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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Dot plots representing the percentage of cell types found in the skin blister fluid by flow cytometric analysis&#46; The LR square &#40;CD3&#8722; CD56&#43;&#41; illustrates the NK cells&#46; The first diagram shows our patient&#39;s data&#44; with 65&#46;5&#37; of NK cells&#46; The diagram below is an example of an SJS&#47;TEN case&#44; with only 7&#46;6&#37; of NK cells&#46; GvHD&#44; graft-versus-host disease&#59; BFC&#44; blister fluid cells&#59; SJS&#47;TEN&#44; Stevens&#8211;Johnson syndrome&#47;toxic epidermal necrolysis&#59; NK cells&#44; natural killer cells&#59; UL&#44; upper-left&#59; UR&#44; upper-right&#59; LL&#44; lower-left&#59; LR&#44; lower-right&#46;</p>"
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One day prior to the transplant&#44; GvHD prophylaxis was initiated with cyclosporine A&#46; The patient received multiple drugs at admission&#44; including antibiotics&#44; such as beta-lactams&#44; trimethoprim&#47;sulfamethoxazole&#44; and vancomycin&#46; One month later&#44; an extensive maculopapular rash with skin detachment and a positive Nikolsky&#39;s sign appeared on the trunk&#44; scalp &#40;including the retroauricular region&#41;&#44; palms&#44; and soles &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Additionally&#44; oral&#44; genital&#44; and ocular mucous membranes were affected as well&#46; There were no signs of GI or hepatic involvement&#46; Clinical diagnosis of GvDH vs SJS&#47;TEN was considered&#46; The skin biopsy confirmed the presence of a completely necrotic epidermis detached from the dermis&#44; which was consistent with both diagnoses&#46; The patient was&#44; therefore&#44; admitted to the ICU&#44; suspected drugs were withdrawn&#44; and treatment with prednisone &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41; and immunoglobulin &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; was initiated&#46; However&#44; skin lesions fail to improve after 48<span class="elsevierStyleHsp" style=""></span>h&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Currently&#44; there are no established biomarkers that can reliably diagnose GvHD&#46; According to a pilot study&#44; a composite biomarker panel including elafin&#44; regenerating islet-derived 3-&#945;&#44; and soluble interleukin-2 receptor-&#945; can be useful to differentiate acute GvHD from non-GvHD patients at onset with specificity and sensitivity rates of 100&#37; and 55&#46;6&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Nevertheless&#44; these biomarkers are not widely available&#44; which is why this analysis could not be conducted&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Flow cytometric analysis of skin blister fluid cells &#40;BFC&#41; was performed&#44; and the results became available in &#60;1<span class="elsevierStyleHsp" style=""></span>h&#46; The CD8&#43;&#47;CD4&#43; ratio among the CD3&#43; T cells found in our analysis was 2&#46;1&#44; and natural killer &#40;NK&#41; cells &#40;CD3-CD56&#43; lymphocytes&#41; accounted for up to 65&#46;5&#37; of the entire lymphocyte population &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; In our centre&#44; this evaluation is always conducted in available BFC of SJS&#47;TEN cases following the protocols established by the PIELenRed consortium&#44; a Spanish interdisciplinary platform for the investigation of severe cutaneous adverse drug reactions&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> The mean CD8&#43;&#47;CD4&#43; ratio in 10 SJS&#47;TEN samples analyzed was 5&#46;5 &#40;range&#44; 2&#46;3&#8211;12&#46;4&#41;&#44; and the mean percentage of NK cells&#44; 11&#46;5&#37; &#40;range&#44; 3&#8211;18&#37;&#41;&#46; As far as we know&#44; no studies have ever compared the amount of CD8&#43;&#44; CD4&#43; and NK cells in blister fluids of GvHD and SJS&#47;TEN&#46; Nevertheless&#44; according to Naik et al&#46;&#44; the CD8&#43;&#47;CD4&#43; ratio in the histopathological analysis of grade IV GvHD skin biopsies was lower vs SJS&#47;TEN &#40;1&#46;78 vs 7&#46;33&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> Furthermore&#44; Wegner et al&#46; reported an increased number of NK cells in GvHD skin samples vs SJS&#47;TEN&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> Therefore&#44; immunohistochemical studies in skin biopsies and flow cytometric analyses of blister fluid may have parallel results&#46; In fact&#44; the findings of our case support the diagnosis of GvHD&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Finally&#44; taking the patient&#39;s past medical history&#44; clinical signs&#44; and flow cytometric data into consideration&#44; the diagnosis of GvHD was considered more likely&#44; and targeted treatment was initiated with ruxolitinib and photopheresis&#44; with rapid improvement of skin lesions&#46; Unfortunately&#44; the patient developed infectious and haemorrhagic complications leading her death on day &#43;57&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">One of the most important reasons for performing flow cytometric analysis of BFC instead of just a conventional biopsy is to help in the differential diagnosis of two entities whose histopathological findings often overlap&#44; causing a diagnostic dilemma&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2&#44;6&#44;7</span></a> In addition&#44; we should emphasize that the results of this test can be obtained very quicky&#58; in &#60;1<span class="elsevierStyleHsp" style=""></span>h in our centre&#46; This can be crucial for decision-making and to start treatment fast&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Although the flow cytometric analysis of BFC is not a currently validated technique&#44; results can likely be parallel to those found in immunohistochemical studies&#46; In the future&#44; this test may be a fast and useful tool to differentiate grade IV GvHD from SJS&#47;TEN&#44; which warrants further investigation&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">This study was supported by a grant from <span class="elsevierStyleGrantSponsor" id="gs1">Instituto de Salud Carlos III&#44; Madrid&#44; Spain &#40;Spanish Ministry of Economy and Competitiveness&#41;</span><span class="elsevierStyleGrantNumber" refid="gs1">FIS PI18&#47;00718</span> &#40;co-funded by <span class="elsevierStyleGrantSponsor" id="gs2">FEDER</span>&#41; to TB&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</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
Flow Cytometric Analysis of Skin Blister Fluid Cells: A Promising Tool in the Differential Diagnosis of Acute Cutaneous Graft-versus-host Disease and Stevens–Johnson Syndrome/Toxic Epidermal Necrolysis
Análisis por citometría de flujo de las células del líquido de las ampollas cutáneas: una herramienta prometedora para la diferenciación de la enfermedad del injerto contra el huésped aguda y el síndrome de Stevens-Johnson/necrólisis epidérmica tóxica
R. de Moraes Souzaa,
Autor para correspondencia
rafa.msouza1@gmail.com

Corresponding author.
, T. Bellónb, E. Fiz Benitoa, E. Sendagorta Cudósa
a Dermatology Division, La Paz University Hospital (Hospital Universitario La Paz), Paseo de la Castellana, 261, CP 28046, Madrid, Spain
b Drug Hypersensitivity Group, Hospital La Paz Institute for Health Research (Instituto de Investigación Sanitaria del Hospital Universitario La Paz – IdiPAZ), Calle de Pedro Rico, 6, CP 28029, Madrid, Spain
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Dot plots representing the percentage of cell types found in the skin blister fluid by flow cytometric analysis&#46; The LR square &#40;CD3&#8722; CD56&#43;&#41; illustrates the NK cells&#46; The first diagram shows our patient&#39;s data&#44; with 65&#46;5&#37; of NK cells&#46; The diagram below is an example of an SJS&#47;TEN case&#44; with only 7&#46;6&#37; of NK cells&#46; GvHD&#44; graft-versus-host disease&#59; BFC&#44; blister fluid cells&#59; SJS&#47;TEN&#44; Stevens&#8211;Johnson syndrome&#47;toxic epidermal necrolysis&#59; NK cells&#44; natural killer cells&#59; UL&#44; upper-left&#59; UR&#44; upper-right&#59; LL&#44; lower-left&#59; LR&#44; lower-right&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Acute graft-versus-host disease &#40;GvHD&#41; is a life-threatening complication following allogeneic hematopoietic stem cell&#44; or solid organ transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Discriminating grade IV cutaneous GvHD from Stevens&#8211;Johnson syndrome&#47;toxic epidermal necrolysis &#40;SJS&#47;TEN&#41; is challenging due to the similar clinical and histopathological features shared by both entities&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> However&#44; distinguishing between the two diagnoses is important because the management of these conditions is not the same&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 61-year-old woman with myelodysplastic syndrome with excess blasts type 2 who underwent allogeneic stem cell transplantation&#46; One day prior to the transplant&#44; GvHD prophylaxis was initiated with cyclosporine A&#46; The patient received multiple drugs at admission&#44; including antibiotics&#44; such as beta-lactams&#44; trimethoprim&#47;sulfamethoxazole&#44; and vancomycin&#46; One month later&#44; an extensive maculopapular rash with skin detachment and a positive Nikolsky&#39;s sign appeared on the trunk&#44; scalp &#40;including the retroauricular region&#41;&#44; palms&#44; and soles &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Additionally&#44; oral&#44; genital&#44; and ocular mucous membranes were affected as well&#46; There were no signs of GI or hepatic involvement&#46; Clinical diagnosis of GvDH vs SJS&#47;TEN was considered&#46; The skin biopsy confirmed the presence of a completely necrotic epidermis detached from the dermis&#44; which was consistent with both diagnoses&#46; The patient was&#44; therefore&#44; admitted to the ICU&#44; suspected drugs were withdrawn&#44; and treatment with prednisone &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41; and immunoglobulin &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41; was initiated&#46; However&#44; skin lesions fail to improve after 48<span class="elsevierStyleHsp" style=""></span>h&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Currently&#44; there are no established biomarkers that can reliably diagnose GvHD&#46; According to a pilot study&#44; a composite biomarker panel including elafin&#44; regenerating islet-derived 3-&#945;&#44; and soluble interleukin-2 receptor-&#945; can be useful to differentiate acute GvHD from non-GvHD patients at onset with specificity and sensitivity rates of 100&#37; and 55&#46;6&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Nevertheless&#44; these biomarkers are not widely available&#44; which is why this analysis could not be conducted&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Flow cytometric analysis of skin blister fluid cells &#40;BFC&#41; was performed&#44; and the results became available in &#60;1<span class="elsevierStyleHsp" style=""></span>h&#46; The CD8&#43;&#47;CD4&#43; ratio among the CD3&#43; T cells found in our analysis was 2&#46;1&#44; and natural killer &#40;NK&#41; cells &#40;CD3-CD56&#43; lymphocytes&#41; accounted for up to 65&#46;5&#37; of the entire lymphocyte population &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; In our centre&#44; this evaluation is always conducted in available BFC of SJS&#47;TEN cases following the protocols established by the PIELenRed consortium&#44; a Spanish interdisciplinary platform for the investigation of severe cutaneous adverse drug reactions&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> The mean CD8&#43;&#47;CD4&#43; ratio in 10 SJS&#47;TEN samples analyzed was 5&#46;5 &#40;range&#44; 2&#46;3&#8211;12&#46;4&#41;&#44; and the mean percentage of NK cells&#44; 11&#46;5&#37; &#40;range&#44; 3&#8211;18&#37;&#41;&#46; As far as we know&#44; no studies have ever compared the amount of CD8&#43;&#44; CD4&#43; and NK cells in blister fluids of GvHD and SJS&#47;TEN&#46; Nevertheless&#44; according to Naik et al&#46;&#44; the CD8&#43;&#47;CD4&#43; ratio in the histopathological analysis of grade IV GvHD skin biopsies was lower vs SJS&#47;TEN &#40;1&#46;78 vs 7&#46;33&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> Furthermore&#44; Wegner et al&#46; reported an increased number of NK cells in GvHD skin samples vs SJS&#47;TEN&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> Therefore&#44; immunohistochemical studies in skin biopsies and flow cytometric analyses of blister fluid may have parallel results&#46; In fact&#44; the findings of our case support the diagnosis of GvHD&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Finally&#44; taking the patient&#39;s past medical history&#44; clinical signs&#44; and flow cytometric data into consideration&#44; the diagnosis of GvHD was considered more likely&#44; and targeted treatment was initiated with ruxolitinib and photopheresis&#44; with rapid improvement of skin lesions&#46; Unfortunately&#44; the patient developed infectious and haemorrhagic complications leading her death on day &#43;57&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">One of the most important reasons for performing flow cytometric analysis of BFC instead of just a conventional biopsy is to help in the differential diagnosis of two entities whose histopathological findings often overlap&#44; causing a diagnostic dilemma&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2&#44;6&#44;7</span></a> In addition&#44; we should emphasize that the results of this test can be obtained very quicky&#58; in &#60;1<span class="elsevierStyleHsp" style=""></span>h in our centre&#46; This can be crucial for decision-making and to start treatment fast&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Although the flow cytometric analysis of BFC is not a currently validated technique&#44; results can likely be parallel to those found in immunohistochemical studies&#46; In the future&#44; this test may be a fast and useful tool to differentiate grade IV GvHD from SJS&#47;TEN&#44; which warrants further investigation&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">This study was supported by a grant from <span class="elsevierStyleGrantSponsor" id="gs1">Instituto de Salud Carlos III&#44; Madrid&#44; Spain &#40;Spanish Ministry of Economy and Competitiveness&#41;</span><span class="elsevierStyleGrantNumber" refid="gs1">FIS PI18&#47;00718</span> &#40;co-funded by <span class="elsevierStyleGrantSponsor" id="gs2">FEDER</span>&#41; to TB&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</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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