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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical history</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 52-year-old woman who had undergone a hysterectomy at the age of 35 due to uterine myomas&#44; presented with an extremely painful nodule on her right shoulder of 1 year duration&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">An erythematous and tender nodule of 20&#8239;mm on the right scapular region &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; was observed&#46; Dermoscopy revealed a white central area with a peripheral crown of serpiginous vessels over a red-yellowish background&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Diagnostic tests</span><p id="par0015" class="elsevierStylePara elsevierViewall">A punch skin biopsy was performed and histologic study &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#8211;B&#41; and immunohistochemistry &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#46; Desmin&#59; 2D&#46; S100&#59; 2E&#46; Ki67&#41; was carried out&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><p id="par1015" class="elsevierStylePara elsevierViewall">What is your diagnosis&#63;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0020" class="elsevierStylePara elsevierViewall">Pilar leiomyoma&#44; multiple cutaneous and uterine leiomyomatosis &#40;or Reed syndrome&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Evolution and treatment</span><p id="par0025" class="elsevierStylePara elsevierViewall">The lesion was excised&#46; Histopathological study showed an ill-defined proliferation of intermingled smooth muscle bands without atypia&#46; No mitotic activity or necrosis was observed in the dermis&#46; On immunohistochemistry&#44; the tumor was positive for desmin&#44; weakly positive for actin and Ki67&#44; and negative for CD34 and S-100 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#8211;E&#41;&#46; A diagnosis of pilar leiomyoma was made&#46; On further questioning&#44; the patient revealed a family history of multiple cutaneous leiomyomas &#40;mother&#44; brother and sister&#41; and uterine leiomyomatosis &#40;mother and sister&#41;&#46; The patient fulfilled the clinical diagnostic criteria for multiple cutaneous and uterine leiomyomatosis &#40;MCUL&#41; or Reed Syndrome<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; A renovesical ultrasound was performed&#44; in order to rule out an associated renal neoplasm&#44; showing a radiologically benign lesion &#40;angiomyolipoma&#41;&#46; Ultrasonographic follow-up every 6 months was then indicated and the patient&#44; referred to the Urology and the Genetic department&#46; The patient was lost to follow-up&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Pilar leiomyomas &#40;PL&#41; are infrequent benign smooth muscle tumors arising from the arrector pili muscle of hair follicles&#46; Within the group of cutaneous leiomyomas&#44; PL constitute the most common subtype&#46; PL usually present as painful erythematous-brownish papulonodules and can present as solitary or multiple lesions &#40;myomatosis cutis miliaris&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; Almost 50&#37; of the PL cause a sharp or burning pain&#46; On dermoscopy&#44; PL can present with a delicate pink-brown pigmented network and irregular crypts with white cloud-like areas and peripheral branching vessels<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#44; although unfocused arborizing telangiectasias have been described in more than 10&#37; of tumors<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">PL have been reported in association with multiple disorders such as esophageal leiomyomas&#44; chronic lymphocytic leukemia and HIV&#46; PL can also be secondary to an autosomal dominant inherited familial syndrome&#58; MCUL or Reed syndrome&#46; Main characteristics of MCUL are the presence of cutaneous leiomyomas &#40;mainly PL&#41;&#44; uterine leiomyomas in women &#40;73&#8211;100&#37;&#41; and renal cell carcinoma &#40;20&#8211;34&#37;&#41;&#46; Clinical diagnostic criteria include multiple cutaneous leiomyoma &#40;with histologic confirmation of one of the lesions&#41; or a biopsy-proven solitary cutaneous leiomyoma plus family history of Reed syndrome<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; MCUL is caused by a heterozygous mutation &#40;1q42&#46;3-q43&#41; in the fumarate hydratase gene &#40;FH&#41;&#44; a Krebs cycle enzyme&#44; but may also act as a tumor suppressor<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; PL present in patients with MCUL by the age of 40&#44; and generally constitute the first manifestation of the syndrome and their most sensitive and specific clinical marker<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; Uterine leiomyomas are developed earlier than in healthy individuals&#44; usually requiring hysterectomy&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The most worrying association of MCUL is with renal cell carcinoma &#40;RCC&#41;&#44; which occurs in up to 30&#37; of patients&#46; RCC in this context tend to be aggressive&#44; with early nodal dissemination and metastases&#46; Abdominal MRI is recommended every 6&#8211;12 months&#44; since small tumors could not be detected by ultrasound and can have a high dissemination potential<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; Genetic testing should be offered&#44; if available&#44; in order to avoid unnecessary imaging in case of negative results&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">PL can be associated with MCUL and RCC&#46; Dermatologists should be aware of the potentially life-threatening consequences of a delayed diagnosis&#46;</p></span></span>"
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Case for Diagnosis
Solitary painful nodule on the scapular region
Nódulo doloroso solitario en la región escapular
F. Alamon-Reig, D. Morgado-Carrasco
Autor para correspondencia
morgadodaniel8@gmail.com

Corresponding author.
, P. Iranzo-Fernández
Departament de Dermatologia, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical history</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 52-year-old woman who had undergone a hysterectomy at the age of 35 due to uterine myomas&#44; presented with an extremely painful nodule on her right shoulder of 1 year duration&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">An erythematous and tender nodule of 20&#8239;mm on the right scapular region &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; was observed&#46; Dermoscopy revealed a white central area with a peripheral crown of serpiginous vessels over a red-yellowish background&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Diagnostic tests</span><p id="par0015" class="elsevierStylePara elsevierViewall">A punch skin biopsy was performed and histologic study &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#8211;B&#41; and immunohistochemistry &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#46; Desmin&#59; 2D&#46; S100&#59; 2E&#46; Ki67&#41; was carried out&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><p id="par1015" class="elsevierStylePara elsevierViewall">What is your diagnosis&#63;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0020" class="elsevierStylePara elsevierViewall">Pilar leiomyoma&#44; multiple cutaneous and uterine leiomyomatosis &#40;or Reed syndrome&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Evolution and treatment</span><p id="par0025" class="elsevierStylePara elsevierViewall">The lesion was excised&#46; Histopathological study showed an ill-defined proliferation of intermingled smooth muscle bands without atypia&#46; No mitotic activity or necrosis was observed in the dermis&#46; On immunohistochemistry&#44; the tumor was positive for desmin&#44; weakly positive for actin and Ki67&#44; and negative for CD34 and S-100 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#8211;E&#41;&#46; A diagnosis of pilar leiomyoma was made&#46; On further questioning&#44; the patient revealed a family history of multiple cutaneous leiomyomas &#40;mother&#44; brother and sister&#41; and uterine leiomyomatosis &#40;mother and sister&#41;&#46; The patient fulfilled the clinical diagnostic criteria for multiple cutaneous and uterine leiomyomatosis &#40;MCUL&#41; or Reed Syndrome<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; A renovesical ultrasound was performed&#44; in order to rule out an associated renal neoplasm&#44; showing a radiologically benign lesion &#40;angiomyolipoma&#41;&#46; Ultrasonographic follow-up every 6 months was then indicated and the patient&#44; referred to the Urology and the Genetic department&#46; The patient was lost to follow-up&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Pilar leiomyomas &#40;PL&#41; are infrequent benign smooth muscle tumors arising from the arrector pili muscle of hair follicles&#46; Within the group of cutaneous leiomyomas&#44; PL constitute the most common subtype&#46; PL usually present as painful erythematous-brownish papulonodules and can present as solitary or multiple lesions &#40;myomatosis cutis miliaris&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; Almost 50&#37; of the PL cause a sharp or burning pain&#46; On dermoscopy&#44; PL can present with a delicate pink-brown pigmented network and irregular crypts with white cloud-like areas and peripheral branching vessels<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#44; although unfocused arborizing telangiectasias have been described in more than 10&#37; of tumors<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">PL have been reported in association with multiple disorders such as esophageal leiomyomas&#44; chronic lymphocytic leukemia and HIV&#46; PL can also be secondary to an autosomal dominant inherited familial syndrome&#58; MCUL or Reed syndrome&#46; Main characteristics of MCUL are the presence of cutaneous leiomyomas &#40;mainly PL&#41;&#44; uterine leiomyomas in women &#40;73&#8211;100&#37;&#41; and renal cell carcinoma &#40;20&#8211;34&#37;&#41;&#46; Clinical diagnostic criteria include multiple cutaneous leiomyoma &#40;with histologic confirmation of one of the lesions&#41; or a biopsy-proven solitary cutaneous leiomyoma plus family history of Reed syndrome<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; MCUL is caused by a heterozygous mutation &#40;1q42&#46;3-q43&#41; in the fumarate hydratase gene &#40;FH&#41;&#44; a Krebs cycle enzyme&#44; but may also act as a tumor suppressor<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; PL present in patients with MCUL by the age of 40&#44; and generally constitute the first manifestation of the syndrome and their most sensitive and specific clinical marker<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; Uterine leiomyomas are developed earlier than in healthy individuals&#44; usually requiring hysterectomy&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The most worrying association of MCUL is with renal cell carcinoma &#40;RCC&#41;&#44; which occurs in up to 30&#37; of patients&#46; RCC in this context tend to be aggressive&#44; with early nodal dissemination and metastases&#46; Abdominal MRI is recommended every 6&#8211;12 months&#44; since small tumors could not be detected by ultrasound and can have a high dissemination potential<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; Genetic testing should be offered&#44; if available&#44; in order to avoid unnecessary imaging in case of negative results&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">PL can be associated with MCUL and RCC&#46; Dermatologists should be aware of the potentially life-threatening consequences of a delayed diagnosis&#46;</p></span></span>"
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