual pigmentation.

UM was first described in 1997 by Tamayo-Sánchez et al.,1 who observed 34 patients with a rash that they called acute annular urticaria and which they proposed differentiating from acute urticaria. Ten years later, Shah et al.2 reported a new series of 19 cases and proposed the term urticaria multiforme because of the similarity of the entity to erythema multiforme. Unlike Tamayo-Sánchez et al., Shah et al. considered the disorder to be a subtype of urticaria because they found that the patients presented dermographism and pruritus, whereas Tamayo-Sánchez et al. had doubted whether pruritus was present because they did not find scratch lesions on any of their patients.

The clinical diagnostic criteria that both authors agree on are as follows:

  • Large annular plaques with a transient ecchymotic center.

  • Individual lesions with a duration of less than 24hours.

  • Associated episode of fever.

  • Total duration of disease: less than 10 days.

  • Edema of the limbs.

The etiology of UM is unknown. In the few reported cases in which the infectious agent was investigated, micoplasm,2,3 adenovirus,2Streptococcus organisms,2 herpes virus 6,4 and the Epstein-Barr virus5 were detected. However, most reports indicate the medications that the patient had been receiving before the appearance of the lesions (Table 2).1,2,5–10 Common medications include amoxicillin and furazolidone (an antibiotic used in the treatment of giardiasis in Mexico), which had been administered in 19 of the 34 cases reported by Tamayo-Sánchez. Likewise, vaccination in the days prior to symptom onset is frequently reported.2,9,10 In our series, all 5 patients had been taking amoxicillin at the time the lesions appeared or up to 3 days before the appearance of the lesions.

Table 2.

Drugs and Vaccines Associated With Urticaria Multiforme in the Literature.

Drug  Article 
Furazolidone  Tamayo-Sánchez et al.1 (×23) 
Amoxicillin  Shah et al.2 (×5)
Emer et al.5
Donnelly and Tackett6
Authried et al.7
Guerrier et al.8
Sempau (×5) 
Amoxicillin–clavulanic acid  Shah et al.2 
Palivizumab (Synagis)  Shah et al.2 
Varicella vaccine  Shah et al.2 
Unknown vaccine  Shah et al.2 
Albuterol  Shah et al.2 
Topiramate  Shah et al.2 
Nitrofurantoin  Shah et al.2 
Aspirin  Guerrier et al.8 
Vaccine against rotavirus, Haemophilus influenzae, diphtheria, tetanus, and pertussis  Starnes et al.9 
Pyrazolone  Tamayo-Sánchez et al.1 
Mesalamine+6-mercaptopurine+omeprazole  Shah et al.2 
Naproxen+tetanus vaccine+human papillomavirus vaccine  Fung et al.10 

Histologic studies have been carried out in only 3 cases.1,5 In these patients, histology revealed dermal edema with a perivascular lymphocytic infiltrate and a few eosinophils, but no epidermal involvement. On the basis of these findings, UM can be differentiated from erythema multiforme (which is usually associated with epidermal necrosis) and from acute urticaria (which is not normally associated with perivascular lymphocytic infiltrate).

The only treatment proposal put forth by Tamayo-Sánchez et al. is the introduction of antipyretics if fever is present and the suspension of suspicious medications, whereas Shah et al. recommend the use of antihistamines on the grounds that UM is a type of urticaria. All other authors propose the use of antihistamines for symptom relief.5,6,8–10 Our 5 patients initially received treatment with antihistamines, and oral corticosteroids were added when symptoms persisted. Both treatments alleviated the existing skin lesions but neither prevented the appearance of new lesions; we therefore doubt the utility of oral corticosteroids in UM. Like Tamayo-Sánchez et al., we observed no signs of scratching in our patients.

The differential diagnosis of UM includes other annular lesions11,12 such as acute urticaria (which is usually associated with intense pruritus but not with fever and lacks central bluish pigmentation), erythema multiforme, and urticarial vasculitis (in which the individual lesions usually persist for several days and leave residual lesions. Facial and acral edema may require differential diagnosis with a drug-induced serum sickness–like reaction that is typically (but not exclusively) associated with the administration of cefaclor and vaccines. This type of reaction appears around 7 to 10 days after the start of treatment and presents as urticarial lesions with a dark center. In contrast to UM, however, the lesions do not have day-to-day fluctuation and tend to be associated with general malaise, arthralgia, and enlarged lymph nodes. Finally, it is important to differentiate UM from acute hemorrhagic edema of infancy, which also appears in children under 24 months of age in association with low-grade fever and has little impact on general health. Unlike UM, in acute hemorrhagic edema of infancy purpuric plaques appear and spread outward, forming annular, targetoid lesions, occasionally with a necrotic or bullous center, which last several days and leave residual pigmentation.

Conclusions

The 5 cases described in this article were seen over the course of 18 months, suggesting that UM is a relatively frequent entity in routine clinical practice. In all 5 cases, the patient had a history of upper respiratory tract infection and had been receiving amoxicillin in the days before the lesions appeared—a finding reported in practically all cases described in the literature. Because UM has an alarming appearance but a benign course, it is important that physicians be able to recognize it in order to reassure the family and avoid unnecessary hospital admissions and diagnostic tests.

Ethical DisclosuresProtection of persons and animals

The authors declare that no experiments were performed on humans or animals for the purpose of this study.

Confidentiality of data

The authors declare that they followed their hospitals’ regulations regarding the publication of patient information.

Right to privacy

The authors declare that no private patient data appear in this article.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

References
[1]
L. Tamayo-Sánchez, R. Ruiz-Maldonado, A. Laterza.
Acute annular urticaria in infants and children.
Pediatr Dermatol, 14 (1997), pp. 231-234
[2]
K.N. Shah, P.J. Honig, A.C. Yan.
Urticaria multiforme: A case series and review of acute annular urticarial hypersensitivity syndromes in children.
Pediatrics, 119 (2007), pp. e1177-e1183
[3]
S.R. Myers, J. Lavelle.
Picture of the month--quiz case. Pneumonia with associated urticarial multiforme rash.
Arch Pediatr Adolesc Med, 163 (2009), pp. 1157
[4]
A. Borghesi, P. Cipelletti, R. Maragliano, P. Manzoni, M. Stronati.
Human herpesvirus 6 associated neonatal urticaria multiforme.
Arch Dis Child Fetal Neonatal Ed, 98 (2013), pp. F450
[5]
J.J. Emer, S.G. Bernardo, O. Kovalerchik, M. Ahmad.
Urticaria multiforme.
J Clin Aesthet Dermatol, 6 (2013), pp. 34-39
[6]
A.F. Donnelly, B. Tackett.
What is your diagnosis? Urticaria multiforme.
Cutis, 89 (2012), pp. 262-263
[7]
G. Authried, L. Bracher, A. Bygum.
Urticaria multiforme is a variation of urticaria, which imitates erythema multiforme.
Ugeskr Laeger, 175 (2013), pp. 436-437
[8]
G. Guerrier, J.M. Daronat, R. Deltour.
Unusual presentation of acute annular urticaria: A case report.
Case Rep Dermatol Med, 2011 (2011), pp. 604390
[9]
L. Starnes, T. Patel, R.B. Skinner.
Urticaria multiforme--a case report.
Pediatr Dermatol, 28 (2011), pp. 436-438
[10]
I.N. Fung, E.M. Berger, L. Castelo-Soccio, T.F. Brown-Whitehorn.
Urticaria multiforme in an 18-year-old girl.
Allergy Clin Immunol Pract, 1 (2013), pp. 520-521
[11]
F. Toledo-Alberola, I. Betlloch-Mas.
Annular erythema of infancy.
Actas Dermosifiliogr, 101 (2010), pp. 473-484
[12]
A.N. Mathur, E.F. Mathes.
Urticaria mimickers in children.
Dermatol Ther, 26 (2013), pp. 467-475

Please cite this article as: Sempau L, Martín-Sáez E, Gutiérrez-Rodríguez C, Gutiérrez-Ortega MC. Cinco casos de urticaria multiforme y revisión de la literatura. Actas Dermosifiliogr. 2016;107:e1–e5.

Copyright © 2014. Elsevier España, S.L.U. and AEDV
Download PDF
Idiomas
Actas Dermo-Sifiliográficas
Article options
Tools
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?