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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 33-year-old healthy female&#44; nurse&#44; Fitzpatrick phototype IV&#44; presented with a history of a piercing proceeded on the left nasal ala in 2019&#46; She referred multiple local traumas in daily activities&#44; such as accidental adhesion of the piercing to clothes or bath towel&#46; In January 2021&#44; a papule appeared on the same nasal region&#46; The patient repeatedly tried to remove the lesion with a small needle&#44; resulting in local bleeding and progressive growth to a tumor&#46; No other lesions or constitutional symptoms have been described&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Dermatological examination revealed small erythematous-brownish nodule&#44; 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm diameter&#44; similar to a keloid adjacent to the nasal piercing &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; No other injuries have been identified&#46; Dermoscopic analysis indicated a yellow-orange central area surrounded by peripheral erythematous border with fine linear telangiectasias&#44; suggestive of xanthogranuloma &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>a and b&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">We proceeded the complete excision of the tumor&#46; Histopathological study identified a nodular dermal proliferation with xanthomized histiocytes&#44; foreign body-type multinucleated giant cells and Touton multinucleated cells&#44; along with scattered lymphocytes&#44; plasma cells and eosinophils &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>a and b&#41;&#46; Immunohistochemistry appointed positive stains for CD68&#46; S100 and CD1a were absent&#46; BRAF-V600E mutations analysis through real-time polymerase chain reaction &#40;PCR&#41; was negative&#46; Laboratory investigation revealed no abnormalities in routine blood examination parameters&#44; triglyceride levels&#44; liver function or renal function&#46; The tests confirmed the diagnosis of adult xanthogranuloma&#44; and there was clinical improvement after surgical removal&#46; The patient maintains dermatological follow-up with no injury recurrence&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Xanthogranuloma is the most common non-Langerhans cell histiocytosis&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> It is a benign proliferative disorder&#44; usually described in early childhood as juvenile xanthogranuloma &#40;JXG&#41;&#46; Almost 85&#37; of cases of JXG occur in infants less than one year of age&#44; with a male preponderance&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Late-onset lesions in adults is infrequent and represents 10&#37; of all xantogranulomas&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Most reports describe adult xanthogranuloma between the third and fourth decades of life&#44; with equal sex distribution&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> The pathogenesis is unknown&#44; and the most associated triggers are infections or physical factors&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> with few studies in the world literature describing trauma-induced xanthogranuloma&#46; The patient described in this report presented an unusual onset of adult xanthogranuloma after recurrent local traumas&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The lesion typically manifests as a reddish or yellowish to brown solitary papulonodule on the head&#44; neck&#44; limbs&#44; and upper trunk&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Nasal involvement is even rarer and only three cases on this specific topography have been published&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#8211;7</span></a> Tan et al&#46; &#40;2014&#41; also reported an unusual presentation of adult xanthogranuloma on the left nasal ala&#44; as we describe herein&#46; However&#44; unlike our case&#44; no trigger factor has been identified&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> A few articles documented multiple lesions and extracutaneous and systemic involvement&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;4&#44;8</span></a> Dermoscopic evaluation is a powerful tool to define diagnostic hypothesis&#44; revealing the characteristic yellow-orange central area surrounded by a peripheral erythematous border with fine linear telangiectasias&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Differential diagnosis includes dermatofibroma&#44; Langerhans cell histiocytosis&#44; other xanthomatous lesions&#44; mastocytoma&#44; and Spitz nevus&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Diagnostic confirmation is made through skin biopsy&#46; Histopathological analysis identifies dense dermal histiocyte infiltrate and Touton giant cells&#44; which are multinucleated cells&#44; with homogeneous eosinophilic cytoplasmic center and peripheral xanthomatization&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Immunohistochemistry is also important to define diagnosis and shows positive stains for Factor XIIIa&#44; CD68&#44; CD163&#44; CD14&#44; and fascin&#46; Stains for S100 and CD1a&#44; specific for Langerhans cells&#44; are negative&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> In cases with atypical histology features or immunohistochemistry suggestive of xanthogranuloma and Langerhans cell histiocytosis &#40;LCH&#41;&#44; the investigation of BRAF-V600E mutations is recommended&#46; BRAF-V600E mutations have been described in LCH and can identify LCH coexisting with xanthogranuloma&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> In this case report&#44; this oncogenic mutation was absent&#44; reaffirming the xanthogranulomatous nature of the tumor&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Usually&#44; no laboratory abnormalities are identified in patients with solitary AXG&#46; However&#44; clinicians should be aware of systemic involvement and hematological malignancies in adults with multiple xantogranulomas&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> In these cases&#44; laboratory and imaging investigation are essential&#46; AXG generally follows a benign course&#44; with spontaneous regression in approximately 3&#8211;6 years&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Surgical excision&#44; CO<span class="elsevierStyleInf">2</span> laser&#44; and intralesional steroids can be performed&#44; mainly for cosmetic reasons&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In this report&#44; the patient&#39;s history and clinical examination suggested a keloid lesion&#46; However&#44; dermoscopic analysis revealed typical findings of xanthogranuloma and guided our Dermatology team to an accurate diagnosis&#46; In conclusion&#44; the correct use of the dermatoscope is effective not only to evaluate melanocytic lesions&#44; but also to non-melanocytic&#44; as in the present case&#46; Dermatologists should use this tool daily in every physical examination to improve diagnostic accuracy&#46; After directing the diagnostic hypothesis&#44; the confirmation was established through histopathology and immunohistochemistry&#44; which were also compatible with adult xanthogranuloma&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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Case and Research Letter
Trauma-induced Adult Xanthogranuloma Mimicking Keloid on the Left Nasal Ala
Xantogranuloma del adulto inducido por traumatismo, que remeda queloide en ala nasal izquierda
E. Neves Souzaa,b,
Autor para correspondencia
neves.emilly@hotmail.com

Corresponding author.
, M. Rodrigues Batalhac, L. Horta da Silvac, M. Neves Souzad
a Universidade Federal do Espírito Santo (UFES), Vitória, ES, Brazil
b Hospital Universitário Cassiano Antônio Moraes (HUCAM), Vitória, ES, Brazil
c Intituto Izamar Milidiú da Silva (IMS), Rio de Janeiro, RJ, Brazil
d Faculdade Multivix, Vitória - ES, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 33-year-old healthy female&#44; nurse&#44; Fitzpatrick phototype IV&#44; presented with a history of a piercing proceeded on the left nasal ala in 2019&#46; She referred multiple local traumas in daily activities&#44; such as accidental adhesion of the piercing to clothes or bath towel&#46; In January 2021&#44; a papule appeared on the same nasal region&#46; The patient repeatedly tried to remove the lesion with a small needle&#44; resulting in local bleeding and progressive growth to a tumor&#46; No other lesions or constitutional symptoms have been described&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Dermatological examination revealed small erythematous-brownish nodule&#44; 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm diameter&#44; similar to a keloid adjacent to the nasal piercing &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; No other injuries have been identified&#46; Dermoscopic analysis indicated a yellow-orange central area surrounded by peripheral erythematous border with fine linear telangiectasias&#44; suggestive of xanthogranuloma &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>a and b&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">We proceeded the complete excision of the tumor&#46; Histopathological study identified a nodular dermal proliferation with xanthomized histiocytes&#44; foreign body-type multinucleated giant cells and Touton multinucleated cells&#44; along with scattered lymphocytes&#44; plasma cells and eosinophils &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>a and b&#41;&#46; Immunohistochemistry appointed positive stains for CD68&#46; S100 and CD1a were absent&#46; BRAF-V600E mutations analysis through real-time polymerase chain reaction &#40;PCR&#41; was negative&#46; Laboratory investigation revealed no abnormalities in routine blood examination parameters&#44; triglyceride levels&#44; liver function or renal function&#46; The tests confirmed the diagnosis of adult xanthogranuloma&#44; and there was clinical improvement after surgical removal&#46; The patient maintains dermatological follow-up with no injury recurrence&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Xanthogranuloma is the most common non-Langerhans cell histiocytosis&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> It is a benign proliferative disorder&#44; usually described in early childhood as juvenile xanthogranuloma &#40;JXG&#41;&#46; Almost 85&#37; of cases of JXG occur in infants less than one year of age&#44; with a male preponderance&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Late-onset lesions in adults is infrequent and represents 10&#37; of all xantogranulomas&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Most reports describe adult xanthogranuloma between the third and fourth decades of life&#44; with equal sex distribution&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> The pathogenesis is unknown&#44; and the most associated triggers are infections or physical factors&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> with few studies in the world literature describing trauma-induced xanthogranuloma&#46; The patient described in this report presented an unusual onset of adult xanthogranuloma after recurrent local traumas&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The lesion typically manifests as a reddish or yellowish to brown solitary papulonodule on the head&#44; neck&#44; limbs&#44; and upper trunk&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Nasal involvement is even rarer and only three cases on this specific topography have been published&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#8211;7</span></a> Tan et al&#46; &#40;2014&#41; also reported an unusual presentation of adult xanthogranuloma on the left nasal ala&#44; as we describe herein&#46; However&#44; unlike our case&#44; no trigger factor has been identified&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> A few articles documented multiple lesions and extracutaneous and systemic involvement&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;4&#44;8</span></a> Dermoscopic evaluation is a powerful tool to define diagnostic hypothesis&#44; revealing the characteristic yellow-orange central area surrounded by a peripheral erythematous border with fine linear telangiectasias&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Differential diagnosis includes dermatofibroma&#44; Langerhans cell histiocytosis&#44; other xanthomatous lesions&#44; mastocytoma&#44; and Spitz nevus&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Diagnostic confirmation is made through skin biopsy&#46; Histopathological analysis identifies dense dermal histiocyte infiltrate and Touton giant cells&#44; which are multinucleated cells&#44; with homogeneous eosinophilic cytoplasmic center and peripheral xanthomatization&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Immunohistochemistry is also important to define diagnosis and shows positive stains for Factor XIIIa&#44; CD68&#44; CD163&#44; CD14&#44; and fascin&#46; Stains for S100 and CD1a&#44; specific for Langerhans cells&#44; are negative&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> In cases with atypical histology features or immunohistochemistry suggestive of xanthogranuloma and Langerhans cell histiocytosis &#40;LCH&#41;&#44; the investigation of BRAF-V600E mutations is recommended&#46; BRAF-V600E mutations have been described in LCH and can identify LCH coexisting with xanthogranuloma&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> In this case report&#44; this oncogenic mutation was absent&#44; reaffirming the xanthogranulomatous nature of the tumor&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Usually&#44; no laboratory abnormalities are identified in patients with solitary AXG&#46; However&#44; clinicians should be aware of systemic involvement and hematological malignancies in adults with multiple xantogranulomas&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> In these cases&#44; laboratory and imaging investigation are essential&#46; AXG generally follows a benign course&#44; with spontaneous regression in approximately 3&#8211;6 years&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Surgical excision&#44; CO<span class="elsevierStyleInf">2</span> laser&#44; and intralesional steroids can be performed&#44; mainly for cosmetic reasons&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In this report&#44; the patient&#39;s history and clinical examination suggested a keloid lesion&#46; However&#44; dermoscopic analysis revealed typical findings of xanthogranuloma and guided our Dermatology team to an accurate diagnosis&#46; In conclusion&#44; the correct use of the dermatoscope is effective not only to evaluate melanocytic lesions&#44; but also to non-melanocytic&#44; as in the present case&#46; Dermatologists should use this tool daily in every physical examination to improve diagnostic accuracy&#46; After directing the diagnostic hypothesis&#44; the confirmation was established through histopathology and immunohistochemistry&#44; which were also compatible with adult xanthogranuloma&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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