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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">The patient was a 79-year-old woman with a history of rheumatoid arthritis&#44; osteoporosis&#44; and advanced chronic kidney disease managed with renal replacement therapy &#40;hemodialysis&#41;&#46; She was referred to the dermatology department of our hospital for assessment of a lesion on her left shoulder that had first appeared several months earlier&#46; The lesion had grown and was occasionally pruritic&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination and Histopathology</span><p id="par0010" class="elsevierStylePara elsevierViewall">At her first visit&#44; we observed a single red-violaceous plaque &#40;8<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>cm&#41; 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with only a pseudovesicular plaque &#40;7<span class="elsevierStyleHsp" style=""></span>mm in diameter&#41; on a residual erythematous-violaceous base remaining &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The lesion had resolved completely at 6 months&#46; Subsequent analysis revealed anemia of chronic disease and increased urea and plasma creatinine &#40;these findings were previously known&#41;&#44; with normal thyroid function and absence of paraproteinemia&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">What is your diagnosis&#63;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Adult self-healing papular mucinosis&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion and Commentary</span><p id="par0030" class="elsevierStylePara elsevierViewall">Cutaneous mucinosis comprises a very diverse and heterogeneous group of diseases&#44; all of which are characterized by abnormal accumulation of mucin in the skin&#46; Mucins are high-molecular-weight proteins composed of glycosaminoglycans&#46; They are synthetized by dermal fibroblasts and act as a key factor in maintaining the hydrosaline balance in the skin&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">According to the most widely accepted classification&#44; which was proposed by Rongioletti and Rebora in 2001&#44; cutaneous mucinosis can be divided into the localized form &#40;papular mucinosis&#44; also known as lichen myxedematosus&#41; and the generalized form &#40;scleromyxedema&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Mucinosis can also be idiopathic &#40;primary&#41; or secondary to other conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Self-healing papular mucinosis &#40;SHPM&#41; is an uncommon entity belonging to the group of localized cutaneous mucinoses &#40;lichen myxedematosus&#41;&#46; Since it is more common in children&#44; it was initially reported as a pediatric condition &#40;1&#8211;15 years&#41; that manifests with multiple lesions and&#44; occasionally&#44; systemic symptoms&#46; However&#44; there have been reports of cases appearing in adulthood and involving localized lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Unlike generalized cutaneous mucinosis &#40;scleromyxedema&#41;&#44; the variants of lichen myxedematosus are not usually associated with systemic diseases&#44; thyroid problems&#44; or paraproteinemia&#46; There have been reports of cases of SHPM in adults with type 2 diabetes mellitus&#44; bacterial pneumonia&#44; and autoimmune diseases such as rheumatoid arthritis&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> However&#44; 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Given the considerable heterogeneity of cutaneous mucinosis&#44; the correlation between disease and symptoms could be key to reaching a correct diagnosis&#44; especially in atypical cases&#46; Lastly&#44; it is important to distinguish between SHPM and self-healing juvenile cutaneous mucinosis&#44; since these are different entities&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflicts of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Cases for Diagnosis
A Pseudovesicular Plaque on the Shoulder
Una placa pseudovesicular en el hombro
Á. Fernández Camporroa,
Autor para correspondencia
angelderma95@gmail.com

Corresponding author.
, S. Mallo Garcíaa, J.M. Calzada Gonzálezb
a Servicio de Dermatología, Hospital Universitario de Cabueñes, Gijón, Spain
b Servicio de Anatomía Patológica, Hospital Universitario de Cabueñes, Gijón, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">The patient was a 79-year-old woman with a history of rheumatoid arthritis&#44; osteoporosis&#44; and advanced chronic kidney disease managed with renal replacement therapy &#40;hemodialysis&#41;&#46; She was referred to the dermatology department of our hospital for assessment of a lesion on her left shoulder that had first appeared several months earlier&#46; The lesion had grown and was occasionally pruritic&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination and Histopathology</span><p id="par0010" class="elsevierStylePara elsevierViewall">At her first visit&#44; we observed a single red-violaceous plaque &#40;8<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>cm&#41; with a clustered pseudovesicular surface on the posterior aspect of her left shoulder &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Histopathology revealed a preserved epidermis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; A diffuse mucin deposit was observed in the upper reticular and papillary dermis &#40;positive for Alcian blue staining&#41;&#44; together with a slight increase in irregularly distributed fibroblasts and a modest perivascular lymphoplasmocytic infiltrate &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; The elastic fibers were diminished and fragmented&#46; Thin-walled arborizing vessels were visible in the deep dermis&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Clinical Course</span><p id="par0015" class="elsevierStylePara elsevierViewall">The lesions began to improve 1 month after the biopsy&#44; with only a pseudovesicular plaque &#40;7<span class="elsevierStyleHsp" style=""></span>mm in diameter&#41; on a residual erythematous-violaceous base remaining &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The lesion had resolved completely at 6 months&#46; Subsequent analysis revealed anemia of chronic disease and increased urea and plasma creatinine &#40;these findings were previously known&#41;&#44; with normal thyroid function and absence of paraproteinemia&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">What is your diagnosis&#63;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Adult self-healing papular mucinosis&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion and Commentary</span><p id="par0030" class="elsevierStylePara elsevierViewall">Cutaneous mucinosis comprises a very diverse and heterogeneous group of diseases&#44; all of which are characterized by abnormal accumulation of mucin in the skin&#46; Mucins are high-molecular-weight proteins composed of glycosaminoglycans&#46; They are synthetized by dermal fibroblasts and act as a key factor in maintaining the hydrosaline balance in the skin&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">According to the most widely accepted classification&#44; which was proposed by Rongioletti and Rebora in 2001&#44; cutaneous mucinosis can be divided into the localized form &#40;papular mucinosis&#44; also known as lichen myxedematosus&#41; and the generalized form &#40;scleromyxedema&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Mucinosis can also be idiopathic &#40;primary&#41; or secondary to other conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Self-healing papular mucinosis &#40;SHPM&#41; is an uncommon entity belonging to the group of localized cutaneous mucinoses &#40;lichen myxedematosus&#41;&#46; Since it is more common in children&#44; it was initially reported as a pediatric condition &#40;1&#8211;15 years&#41; that manifests with multiple lesions and&#44; occasionally&#44; systemic symptoms&#46; However&#44; there have been reports of cases appearing in adulthood and involving localized lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Unlike generalized cutaneous mucinosis &#40;scleromyxedema&#41;&#44; the variants of lichen myxedematosus are not usually associated with systemic diseases&#44; thyroid problems&#44; or paraproteinemia&#46; There have been reports of cases of SHPM in adults with type 2 diabetes mellitus&#44; bacterial pneumonia&#44; and autoimmune diseases such as rheumatoid arthritis&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> However&#44; the etiology-pathogenesis of SHPM is unknown&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Adult SHPM is traditionally characterized by multiple pseudovesicular papules arranged symmetrically and mainly affecting the upper half of the skin &#40;head&#44; neck&#44; shoulders&#44; abdomen&#41;&#46; The papules may coalesce to form plaques and&#47;or nodules and may be associated with systemic symptoms &#40;fever&#44; asthenia&#44; joint and muscle pain&#41;&#46; Very few cases of adult SHPM with unilateral and asymmetrical involvement have been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> The skin lesions tend to resolve spontaneously over a period of weeks or months&#46; Histology frequently reveals abundant mucinous material in the middle and upper dermis&#44; with a slight increase in the fibroblast count&#46; These findings usually appear alongside a nonspecific inflammatory pattern&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">We present a case of adult SHPM that presented asymmetrically and involuted spontaneously&#46; Given the considerable heterogeneity of cutaneous mucinosis&#44; the correlation between disease and symptoms could be key to reaching a correct diagnosis&#44; especially in atypical cases&#46; Lastly&#44; it is important to distinguish between SHPM and self-healing juvenile cutaneous mucinosis&#44; since these are different entities&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conflicts of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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