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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 33-year-old woman of Peruvian nationality was admitted to the intensive care unit with a pulmonary embolism&#46; While admitted to the hospital&#44; she presented multiple complications&#44; such as consecutive episodes of sepsis due to <span class="elsevierStyleItalic">Escherichia coli</span>&#44; <span class="elsevierStyleItalic">Klebsiella</span><span class="elsevierStyleItalic">pneumoniae</span>&#44; and <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#44; which required hemodynamic support&#44; mechanical ventilation&#44; and broad antibiotic coverage&#46; Seven weeks after admission&#44; a dermatologic assessment was requested due to skin lesions that had appeared on the torso and later spread to the proximal part of the lower limbs&#46; The week prior to admission&#44; the patient had undergone surgery for a suprasellar meningioma&#44; with no immediate complications&#44; after which she was prescribed high-dose corticosteroid treatment&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The physical examination revealed exanthema consisting of nonpalpable petechiae&#44; grouped in a reticular pattern&#44; in the periumbilical region and on the anterior and proximal surfaces of both thighs&#59; the petechiae did not fade under glass &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; Histopathology revealed a moderate perivascular infiltrate in the superficial and deep dermis&#44; with lymphocytes and eosinophils&#46; Moreover&#44; elongated structures were observed in the deep dermis&#44; among the strands of collagen&#44; with basophilic stippling in their interior&#59; the structures were identified as nematode larvae &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Blood tests revealed anemia and leukocytosis with eosinophilia&#44; and nematode larvae were detected in the microbiologic study of the bronchoalveolar lavage&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The microorganism was identified as <span class="elsevierStyleItalic">Strongyloides stercoralis</span> and cultures of bronchoalveolar lavage and feces confirmed growth&#59; the patient was therefore diagnosed with <span class="elsevierStyleItalic">Strongyloides</span> hyperinfestation and disseminated strongyloidiasis&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Treatment was instated with ivermectin administered via nasogastric tube&#46; As no improvement was observed in terms of blood tests or parasite load&#44; and in light of suspected poor digestive absorption due to the patient&#39;s critical state and paralytic ileus&#44; the medication was then administered subcutaneously at a dosage of 200<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;d&#44; after requesting compassionate use&#46; The parasite load fell with the treatment&#44; but the patient never recovered from the neurologic clinical symptoms&#44; suffered a continuous series of superinfections&#44; and died&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Strongyloidiasis is a disease caused by the parasite <span class="elsevierStyleItalic">S&#46; stercoralis&#46;</span> This is a nematode with a global distribution&#44; whose main reservoir is humans&#59; it is endemic in rural areas of tropical and subtropical regions and&#44; in Peru&#44; it is considered to be highly endemic&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> It has 2 reproductive cycles&#44; a free-living cycle in the soil and a parasitic cycle in the host intestine&#46; Thus&#44; in the filariform stage&#44; the larvae penetrate the skin and migrate through the venous system to the lungs and the intestine&#44; where they mature and reproduce&#59; the eggs and larvae are eliminated by the host via the feces&#46; They have the ability to complete their cycle in the human host&#44; produce autoinfection&#44; and evade the host immune response&#44; producing chronic disease lasting decades&#46; In this way&#44; they rarely produce symptoms&#44; except for nonspecific gastrointestinal symptoms accompanied by eosinophilia in blood tests&#46; Systemic dissemination is rare and may occur in immunosuppressed patients&#44; especially during treatment with corticosteroids&#44; with high mortality &#40;between 70&#37; and 90&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Development of disseminated disease should be suspected in patients with a history of travel to areas where the disease is endemic &#40;even when many years have since passed&#41;&#44; a history of corticosteroid therapy&#44; persistent bacteremia with organisms of enteric origin &#40;as the parasites tend to serve as carriers for those organisms&#41;&#44; nonspecific gastrointestinal and respiratory systems&#44; neurological abnormalities&#44; and concomitant infection with other intestinal parasites&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> Eosinophilia is characteristic of the disease&#44; although it may be absent in immunosuppressed patients&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Cutaneous manifestations are rare and may appear as a purpuric petechial rash&#59; periumbilical petechial rash is a sign of poor prognosis&#44; previously described in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> The lesions are purpuric&#44; nonpalpable&#44; and take on the appearance of fingerprints&#44; typically located in the periumbilical region and on the anterior surface of the thighs&#46; The biopsy may show parasites around the blood vessels&#44; with no signs of vasculitis&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The microbiologic diagnosis is based on serology&#44; specific culture in feces&#44; or direct observation of the nematode&#46; The treatment of choice is oral ivermectin at a dosage of 200<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;d&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> On very specific occasions&#44; it is necessary to use the subcutaneous presentation of this drug&#44; especially in cases of gastrointestinal involvement secondary to hyperinfestation with obstruction or paralytic ileus&#44; and in patients with a low level of consciousness&#8212;situations where absorption and tolerance of the orally administered drug are in question&#46; Subcutaneous administration constitutes compassionate use and favorable results have been reported in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Thiabendazole and albendazole are therapeutic alternatives&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">As dermatologists&#44; we must suspect strongyloidiasis in the case of a patient with periumbilical petechial rash&#44; especially if the patient has traveled to regions where the disease is endemic and has received immunosuppressant treatment&#44; including oral corticosteroids&#46; It is essential to rule out strongyloidiasis by means of serological screening in at-risk patients before instating immunosuppressant or biologic treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">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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Case and Research Letter
Periumbilical Petechiae in a Critically Ill Patient: An Important Sign for Dermatologists to Recognize
Lesiones petequiales periumbilicales en paciente crítica, signo a conocer por un dermatólogo
K. Krasnovskaa,
Autor para correspondencia
khrystyna.kn@gmail.com

Corresponding author.
, E. Sendagorta Cudosa, V. Baena Romerob, F. de la Calle-Prietoc
a Servicio de Dermatología Médico-Quirúrgica y Venereología, Hospital Universitario La Paz, Madrid, Spain
b Servicio de Anatomía Patológica, Hospital Universitario La Paz, Madrid, Spain
c Unidad de Medicina Tropical y del Viajero, CSUR Patología Importada, Hospital Universitario La Paz, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 33-year-old woman of Peruvian nationality was admitted to the intensive care unit with a pulmonary embolism&#46; While admitted to the hospital&#44; she presented multiple complications&#44; such as consecutive episodes of sepsis due to <span class="elsevierStyleItalic">Escherichia coli</span>&#44; <span class="elsevierStyleItalic">Klebsiella</span><span class="elsevierStyleItalic">pneumoniae</span>&#44; and <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&#44; which required hemodynamic support&#44; mechanical ventilation&#44; and broad antibiotic coverage&#46; Seven weeks after admission&#44; a dermatologic assessment was requested due to skin lesions that had appeared on the torso and later spread to the proximal part of the lower limbs&#46; The week prior to admission&#44; the patient had undergone surgery for a suprasellar meningioma&#44; with no immediate complications&#44; after which she was prescribed high-dose corticosteroid treatment&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The physical examination revealed exanthema consisting of nonpalpable petechiae&#44; grouped in a reticular pattern&#44; in the periumbilical region and on the anterior and proximal surfaces of both thighs&#59; the petechiae did not fade under glass &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; Histopathology revealed a moderate perivascular infiltrate in the superficial and deep dermis&#44; with lymphocytes and eosinophils&#46; Moreover&#44; elongated structures were observed in the deep dermis&#44; among the strands of collagen&#44; with basophilic stippling in their interior&#59; the structures were identified as nematode larvae &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Blood tests revealed anemia and leukocytosis with eosinophilia&#44; and nematode larvae were detected in the microbiologic study of the bronchoalveolar lavage&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The microorganism was identified as <span class="elsevierStyleItalic">Strongyloides stercoralis</span> and cultures of bronchoalveolar lavage and feces confirmed growth&#59; the patient was therefore diagnosed with <span class="elsevierStyleItalic">Strongyloides</span> hyperinfestation and disseminated strongyloidiasis&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Treatment was instated with ivermectin administered via nasogastric tube&#46; As no improvement was observed in terms of blood tests or parasite load&#44; and in light of suspected poor digestive absorption due to the patient&#39;s critical state and paralytic ileus&#44; the medication was then administered subcutaneously at a dosage of 200<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;d&#44; after requesting compassionate use&#46; The parasite load fell with the treatment&#44; but the patient never recovered from the neurologic clinical symptoms&#44; suffered a continuous series of superinfections&#44; and died&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Strongyloidiasis is a disease caused by the parasite <span class="elsevierStyleItalic">S&#46; stercoralis&#46;</span> This is a nematode with a global distribution&#44; whose main reservoir is humans&#59; it is endemic in rural areas of tropical and subtropical regions and&#44; in Peru&#44; it is considered to be highly endemic&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> It has 2 reproductive cycles&#44; a free-living cycle in the soil and a parasitic cycle in the host intestine&#46; Thus&#44; in the filariform stage&#44; the larvae penetrate the skin and migrate through the venous system to the lungs and the intestine&#44; where they mature and reproduce&#59; the eggs and larvae are eliminated by the host via the feces&#46; They have the ability to complete their cycle in the human host&#44; produce autoinfection&#44; and evade the host immune response&#44; producing chronic disease lasting decades&#46; In this way&#44; they rarely produce symptoms&#44; except for nonspecific gastrointestinal symptoms accompanied by eosinophilia in blood tests&#46; Systemic dissemination is rare and may occur in immunosuppressed patients&#44; especially during treatment with corticosteroids&#44; with high mortality &#40;between 70&#37; and 90&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Development of disseminated disease should be suspected in patients with a history of travel to areas where the disease is endemic &#40;even when many years have since passed&#41;&#44; a history of corticosteroid therapy&#44; persistent bacteremia with organisms of enteric origin &#40;as the parasites tend to serve as carriers for those organisms&#41;&#44; nonspecific gastrointestinal and respiratory systems&#44; neurological abnormalities&#44; and concomitant infection with other intestinal parasites&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> Eosinophilia is characteristic of the disease&#44; although it may be absent in immunosuppressed patients&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Cutaneous manifestations are rare and may appear as a purpuric petechial rash&#59; periumbilical petechial rash is a sign of poor prognosis&#44; previously described in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> The lesions are purpuric&#44; nonpalpable&#44; and take on the appearance of fingerprints&#44; typically located in the periumbilical region and on the anterior surface of the thighs&#46; The biopsy may show parasites around the blood vessels&#44; with no signs of vasculitis&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The microbiologic diagnosis is based on serology&#44; specific culture in feces&#44; or direct observation of the nematode&#46; The treatment of choice is oral ivermectin at a dosage of 200<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;d&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> On very specific occasions&#44; it is necessary to use the subcutaneous presentation of this drug&#44; especially in cases of gastrointestinal involvement secondary to hyperinfestation with obstruction or paralytic ileus&#44; and in patients with a low level of consciousness&#8212;situations where absorption and tolerance of the orally administered drug are in question&#46; Subcutaneous administration constitutes compassionate use and favorable results have been reported in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Thiabendazole and albendazole are therapeutic alternatives&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">As dermatologists&#44; we must suspect strongyloidiasis in the case of a patient with periumbilical petechial rash&#44; especially if the patient has traveled to regions where the disease is endemic and has received immunosuppressant treatment&#44; including oral corticosteroids&#46; It is essential to rule out strongyloidiasis by means of serological screening in at-risk patients before instating immunosuppressant or biologic treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">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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                      "titulo" => "Necesidad de cribado de enfermedad de Chagas y de infestaci&#243;n por Strongyloides previo a inicio de terapia biol&#243;gica en pa&#237;ses no end&#233;micos"
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Información del artículo
ISSN: 00017310
Idioma original: Inglés
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