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vesicles &#40;at birth or shortly afterwards&#41;&#44; verrucous lesions&#44; hyperpigmentation&#44; and hypopigmentation&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Extracutaneous involvement &#40;neurologic and ocular alterations&#41; determines functional prognosis and leads to irreversible sequelae linked to severe disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">IP is an X-linked dominant disorder caused by a mutation in the <span class="elsevierStyleItalic">NEMO</span> gene&#46; Between 65&#37; and 75&#37; of cases are caused by sporadic mutations&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">IP with an X-linked dominant inheritance pattern is usually lethal in male fetuses&#44; with very few survivors reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;5</span></a> The International Incontinentia Pigmenti Consortium has proposed 3 mechanisms to explain why some males survive&#58; <span class="elsevierStyleItalic">1</span>&#41; presence of a concomitant 47&#44;XXY karyotype &#40;Klinefelter syndrome&#41;&#44; <span class="elsevierStyleItalic">2</span>&#41; somatic mosaicism &#40;46&#44;XY&#47;47&#44;XXY&#41;&#44; which can only be demonstrated by fluorescence in situ hybridization&#44; and <span class="elsevierStyleItalic">3</span>&#41; hypomorphic mutations resulting in mild IP&#46; Somatic mosaicism is the most common mechanism&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">We describe 2 cases of IP in male neonates and review the diagnostic criteria&#44; etiology&#44; pathogenesis&#44; clinical manifestations&#44; and complications of this rare disease&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The first case involved a 4-day-old boy born to a healthy 37-year-old woman following a well-controlled&#44; complication-free pregnancy&#46; 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leaving a series of hyperpigmented lesions limited to the popliteal area &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The histopathology study showed IP in the vesicular phase &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>C&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The boy had a 46&#44;XY normal karyotype&#44; and the fundus examination and transfontanellar ultrasound showed no alterations&#46; He progressed well and the skin lesions disappeared spontaneously&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">IP is a rare X-linked genodermatosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;3&#44;4&#44;6&#8211;9</span></a> It is seldom diagnosed in male neonates&#44; as its mode of inheritance is normally associated with fetal death&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Few cases of surviving males have been reported worldwide&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6&#44;9</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The presumptive diagnosis is clinical and based on observation of early skin lesions&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Both patients described in this series had vesiculobullous lesions &#40;stage 1&#41; along the lines of Blaschko at birth and subsequently developed verrucous lesions and hyperpigmentation&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Typical skin lesions are considered major criteria for the diagnosis of IP&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">According to Rosser&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> 2 or more major diagnostic criteria or 1 major and 1 minor criterion are required &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; to confirm diagnosis when there is no evidence of IP in a first-degree female relative and when molecular diagnosis &#40;detection of <span class="elsevierStyleItalic">NEMO</span> mutation&#41; is not available &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">The 2 patients in this series had typical skin IP skin changes &#40;major criterion&#41; and typical histopathologic findings &#40;minor criterion&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Although IP is generally considered lethal in males&#44; there have been some survivors&#46; Proposed mechanisms to explain the small number of survivors reported are the concomitant presence of the 47&#44;XXY karyotype &#40;Klinefelter syndrome&#41; and somatic mosaicism&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6&#44;8</span></a> In both our cases&#44; the karyotype was normal&#46; Based on frequency&#44; somatic mosaicism could explain why these patients survived&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The main entities to be considered in the differential diagnosis are other skin diseases that present with vesiculobullous lesions&#46; Because of their frequency and severity&#44; infectious causes must be ruled out&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In the second case in this series&#44; the patient was not diagnosed at birth&#44; despite the presence of characteristic IP lesions&#46; IP is rare and therefore there is a low index of suspicion among physicians&#46; It is probably underdiagnosed or misdiagnosed in patients with mild forms&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">There are clinical cases indicating that mosaicism is common in male patients with IP who do not develop multisystemic disease and who have skin changes that tend to disappear&#44; as in our patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6&#44;8</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Central nervous system involvement and eye abnormalities are the main determinants of morbidity and mortality in IP&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2&#44;5&#44;8</span></a> Because these alterations can appear with time&#44; multidisciplinary follow-up and genetic counseling are important&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">This study was approved by the ethics committee at Centro Hospitalario Pereira Rossell&#46; Consent for publication was obtained from the patients&#8217; parents&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A&#44; Vesiculobullous lesions with a diameter of 2 to 3<span class="elsevierStyleHsp" style=""></span>mm on the inner aspect of the left leg along the lines of Blaschko&#46; B&#44; Verrucous&#44; crusty lesions with hyperpigmentation&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A&#44; Epidermal acanthosis&#46; Subcorneal vesicle with eosinophils&#46; B&#44; Epidermal acanthosis&#46; Dermis with eosinophils&#46; C&#44; Perivascular dermal inflammatory infiltrate with eosinophils&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A and B&#44; Verrucous &#40;stage 2&#41; lesions along the lines of Blaschko&#46; C&#44; Epidermis&#58; spongiosis with intradermal spongiotic vesicles and exocytosis of numerous eosinophils&#46; Dyskeratotic cells with hyaline cytoplasm&#46; Dermis with edema and mononuclear superficial inflammatory infiltrate with eosinophils and melanophages&#46;</p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">In all cases eosinophilia or skewed X chromosome inactivation support a diagnosis&#46;</p>"
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                  \t\t\t\t">Typical neonatal rash consisting of vesicles and erythema &#40;stage 1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Dental anomalies&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Verrucous papules or plaques along the lines of Blaschko &#40;stage 2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Linear&#44; atrophic&#44; hairless lesions on extremities &#40;stage 4&#41; or scarring alopecia of the vertex&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Mammary gland and&#47;or nipple anomalies&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Diagnostic Criteria for Incontinentia Pigmenti&#46;</p>"
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Case and Research Letter
Is Incontinentia Pigmenti More Serious in Males? A Report of 2 Cases
Incontinencia pigmenti: ¿es una entidad más grave en los varones? Reporte de 2 casos
V. Vezzaroa, M. De Maríaa,
Autor para correspondencia
manudemaria12@gmail.com

Corresponding author.
, L. Lucasa, A. Acostab
a Departamento de Neonatología – Centro Hospitalario Pereira Rossell, Universidad de la República, Montevideo, Uruguay
b Cátedra de Dermatología, Centro Hospitalario Pereira Rossell, Universidad de la República, Montevideo, Uruguay
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vesicles &#40;at birth or shortly afterwards&#41;&#44; verrucous lesions&#44; hyperpigmentation&#44; and hypopigmentation&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Extracutaneous involvement &#40;neurologic and ocular alterations&#41; determines functional prognosis and leads to irreversible sequelae linked to severe disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">IP is an X-linked dominant disorder caused by a mutation in the <span class="elsevierStyleItalic">NEMO</span> gene&#46; Between 65&#37; and 75&#37; of cases are caused by sporadic mutations&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">IP with an X-linked dominant inheritance pattern is usually lethal in male fetuses&#44; with very few survivors reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;5</span></a> The International Incontinentia Pigmenti Consortium has proposed 3 mechanisms to explain why some males survive&#58; <span class="elsevierStyleItalic">1</span>&#41; presence of a concomitant 47&#44;XXY karyotype &#40;Klinefelter syndrome&#41;&#44; <span class="elsevierStyleItalic">2</span>&#41; somatic mosaicism &#40;46&#44;XY&#47;47&#44;XXY&#41;&#44; which can only be demonstrated by fluorescence in situ hybridization&#44; and <span class="elsevierStyleItalic">3</span>&#41; hypomorphic mutations resulting in mild IP&#46; Somatic mosaicism is the most common mechanism&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">We describe 2 cases of IP in male neonates and review the diagnostic criteria&#44; etiology&#44; pathogenesis&#44; clinical manifestations&#44; and complications of this rare disease&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The first case involved a 4-day-old boy born to a healthy 37-year-old woman following a well-controlled&#44; complication-free pregnancy&#46; The woman had 3 other children&#44; all healthy&#44; from 3 pregnancies&#46; The boy had been born at term &#40;37 weeks&#41; by vaginal delivery&#46; At birth&#44; he had a series of vesiculobullous lesions with yellowish fluid along the lines of Blaschko on the inner aspect of the left leg&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The lesions evolved into verrucous and subsequently hyperpigmented lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A and B&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Histopathologic features were consistent with early-stage IP &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The boy had a 46&#44;XY normal karyotype&#44; and no abnormalities were observed in the fundus examination or the transfontanellar ultrasound&#46; He progressed favorably and was discharged at 15 days of life&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The second case involved a 9-day-old boy born to a healthy 36-year-old mother with a child from another pregnancy&#46; The pregnancy had been well controlled and free of complications&#46; The boy had been born by vaginal delivery at term&#46; At birth&#44; he had vesiculobullous lesions with clear fluid on the right leg&#59; the lesions followed a linear distribution in the dorsal popliteal region&#46; He was discharged at 48<span class="elsevierStyleHsp" style=""></span>h of life without paraclinical tests&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">When the boy was 9 days old&#44; the pediatrician examined the lesions&#44; which were verrucous by this stage&#44; and established a presumptive diagnosis of IP &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#46; The rest of the physical examination was normal&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The area affected by the lesions became smaller&#44; leaving a series of hyperpigmented lesions limited to the popliteal area &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The histopathology study showed IP in the vesicular phase &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>C&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The boy had a 46&#44;XY normal karyotype&#44; and the fundus examination and transfontanellar ultrasound showed no alterations&#46; He progressed well and the skin lesions disappeared spontaneously&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">IP is a rare X-linked genodermatosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;3&#44;4&#44;6&#8211;9</span></a> It is seldom diagnosed in male neonates&#44; as its mode of inheritance is normally associated with fetal death&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Few cases of surviving males have been reported worldwide&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6&#44;9</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The presumptive diagnosis is clinical and based on observation of early skin lesions&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Both patients described in this series had vesiculobullous lesions &#40;stage 1&#41; along the lines of Blaschko at birth and subsequently developed verrucous lesions and hyperpigmentation&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Typical skin lesions are considered major criteria for the diagnosis of IP&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">According to Rosser&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> 2 or more major diagnostic criteria or 1 major and 1 minor criterion are required &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; to confirm diagnosis when there is no evidence of IP in a first-degree female relative and when molecular diagnosis &#40;detection of <span class="elsevierStyleItalic">NEMO</span> mutation&#41; is not available &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">The 2 patients in this series had typical skin IP skin changes &#40;major criterion&#41; and typical histopathologic findings &#40;minor criterion&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Although IP is generally considered lethal in males&#44; there have been some survivors&#46; Proposed mechanisms to explain the small number of survivors reported are the concomitant presence of the 47&#44;XXY karyotype &#40;Klinefelter syndrome&#41; and somatic mosaicism&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6&#44;8</span></a> In both our cases&#44; the karyotype was normal&#46; Based on frequency&#44; somatic mosaicism could explain why these patients survived&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The main entities to be considered in the differential diagnosis are other skin diseases that present with vesiculobullous lesions&#46; Because of their frequency and severity&#44; infectious causes must be ruled out&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In the second case in this series&#44; the patient was not diagnosed at birth&#44; despite the presence of characteristic IP lesions&#46; IP is rare and therefore there is a low index of suspicion among physicians&#46; It is probably underdiagnosed or misdiagnosed in patients with mild forms&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">There are clinical cases indicating that mosaicism is common in male patients with IP who do not develop multisystemic disease and who have skin changes that tend to disappear&#44; as in our patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6&#44;8</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Central nervous system involvement and eye abnormalities are the main determinants of morbidity and mortality in IP&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2&#44;5&#44;8</span></a> Because these alterations can appear with time&#44; multidisciplinary follow-up and genetic counseling are important&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">This study was approved by the ethics committee at Centro Hospitalario Pereira Rossell&#46; Consent for publication was obtained from the patients&#8217; parents&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A&#44; Vesiculobullous lesions with a diameter of 2 to 3<span class="elsevierStyleHsp" style=""></span>mm on the inner aspect of the left leg along the lines of Blaschko&#46; B&#44; Verrucous&#44; crusty lesions with hyperpigmentation&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A&#44; Epidermal acanthosis&#46; Subcorneal vesicle with eosinophils&#46; B&#44; Epidermal acanthosis&#46; Dermis with eosinophils&#46; C&#44; Perivascular dermal inflammatory infiltrate with eosinophils&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A and B&#44; Verrucous &#40;stage 2&#41; lesions along the lines of Blaschko&#46; C&#44; Epidermis&#58; spongiosis with intradermal spongiotic vesicles and exocytosis of numerous eosinophils&#46; Dyskeratotic cells with hyaline cytoplasm&#46; Dermis with edema and mononuclear superficial inflammatory infiltrate with eosinophils and melanophages&#46;</p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">In all cases eosinophilia or skewed X chromosome inactivation support a diagnosis&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Major criteria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Typical neonatal rash consisting of vesicles and erythema &#40;stage 1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Dental anomalies&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Verrucous papules or plaques along the lines of Blaschko &#40;stage 2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Central nervous system anomalies&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Typical hyperpigmentation along the lines of Blaschko &#40;stage 3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Eye anomalies&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Linear&#44; atrophic&#44; hairless lesions on extremities &#40;stage 4&#41; or scarring alopecia of the vertex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">Mammary gland and&#47;or nipple anomalies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Palate anomalies&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Hair anomalies&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Typical skin histopathologic findings&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Diagnostic Criteria for Incontinentia Pigmenti&#46;</p>"
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                      "autores" => array:1 [
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ISSN: 00017310
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