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A Life-Threatening Autoimmune Blistering Disease" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "902" "paginaFinal" => "910" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Tirado-Sánchez, A. Bonifaz" "autores" => array:2 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Tirado-Sánchez" "email" => array:1 [ 0 => "atsdermahgm@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Bonifaz" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital General de México, Mexico" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pénfigo paraneoplásico. Una enfermedad ampollosa autoinmune grave" ] ] "resumenGrafico" => array:2 [ "original" => 1 "multimedia" => array:5 [ "identificador" => "fig0025" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 906 "Ancho" => 1333 "Tamanyo" => 82683 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In 1990, Anhalt et al.<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">1</span></a> reported a new clinical entity named as “Paraneoplastic pemphigus”, fulfilling five diagnostic criteria. Subsequently, their findings were confirmed by several studies.<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">2–9</span></a> Nguyen et al.<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">10</span></a> described PNP as a heterogeneous autoimmune syndrome that affects several internal organs, and that its pathophysiology is not limited to antibodies targeting adhesion molecules like other subtypes of pemphigus. In 2001, they proposed the term “Paraneoplastic autoimmune multi-organ syndrome” instead of PNP. This is because the autoantibodies in the disease bind to the kidney, smooth and striated muscle, as well as the epithelium of the small intestine, colon and thyroid.<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">3</span></a> The term more widely used in most reports and reviews, including the present paper, is PNP. About the position of PNP among skin disorders, some studies<a class="elsevierStyleCrossRefs" href="#bib0480"><span class="elsevierStyleSup">11–13</span></a> propose to include it as a type of pemphigus with an associated tumor, whereas others<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">14–16</span></a> describe it as an independent autoimmune disorder; moreover, PNP does not fully meet Curth's criteria for cutaneous paraneoplastic syndrome (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Paraneoplastic pemphigus is closely related to benign or malignant tumors. The most often reported malignancies are lymphomatoid and hematologic (B-cell lymphoma, chronic lymphocytic leukemia, Castleman's disease, Waldenstrom's macroglobulinemia, and thymoma, with or without myasthenia gravis). Interactions between the immune system and concomitant neoplasm seem to be key pathogenic steps with autoantibodies directed against both desmosomal and hemidesmosomal antigens. In PNP, most patients develop autoantibodies against periplakins and envoplakins.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In 1990, Anhalt et al.<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">1</span></a> first described five cases of patients with a rare form of atypical pemphigus that were all associated with lymphoproliferative diseases. PNP mostly affects adults between 45 and 70 years old, but it may also be found in younger patients, in whom Castleman's disease is more commonly seen. There is no known correlation between incidence of the disease and specific gender, race, or geographical distribution.<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Based on its very unique clinical pictures, as well as its histologic and immunologic features, and most of all its elevated mortality (90% if untreated), diagnosis should be stated promptly.<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">3,17–20</span></a> Prognosis depends on the nature of the associated tumor. Some patients experience rapid improvement after excision of a benign tumor, such as PNP associated to Castleman's disease. However, malignant tumors are often accompanied not only by higher mortality from the associated malignancy but also because the PNP can be severe and often recalcitrant.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Epidemiology</span><p id="par0025" class="elsevierStylePara elsevierViewall">The exact incidence of PNP is unknown but it is less common than pemphigus vulgaris or pemphigus foliaceus. There appears to be no age preference.<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">4</span></a> Although PNP presents most often in older patients aged between 45 and 70 years, it also occurs in younger patients. The disease has been reported in patients ranging from 7 to 83 years-old.<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">5</span></a> Ogawa et al.<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">21</span></a> studied 496 patients with malignancy and recorded 25 cases of pemphigus (5%), an elevated number when compared with controls. There was a positive correlation with advancing age. The mean age of pemphigus patients with malignancy was 64.7 years.<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">21</span></a> It appears to be no gender predilection.<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">2,22</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The associated malignant or benign neoplasm may be occult or already diagnosed at the point of PNP presentation. PNP may also develop after the tumor has been treated.<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">6,7</span></a> The most commonly associated tumors are hematological, accounting for nearly 84% of all cases, these include non-Hodgkin's lymphoma (38.6%), chronic lymphocytic leukemia (18.4%), Castleman's disease (18.4%), thymoma (5.5%), Waldenström macroglobulinemia (1.2%), Hodgkin's lymphoma (0.6%) and monoclonal gammopathy (0.6%).<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">4</span></a> Non-hematological neoplasms include carcinomas (8.6%), sarcomas (6.2%)<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">23</span></a> and melanoma (0.6%).<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In children and adolescents, PNP is most commonly associated with Castleman's disease<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">8</span></a> and PNP is often the presenting sign of Castleman's disease.<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">9</span></a> This tumor is rare in the general population but is the third most common neoplasm associated with PNP.<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">24</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Etiopathogenesis</span><p id="par0040" class="elsevierStylePara elsevierViewall">PNP is an autoimmune disorder launched by an underlying neoplasm (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Etiopathogenesis of PNP is not fully described.<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">4</span></a> Skin lesions are thought to be originated by an antibody-mediated autoimmune response to tumor antigens that cross-react with epithelial antigens. Tumor autoantibodies produce and release cytokines (such as interleukin-6) that enhance B-cells differentiation<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">5</span></a> and foster to develop the humoral response.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">PNP is often a clinical marker of benign and malignant neoplasms, most commonly malignancies of the lymphatic system.<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">6</span></a> Ohzono et al.<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">7</span></a> described the associated tumors in 104 PNP cases. Their clinical and histopathological findings were similar to those in previous reports.<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">3,4,6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Some patients have tumors that are difficult to diagnose, such as follicular dendritic cell sarcomas located in the retroperitoneal space.<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">8</span></a> Studies of patients with non-Hodgkin lymphoma revealed that most severe lesions during the PNP occur 2–3 years after diagnosis of lymphoma.<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">6</span></a> Castleman's disease, also known as giant lymph node hyperplasia, occurs most commonly in children.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Previous studies have shown that HLA-DR4 and DR14 alleles confer strong susceptibility to pemphigus vulgaris and foliaceous; however, PNP is not associated with these alleles. HLA-DRB1*03 in Caucasian patients<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">24</span></a> and Cw*14 in Chinese patients have been reported in PNP.<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">25</span></a> These findings indicate that people with different racial backgrounds have a different susceptibility to PNP.</p><p id="par0060" class="elsevierStylePara elsevierViewall">It is hypothesized that tumor antigens evoke not only a humoral response but a cellular one.<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">4,5</span></a> While direct immunofluorescence findings of autoantibodies bound to the cell surface of affected epithelium support a humoral response, histopathological findings of individual keratinocyte necrosis with lymphocyte exocytosis support the role of cell-mediated immunity.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In order to explain such hypothesis, several explanations have been proposed, like production of autoantibodies to epithelial proteins by tumors, supported by finding B-cells-producing IgG antibodies directed to epidermal antigens in Castleman's disease<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">26</span></a>; cross-reactivity of tumor antigens and epidermal antigens; high levels of interleukin-6, which promotes B-cell differentiation and immunoglobulin production.<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">27</span></a> Anti-IL-6 monoclonal antibody inhibitors (Tocilizumab) have been successfully used for treating Castleman's disease<a class="elsevierStyleCrossRefs" href="#bib0565"><span class="elsevierStyleSup">28–30</span></a>; epitope spreading and cellular immunity-mediated processes have been reported in previous studies.<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">31,32</span></a> Cummins et al.<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">32</span></a> reported a series of four patients with a lichenoid variant of PNP without detectable autoantibodies. They inferred that these patients had disease mainly mediated by cytotoxic T lymphocytes rather than autoantibodies. Nguyen et al.<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">10</span></a> also showed the presence of cytotoxic T lymphocytes, macrophages, and natural killer cells in tissues affected by PNP. These theories support that both cellular and humoral immunity are implicated in the pathogenesis of PNP.<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">33</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Clinical</span><p id="par0070" class="elsevierStylePara elsevierViewall">Various lesions may occur in patients with PNP. Although characterized by severe oral mucositis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), a generalized polymorphous cutaneous eruption and pulmonary involvement may develop. Typically, the first symptoms are usually florid, painful as well as intractable stomatitis, and also, it can involve the vermilion of the lips, oro and nasopharynx, the nose (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), tongue, esophagus, stomach; duodenum, intestines and the pulmonary epithelium, as well as the conjunctiva<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">34</span></a> and anogenital region (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) are also affected.<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">2,3,35–38</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The lesions are polymorphic, and symptoms include blisters, erosions, spots, papules, and plaques. Nikolsky sign can be present. Cutaneous lesions usually appear after the onset of mucosal lesions and may involve any site, mostly the upper body. Nguyen et al.<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">10</span></a> proposed a classification including several clinical presentations of PNP. It is believed that each category occurs with nearly equal incidence.</p><p id="par0080" class="elsevierStylePara elsevierViewall">PNP cutaneous lesions can be classified into several groups according to the types of changes:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall">Pemphigus-like: flaccid blisters, erosions, crust, and erythema.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0090" class="elsevierStylePara elsevierViewall">Bullous pemphigoid-like: scaly erythematous papules and stretched vesicles. These are more commonly seen on the extremities.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">Erythema multiforme-like: polymorphic changes, mainly erythematous peeling pellets with erosions and sometimes even with recalcitrant ulcerations (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall">Graft-versus-host disease: scattered dusky red scaly papules.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0105" class="elsevierStylePara elsevierViewall">Lichen planus-like: the presenting picture consists in flat, red-brown scaly papules and plaques, as well as intense mucous membrane involvement, more commonly seen in children on the trunk and extremities (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), and rapidly extending to the face and neck.<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">38</span></a> Scaly lesions on the palms and soles may accompany the lichenoid lesions.</p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">Patients with PNP can develop life-threatening restrictive bronchiolitis obliterans. The frequency of the involvement of the respiratory system and its pathological mechanisms are unknown.<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">39</span></a> In a study of 17 patients with PNP, restrictive bronchiolitis was found only in three patients. However, in another analysis where 28 patients with PNP and concomitant Castleman's disease were examined, the respiratory system was affected in 26 cases.<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">40,41</span></a> Pulmonary disease, when present, is irreversible despite aggressive therapy.<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">2,3,42</span></a> The recently discovered autoantigen, epiplakin, has demonstrated correlation with development of bronchiolitis obliterans in Japanese patients.<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">43</span></a> Epiplakin is present in the respiratory bronchiole, and mice injected with epiplakin autoantibody showed abnormal changes in the histopathology of their pulmonary epithelia. While more research is needed, these early results indicate that epiplakin may represent a specific autoantigen in PNP-related bronchiolitis obliterans.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Differential diagnosis of PNP is extensive (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>), and includes pemphigus vulgaris, mucous membrane pemphigoid, erythema multiforme, Stevens–Johnson syndrome, lichen planus, graft-versus-host disease, and herpes simplex virus infection. When PNP is suspected, an extensive baseline workup should be conducted, including: blood cell count, lactate dehydrogenase, flow cytometry, as well as chest, abdomen, and pelvis CT scan. The existence of a neoplasm is often recognized prior to PNP (30% of cases approximately).<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">22</span></a></p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Histology</span><p id="par0120" class="elsevierStylePara elsevierViewall">The disease often require several biopsies to achieve diagnosis.<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">44</span></a> Horn and Anhalt<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">45</span></a> examined 16 skin and oral mucous membrane biopsy specimens from six patients with PNP, and observed epidermal acantholysis, suprabasal cleft formation, dyskeratotic keratinocytes and vacuolar changes in the basal epidermis, and epidermal exocytosis of inflammatory cells. According to the morphology of the clinical lesions, the histopathology may reveal a different spectrum from minor inflammatory bullous lesions to a dense lichenoid reaction.<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">45</span></a> Additionally, there might be vacuolar degeneration of the basal layer associated with band-like infiltrate of lymphocytes in the dermis (lichenoid features). Prompt clinic-pathologic correlation is recommended in these patients, as well as evaluations for neoplasm.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Immunology</span><p id="par0125" class="elsevierStylePara elsevierViewall">Immunopathology plays an important role in the diagnosis of PNP. The variety of possible autoantigens and the combination in which they occur, account for the diverse nature of this disorder, and thus for the conflicting findings.<a class="elsevierStyleCrossRefs" href="#bib0655"><span class="elsevierStyleSup">46–48</span></a> DIF performed on a perilesional biopsy may reveal intercellular deposits of IgG and C3 autoantibodies. In addition, linear deposits of IgG or C3 in the basement membrane zone, due to autoantibody binding to BPAG1-2, may be present. This helps distinguish PNP from other types of pemphigus, in which immunoglobulin deposits are found between keratinocytes but not on the basement membrane.<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">3,5</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Direct immunofluorescence can be negative in a few PNP patients, however, most cases exhibit positive DIF and thus, it is necessary for diagnosing PNP. False negatives on DIF are common in PNP for mucosal biopsies when necrotic tissue is predominant.<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">5</span></a> Another reason is that a significant proportion of lesions are lichenoid, with predominant cellular immunity instead of humoral immunity.<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">5,32</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The autoantibody profile of PNP has been recently studied.<a class="elsevierStyleCrossRefs" href="#bib0655"><span class="elsevierStyleSup">46,47,49</span></a> Elegant studies<a class="elsevierStyleCrossRefs" href="#bib0675"><span class="elsevierStyleSup">50–53</span></a> have suggested that patients with PNP have autoantibodies against the plakin family (e.g. envoplakin and periplakin). Antibodies against desmoglein 1 and 3 (antigens for classic pemphigus), however, these antibodies may play a role in the initial stages of the development of PNP.<a class="elsevierStyleCrossRefs" href="#bib0695"><span class="elsevierStyleSup">54,55</span></a> The presence of autoantibodies to plakins is a characteristic feature of PNP. Envoplakin and periplakin antibody levels are most specific,<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">56</span></a> followed by desmoplakin I and II.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Paraneoplastic pemphigus is the result of either a humoral or cell-mediated responses. This combined pathogenesis is clinically expressed in the varied pictures of PNP in contrast with those of pemphigus vulgaris. Auto-reactive cellular toxicity, mediated by cluster differentiating T lymphocytes (CD8+ cytotoxic T lymphocytes), CD56+ natural killer cells, and CD68+ macrophages, has also been implicated.<a class="elsevierStyleCrossRefs" href="#bib0705"><span class="elsevierStyleSup">56,50</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Indirect immunofluorescence shows that IgG antibodies bind to the stratified epithelium in the esophagus and other tissues from monkeys. In contrast to pemphigus vulgaris and foliaceus, these antibodies also bind with the transitional and cylindrical epithelium of the urinary bladder, bronchi, small intestine, and colon, as well as, to a lesser extent, with myocardium and skeletal muscles and thyroid epithelium.<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">50</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In a previous study, Anhalt et al. showed that rat bladder immunofluorescence testing technique has a sensitivity of 75% and a specificity of 83% for diagnosing PNP. This can be explained because the transitional epithelium of the rat bladder contains desmoplakin but not envoplakin, periplakin and desmoglein,<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">5</span></a> and not all patients with PNP have antibodies against all the antigens of the plakin complex.<a class="elsevierStyleCrossRefs" href="#bib0675"><span class="elsevierStyleSup">50,57</span></a> Plakin autoantibodies have been found in specific diseases: anti-desmoplakin antibodies in pemphigus vulgaris and erythema multiforme, anti-periplakin antibodies in pemphigus foliaceous and toxic epidermal necrolysis and rarely, anti-envoplakin antibodies in pemphigus foliaceous and vulgaris.<a class="elsevierStyleCrossRefs" href="#bib0705"><span class="elsevierStyleSup">56–58</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Poot et al.,<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">59</span></a> in a previous study, showed that indirect immunofluorescence with salt-split skin, showing a cytoplasmic staining of all layers of the epithelium, was a highly specific pattern of PNP, similarly as positive rat bladder indirect immunofluorescence.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Immunoprecipitation is the most sensitive and specific test for measuring anti-plakin antibodies in PNP.<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">59</span></a> A positive immunoprecipitation test qualifies as a major criterion for the diagnosis of PNP,<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">2</span></a> however, it has limited availability. Alternatives for the detection of plakin autoantibodies include immunoblotting and ELISA. Immunoblotting can be performed using an extract of cultured human keratinocytes to detect all desmosomal proteins: desmoglein 3 (130<span class="elsevierStyleHsp" style=""></span>kDa), desmoplakin 1 (250<span class="elsevierStyleHsp" style=""></span>kDa), BP230, desmoplakin 2 (210<span class="elsevierStyleHsp" style=""></span>kDa), envoplakin (210<span class="elsevierStyleHsp" style=""></span>kDa), plectin (>400<span class="elsevierStyleHsp" style=""></span>kDa), periplakin (190<span class="elsevierStyleHsp" style=""></span>kDa), epiplakin,<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">43</span></a> and occasionally desmoglein 1 (160<span class="elsevierStyleHsp" style=""></span>kDa). Immunoblotting and ELISA may also be performed using recombinant fragments of periplakin and envoplakin.<a class="elsevierStyleCrossRefs" href="#bib0725"><span class="elsevierStyleSup">60,61</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Diagnosis</span><p id="par0165" class="elsevierStylePara elsevierViewall">Even when there is no consensus about the diagnostic criteria for PNP; the diagnosis is based on the criteria of Anhalt et al.<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">1</span></a> mostly on clinical and histologic observations, direct immunofluorescence, indirect immunofluorescence, and immunoprecipitation tests (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), furthermore, Camisa and Helm<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">14</span></a> have classified these criteria into major and minor signs. Three major or two major and two minor signs are required to make a diagnosis of PNP. The most common laboratory finding is the immunoprecipitation pattern which is characteristic<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">1,62</span></a> and may allow prompt diagnosis and active management of PNP.<a class="elsevierStyleCrossRefs" href="#bib0740"><span class="elsevierStyleSup">63,64</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">The first diagnostic criteria made by Anhalt et al.<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">1</span></a> include (1) characteristic clinical appearance and histopathology and, (2) detection of tissue bound, circulating autoantibodies via direct immunofluorescence, indirect immunofluorescence and immunoprecipitation studies.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Anhalt further described other characteristics of PNP such as painful stomatitis, a polymorphous skin eruption with histological findings showing lichenoid or acantholytic changes, supportive immunofluorescence findings showing intercellular and basement membrane binding, serum antibodies that bind simple, columnar, and transitional epithelium, coexistence of lymphoproliferative disorders, and the presence of anti-dsg, desmoplakin I and II, envoplakin, periplakin, bullous pemphigoid antigen 1, and plectin antibodies.<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Extension work-up</span><p id="par0180" class="elsevierStylePara elsevierViewall">In patients suspected of PNP, an extensive work-up for an underlying associated malignancy must be performed if no tumor has been diagnosed so far. This should include a chest, abdomen and pelvis computed tomography scan.<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">65</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Treatment</span><p id="par0185" class="elsevierStylePara elsevierViewall">To date, PNP treatment has been rather disappointing. It is vital to define and treat the associated neoplasm in PNP. In patients with an operable tumor, a surgical cure is often the best chance of inducing remission of PNP.<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">66</span></a> The skin and mucosal eruptions cause severe morbidity and are often recalcitrant.<a class="elsevierStyleCrossRefs" href="#bib0750"><span class="elsevierStyleSup">65,66</span></a> The response to therapy is generally poor. Firstly, treatment is aimed at decreasing the production of autoantibodies.<a class="elsevierStyleCrossRefs" href="#bib0760"><span class="elsevierStyleSup">67–69</span></a> A better prognosis can be expected when the neoplasm is less aggressive (e.g. thymoma and Castleman's disease).<a class="elsevierStyleCrossRefs" href="#bib0755"><span class="elsevierStyleSup">66,70–75</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Concurrent to a medical workup in patients without operable neoplasms, several non-surgical treatments have proven effective in reducing symptoms in these patients.<a class="elsevierStyleCrossRef" href="#bib0805"><span class="elsevierStyleSup">76</span></a> Initially, glucocorticosteroid therapy should be added (prednisone (0.5–1.0<span class="elsevierStyleHsp" style=""></span>mg/kg)).<a class="elsevierStyleCrossRef" href="#bib0810"><span class="elsevierStyleSup">77</span></a> Cutaneous lesions tend to crust over and heal faster than mucosal. Steroid-sparing agents can be added to glucocorticoid therapy to reduce the total steroid burden. The addition of steroid-sparing agents, such as azathioprine, cyclosporine A,<a class="elsevierStyleCrossRefs" href="#bib0810"><span class="elsevierStyleSup">77,78</span></a> and mycophenolate mofetil,<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">74</span></a> may reduce steroid intake and thus limit potential side-effects; however, a high level of caution is advised in patients with PNP and confirmed malignancy, where immunosuppression is paramount and dictates the mainstay of treatment options. Stem cell ablation therapy using high-dose cyclophosphamide without skin cell rescue has been used in some cases,<a class="elsevierStyleCrossRefs" href="#bib0775"><span class="elsevierStyleSup">70,79</span></a> but this is hazardous.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Less conventional therapies may be considered when the first-choice therapy fails; when the patient is severely ill or when prompt intervention is required. While results with plasmapheresis and intravenous immunoglobulin have been disappointing,<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">5</span></a> rituximab, a monoclonal antibody to CD20 on B-cells, has shown promising results in patients with underlying B-cell lymphoma.<a class="elsevierStyleCrossRefs" href="#bib0780"><span class="elsevierStyleSup">71,80</span></a> Patients can be treated with the lymphoma protocol at a dose of 375<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span> weekly for 4 weeks, or the rheumatologic protocol of 1<span class="elsevierStyleHsp" style=""></span>g once and repeated in 2 weeks. Additional cycles may be administered every 6–12 months depending on clinical response and recovery of the B-cell (CD20-CD19) population. Rituximab is usually well tolerated, but notable adverse effects of treatment include infusion and allergic reactions. Severe, life-threatening anaphylactic reactions have occurred. For this reason, rituximab is infused in a monitored setting such as an infusion center where an allergy can be rapidly identified and treated.<a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">80</span></a> In addition, progressive multifocal leukoencephalopathy, a fatal and untreatable reactivation of Creutzfeldt Jakob virus in the brain, has been reported in association with rituximab.<a class="elsevierStyleCrossRef" href="#bib0830"><span class="elsevierStyleSup">81</span></a> This reactivation occurs only in the setting of severe immunosuppression. Alemtuzumab, a humanized monoclonal antibody against CD52, has also been successfully when used to induce long-term remission in a patient with underlying B-cell chronic lymphocytic leukemia.<a class="elsevierStyleCrossRefs" href="#bib0800"><span class="elsevierStyleSup">75,82</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">The concomitant use of rituximab with intravenous immunoglobulin has proven successful in patients who do not respond to conventional therapy or using rituximab as monotherapy. Intravenous immunoglobulin at 2<span class="elsevierStyleHsp" style=""></span>g/kg per monthly cycle is usually dosed. Intravenous immunoglobulin is well tolerated and it has shown to be effective, rapidly reducing pathogenic autoantibodies in patients with autoimmune bullous diseases. Another benefit of intravenous immunoglobulin is the fact that it can be added into the patient's existing treatment regimen without added concern of additional immunosuppression, becoming a popular approach among clinicians who treat PNP. Intravenous immunoglobulin's favorable safety profile makes it an obvious choice in patients who are often on complicated treatments for PNP and an underlying malignancy. However, the considerable high cost has limited its extensive use.<a class="elsevierStyleCrossRef" href="#bib0810"><span class="elsevierStyleSup">77</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Patients with PNP have an increased susceptibility to skin infections related to the loss of skin integrity and the use of potent immunosuppressant. Early treatment of secondary infections with proper systemic antimicrobial therapy is of significant relevance to prevent sepsis and death.<a class="elsevierStyleCrossRef" href="#bib0840"><span class="elsevierStyleSup">83</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Adequate analgesia should be provided as the lesions can be painful. Oropharyngeal ulcerations may also interfere with proper feeding, and a nasogastric tube may be required.<a class="elsevierStyleCrossRef" href="#bib0810"><span class="elsevierStyleSup">77</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Importantly, involvement of the respiratory tract epithelium can lead to bronchiolitis obliterans, respiratory insufficiency and subsequent death. A perioperative infusion of high-dose intravenous immunoglobulin during the surgical removal of Castleman's disease has been suggested to reduce the risk of bronchiolitis obliterans, which is the most common cause of death in PNP patients with Castleman's disease.<a class="elsevierStyleCrossRefs" href="#bib0730"><span class="elsevierStyleSup">61,65,66</span></a> Lung transplantation has been reported in managing progressive respiratory insufficiency caused by constrictive bronchiolitis in a 14 year-old patient with PNP and Castleman's disease.<a class="elsevierStyleCrossRef" href="#bib0845"><span class="elsevierStyleSup">84</span></a></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Prognosis</span><p id="par0220" class="elsevierStylePara elsevierViewall">The overall prognosis of PNP is poor. The mortality rate ranges from 75% to 90%, being respiratory failure the main cause of death.<a class="elsevierStyleCrossRef" href="#bib0830"><span class="elsevierStyleSup">81</span></a> The prognosis is better when the disease is associated with benign tumors and may even remit when tumors are excised.</p><p id="par0225" class="elsevierStylePara elsevierViewall">The outcome of PNP, however, does not simply parallel the course of the underlying malignancy. Complications resulting from PNP and its treatment contribute significantly to morbidity and mortality. These include sepsis, multi-organ failure, gastrointestinal hemorrhage and respiratory failure related to bronchiolitis obliterans.<a class="elsevierStyleCrossRef" href="#bib0840"><span class="elsevierStyleSup">83</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">Ohzono et al.<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">7</span></a> in a study of 104 PNP patients, of whom 40 died; the main cause of death in these patients was bronchiolitis obliterans (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>16/40, 40%), while the second cause (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>24/40, 60%) was infection (mainly pneumonia) and the third cause related to the associated tumor.</p><p id="par0235" class="elsevierStylePara elsevierViewall">Bronchiolitis obliterans correlates with poor prognosis. Pulmonary involvement occurs in 30–92.8% of patients and it is estimated that one-third of the deaths in PNP are due to pulmonary insufficiency. It is known that constrictive bronchiolitis can continue to worsen despite improvement in muco-cutaneous manifestations after immunosuppressive therapy and resection of tumor.<a class="elsevierStyleCrossRef" href="#bib0850"><span class="elsevierStyleSup">85</span></a> A prompt diagnosis and early introduction of treatment are mandatory.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0240" class="elsevierStylePara elsevierViewall">Through this literature review, we acquired a global context of paraneoplastic pemphigus. We present the main clinical features, the fundamental principles of its etiopathogeny, review the diagnostic aspects that integrate criteria distinguishing the entity from others such as pemphigus vulgaris; the main associated tumors, where we share part of the experience obtained in these almost 20 years studying autoimmune bullous diseases; finally the main treatment options and the prognostic factors of the disease are discussed. We emphasize the importance of making a timely diagnosis and choosing the most appropriate treatment option for each specific case.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ethical disclosures</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Protection of human and animal subjects</span><p id="par0245" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Confidentiality of data</span><p id="par0250" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Right to privacy and informed consent</span><p id="par0255" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interests</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres949070" "titulo" => "Graphical abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:3 [ "identificador" => "xres949072" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 2 => array:2 [ "identificador" => "xpalclavsec921178" "titulo" => "Keywords" ] 3 => array:3 [ "identificador" => "xres949071" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0015" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec921177" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:2 [ "identificador" => "sec0010" "titulo" => "Epidemiology" ] 7 => array:2 [ "identificador" => "sec0015" "titulo" => "Etiopathogenesis" ] 8 => array:3 [ "identificador" => "sec0020" "titulo" => "Clinical" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Histology" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Immunology" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Diagnosis" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Extension work-up" ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Treatment" ] ] ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Prognosis" ] 10 => array:2 [ "identificador" => "sec0055" "titulo" => "Conclusions" ] 11 => array:3 [ "identificador" => "sec0060" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0070" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0075" "titulo" => "Right to privacy and informed consent" ] ] ] 12 => array:2 [ "identificador" => "sec0080" "titulo" => "Conflict of interests" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-11-26" "fechaAceptado" => "2017-04-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec921178" "palabras" => array:6 [ 0 => "Paraneoplastic pemphigus" 1 => "Rituximab" 2 => "Antibody production" 3 => "Lymphoproliferative origin" 4 => "Prognosis" 5 => "Pemphigus" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec921177" "palabras" => array:6 [ 0 => "Pénfigo paraneoplásico" 1 => "Rituximab" 2 => "Producción de anticuerpos" 3 => "Origen linfoproliferativo" 4 => "Pronóstico" 5 => "Pénfigo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Paraneoplastic pemphigus (PNP), a subset of pemphigus, is a unique autoimmune blistering condition that can affect multiple organs other than the skin. It is a life-threatening disease associated with an underlying malignancy, most commonly of lymphoproliferative origin. The clinical picture may resemble pemphigus, pemphigoid, erythema multiforme, graft-versus-host disease, or lichen planus. The earliest and most consistent finding is a painful, severe, chronic and often recalcitrant stomatitis. Treatment of PNP is difficult. Immunosuppressive agents are required to decrease blistering, and treating the underlying tumor may control autoantibody production. In this review, we included essential diagnostic aspects of PNP and the most useful treatment options in the dermatologist practice.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El pénfigo paraneoplásico (PNP), una variedad de pénfigo, es una enfermedad ampollosa autoinmune que puede afectar a múltiples órganos distintos de la piel. Es una enfermedad grave asociada con una malignidad subyacente, comúnmente de origen linfoproliferativo. Las lesiones clínicas pueden parecerse al pénfigo, penfigoide, eritema multiforme, enfermedad de injerto contra huésped o liquen plano. El hallazgo más temprano y más consistente es una estomatitis dolorosa, grave, crónica y, a menudo, recalcitrante. El tratamiento del PNP es difícil. Se requieren agentes inmunosupresores para disminuir la formación de ampollas y el tratamiento del tumor subyacente puede controlar la producción de autoanticuerpos. En esta revisión se incluyeron los aspectos diagnósticos más esenciales del PNP y las opciones de tratamiento más útiles en la práctica dermatológica.</p></span>" ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1851 "Ancho" => 2730 "Tamanyo" => 231505 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Pathogenesis of paraneoplastic pemphigus. Neoplasms develop immune dysregulation and therefore the production of autoantibodies against self-antigens. Antigen-processing cells assimilate antigens that are cross-reactive with several skin antigens, presenting them to CD4+ T cells, and therefore to the known immune cascade that ends in the formation of autoantibodies against different substrates. The tumor itself can develop an immune process with the release of proinflammatory cytokines (IL-12 and IFN). This mechanism can be enhanced by the epitope spreading creating secondary epitopes, increasing antibody production; this mechanism contributes to epidermal and subepidermal lesions (pemphigus and pemphigoid-like lesions). Cell-mediated immune activation (mainly CD8+ T cells) also develops and contributes to several skin lesions (lichenoid and graft-versus-host disease-like).</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" => 750 "Ancho" => 596 "Tamanyo" => 151477 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Severe oral mucositis, also involving the nose.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 750 "Ancho" => 999 "Tamanyo" => 153975 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Erosions affecting the glans of penis. It is evident the lichenoid lesions on the hands.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 750 "Ancho" => 999 "Tamanyo" => 94249 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Several erosions on the palms of the hands, often recalcitrant.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">PNP: paraneoplastic pemphigus.</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="left" valign="top" scope="col" style="border-bottom: 2px solid black">Criteria \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Both conditions began simultaneously (neoplasia and paraneoplasia). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Development of a parallel course (treatment of the neoplasia results in regression of the skin lesion; recurrence of the neoplasia implies recurrence of the skin lesion). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">The skin lesion is not associated with a genetic syndrome. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">There is a specific type of neoplasia that occurs with paraneoplasia. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">The dermatosis is rare in the general population. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">There is a high frequency of association between both conditions. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1607279.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Curth's criteria for the diagnosis of cutaneous paraneoplastic syndrome.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">PNP: paraneoplastic pemphigus; DIF: direct immunofluorescence; IIF: indirect immunofluorescence.</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="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristic \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">Features \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Clinical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Painful mucosal erosions with a polymorphous skin eruption culminating in vesicles/bullae in the context of an occult/confirmed neoplasm. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Histopathology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Suprabasal acantholysis with clefting and suprabasal acantholysis resembling pemphigus vulgaris; interface dermatitis and exocytosis of inflammatory cells into the epidermis resembling lupus erythematosus; dyskeratosis (keratinocyte necrosis) with suprabasal acantholysis is a clue to PNP; may resemble changes seen in erythema multiforme or graft versus host disease; a lichenoid band may be seen along the dermal-epidermal junction resembling lichen planus. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DIF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Deposition of complement and IgG in intracellular epidermal spaces and in the basement membrane zone in linear granular lesions. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IIF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">IIF of patient serum with rat bladder epithelia shows intercellular staining. Confirmation of autoantibodies to periplakin and/or envoplakin. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neoplasm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Association with neoplasms (in order of frequency: non-Hodgkin lymphoma); chronic lymphocytic leukemia; Castleman disease; carcinoma; thymoma; sarcoma (liposarcoma, leiomyosarcoma, reticulum cell sarcoma, malignant nerve sheath tumor); Waldenström's macroglobulinemia; Hodgkin lymphoma, monoclonal gammopathy; melanoma. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1607280.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Characteristics of paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome.</p>" ] ] 6 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oral mucositis due to chemotherapy and other causes of severe oral ulceration \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pemphigus (vulgaris, drug-induced) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bullous pemphigoid and other autoimmune blistering disorders (including epidermolysis bullosa) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mucous membrane pemphigoid (Cicatricial pemphigoid) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Drug eruptions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oral (erosive) lichen planus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Graft versus host disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Erythema multiforme \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stevens–Johnson syndrome and toxic epidermal necrolysis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Major aphthous stomatitis \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1607281.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Differential diagnosis of PNP.</p>" ] ] 7 => array:5 [ "identificador" => "fig0025" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 906 "Ancho" => 1333 "Tamanyo" => 82683 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:85 [ 0 => array:3 [ "identificador" => "bib0430" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus. An autoimmune mucocutaneous disease associated with neoplasia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJM199012203232503" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "1990" "volumen" => "323" "paginaInicial" => "1729" "paginaFinal" => "1735" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0435" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "pii:S1658-3876(16)30028-0" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus as a presentation of acute myeloid leukemia: early diagnosis and remission" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Hematol Oncol Stem Cell Ther" "fecha" => "2016" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0440" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic autoimmune multiorgan syndrome: 20 years after" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-4632.2011.04868.x" "Revista" => array:6 [ "tituloSerie" => "Int J Dermatol" "fecha" => "2011" "volumen" => "50" "paginaInicial" => "905" "paginaFinal" => "914" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0445" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical and immunopathological spectrum of paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1610-0387.2010.07380.x" "Revista" => array:6 [ "tituloSerie" => "J Dtsch Dermatol Ges" "fecha" => "2010" "volumen" => "8" "paginaInicial" => "598" "paginaFinal" => "606" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0450" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus: the role of tumours and drugs" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2001" "volumen" => "144" "paginaInicial" => "1102" "paginaFinal" => "1104" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0455" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neoplasms associated with paraneoplastic pemphigus: a review with emphasis on non-hematologic malignancy and oral mucosal manifestations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.oraloncology.2003.09.020" "Revista" => array:6 [ "tituloSerie" => "Oral Oncol" "fecha" => "2004" "volumen" => "40" "paginaInicial" => "553" "paginaFinal" => "562" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0460" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical and immunological findings in 104 cases of paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/bjd.14162" "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2015" "volumen" => "173" "paginaInicial" => "1447" "paginaFinal" => "1452" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0465" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Adv Dermatol" "fecha" => "1997" "volumen" => "12" "paginaInicial" => "77" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0470" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1087-0024.2004.00832.x" "Revista" => array:6 [ "tituloSerie" => "J Investig Dermatol Symp Proc" "fecha" => "2004" "volumen" => "9" "paginaInicial" => "29" "paginaFinal" => "33" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0475" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Classification, clinical manifestations, and immunopathological mechanisms of the epithelial variant of paraneoplastic autoimmune multiorgan syndrome: a reappraisal of paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Dermatol" "fecha" => "2001" "volumen" => "137" "paginaInicial" => "193" "paginaFinal" => "206" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0480" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus: a subset of patients with pemphigus and neoplasia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Cutan Pathol" "fecha" => "1993" "volumen" => "20" "paginaInicial" => "203" "paginaFinal" => "210" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0485" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pemphigus: past, present and future" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Dermatology" "fecha" => "1994" "volumen" => "189" "numero" => "Suppl. 2" "paginaInicial" => "26" "paginaFinal" => "29" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0490" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recent advances in the study of the pathophysiology of pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00403-002-0366-3" "Revista" => array:7 [ "tituloSerie" => "Arch Dermatol Res" "fecha" => "2003" "volumen" => "295" "numero" => "Suppl 1" "paginaInicial" => "S2" "paginaFinal" => "S11" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0495" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus is a distinct neoplasia-induced autoimmune disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ …2] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Dermatol" "fecha" => "1993" "volumen" => "129" "paginaInicial" => "883" "paginaFinal" => "886" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0500" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus. A distinct autoimmune vesiculobullous disorder associated with neoplasia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Oral Surg Oral Med Oral Pathol" "fecha" => "1993" "volumen" => "75" "paginaInicial" => "209" "paginaFinal" => "213" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0505" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic autoimmune multiorgan syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2004.07.008" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2004" "volumen" => "51" "paginaInicial" => "631" "paginaFinal" => "632" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0510" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus associated with follicular dendritic cell sarcoma: report of a case and review of literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Int J Clin Exp Pathol" "fecha" => "2015" "volumen" => "8" "paginaInicial" => "11983" "paginaFinal" => "11994" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0515" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Dermatol Clin" "fecha" => "1993" "volumen" => "11" "paginaInicial" => "473" "paginaFinal" => "481" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0520" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A case of retroperitoneal Castleman's disease with paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.11817/j.issn.1672-7347.2016.05.016" "Revista" => array:6 [ "tituloSerie" => "Zhong Nan Da Xue Xue Bao Yi Xue Ban" "fecha" => "2016" "volumen" => "41" "paginaInicial" => "548" "paginaFinal" => "552" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0525" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus. The role of tumours and drugs" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2001" "volumen" => "144" "paginaInicial" => "1102" "paginaFinal" => "1104" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0530" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The incidence of external malignancies in pemphigus and bullous pemphigoid in Japan" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Dermatol Sci" "fecha" => "1995" "volumen" => "9" "paginaInicial" => "135" "paginaFinal" => "141" ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0535" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ …2] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Oral Oncol" "fecha" => "1998" "volumen" => "34" "paginaInicial" => "437" "paginaFinal" => "440" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0540" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus associated with malignant fibrous histiocytoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ …2] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-4632.2006.03073.x" "Revista" => array:6 [ "tituloSerie" => "Int J Dermatol" "fecha" => "2006" "volumen" => "45" "paginaInicial" => "1374" "paginaFinal" => "1375" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0545" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus is associated with the DRB1*03 allele" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Autoimmun" "fecha" => "2003" "volumen" => "20" "paginaInicial" => "91" "paginaFinal" => "95" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0550" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Genotyping of HLA-I and HLA-II alleles in Chinese patients with paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2133.2007.08361.x" "Revista" => array:7 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2008" "volumen" => "158" "paginaInicial" => "587" "paginaFinal" => "591" "link" => array:1 [ 0 => array:2 [ …2] ] "itemHostRev" => array:3 [ "pii" => "S1386653216305339" "estado" => "S300" "issn" => "13866532" ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0555" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Castleman's tumors and production of autoantibody in paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(04)15539-6" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2004" "volumen" => "363" "paginaInicial" => "525" "paginaFinal" => "531" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0560" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Elevated levels of interleukin-6 in paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1046/j.1523-1747.1999.00520.x" "Revista" => array:6 [ "tituloSerie" => "J Invest Dermatol" "fecha" => "1999" "volumen" => "112" "paginaInicial" => "396" "paginaFinal" => "398" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0565" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Humanized anti-interleukin-6 receptor antibody treatment of multicentric Castleman disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1182/blood-2004-12-4602" "Revista" => array:6 [ "tituloSerie" => "Blood" "fecha" => "2005" "volumen" => "106" "paginaInicial" => "2627" "paginaFinal" => "2632" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0570" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cutaneous Castleman's disease responds to anti interleukin-6 treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1158/1535-7163.MCT-07-0256" "Revista" => array:6 [ "tituloSerie" => "Mol Cancer Ther" "fecha" => "2007" "volumen" => "6" "paginaInicial" => "2386" "paginaFinal" => "2390" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0575" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anti-interleukin-6 antibody (tocilizumab) treatment of multicentric Castleman's disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Intern Med" "fecha" => "2007" "volumen" => "46" "paginaInicial" => "771" "paginaFinal" => "774" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0580" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Graft-versus-host disease-like immunophenotype and apoptotic keratinocyte death in paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1046/j.1365-2133.1999.03123.x" "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "1999" "volumen" => "141" "paginaInicial" => "739" "paginaFinal" => "746" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0585" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lichenoid paraneoplastic pemphigus in the absence of detectable antibodies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2006.06.007" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2007" "volumen" => "56" "paginaInicial" => "153" "paginaFinal" => "159" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0590" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic autoimmune multiorgan syndrome: review of the literature and support for a cytotoxic role in pathogenesis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1080/08916930600972099" "Revista" => array:6 [ "tituloSerie" => "Autoimmunity" "fecha" => "2006" "volumen" => "39" "paginaInicial" => "617" "paginaFinal" => "630" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0595" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Conjunctival involvement in paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Ophthalmol" "fecha" => "1992" "volumen" => "114" "paginaInicial" => "621" "paginaFinal" => "624" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0600" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A progressive blistering eruption in a patient with lymphoma. Paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Arch Dermatol" "fecha" => "1997" "volumen" => "133" "paginaInicial" => "100" "paginaFinal" => "101" ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0605" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A 79-year-old woman with gastric lymphoma and erosive mucosal and cutaneous lesions. Case records of the Massachusetts General Hospital. Weekly clinico-pathological exercises. Case 23-2003" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMcpc030016" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2003" "volumen" => "349" "paginaInicial" => "382" "paginaFinal" => "391" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 36 => array:3 [ "identificador" => "bib0610" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus: a refractory autoimmune mucocutaneous disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/120347540200600505" "Revista" => array:6 [ "tituloSerie" => "J Cutan Med Surg" "fecha" => "2002" "volumen" => "6" "paginaInicial" => "434" "paginaFinal" => "437" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 37 => array:3 [ "identificador" => "bib0615" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus presenting as a lichen planus pemphigoides-like eruption" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Dermatol" "fecha" => "1993" "volumen" => "129" "paginaInicial" => "866" "paginaFinal" => "869" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 38 => array:3 [ "identificador" => "bib0620" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus: a brief update" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ …2] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1440-0960.2005.126_1.x" "Revista" => array:6 [ "tituloSerie" => "Australas J Dermatol" "fecha" => "2005" "volumen" => "46" "paginaInicial" => "1" "paginaFinal" => "8" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 39 => array:3 [ "identificador" => "bib0625" "etiqueta" => "40" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Constrictive bronchiolitis associated with paraneoplastic autoimmune multiorgan syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1440-1843.2008.01397.x" "Revista" => array:6 [ "tituloSerie" => "Respirology" "fecha" => "2009" "volumen" => "14" "paginaInicial" => "129" "paginaFinal" => "133" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 40 => array:3 [ "identificador" => "bib0630" "etiqueta" => "41" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus in association with Castleman's disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2003" "volumen" => "149" "paginaInicial" => "1143" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 41 => array:3 [ "identificador" => "bib0635" "etiqueta" => "42" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus with autoantibody deposition in bronchial epithelium after autologous bone marrow transplantation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "1992" "volumen" => "267" "paginaInicial" => "1500" "paginaFinal" => "1502" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 42 => array:3 [ "identificador" => "bib0640" "etiqueta" => "43" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epiplakin is a paraneoplastic pemphigus autoantigen and related to bronchiolitis obliterans in Japanese patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/JID.2015.408" "Revista" => array:7 [ "tituloSerie" => "J Invest Dermatol" "fecha" => "2016" "volumen" => "136" "paginaInicial" => "399" "paginaFinal" => "408" "link" => array:1 [ 0 => array:2 [ …2] ] "itemHostRev" => array:3 [ "pii" => "S0140673614616986" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 43 => array:3 [ "identificador" => "bib0645" "etiqueta" => "44" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus associated with Castleman tumor, myasthenia gravis and bronchiolitis obliterans" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "1999" "volumen" => "41" "paginaInicial" => "393" "paginaFinal" => "400" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 44 => array:3 [ "identificador" => "bib0650" "etiqueta" => "45" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Histologic features of paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ …2] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Dermatol" "fecha" => "1992" "volumen" => "128" "paginaInicial" => "1091" "paginaFinal" => "1095" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 45 => array:3 [ "identificador" => "bib0655" "etiqueta" => "46" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Indirect immunofluorescence on rat bladder transitional epithelium: a test with high specificity for paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "1993" "volumen" => "28" "paginaInicial" => "696" "paginaFinal" => "699" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 46 => array:3 [ "identificador" => "bib0660" "etiqueta" => "47" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidermal adhesion molecules and basement membrane components as target structures of autoimmunity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ …2] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Virchows Arch" "fecha" => "1998" "volumen" => "432" "paginaInicial" => "487" "paginaFinal" => "504" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 47 => array:3 [ "identificador" => "bib0665" "etiqueta" => "48" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Immunopathology of paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Dermatol" "fecha" => "2001" "volumen" => "19" "paginaInicial" => "675" "paginaFinal" => "682" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 48 => array:3 [ "identificador" => "bib0670" "etiqueta" => "49" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus sera react strongly with multiple epitopes on the various regions of envoplakin and periplakin, except for the c-terminal homologous domain of periplakin" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1046/j.1523-1747.2001.01263.x" "Revista" => array:6 [ "tituloSerie" => "J Invest Dermatol" "fecha" => "2001" "volumen" => "116" "paginaInicial" => "556" "paginaFinal" => "563" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 49 => array:3 [ "identificador" => "bib0675" "etiqueta" => "50" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Accuracy of indirect immunofluorescence testing in the diagnosis of paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "1995" "volumen" => "32" "paginaInicial" => "441" "paginaFinal" => "447" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 50 => array:3 [ "identificador" => "bib0680" "etiqueta" => "51" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Making sense of antigens and antibodies in pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "1999" "volumen" => "40" "paginaInicial" => "763" "paginaFinal" => "766" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 51 => array:3 [ "identificador" => "bib0685" "etiqueta" => "52" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Conformational epitope mapping and IgG subclass distribution of desmoglein 3 in paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0190" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2003" "volumen" => "49" "paginaInicial" => "1023" "paginaFinal" => "1028" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 52 => array:3 [ "identificador" => "bib0690" "etiqueta" => "53" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluation of a newly available ELISA for envoplakin autoantibodies for the diagnosis of paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Drugs Dermatol" "fecha" => "2015" "volumen" => "14" "paginaInicial" => "1103" "paginaFinal" => "1106" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 53 => array:3 [ "identificador" => "bib0695" "etiqueta" => "54" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Antibody titers to desmogleins 1 and 3 in a patient with paraneoplastic pemphigus associated with follicular dendritic cell sarcoma" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archderm.140.12.1500" "Revista" => array:6 [ "tituloSerie" => "Arch Dermatol" "fecha" => "2004" "volumen" => "140" "paginaInicial" => "1500" "paginaFinal" => "1503" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 54 => array:3 [ "identificador" => "bib0700" "etiqueta" => "55" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Plectin serves as an autoantigen in paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1046/j.1523-1747.1999.00695.x" "Revista" => array:6 [ "tituloSerie" => "J Invest Dermatol" "fecha" => "1999" "volumen" => "113" "paginaInicial" => "422" "paginaFinal" => "423" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 55 => array:3 [ "identificador" => "bib0705" "etiqueta" => "56" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Envoplakin and periplakin are the paraneoplastic pemphigus antigens" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Kurume Med J" "fecha" => "1999" "volumen" => "46" "paginaInicial" => "71" "paginaFinal" => "78" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 56 => array:3 [ "identificador" => "bib0710" "etiqueta" => "57" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Antidesmoplakin antibodies in pemphigus vulgaris" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2133.2005.06987.x" "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2006" "volumen" => "154" "paginaInicial" => "624" "paginaFinal" => "628" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 57 => array:3 [ "identificador" => "bib0715" "etiqueta" => "58" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Envoplakin and periplakin, the paraneoplastic pemphigus antigens, are also recognized by pemphigus foliaceus autoantibodies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1046/j.1523-1747.2000.00088-2.x" "Revista" => array:6 [ "tituloSerie" => "J Invest Dermatol" "fecha" => "2000" "volumen" => "115" "paginaInicial" => "505" "paginaFinal" => "507" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 58 => array:3 [ "identificador" => "bib0720" "etiqueta" => "59" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Direct and indirect immunofluorescence staining patters in the diagnosis of paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/bjd.14282" "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2016" "volumen" => "174" "paginaInicial" => "912" "paginaFinal" => "915" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 59 => array:3 [ "identificador" => "bib0725" "etiqueta" => "60" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Characterization of paraneoplastic pemphigus autoantigens by immunoblot analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Invest Dermatol" "fecha" => "1995" "volumen" => "104" "paginaInicial" => "829" "paginaFinal" => "834" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 60 => array:3 [ "identificador" => "bib0730" "etiqueta" => "61" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Development of ELISA for the specific determination of autoantibodies against envoplakin and periplakin in paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.cca.2009.08.022" "Revista" => array:6 [ "tituloSerie" => "Clin Chim Acta" "fecha" => "2009" "volumen" => "410" "paginaInicial" => "13" "paginaFinal" => "18" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 61 => array:3 [ "identificador" => "bib0735" "etiqueta" => "62" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus: oral involvement as the sole manifestation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Acta Derm Venereol" "fecha" => "1996" "volumen" => "76" "paginaInicial" => "253" "paginaFinal" => "254" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 62 => array:3 [ "identificador" => "bib0740" "etiqueta" => "63" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The mechanism of respiratory failure in paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJM199909093411115" "Revista" => array:5 [ "tituloSerie" => "N Engl J Med" "fecha" => "1999" "volumen" => "341" "paginaInicial" => "848" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 63 => array:3 [ "identificador" => "bib0745" "etiqueta" => "64" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The mechanism of respiratory failure in paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "N Engl J Med" "fecha" => "1999" "volumen" => "341" "paginaInicial" => "1406" "paginaFinal" => "1410" ] ] ] ] ] ] 64 => array:3 [ "identificador" => "bib0750" "etiqueta" => "65" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ …2] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1346-8138.2007.00322.x" "Revista" => array:6 [ "tituloSerie" => "J Dermatol" "fecha" => "2007" "volumen" => "34" "paginaInicial" => "503" "paginaFinal" => "511" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 65 => array:3 [ "identificador" => "bib0755" "etiqueta" => "66" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A critical role of surgery in the treatment for paraneoplastic pemphigus caused by localized Castleman's disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s12032-009-9304-y" "Revista" => array:6 [ "tituloSerie" => "Med Oncol" "fecha" => "2010" "volumen" => "27" "paginaInicial" => "907" "paginaFinal" => "911" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 66 => array:3 [ "identificador" => "bib0760" "etiqueta" => "67" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Exacerbation of paraneoplastic pemphigus by cyclophosphamide treatment: detection of novel autoantigens and bronchial autoantibodies" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2133.2004.05978.x" "Revista" => array:7 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2004" "volumen" => "150" "paginaInicial" => "1018" "paginaFinal" => "1024" "link" => array:1 [ 0 => array:2 [ …2] ] "itemHostRev" => array:3 [ "pii" => "S1386653214003242" "estado" => "S300" "issn" => "13866532" ] ] ] ] ] ] ] 67 => array:3 [ "identificador" => "bib0765" "etiqueta" => "68" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of autoimmune skin disorders in the elderly" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ …2] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Drugs Aging" "fecha" => "2004" "volumen" => "21" "paginaInicial" => "767" "paginaFinal" => "777" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 68 => array:3 [ "identificador" => "bib0770" "etiqueta" => "69" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "New approaches to the treatment of pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ …1] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Invest Dermatol Symp Proc" "fecha" => "2004" "volumen" => "9" "paginaInicial" => "84" "paginaFinal" => "91" ] ] ] ] ] ] 69 => array:3 [ "identificador" => "bib0775" "etiqueta" => "70" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Immunoablative high-dose cyclophosphamide without stem cell rescue in a patient with pemphigus vulgaris" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1067/mjd.2000.110397" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2000" "volumen" => "43" "paginaInicial" => "1065" "paginaFinal" => "1069" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 70 => array:3 [ "identificador" => "bib0780" "etiqueta" => "71" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Using rituximab (anti-CD20 antibody) in a patient with paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Drugs Dermatol" "fecha" => "2003" "volumen" => "2" "paginaInicial" => "564" "paginaFinal" => "567" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 71 => array:3 [ "identificador" => "bib0785" "etiqueta" => "72" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Immunoablative high-dose cyclophosphamide without stem cell rescue in paraneoplastic pemphigus: report of a case and review of this new therapy for severe autoimmune disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "1999" "volumen" => "40" "paginaInicial" => "750" "paginaFinal" => "754" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 72 => array:3 [ "identificador" => "bib0790" "etiqueta" => "73" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus treated with dexamethasone/cyclophosphamide pulse therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur J Dermatol" "fecha" => "1998" "volumen" => "8" "paginaInicial" => "551" "paginaFinal" => "553" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 73 => array:3 [ "identificador" => "bib0795" "etiqueta" => "74" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of mycophenolate mofetil in the treatment of paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2000" "volumen" => "142" "paginaInicial" => "506" "paginaFinal" => "508" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 74 => array:3 [ "identificador" => "bib0800" "etiqueta" => "75" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Alemtuzumab-induced remission of both severe paraneoplastic pemphigus and leukaemic bone marrow infiltration in a case of treatment-resistant B-cell chronic lymphocytic leukaemia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1600-0609.2004.00280.x" "Revista" => array:6 [ "tituloSerie" => "Eur J Haematol" "fecha" => "2004" "volumen" => "73" "paginaInicial" => "206" "paginaFinal" => "209" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 75 => array:3 [ "identificador" => "bib0805" "etiqueta" => "76" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus: potential therapeutic effect of plasmapheresis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "1996" "volumen" => "134" "paginaInicial" => "987" "paginaFinal" => "989" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 76 => array:3 [ "identificador" => "bib0810" "etiqueta" => "77" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ …2] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-4632.2009.03995.x" "Revista" => array:5 [ "tituloSerie" => "Int J Dermatol" "fecha" => "2009" "volumen" => "48" "paginaInicial" => "162" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 77 => array:3 [ "identificador" => "bib0815" "etiqueta" => "78" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Successful treatment of B cell chronic lymphocytic leukemia-associated severe paraneoplastic pemphigus with cyclosporin A" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1159/000070972" "Revista" => array:6 [ "tituloSerie" => "Acta Haematol" "fecha" => "2003" "volumen" => "109" "paginaInicial" => "202" "paginaFinal" => "205" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 78 => array:3 [ "identificador" => "bib0820" "etiqueta" => "79" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Immunoablative high-dose cyclophosphamide without stem cell rescue in pemphigus foliaceus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ …3] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Int J Dermatol" "fecha" => "2002" "volumen" => "41" "paginaInicial" => "340" "paginaFinal" => "344" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 79 => array:3 [ "identificador" => "bib0825" "etiqueta" => "80" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus. A report of two cases associated with chronic B-cell lymphocytic leukaemia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2001" "volumen" => "145" "paginaInicial" => "127" "paginaFinal" => "131" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 80 => array:3 [ "identificador" => "bib0830" "etiqueta" => "81" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Progressive respiratory failure in paraneoplastic pemphigus associated with chronic lymphocytic leukemia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1159/000077312" "Revista" => array:6 [ "tituloSerie" => "Dermatology" "fecha" => "2004" "volumen" => "208" "paginaInicial" => "251" "paginaFinal" => "254" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 81 => array:3 [ "identificador" => "bib0835" "etiqueta" => "82" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus as the initial presentation of chronic lymphocytic leukemia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Ann Oncol" "fecha" => "2001" "volumen" => "12" "paginaInicial" => "115" "paginaFinal" => "118" "link" => array:1 [ 0 => array:2 [ …2] ] "itemHostRev" => array:3 [ "pii" => "S1201971215001307" "estado" => "S300" "issn" => "12019712" ] ] ] ] ] ] ] 82 => array:3 [ "identificador" => "bib0840" "etiqueta" => "83" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prognostic factors of paraneoplastic pemphigus" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archdermatol.2012.1830" "Revista" => array:6 [ "tituloSerie" => "Arch Dermatol" "fecha" => "2012" "volumen" => "148" "paginaInicial" => "1165" "paginaFinal" => "1172" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 83 => array:3 [ "identificador" => "bib0845" "etiqueta" => "84" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus and bronchiolitis obliterans associated with a mediastinal mass: a rare case of Castleman's disease with respiratory failure requiring lung transplantation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ …5] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/jpsu.2001.28877" "Revista" => array:5 [ "tituloSerie" => "J Pediatr Surg" "fecha" => "2001" "volumen" => "36" "paginaInicial" => "E22" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 84 => array:3 [ "identificador" => "bib0850" "etiqueta" => "85" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paraneoplastic pemphigus with bronchiolitis obliterans in a child" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ …6] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatr Dermatol" "fecha" => "2003" "volumen" => "20" "paginaInicial" => "238" "paginaFinal" => "242" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00017310/0000010800000010/v1_201711300829/S0001731017303708/v1_201711300829/en/main.assets" "Apartado" => array:4 [ "identificador" => "6158" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Revisiones" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00017310/0000010800000010/v1_201711300829/S0001731017303708/v1_201711300829/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731017303708?idApp=UINPBA000044" ]
año/Mes | Html | Total | |
---|---|---|---|
2024 Noviembre | 19 | 15 | 34 |
2024 Octubre | 108 | 77 | 185 |
2024 Septiembre | 128 | 66 | 194 |
2024 Agosto | 153 | 68 | 221 |
2024 Julio | 141 | 71 | 212 |
2024 Junio | 139 | 71 | 210 |
2024 Mayo | 129 | 61 | 190 |
2024 Abril | 120 | 42 | 162 |
2024 Marzo | 165 | 41 | 206 |
2024 Febrero | 217 | 53 | 270 |
2024 Enero | 147 | 46 | 193 |
2023 Diciembre | 208 | 33 | 241 |
2023 Noviembre | 250 | 49 | 299 |
2023 Octubre | 145 | 47 | 192 |
2023 Septiembre | 148 | 53 | 201 |
2023 Agosto | 106 | 24 | 130 |
2023 Julio | 128 | 46 | 174 |
2023 Junio | 100 | 32 | 132 |
2023 Mayo | 118 | 42 | 160 |
2023 Abril | 94 | 23 | 117 |
2023 Marzo | 98 | 37 | 135 |
2023 Febrero | 112 | 29 | 141 |
2023 Enero | 80 | 32 | 112 |
2022 Diciembre | 129 | 43 | 172 |
2022 Noviembre | 119 | 39 | 158 |
2022 Octubre | 150 | 50 | 200 |
2022 Septiembre | 156 | 48 | 204 |
2022 Agosto | 150 | 49 | 199 |
2022 Julio | 106 | 61 | 167 |
2022 Junio | 76 | 47 | 123 |
2022 Mayo | 114 | 56 | 170 |
2022 Abril | 163 | 50 | 213 |
2022 Marzo | 188 | 59 | 247 |
2022 Febrero | 186 | 53 | 239 |
2022 Enero | 175 | 57 | 232 |
2021 Diciembre | 97 | 48 | 145 |
2021 Noviembre | 111 | 57 | 168 |
2021 Octubre | 74 | 122 | 196 |
2021 Septiembre | 71 | 50 | 121 |
2021 Agosto | 54 | 68 | 122 |
2021 Julio | 78 | 72 | 150 |
2021 Junio | 46 | 57 | 103 |
2021 Mayo | 65 | 85 | 150 |
2021 Abril | 105 | 112 | 217 |
2021 Marzo | 120 | 109 | 229 |
2021 Febrero | 93 | 66 | 159 |
2021 Enero | 56 | 54 | 110 |
2020 Diciembre | 58 | 45 | 103 |
2020 Noviembre | 31 | 57 | 88 |
2020 Octubre | 45 | 73 | 118 |
2020 Septiembre | 54 | 43 | 97 |
2020 Agosto | 45 | 50 | 95 |
2020 Julio | 45 | 46 | 91 |
2020 Junio | 40 | 62 | 102 |
2020 Mayo | 26 | 42 | 68 |
2020 Abril | 36 | 32 | 68 |
2020 Marzo | 28 | 21 | 49 |
2020 Febrero | 6 | 2 | 8 |
2020 Enero | 5 | 2 | 7 |
2019 Diciembre | 13 | 2 | 15 |
2019 Noviembre | 5 | 0 | 5 |
2019 Septiembre | 11 | 0 | 11 |
2019 Agosto | 3 | 0 | 3 |
2019 Julio | 6 | 0 | 6 |
2019 Junio | 4 | 0 | 4 |
2019 Mayo | 8 | 1 | 9 |
2019 Abril | 3 | 2 | 5 |
2019 Marzo | 14 | 2 | 16 |
2019 Febrero | 5 | 2 | 7 |
2019 Enero | 1 | 0 | 1 |
2018 Diciembre | 9 | 6 | 15 |
2018 Noviembre | 5 | 4 | 9 |
2018 Octubre | 21 | 0 | 21 |
2018 Septiembre | 6 | 0 | 6 |
2018 Agosto | 0 | 2 | 2 |
2018 Julio | 1 | 1 | 2 |
2018 Junio | 3 | 1 | 4 |
2018 Mayo | 0 | 1 | 1 |
2018 Abril | 4 | 0 | 4 |
2018 Marzo | 2 | 1 | 3 |
2018 Febrero | 29 | 11 | 40 |
2018 Enero | 36 | 33 | 69 |
2017 Diciembre | 70 | 91 | 161 |
2017 Noviembre | 5 | 28 | 33 |
2017 Octubre | 0 | 35 | 35 |
2017 Septiembre | 0 | 39 | 39 |
2017 Agosto | 0 | 58 | 58 |