Cases for Diagnosis
Edematous Infraumbilical Plaque in a Pregnant Woman
Placa edematosa infraumbilical en paciente gestante
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Áreas de vacuolización de la capa basal junto con exocitosis de células inflamatorias. B) Tinción azul alcián (×10). Epidermis adelgazada e incremento de mucina en la dermis.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "V.H. Pinos León, J. Granizo Rubio, J. Sánchez Villarroel" "autores" => array:3 [ 0 => array:2 [ "nombre" => "V.H." "apellidos" => "Pinos León" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Granizo Rubio" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Sánchez Villarroel" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731022007621?idApp=UINPBA000044" "url" => "/00017310/0000011400000003/v1_202303051528/S0001731022007621/v1_202303051528/es/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0001731022005944" "issn" => "00017310" "doi" => "10.1016/j.ad.2021.05.029" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "3103" "copyright" => "AEDV" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2023;114:257-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">CASOS PARA DIAGNÓSTICO</span>" "titulo" => "Placa edematosa infraumbilical en paciente gestante" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "257" "paginaFinal" => "258" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Edematous Infraumbilical Plaque in a Pregnant Woman" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 381 "Ancho" => 1005 "Tamanyo" => 170674 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Tinción con hematoxilina-eosina (HE). Se observa también edema en la dermis, intercalado con fibrosis y con escaso infiltrado linfoide perivascular superficial (A). Tinción para podoplanina (D2-40) en la que destacan algunos vasos linfáticos ectásicos dérmicos (B).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Cruañes-Monferrer, A. Gil Liñan, A. Ramírez Andreo" "autores" => array:3 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Cruañes-Monferrer" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Gil Liñan" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Ramírez Andreo" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731022005944?idApp=UINPBA000044" "url" => "/00017310/0000011400000003/v1_202303051528/S0001731022005944/v1_202303051528/es/main.assets" ] "asociados" => array:1 [ 0 => array:19 [ "pii" => "S0001731022005944" "issn" => "00017310" "doi" => "10.1016/j.ad.2021.05.029" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "3103" "copyright" => "AEDV" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2023;114:257-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">CASOS PARA DIAGNÓSTICO</span>" "titulo" => "Placa edematosa infraumbilical en paciente gestante" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "257" "paginaFinal" => "258" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Edematous Infraumbilical Plaque in a Pregnant Woman" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 381 "Ancho" => 1005 "Tamanyo" => 170674 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Tinción con hematoxilina-eosina (HE). Se observa también edema en la dermis, intercalado con fibrosis y con escaso infiltrado linfoide perivascular superficial (A). Tinción para podoplanina (D2-40) en la que destacan algunos vasos linfáticos ectásicos dérmicos (B).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Cruañes-Monferrer, A. Gil Liñan, A. Ramírez Andreo" "autores" => array:3 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Cruañes-Monferrer" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Gil Liñan" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Ramírez Andreo" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731022005944?idApp=UINPBA000044" "url" => "/00017310/0000011400000003/v1_202303051528/S0001731022005944/v1_202303051528/es/main.assets" ] ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Cases for Diagnosis</span>" "titulo" => " Edematous Infraumbilical Plaque in a Pregnant Woman" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "T257" "paginaFinal" => "T258" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. Cruañes-Monferrer, A. Gil Liñan, A. Ramírez Andreo" "autores" => array:3 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Cruañes-Monferrer" "email" => array:1 [ 0 => "joanacm93@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Gil Liñan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Ramírez Andreo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología y Venereología, Hospital Universitario Reina Sofía de Murcia, Murcia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario Reina Sofía de Murcia, Murcia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Placa edematosa infraumbilical en paciente gestante" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 973 "Ancho" => 1264 "Tamanyo" => 155327 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Infraumbilical edematous plaque, with an orange peel appearance and well-defined borders.</p>" ] ] ] "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 22-year-old primipara in her 36th week of gestation (body mass index, 22) came to the clinic because of a change in the appearance of the skin below the umbilicus. The skin first began to change 2 weeks previously and was associated with pain and itching. The patient was afebrile and did not recall previous injury in the area.</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 clearly delimited nonerythematous indurated plaque with well-defined borders in the infraumbilical area (15<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>cm). It was remarkable for its orange-peel appearance, with symmetrical depressed dimples (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Palpation revealed edema with pitting. No edema was observed on the lower limbs or vulva, and there were no palpable enlarged inguinal lymph nodes.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Histopathology analysis revealed marked dermal edema, with mild superficial and deep chronic perivascular inflammation, as well as fibrosis in the dermis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Staining for podoplanin (D2-40) highlighted irregular superficial lymphangiectasia (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Additional Tests</span><p id="par0020" class="elsevierStylePara elsevierViewall">Soft tissue ultrasound (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) revealed diffuse thickening of the dermis and subcutaneous cellular tissue, with marked local accumulation of fluid (visible as linear anechoic tracts). Doppler mode revealed no increase in vascularization.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">What is Your Diagnosis?</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was diagnosed with lymphedema of the lower abdominal wall secondary to pregnancy.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">After delivery, the plaque involuted gradually, leaving no scar tissue.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Commentary</span><p id="par0040" class="elsevierStylePara elsevierViewall">Primary lymphedema is a congenital disease caused by abnormal development of the lymphatic system. Secondary, or acquired, lymphedema is more common and may have multiple underlying causes leading to obstruction of lymph drainage. The main cause of abdominal lymphedema is involvement of the regional lymph nodes that collect the drainage from the abdominal wall owing to resection, ablation, or radiation of the nodes.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> It may also result from invasion of the lymph node by a tumor or infection by filariae. Similarly, lymphedema of the abdominal wall may appear suddenly after high-impact injury.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In morbidly obese patients, lymphedema may appear in the infraumbilical area and is known as panniculus morbidus.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> This can grow very large, taking on the appearance of a pedunculated tumor. It is also thought to be caused mainly by obstruction of lymphatic drainage (owing to the mass effect of abdominal obesity) from the infraumbilical abdominal wall, which is collected in the superficial inguinal lymph nodes and in the common iliac lymph nodes.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> The lymphatic vessels of the supraumbilical abdominal wall, in contrast, drain to the parasternal or axillary lymph nodes, thus explaining why lymphedema usually appears in the infraumbilical area.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Abdominal lymphedema is rarely reported in pregnant women. The differential diagnosis should include malignant entities such as lymphangitis carcinomatosa, liposarcoma, and angiosarcoma.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> The patient should also be screened for infections such as cellulitis and erysipelas. Other differential diagnoses include scleredema of Buschke<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> and eosinophilic fasciitis.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> The pathogenic mechanism in pregnant women is similar to that of morbidly obese individuals owing to obstruction of lymph drainage from the abdominal wall.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The most definitive histological characteristic is marked dermal edema, together with lymphangiectasia and the variable presence of dermal fibrosis.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">This disease does not require treatment in the case of pregnant women, since the edema usually resolves after delivery. The recommendation in the case of morbidly obese patients is weight loss combined with other conservative options, such as lymphatic drainage via massage or abdominal compression bandages. If these measures fail, surgical resection of the redundant tissue is an option.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 3 => array:3 [ "identificador" => "sec0020" "titulo" => "Additional Tests" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical Course and Treatment" ] ] ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Commentary" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 973 "Ancho" => 1264 "Tamanyo" => 155327 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Infraumbilical edematous plaque, with an orange peel appearance and well-defined borders.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 639 "Ancho" => 1681 "Tamanyo" => 374614 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Staining with hematoxylin–eosin. (A) Note the dermal edema, interspersed with fibrosis and a scant superficial perivascular lymphoid infiltrate. (B) Staining with podoplanin (D2-40) highlighting lymphangiectasia in the dermis (B).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 923 "Ancho" => 1264 "Tamanyo" => 140394 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Soft tissue ultrasound. Note the accumulation of fluid in the area, seen as linear anechoic tracts.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Massive localized lymphedema: a clinicopathologic study of 46 patients with an enrichment for multiplicity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "H. Kurt" 1 => "C.A. Arnold" 2 => "J.E. Payne" 3 => "M.J. Miller" 4 => "R.J. Skoracki" 5 => "O.H. 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Huff" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0190-9622(85)70116-8" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "1985" "volumen" => "12" "paginaInicial" => "930" "paginaFinal" => "932" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3158678" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00017310/0000011400000003/v1_202303051528/S0001731023000492/v1_202303051528/en/main.assets" "Apartado" => array:4 [ "identificador" => "6161" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Casos para el diagnóstico" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00017310/0000011400000003/v1_202303051528/S0001731023000492/v1_202303051528/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731023000492?idApp=UINPBA000044" ]
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