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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 63-year-old Chinese woman with no medical history of interest was referred to the dermatology clinic for long-standing skin lesions on the chest&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed a geographic plaque covering a large area of the chest&#44; formed by the confluence of infiltrated and exophytic nodules&#44; with some erosive areas&#46; The patient presented marked bilateral axillary and submandibular lymphadenopathy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Dermoscopy showed homogeneous orange areas with telangiectasias and erosions &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Histology of a punch biopsy showed the presence of compact&#44; dense&#44; superficial and deep granulomatous infiltrate with mild necrosis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Ziehl-Neelsen staining&#44; polymerase chain reaction &#40;PCR&#41; for <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span>&#44; and bacterial culture were negative&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Additional Tests</span><p id="par0020" class="elsevierStylePara elsevierViewall">Laboratory test findings revealed lymphopenia &#40;0&#46;9<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#41; and negative results for serological tests &#40;human immunodeficiency virus &#91;HIV&#93;&#44; hepatitis B and C&#41;&#44; interferon-&#947; release assay &#40;IGRA&#41;&#44; and tumor markers for lymphoproliferative processes &#40;&#946;2-microglobulin and lactate dehydrogenase &#91;LDH&#93;&#41;&#46; Thoracic computed tomography revealed the presence of marked lymphadenopathy of the axillary and supraclavicular lymph nodes and the internal mammary chains&#44; as well as calcified subpleural nodules&#44; all suggestive of a lymphoproliferative syndrome&#46; The results of a purified protein derivative &#40;PPD&#41; skin test were positive&#46; The axillary lymph node was resected for histological and microbiological examination&#46; Histology showed findings similar to those of the skin biopsy&#44; and culture and PCR were positive for <span class="elsevierStyleItalic">M&#46; tuberculosis</span>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">What is your diagnosis&#63;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Lupus vulgaris in a patient with active lymph node tuberculosis&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Treatment and Disease Course</span><p id="par0035" class="elsevierStylePara elsevierViewall">Tuberculostatic treatment was initiated with quadruple therapy &#40;rifampicin&#44; isoniazid&#44; pyrazinamide&#44; and ethambutol&#41;&#46; The patient underwent follow-up for only 1 month&#44; and was subsequently lost to follow-up after returning to her home country&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Tuberculosis continues to be a prevalent infection&#46; Lupus vulgaris accounts for 60&#37; of skin manifestations of tuberculosis&#46; The clinical differential diagnosis should include other chronic granulomatous infections&#44; cutaneous lymphomas&#44; and even cutaneous carcinomatosis of an unknown primary tumor&#46; It should be borne in mind that culture for mycobacteria is positive in only 40&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> Likewise&#44; the diagnostic yield of Ziehl-Neelsen staining is limited by its poor sensitivity&#46; Deep fungal infection and sarcoidosis should be considered as alternative histological diagnoses&#46; The characteristic clinical presentation consists of granulomatous lesions that are usually asymptomatic &#40;as in the present case&#41;&#44; despite their striking presentation&#44; grow slowly and progressively with a tendency towards ulceration&#44; and have a characteristic &#8220;apple jelly&#8221;-like appearance on diascopy&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> Lupus vulgaris can be associated with active tuberculosis in other locations&#44; such as the lymphatic system&#44; as in our patient&#46; Diagnosis is based on a suggestive clinical picture and compatible histology&#46; IGRAs can produce false negative results&#44; especially in patients with lymphopenia&#44; regardless of etiology&#44; as occurred in the present case&#46; This technique consists of the detection of interferon-&#947; released by sensitized peripheral blood T lymphocytes after in vitro stimulation with specific <span class="elsevierStyleItalic">M&#46; tuberculosis</span> antigens&#44; which are absent in the attenuated strain of <span class="elsevierStyleItalic">Mycobacterium bovis</span> in the bacillus Calmette-Gu&#233;rin &#40;BCG&#41; vaccine&#44; and in most environmental mycobacteria&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> Of the 2 available IGRA types&#44; QuantiFERON &#40;QFT-GIT&#41; and T-SPOT TB &#40;ELISpot&#41;&#44; the latter is the most sensitive in immunosuppressed patients&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> In individuals with profound immunosuppression &#40;mainly due to HIV&#44; but also severe non-HIV-associated lymphopenia&#41;&#44; IGRAs can produce positive results when the test is repeated once the patient recovers their immunity after receiving appropriate treatment&#46; The striking presentation in our patient may be a consequence of the delay in seeking a consultation &#40;due to the language barrier or social difficulties&#41;&#44; or the disease course in this particular patient&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">This work has not received any type of funding&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Cases for Diagnosis
Extensive Ulcerated Plaques and Nodules of Long-standing Duration in a Chinese Woman
Placas y nódulos ulcerados extensos y de larga evolución en una paciente de origen chino
V. Mora-Fernández
Autor para correspondencia
veroniamora@hotmail.com

Corresponding author.
, V. Morillas-Lahuerta, J.M. Carrascosa Carrillo
Servicio de Dermatología y venereología, Hospital Universitari Germans Trias i Pujol, Universidad Autónoma de Barcelona, Badalona, Spain
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2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Histology of a punch biopsy showed the presence of compact&#44; dense&#44; superficial and deep granulomatous infiltrate with mild necrosis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Ziehl-Neelsen staining&#44; polymerase chain reaction &#40;PCR&#41; for <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span>&#44; and bacterial culture were negative&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Additional Tests</span><p id="par0020" class="elsevierStylePara elsevierViewall">Laboratory test findings revealed lymphopenia &#40;0&#46;9<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#41; and negative results for serological tests &#40;human immunodeficiency virus &#91;HIV&#93;&#44; hepatitis B and C&#41;&#44; interferon-&#947; release assay &#40;IGRA&#41;&#44; and tumor markers for lymphoproliferative processes &#40;&#946;2-microglobulin and lactate dehydrogenase &#91;LDH&#93;&#41;&#46; Thoracic computed tomography revealed the presence of marked lymphadenopathy of the axillary and supraclavicular lymph nodes and the internal mammary chains&#44; as well as calcified subpleural nodules&#44; all suggestive of a lymphoproliferative syndrome&#46; The results of a purified protein derivative &#40;PPD&#41; skin test were positive&#46; The axillary lymph node was resected for histological and microbiological examination&#46; Histology showed findings similar to those of the skin biopsy&#44; and culture and PCR were positive for <span class="elsevierStyleItalic">M&#46; tuberculosis</span>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">What is your diagnosis&#63;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Lupus vulgaris in a patient with active lymph node tuberculosis&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Treatment and Disease Course</span><p id="par0035" class="elsevierStylePara elsevierViewall">Tuberculostatic treatment was initiated with quadruple therapy &#40;rifampicin&#44; isoniazid&#44; pyrazinamide&#44; and ethambutol&#41;&#46; The patient underwent follow-up for only 1 month&#44; and was subsequently lost to follow-up after returning to her home country&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Tuberculosis continues to be a prevalent infection&#46; Lupus vulgaris accounts for 60&#37; of skin manifestations of tuberculosis&#46; The clinical differential diagnosis should include other chronic granulomatous infections&#44; cutaneous lymphomas&#44; and even cutaneous carcinomatosis of an unknown primary tumor&#46; It should be borne in mind that culture for mycobacteria is positive in only 40&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> Likewise&#44; the diagnostic yield of Ziehl-Neelsen staining is limited by its poor sensitivity&#46; Deep fungal infection and sarcoidosis should be considered as alternative histological diagnoses&#46; The characteristic clinical presentation consists of granulomatous lesions that are usually asymptomatic &#40;as in the present case&#41;&#44; despite their striking presentation&#44; grow slowly and progressively with a tendency towards ulceration&#44; and have a characteristic &#8220;apple jelly&#8221;-like appearance on diascopy&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> Lupus vulgaris can be associated with active tuberculosis in other locations&#44; such as the lymphatic system&#44; as in our patient&#46; Diagnosis is based on a suggestive clinical picture and compatible histology&#46; IGRAs can produce false negative results&#44; especially in patients with lymphopenia&#44; regardless of etiology&#44; as occurred in the present case&#46; This technique consists of the detection of interferon-&#947; released by sensitized peripheral blood T lymphocytes after in vitro stimulation with specific <span class="elsevierStyleItalic">M&#46; tuberculosis</span> antigens&#44; which are absent in the attenuated strain of <span class="elsevierStyleItalic">Mycobacterium bovis</span> in the bacillus Calmette-Gu&#233;rin &#40;BCG&#41; vaccine&#44; and in most environmental mycobacteria&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> Of the 2 available IGRA types&#44; QuantiFERON &#40;QFT-GIT&#41; and T-SPOT TB &#40;ELISpot&#41;&#44; the latter is the most sensitive in immunosuppressed patients&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> In individuals with profound immunosuppression &#40;mainly due to HIV&#44; but also severe non-HIV-associated lymphopenia&#41;&#44; IGRAs can produce positive results when the test is repeated once the patient recovers their immunity after receiving appropriate treatment&#46; The striking presentation in our patient may be a consequence of the delay in seeking a consultation &#40;due to the language barrier or social difficulties&#41;&#44; or the disease course in this particular patient&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">This work has not received any type of funding&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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