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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hypereosinophilic syndrome &#40;HES&#41; is defined by a concentration of eosinophils in peripheral blood greater than 1500<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;L&#44; accompanied by organ damage or dysfunction not attributable to other causes&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">HESs include the lymphoproliferative form &#40;L-HES&#41;&#44; in which there is an abnormal T-cell &#40;TC&#41; population in peripheral blood&#44; with clonal rearrangement of the TC receptors &#40;TCRs&#41;&#46; These produce eosinophil-derived cytokines&#46; Therefore&#44; unlike the clonal myeloproliferative variant&#44; L-HES is a mixture of a clonal process &#40;TC clones&#41; and a reactive one &#40;eosinophilia derived from the secretion of cytokines from these TCs&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2&#44;4&#8211;6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Close follow-up of these patients is essential&#44; as 10&#8211;20&#37; may progress to cutaneous T-cell lymphoma &#40;CTCL&#41; with a poor prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;8</span></a> It is important to distinguish between the 2 entities&#44; given the indolent course in the case of patients with L-HES compared with the worse prognosis in CTCL&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A 67-year-old man attended the clinic with symptoms of 3 months standing of polyarthralgia&#44; multiple migratory bilateral pulmonary infiltrates&#44; generalized highly itchy maculopapular skin rash&#44; and constitutional syndrome with asthenia&#44; anorexia&#44; and weight loss &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Laboratory analysis showed leukocytosis of 58<span class="elsevierStyleHsp" style=""></span>600&#47;&#956;L with neutrophilia of 11<span class="elsevierStyleHsp" style=""></span>100&#47;&#956;L and eosinophilia of 44<span class="elsevierStyleHsp" style=""></span>100&#47;&#956;L&#44; with elevated acute-phase reactants &#40;CRP&#44; 147&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#59; VSG&#44; 46<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#59; LDH&#44; 335<span class="elsevierStyleHsp" style=""></span>U&#47;L&#41;&#46; Study of urine&#44; allergies&#44; echocardiogram&#44; autoimmunity&#44; serology&#44; and parasites was negative&#46; A mutation in the <span class="elsevierStyleItalic">FIP1L1-PDGFRA</span> gene was ruled out by fluorescent in situ hybridization &#40;FISH&#41; in peripheral blood&#46; Bone marrow study showed increased eosinophils with a high percentage of lymphocytes with atypical immunophenotype &#40;CD3<span class="elsevierStyleSup">&#8722;</span>&#44; CD4<span class="elsevierStyleSup">&#8722;</span>&#44; and CD8<span class="elsevierStyleSup">&#8722;</span>&#41;&#46; The histological study of a punch biopsy showed spongiotic dermatitis with eosinophils and follicular involvement &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">With these results&#44; L-HES was suspected and prednisone 60<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#44; hydroxyurea 500<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#44; and methotrexate 20<span class="elsevierStyleHsp" style=""></span>mg&#47;week were administered&#46; One month later&#44; the patient presented with a notable worsening of symptoms&#44; with the onset of large swollen lymph nodes on the right side of the groin&#46; Another skin biopsy &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; showed a T lymphoid infiltrate with epidermotropism and abundant eosinophils and a lymph node biopsy revealed complete loss of architecture &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; These cells were positive for CD3&#44; CD4&#44; and CD5&#44; with loss of CD7&#44; and negative for CD8&#44; CD20&#44; and CD30&#44; presenting monoclonality for TCR beta and gamma&#46; Likewise&#44; the presence of S&#233;zary cells in peripheral blood was ruled out&#44; as well as systemic involvement&#46; These findings led to diagnosis of erythrodermic mycosis fungoides with lymph node involvement &#40;stage IVA2&#41;&#46; In accordance with this diagnosis&#44; prednisone 45<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#44; interferon alfa 2a 3 MIU &#40;3 injections per week&#41;&#44; bexarotene 300<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#44; and weekly methotrexate 20<span class="elsevierStyleHsp" style=""></span>mg were administered&#46; In light of the poor therapeutic response&#44; and with the suspicion of underlying S&#233;zary syndrome&#44; the lymphoid phenotype was reassessed and the presence of S&#233;zary cells was detected&#44; with 2&#46;2&#37; atypical TCs and a CD4&#47;CD8 ratio of 9&#46;09&#44; with 5&#37; positive for CD3&#44; CD2&#44; CD5&#44; and negative for CD7&#44; CD4&#44; CD8&#44; and CD26&#44; and eosinophilia of 62&#37; in the flow cytometry&#46; The final diagnosis was S&#233;zary syndrome &#40;stage IVA2&#41;&#46; Chemotherapy was started with the CHOP regimen&#46; The patient died 4 days after starting treatment&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The case analysis questions whether the patient had CTCL from the start and whether the hypereosinophilia was reactive to this entity or whether it was malign progression from L-HES&#46; Transcriptome analysis has determined specific biomarkers for each entity in some studies&#44; thereby enabling these 2 entities to be identified early&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;9</span></a> Our impression is that the patient probably had S&#233;zary syndrome from the outset and that hypereosinophilia was reactive and manifest as L-HES&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Eosinophilia has an important prognostic role in CTCL&#44; with median survival 3 years lower in patients with eosinophil levels above 700&#47;&#956;L&#46; Some authors have considered eosinophilia on diagnosis as the only prognostic variable associated with disease progression and disease-related death&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> In addition&#44; eosinophils could be an indirect marker of tumor load&#44; as their level increases due to synthesis of eosinophil-derived cytokines by neoplastic cells and they therefore may be useful as response markers for antitumor treatment&#46; Further studies to confirm this hypothesis could help guide treatment in these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In summary&#44; we can conclude that it is extremely difficult to know whether we are facing natural disease progression or an undiagnosed lymphoma&#44; 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Case and Research Letter
Hypereosinophilic Syndrome and T-Cell Lymphoma: Which Comes First?
Síndrome hipereosinofílico y linfoma de células T, ¿quién va primero?
M. Meruelo Ruano
Autor para correspondencia
, N. González Romero, A. Lobato Izagirre, I. Gainza Apraiz
Servicio de Dermatología, Hospital Universitario Basurto, Bilbao, Spain
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Lymph node biopsy&#46; Erasure of the general architecture of the lymph node&#44; with loss of lymphoid follicles in the cortex&#44; replaced by a diffuse lymphoid proliferation&#46; At higher magnification&#44; generalized lymphoid expansion can be seen&#44; accompanied by numerous eosinophils&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hypereosinophilic syndrome &#40;HES&#41; is defined by a concentration of eosinophils in peripheral blood greater than 1500<span class="elsevierStyleHsp" style=""></span>cells&#47;&#956;L&#44; accompanied by organ damage or dysfunction not attributable to other causes&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">HESs include the lymphoproliferative form &#40;L-HES&#41;&#44; in which there is an abnormal T-cell &#40;TC&#41; population in peripheral blood&#44; with clonal rearrangement of the TC receptors &#40;TCRs&#41;&#46; These produce eosinophil-derived cytokines&#46; Therefore&#44; unlike the clonal myeloproliferative variant&#44; L-HES is a mixture of a clonal process &#40;TC clones&#41; and a reactive one &#40;eosinophilia derived from the secretion of cytokines from these TCs&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2&#44;4&#8211;6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Close follow-up of these patients is essential&#44; as 10&#8211;20&#37; may progress to cutaneous T-cell lymphoma &#40;CTCL&#41; with a poor prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7&#44;8</span></a> It is important to distinguish between the 2 entities&#44; given the indolent course in the case of patients with L-HES compared with the worse prognosis in CTCL&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A 67-year-old man attended the clinic with symptoms of 3 months standing of polyarthralgia&#44; multiple migratory bilateral pulmonary infiltrates&#44; generalized highly itchy maculopapular skin rash&#44; and constitutional syndrome with asthenia&#44; anorexia&#44; and weight loss &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Laboratory analysis showed leukocytosis of 58<span class="elsevierStyleHsp" style=""></span>600&#47;&#956;L with neutrophilia of 11<span class="elsevierStyleHsp" style=""></span>100&#47;&#956;L and eosinophilia of 44<span class="elsevierStyleHsp" style=""></span>100&#47;&#956;L&#44; with elevated acute-phase reactants &#40;CRP&#44; 147&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#59; VSG&#44; 46<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#59; LDH&#44; 335<span class="elsevierStyleHsp" style=""></span>U&#47;L&#41;&#46; Study of urine&#44; allergies&#44; echocardiogram&#44; autoimmunity&#44; serology&#44; and parasites was negative&#46; A mutation in the <span class="elsevierStyleItalic">FIP1L1-PDGFRA</span> gene was ruled out by fluorescent in situ hybridization &#40;FISH&#41; in peripheral blood&#46; Bone marrow study showed increased eosinophils with a high percentage of lymphocytes with atypical immunophenotype &#40;CD3<span class="elsevierStyleSup">&#8722;</span>&#44; CD4<span class="elsevierStyleSup">&#8722;</span>&#44; and CD8<span class="elsevierStyleSup">&#8722;</span>&#41;&#46; The histological study of a punch biopsy showed spongiotic dermatitis with eosinophils and follicular involvement &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">With these results&#44; L-HES was suspected and prednisone 60<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#44; hydroxyurea 500<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#44; and methotrexate 20<span class="elsevierStyleHsp" style=""></span>mg&#47;week were administered&#46; One month later&#44; the patient presented with a notable worsening of symptoms&#44; with the onset of large swollen lymph nodes on the right side of the groin&#46; Another skin biopsy &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; showed a T lymphoid infiltrate with epidermotropism and abundant eosinophils and a lymph node biopsy revealed complete loss of architecture &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; These cells were positive for CD3&#44; CD4&#44; and CD5&#44; with loss of CD7&#44; and negative for CD8&#44; CD20&#44; and CD30&#44; presenting monoclonality for TCR beta and gamma&#46; Likewise&#44; the presence of S&#233;zary cells in peripheral blood was ruled out&#44; as well as systemic involvement&#46; These findings led to diagnosis of erythrodermic mycosis fungoides with lymph node involvement &#40;stage IVA2&#41;&#46; In accordance with this diagnosis&#44; prednisone 45<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#44; interferon alfa 2a 3 MIU &#40;3 injections per week&#41;&#44; bexarotene 300<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h&#44; and weekly methotrexate 20<span class="elsevierStyleHsp" style=""></span>mg were administered&#46; In light of the poor therapeutic response&#44; and with the suspicion of underlying S&#233;zary syndrome&#44; the lymphoid phenotype was reassessed and the presence of S&#233;zary cells was detected&#44; with 2&#46;2&#37; atypical TCs and a CD4&#47;CD8 ratio of 9&#46;09&#44; with 5&#37; positive for CD3&#44; CD2&#44; CD5&#44; and negative for CD7&#44; CD4&#44; CD8&#44; and CD26&#44; and eosinophilia of 62&#37; in the flow cytometry&#46; The final diagnosis was S&#233;zary syndrome &#40;stage IVA2&#41;&#46; Chemotherapy was started with the CHOP regimen&#46; The patient died 4 days after starting treatment&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The case analysis questions whether the patient had CTCL from the start and whether the hypereosinophilia was reactive to this entity or whether it was malign progression from L-HES&#46; Transcriptome analysis has determined specific biomarkers for each entity in some studies&#44; thereby enabling these 2 entities to be identified early&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;9</span></a> Our impression is that the patient probably had S&#233;zary syndrome from the outset and that hypereosinophilia was reactive and manifest as L-HES&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Eosinophilia has an important prognostic role in CTCL&#44; with median survival 3 years lower in patients with eosinophil levels above 700&#47;&#956;L&#46; Some authors have considered eosinophilia on diagnosis as the only prognostic variable associated with disease progression and disease-related death&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> In addition&#44; eosinophils could be an indirect marker of tumor load&#44; as their level increases due to synthesis of eosinophil-derived cytokines by neoplastic cells and they therefore may be useful as response markers for antitumor treatment&#46; Further studies to confirm this hypothesis could help guide treatment in these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In summary&#44; we can conclude that it is extremely difficult to know whether we are facing natural disease progression or an undiagnosed lymphoma&#44; highlighting the need for more reliable markers to address this question&#46; What we can say&#44; based on the literature&#44; is that eosinophilia is a warning sign for patients with CTCL&#44; and long-term follow-up patients with L-HES are vital&#46;</p></span>"
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