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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In pustular psoriasis&#44; hypocalcemia is viewed as the consequence of the dermatosis rather than being recognized as a trigger&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> In the other clinical presentations of psoriasis&#44; hypocalcemia is not usually described&#44; and the relationship between hypocalcemia and psoriasis flares is unclear&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">An interesting aspect of this relationship is the observation of the dynamics of hypocalcemia remediation on the clinical remission of psoriasis&#46; We report the case of a patient with surgical hypoparathyroidism in whom severe hypocalcemia precipitated typical pustular psoriasis of von Zumbusch which improved with calcium supplementation alone&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 60 years old female patient&#44; admitted in our structure for erythroderma&#46; Her past medical history was related to a total thyro-parthyroidectomy 5 years ago complicated by hypocalcaemia&#44; with irregular use of levothyroxine and calcium supplementation&#46; This erythroderma which evolved since six weeks was associated with unmeasured fever&#44; resting tremor&#44; tetanies crises&#44; dyspnea and a decrease in her general state of health&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">On admission&#44; the patient was in a regular general state of health&#44; feverish at 38&#46;5 with sinus tachycardia&#44; and discrete tachypnea&#46; Physical examination revealed diffuse crackles and wheezing&#44; resting tremor of the hands with positive trousseau and chvostek signs&#46; The skin showed edematous erythroderma with diffuse pustular lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The laboratory examinations showed inflammatory syndrome with&#44; elevated C-reactive protein &#40;CRP&#41; of 210<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#44; erythrocyte sedimentation rate of 150<span class="elsevierStyleHsp" style=""></span>mm&#47;h and inflammatory anemia&#46; Severe hypocalcemia &#40;total calcium 3&#46;5<span class="elsevierStyleHsp" style=""></span>mEq&#47;dl&#41;&#46; Albumin&#44; liver enzymes&#44; renal function and urinalysis were normal&#46; The hormonal assessment had shown hypothyroidism with TSH at 10&#46;1<span class="elsevierStyleHsp" style=""></span>&#956;IU&#47;ml&#44; free T4 at 1&#46;3<span class="elsevierStyleHsp" style=""></span>ng&#47;dl and hypoparathyroidism with parathyroid hormone<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">A skin biopsy was per-formed for diagnostic purpose&#44; with histopathological findings consistent with pustular psoriasis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Correction of the serum calcium improved the severe skin lesions and no specific treatment was necessary&#44; emphasizing that fluctuations in serum calcixim affect psoriasis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Calcium has a role in keratinocyte differentiation and proliferation&#44; and cell adhesion requires cadherins&#44; which are calcium-dependent molecules but the mechanism operating between calcium and keratinocyte differentiation is not fully understood&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> The association between psoriasis and hypocalcemia is known&#44; especially in pustular psoriasis&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;3</span></a> There are two hypotheses which can explain this association&#46; It has been suggested that calcium homeostasis could be involved in the development or exacerbation of psoriasis&#44; since hypocalcemia can damage cell adhesion molecules&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;4</span></a> In the other hand Hypocalcemia can be secondary to the extensive cutaneous inflammation resulting from an extravasation of albumin and albumin-bound calcium into the interstitial space&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;4</span></a> In our case&#44; hypocalcemia appears to be a relevant factor in inducing this psoriasis flare because hypocalcemia was present before the psoriasis and correction of the serum calcium improved the severe skin lesions&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The link between calcium supplementation and improvement of pustular psoriasis has been reported previously&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;3&#8211;5</span></a> In some cases calcium supplementation alone was sufficient and in others correction of hypocalcemia brought improvement but specific treatment was subsequently necessary&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conclusion</span><p id="par0050" class="elsevierStylePara elsevierViewall">We illustrate through this observation the direct role of hypocalcemia in triggering pustular psoriarisis in genetically predisposed patients&#44; but the exact mechanism is still poorly understood given the low number of cases reported in the literature&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflict of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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