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A biopsy specimen taken from the BCG vaccination site revealed thickened collagen bundles throughout the dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Patchy lymphocytic infiltrates and fibrosis of septal connective tissues were seen in the subcutaneous tissue&#46; Laboratory tests revealed positive antinuclear antibodies &#40;1&#58;320&#44; speckled and nucleolar&#41; and values within the normal range for rheumatoid factor and anti-DNA&#44; anti-centromere&#44; and anti-U1RNP antibodies&#46; Liver and kidney function&#44; serum complement levels&#44; creatine phosphokinase&#44; aldolase&#44; and myoglobin were also all within normal ranges&#46; Three-dimensional computed tomography of the scalp did not reveal any abnormal findings&#46; The patient was initially treated with oral prednisolone &#40;15<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41;&#44; followed by the addition of methotrexate &#40;6<span class="elsevierStyleHsp" style=""></span>mg&#47;wk&#41;&#44; which led to satisfactory results&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Morphea is sometimes triggered by local stimuli&#44; such as minor trauma&#44; irradiation&#44; vaccination&#44; implantation of silicon prostheses&#44; needle biopsy&#44; laparoscopy&#44; and drug injections&#59; it can also arise at the site of surgical and herpes zoster scars&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;7</span></a> The Koebner phenomenon is seen in various disorders&#44; including morphea&#46; The pathogenesis of this phenomenon has not yet been fully elucidated&#46; Upon epidermal injury&#44; several proinflammatory cytokines&#44; such as interleukin 1&#44; tumor necrosis factor &#945;&#44; and granulocyte macrophage-colony stimulating factor &#40;GM-CSF&#41;&#44; are released&#44; possibly inducing further inflammation&#46; Ueki<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> proposed a 2-step theory to explain the pathophysiology of the Koebner phenomenon&#46; The first step&#44; referred to as a nonspecific inflammatory step&#44; would involve multiple environmentally induced factors such as cytokines&#44; stress proteins&#44; adhesion molecules&#44; and autoantigens translocated from intracellular areas&#44; while the second&#44; disease-specific&#44; step would involve disease-specific reactions mediated by T cells&#44; B cells&#44; autoantibodies&#44; and immune complex deposition under the restriction of susceptible backgrounds&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Dermatological complications of BCG vaccination generally include induration and severe ulceration&#44; but cases of granuloma annulare&#44; abscesses&#44; papular tuberculids&#44; lupus vulgaris&#44; and benign and malignant tumors have also been reported&#46; Keloid formation at the BCG vaccination site is well known&#44; but few cases of morphea have been reported to date&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> In one of the cases&#44; the lesions appeared on the shoulder a year after BCG vaccination&#44; which was proposed as a possible trigger for the skin changes&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Another case was reported in a series of 7 cases of sclerodermatous conditions after bone marrow transplantation&#44; but a detailed description was not provided&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Our patient developed linear scleroderma that started at the site of a BCG scar&#44; without prior keloid scarring&#46; Previous trauma may be associated with persistent inflammation and the release of various mediators such as cytokines and growth factors&#44; or neurotransmitters from degenerative peripheral nerves&#46;</p></span>"
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Case and Research Letter
Pediatric generalized morphea that developed at a BCG vaccination site
Morfea generalizada pediátrica de aparición en el sitio de la inyección de la vacuna BCG
M. Matsumoto, T. Yamamoto
Autor para correspondencia
toyamade@fmu.ac.jp

Corresponding author.
Department of Dermatology, Fukushima Medical University, Fukushima, Japan
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which led to satisfactory results&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Morphea is sometimes triggered by local stimuli&#44; such as minor trauma&#44; irradiation&#44; vaccination&#44; implantation of silicon prostheses&#44; needle biopsy&#44; laparoscopy&#44; and drug injections&#59; it can also arise at the site of surgical and herpes zoster scars&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;7</span></a> The Koebner phenomenon is seen in various disorders&#44; including morphea&#46; The pathogenesis of this phenomenon has not yet been fully elucidated&#46; Upon epidermal injury&#44; several proinflammatory cytokines&#44; such as interleukin 1&#44; tumor necrosis factor &#945;&#44; and granulocyte macrophage-colony stimulating factor &#40;GM-CSF&#41;&#44; are released&#44; possibly inducing further inflammation&#46; Ueki<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> proposed a 2-step theory to explain the pathophysiology of the Koebner phenomenon&#46; The first step&#44; referred to as a nonspecific inflammatory step&#44; would involve multiple environmentally induced factors such as cytokines&#44; stress proteins&#44; adhesion molecules&#44; and autoantigens translocated from intracellular areas&#44; while the second&#44; disease-specific&#44; step would involve disease-specific reactions mediated by T cells&#44; B cells&#44; autoantibodies&#44; and immune complex deposition under the restriction of susceptible backgrounds&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Dermatological complications of BCG vaccination generally include induration and severe ulceration&#44; but cases of granuloma annulare&#44; abscesses&#44; papular tuberculids&#44; lupus vulgaris&#44; and benign and malignant tumors have also been reported&#46; Keloid formation at the BCG vaccination site is well known&#44; but few cases of morphea have been reported to date&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> In one of the cases&#44; the lesions appeared on the shoulder a year after BCG vaccination&#44; which was proposed as a possible trigger for the skin changes&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Another case was reported in a series of 7 cases of sclerodermatous conditions after bone marrow transplantation&#44; but a detailed description was not provided&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Our patient developed linear scleroderma that started at the site of a BCG scar&#44; without prior keloid scarring&#46; Previous trauma may be associated with persistent inflammation and the release of various mediators such as cytokines and growth factors&#44; or neurotransmitters from degenerative peripheral nerves&#46;</p></span>"
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