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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Hyperkeratotic white-yellowish plaques affecting the entire external labial mucosa &#40;A&#41;&#46; Bilateral and symmetrical whitish velvety plaques on the buccal&#44; internal labial&#44; and lateral lingual mucosae &#40;B&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A healthy 5-month-old boy&#44; with no relevant family history and an unremarkable pregnancy and delivery was evaluated due to the presence of whitish plaques located on the external and internal oral mucosa &#40;<a class="elsevierStyleCrossRef" href="#fig1">fig&#46; 1</a>&#41;&#44; which the parents reported as congenital&#46; He exhibited a white-yellowish plaque affecting the external labial mucosa&#44; and whitish&#44; velvety plaques that did not detach with friction were observed on the lateral lingual mucosa and buccal mucosa&#46; No other abnormalities were observed in the nails&#44; hair&#44; skin&#44; or mucous membranes&#46; He also did not present with stridor either&#46; Neither parent had similar lesions&#46; A laryngoscopy under sedation ruled out respiratory tract involvement&#46; A biopsy of the buccal lesions revealed the presence of an acanthotic mucosa with clear cytoplasm keratinocytes&#44; intracellular edema&#44; and isolated dyskeratotic cells &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46; No alterations were detected in the molecular study either&#46; For the genetic study&#44; the human exome was sequenced using Illumina DNA Prep with Exome v2&#46;0 PLUS Enrichment with a total coverage of 37&#46;5 Mb from a peripheral blood DNA sample&#46; The Geneyx analysis software was used for tertiary test based on the following HPO phenotypes&#58; nevus&#44; white sponge nevus&#44; and pachyonychia congenita&#46; Additionally&#44; the KRT13&#44; KRT4&#44; KRT6A&#44; and KRT6B genes were specifically reviewed&#46; Based on the clinical-histopathological findings and the absence of other associated signs&#44; a diagnosis of white sponge nevus &#40;WSN&#41; was established&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">WSN is a rare disease of autosomal dominant inheritance and variable penetrance and expressivity<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; Germline mutations in the keratin 4 and 13 genes have been isolated in patients with this condition&#46; Despite this&#44; Liu et al&#46; conducted a molecular study on peripheral blood in 5 patients with sporadic WSN&#44; and only 1 was found to have a mutation in 1 of these cytokeratins&#44; as opposed to the 3 patients with familial WSN analyzed&#44; all of whom had mutations in keratin 4 or cytokeratin 13<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3&#44;4</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The most common location is the buccal mucosa&#44; followed by other parts of the oral or labial mucosa&#46; However&#44; it can also damage the esophagus&#44; respiratory tract&#44; rectum&#44; or genitals&#46; Clinically&#44; it shows as thickened&#44; whitish&#44; bilateral&#44; and symmetrical plaques with a velvety surface that do not disappear with friction<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2&#44;5</span></a>&#46; Histopathologically&#44; it is characterized by the presence of acanthosis&#44; hyperparakeratosis&#44; vacuolization of keratinocytes in the suprabasal layers&#44; and ocasionally perinuclear eosinophilic deposits of cytokeratin tonofilaments&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Although WSN often develops in early childhood&#44; with a clinical diagnosis&#44; it can also be detected in adults&#44; for whom histopathological tests are advised to rule out the presence of any other possible etiologies<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a>&#46; In children&#44; candidiasis should be ruled out and differentiated from other entities such as pachyonychia congenita&#44; benign hereditary intraepithelial dyskeratosis&#44; and congenital dyskeratosis &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; If WSN is suspected in adulthood&#44; the differential diagnosis should include lichen planus&#44; squamous cell carcinoma&#44; linea alba&#44; frictional leukoplakia&#44; Darier disease&#44; lupus erythematosus&#44; or secondary syphilis<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Multiple treatments with variable effectiveness for WSN have been described&#44; such as topical or oral tetracyclines&#44; surgery&#44; CO<span class="elsevierStyleInf">2</span> laser&#44; beta-carotenes&#44; chlorhexidine rinses&#44; and others&#46; The therapeutic goal is primarily aesthetic since it is a benign and asymptomatic condition<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2&#44;3</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; a sporadic WSN with extensive involvement of the oral mucosa has been described&#46; Notably&#44; there was significant involvement of the external labial mucosa&#44; which is uncommon for this entity&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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                  \t\t\t\t">Associated with telomeric alterations&#46; Higher number of pathogenic mutations in the DKC1 gene&#44; followed by RTEL1 and TERT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Palmoplantar keratoderma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Whitish lesions on the bulbar conjunctiva and oral mucosa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Predominantly in males&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Laryngeal involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Conjunctival hyperemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reticulated hyperpigmentation &#40;possible hypopigmentation&#44; atrophy&#44; poikiloderma&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Subungual hyperkeratosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nail dystrophy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hyperhidrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Leukoplakia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Oral leukoplakia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Involvement of other organs&#58; bone marrow&#44; lungs&#44; liver&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Epidermal cysts or multiple steatocystomas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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Carta científico-clínica
Extensive White Sponge Nevus
Nevus blanco esponjoso extenso
A. Llull-Ramos
Autor para correspondencia
anallullramos@gmail.com

Corresponding author.
, I. Gracia-Darder, A. Martín-Santiago
Servicio de Dermatología, Hospital Universitario Son Espases, Palma, Islas Baleares, Spain
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Hyperkeratotic white-yellowish plaques affecting the entire external labial mucosa &#40;A&#41;&#46; Bilateral and symmetrical whitish velvety plaques on the buccal&#44; internal labial&#44; and lateral lingual mucosae &#40;B&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A healthy 5-month-old boy&#44; with no relevant family history and an unremarkable pregnancy and delivery was evaluated due to the presence of whitish plaques located on the external and internal oral mucosa &#40;<a class="elsevierStyleCrossRef" href="#fig1">fig&#46; 1</a>&#41;&#44; which the parents reported as congenital&#46; He exhibited a white-yellowish plaque affecting the external labial mucosa&#44; and whitish&#44; velvety plaques that did not detach with friction were observed on the lateral lingual mucosa and buccal mucosa&#46; No other abnormalities were observed in the nails&#44; hair&#44; skin&#44; or mucous membranes&#46; He also did not present with stridor either&#46; Neither parent had similar lesions&#46; A laryngoscopy under sedation ruled out respiratory tract involvement&#46; A biopsy of the buccal lesions revealed the presence of an acanthotic mucosa with clear cytoplasm keratinocytes&#44; intracellular edema&#44; and isolated dyskeratotic cells &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46; No alterations were detected in the molecular study either&#46; For the genetic study&#44; the human exome was sequenced using Illumina DNA Prep with Exome v2&#46;0 PLUS Enrichment with a total coverage of 37&#46;5 Mb from a peripheral blood DNA sample&#46; The Geneyx analysis software was used for tertiary test based on the following HPO phenotypes&#58; nevus&#44; white sponge nevus&#44; and pachyonychia congenita&#46; Additionally&#44; the KRT13&#44; KRT4&#44; KRT6A&#44; and KRT6B genes were specifically reviewed&#46; Based on the clinical-histopathological findings and the absence of other associated signs&#44; a diagnosis of white sponge nevus &#40;WSN&#41; was established&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">WSN is a rare disease of autosomal dominant inheritance and variable penetrance and expressivity<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;2</span></a>&#46; Germline mutations in the keratin 4 and 13 genes have been isolated in patients with this condition&#46; Despite this&#44; Liu et al&#46; conducted a molecular study on peripheral blood in 5 patients with sporadic WSN&#44; and only 1 was found to have a mutation in 1 of these cytokeratins&#44; as opposed to the 3 patients with familial WSN analyzed&#44; all of whom had mutations in keratin 4 or cytokeratin 13<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3&#44;4</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The most common location is the buccal mucosa&#44; followed by other parts of the oral or labial mucosa&#46; However&#44; it can also damage the esophagus&#44; respiratory tract&#44; rectum&#44; or genitals&#46; Clinically&#44; it shows as thickened&#44; whitish&#44; bilateral&#44; and symmetrical plaques with a velvety surface that do not disappear with friction<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2&#44;5</span></a>&#46; Histopathologically&#44; it is characterized by the presence of acanthosis&#44; hyperparakeratosis&#44; vacuolization of keratinocytes in the suprabasal layers&#44; and ocasionally perinuclear eosinophilic deposits of cytokeratin tonofilaments&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Although WSN often develops in early childhood&#44; with a clinical diagnosis&#44; it can also be detected in adults&#44; for whom histopathological tests are advised to rule out the presence of any other possible etiologies<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a>&#46; In children&#44; candidiasis should be ruled out and differentiated from other entities such as pachyonychia congenita&#44; benign hereditary intraepithelial dyskeratosis&#44; and congenital dyskeratosis &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; If WSN is suspected in adulthood&#44; the differential diagnosis should include lichen planus&#44; squamous cell carcinoma&#44; linea alba&#44; frictional leukoplakia&#44; Darier disease&#44; lupus erythematosus&#44; or secondary syphilis<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;2</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Multiple treatments with variable effectiveness for WSN have been described&#44; such as topical or oral tetracyclines&#44; surgery&#44; CO<span class="elsevierStyleInf">2</span> laser&#44; beta-carotenes&#44; chlorhexidine rinses&#44; and others&#46; The therapeutic goal is primarily aesthetic since it is a benign and asymptomatic condition<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2&#44;3</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; a sporadic WSN with extensive involvement of the oral mucosa has been described&#46; Notably&#44; there was significant involvement of the external labial mucosa&#44; which is uncommon for this entity&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pachyonychia congenita<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Benign hereditary intraepithelial dyskeratosis<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Congenital dyskeratosis<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Mutations in cytokeratins&#58;&#160;6A&#44; 6B&#44; 6C&#44; 16&#44; and 17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Corneal dystrophy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">Associated with telomeric alterations&#46; Higher number of pathogenic mutations in the DKC1 gene&#44; followed by RTEL1 and TERT&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Palmoplantar keratoderma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Whitish lesions on the bulbar conjunctiva and oral mucosa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">Predominantly in males&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Conjunctival hyperemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">Reticulated hyperpigmentation &#40;possible hypopigmentation&#44; atrophy&#44; poikiloderma&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Subungual hyperkeratosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Hyperhidrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">Involvement of other organs&#58; bone marrow&#44; lungs&#44; liver&nbsp;\t\t\t\t\t\t\n
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