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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Tinea capitis was thought to be found almost exclusively in children<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> and most commonly caused by <span class="elsevierStyleItalic">Microsporum audouinii</span> or <span class="elsevierStyleItalic">Microsporum canis&#46;</span><a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;7</span></a> In recent years&#44; however&#44; the epidemiological profile of the disease has changed in terms of both incidence and causative agents&#44; and its prevalence has increased in adult patients&#44; especially elderly women&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;7</span></a> In order to correctly diagnose and manage tinea capitis&#44; physicians need to be familiar with the clinical signs of the disease in elderly patients&#44; as well as the therapeutic responses seen in this age group&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present 4 cases of tinea capitis in elderly women with atypical clinical manifestations and pathogens &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; All 4 cases were diagnosed in the dermatology department of our hospital in the past 6 months&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Descriptions</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Description 1</span><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 71-year-old woman who presented with hair loss and pruritic lesions on her back and scalp&#46; The symptoms had first appeared 3 months earlier&#46; The patient had been diagnosed with eczema and had received treatment with topical corticosteroids for several months&#46; The pruritus had decreased slightly&#44; but the alopecia had progressively worsened&#46; The patient had not been in contact with animals&#46; Physical examination revealed a scaly&#44; erythematous annular plaque covering the neck and the upper third of the back&#46; A large alopecic plaque with abundant whitish desquamation was present on the scalp &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; and hair fell out easily with traction&#46; Skin-scale and hair samples were collected for direct microscopic examination using the potassium hydroxide technique&#44; which revealed hyphae&#44; and for culture&#44; which was positive for <span class="elsevierStyleItalic">Trichophyton tonsurans</span>&#46; Oral treatment with itraconazole &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; resulted in marked improvement in the lesions at 1 month&#46; After that&#44; however&#44; improvement slowed&#44; despite the fact that the patient reported taking the drugs correctly&#46; Clinical symptoms persisted and cultures were still positive 7 months after the start of treatment&#46; The treatment was therefore changed to oral terbinafine &#40;250<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#44; which resulted in complete resolution within 1 month&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Description 2</span><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was a 65-year-old woman who presented with slightly pruritic scalp lesions that had appeared 3 months earlier&#46; During the preceding 3 months&#44; she had received treatment with topical corticosteroids&#44; antibiotics&#44; and ciclopirox olamine shampoo&#44; but her condition had not improved&#46; The patient had not been in contact with animals or with people who had similar lesions&#46; Physical examination revealed an erythematous&#44; partially alopecic plaque on the cranial vertex characterized by superficial crusts and pustules &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Histopathologic examination of the biopsy specimen revealed clear evidence of folliculitis and a granulomatous foreign-body reaction&#46; The bacterial culture was negative and <span class="elsevierStyleItalic">Trichophyton rubrum</span> colonies were isolated in the fungal culture&#46; Oral treatment with itraconazole &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; was initiated and the clinical and microbiologic symptoms resolved completely after 6 weeks&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Description 3</span><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was a 69-year-old woman who presented with a crusted tumoral growth on her scalp that had appeared 6 weeks earlier&#46; She had received no prior topical or systemic treatment&#46; Physical examination revealed a crusted lesion on the back of the head&#46; The crust concealed fleshy exophytic granulation tissue&#46; Fungal culture was positive for <span class="elsevierStyleItalic">T tonsurans</span>&#46; Eight weeks after oral treatment with terbinafine &#40;250<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; was initiated&#44; there was still some evidence of scarring alopecia but no signs of inflammation&#44; desquamation&#44; or traction hair loss&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Description 4</span><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was a 72-year-old woman who presented with a 3-week history of 2 crusted&#44; inflammatory lesions on her scalp&#46; She had completed a 3-day treatment with topical corticosteroids and oral cloxacillin&#46; The perilesional erythema had resolved but the rest of the lesion had not improved&#46; The patient had no fever or other symptoms&#46; Physical examination revealed one crusted lesion on the left parietal-temporal region of the scalp &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; and another on the forehead&#46; The crust was removed from the lesion on the forehead&#44; revealing an eroded surface with suppuration at various points&#46; Regional lymph nodes were enlarged and palpable&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Although an initial biopsy showed nonspecific changes&#44; a second histologic study revealed the presence of mixed dermal infiltration with numerous eosinophils&#44; as well as spores and filaments inside the follicles&#46; These findings&#44; together with positive culture results&#44; allowed us to establish a diagnosis of <span class="elsevierStyleItalic">Trichophyton mentagrophytes</span> infection&#46; Oral treatment with itraconazole &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; was initiated&#46; The symptoms improved slowly&#44; resolving completely within 35 days of the start of treatment&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">This case series shows that scalp ringworm in elderly patients is relatively common and often presents with atypical clinical characteristics&#46; Low clinical suspicion can lead to inappropriate empiric treatments that delay diagnosis and complicate the therapeutic response&#46;Tinea capitis is usually seen in children between the ages of 3 and 7&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Although the disease was once thought to be rare in adulthood&#44; a growing number of authors have reported an increase in tinea capitis among adults&#44; particularly menopausal and elderly women&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Factors that may favor the development of the disease at this age include hormonal changes&#44; the use of certain hair-care products&#44; and using the services of hair salons&#44; which can be a source of infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In most of the cases that have been reported&#44; including our own case series&#44; diagnosis was delayed&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This delay is probably due to both the rarity of this infection in adults and its atypical clinical manifestations&#44; which can be confused with inflammatory processes such as seborrheic dermatitis or psoriasis&#46; Atypical manifestations seem to be more common in patients infected with <span class="elsevierStyleItalic">T tonsurans</span> &#40;as in 2 of our cases&#41;&#44; who often present either diffuse desquamation with mild alopecia and lesions suggestive of seborrheic dermatitis or pustular inflammatory lesions and associated regional lymphadenopathy&#44; a clinical picture that can lead to an incorrect diagnosis of bacterial infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5&#44;8&#44;9</span></a> Although <span class="elsevierStyleItalic">M canis</span> remains the most common causative agent of tinea capitis in southern Europe&#44; with a prevalence greater than 80&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> the epidemiology of these infections has changed considerably in recent years&#46; A growing number of cases have been attributed to the following species&#58; <span class="elsevierStyleItalic">T mentagrophytes</span>&#44; <span class="elsevierStyleItalic">Trichophyton verrucosum</span>&#44; <span class="elsevierStyleItalic">T tonsurans</span>&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;10&#44;11</span></a> and <span class="elsevierStyleItalic">T rubrum&#46;</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Specifically in Barcelona&#44; <span class="elsevierStyleItalic">T mentagrophytes</span><a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> has been highly prevalent&#44; whereas <span class="elsevierStyleItalic">T tonsurans</span> is the species most frequently isolated in the United States&#44; the United Kingdom&#44; and Canada&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;13&#44;14</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">These changes are attributable to many factors&#44; in particular the rise of travel to endemic areas and the migratory flows from the Southern to the Northern hemisphere&#46; In addition to facilitating contagion&#44; migration has also helped to spread species endemic to Africa and Asia&#8211;generally anthropophilic fungi&#8211;to urban areas in Europe&#44; especially neighborhoods where immigrants make up a high percentage of the population&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11&#44;14</span></a> In keeping with what seems to be the current trend for this disease&#44; the species found in our 4 patients&#8211;all city dwellers&#8211;were anthropophilic&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">It should be noted that fungal culture was essential to either confirming the clinical suspicion or redirecting the diagnosis in all 4 cases&#46; Fungal culture should therefore be used routinely in cases of desquamative conditions of the scalp that involve pruritus or an inflammatory appearance&#44; especially in elderly patients whose symptoms do not respond satisfactorily to the prescribed treatment&#46; It should also be emphasized that patients with fungal infections of the skin are often referred to a specialist&#8211;as 3 of the patients in this series were&#8211;after receiving treatment with topical corticosteroids&#44; which mask the clinical presentation and further modify the patient&#39;s response&#44; or with azole shampoos&#44; which do not resolve the process but can affect the sensitivity of diagnostic tests&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The diversity of the treatments prescribed in this series can be explained by the preferences of the various physicians caring for the different patients&#46; Although griseofulvin remains&#44; for some authors&#44; the treatment of choice for scalp ringworm in children and adults&#44; both terbinafine and itraconazole are considered acceptable alternatives &#40;the latter in particular for cases caused by fungi of the genus <span class="elsevierStyleItalic">Trichophyton</span>&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">It should be noted that the disease&#39;s apparent resistance to itraconazole&#8211;a drug considered effective against tinea capitis&#8211;in the case of the first patient may be associated with failure to follow the prescribed regimen strictly&#46; Moreover&#44; in most of the cases in the literature reporting a good response&#44; the dose recommended is 200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; although some authors recommend a dose of 5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#46; The recommended dose in the first patient in this series would therefore be between 300 and 400<span class="elsevierStyleHsp" style=""></span>mg&#47;day as the patient weighed approximately 65<span class="elsevierStyleHsp" style=""></span>kg&#46; No resistance to itraconazole has been reported in cases of scalp ringworm caused by <span class="elsevierStyleItalic">T tonsurans</span>&#46; Itraconazole resistance has been reported&#44; however&#44; in cases caused by <span class="elsevierStyleItalic">T mentagrophytes</span> &#40;in Latin America&#41;&#44; and cases caused by <span class="elsevierStyleItalic">T tonsurans</span> have shown resistance to fluconazole&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;18</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In conclusion&#44; the differential diagnosis of any scaly and&#47;or inflammatory skin condition in elderly patients&#44; including those with alopecia&#44; should include tinea capitis&#44; and fungal cultures should be performed routinely in cases of suboptimal response to anti-inflammatory treatments&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare&#46;</p></span></span>"
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          "titulo" => "Case Descriptions"
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              "titulo" => "Case Description 2"
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              "titulo" => "Case Description 3"
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              "identificador" => "sec0030"
              "titulo" => "Case Description 4"
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        6 => array:2 [
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        7 => array:2 [
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            0 => "Tinea capitis"
            1 => "Aged"
            2 => "Culture"
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          "palabras" => array:3 [
            0 => "<span class="elsevierStyleItalic">Tinea capitis</span>"
            1 => "Edad avanzada"
            2 => "Cultivo"
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Tinea capitis is a condition usually found only in children&#46; However&#44; its epidemiological profile has changed in recent decades&#44; with regard to age at onset and the causative microorganisms&#46; We report the cases of 4 women over 65 years of age diagnosed with tinea capitis&#46; One presented plaques of alopecia with desquamation and the other 3 developed crusted inflammatory lesions&#46; Cultures were positive for <span class="elsevierStyleItalic">Trichophyton tonsurans</span> &#40;2 patients&#41;&#44; <span class="elsevierStyleItalic">Trichophyton rubrum</span>&#44; and <span class="elsevierStyleItalic">Trichophyton mentagrophytes</span>&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The relative rarity of tinea capitis in the elderly and the frequently atypical presentation in this age group can delay diagnosis&#44; leading to irreversible sequelae and increasing the risk of contagion&#46; Fungal culture should be included in the study of persistent&#44; atypical dermatoses of the scalp&#44; particularly in the elderly&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La <span class="elsevierStyleItalic">tinea capitis</span> se ha considerado cl&#225;sicamente como un proceso casi exclusivo de la infancia&#46; Sin embargo&#44; en las &#250;ltimas d&#233;cadas se han observado algunos cambios en su perfil epidemiol&#243;gico&#44; tanto en lo que concierne a las edades de presentaci&#243;n como a los agentes responsables&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se describen los casos de 4 mujeres mayores de 65 a&#241;os diagnosticadas de <span class="elsevierStyleItalic">tinea capitis</span>&#46; Una de ellas presentaba placas alop&#233;cicas con descamaci&#243;n&#44; mientras que en las otras tres las lesiones eran inflamatorias y costrosas&#46; Los cultivos fueron positivos para <span class="elsevierStyleItalic">Trichophyton tonsurans</span> &#40;2 pacientes&#41;&#44; <span class="elsevierStyleItalic">Trichophyton rubrum</span> y <span class="elsevierStyleItalic">Trichophyton mentagrophytes</span>&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La relativa infrecuencia de la <span class="elsevierStyleItalic">tinea capitis</span> en la edad avanzada y&#44; por otra parte&#44; su frecuente atipicidad cl&#237;nica condicionan un diagn&#243;stico tard&#237;o&#44; circunstancia que puede condicionar secuelas irreversibles e incrementa la posibilidad de contagios&#46; El cultivo f&#250;ngico deber&#237;a incorporarse en el estudio de las dermatosis del cuero cabelludo de curso at&#237;pico y persistente&#44; especialmente en individuos de edad avanzada&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Morell L&#44; et al&#46; <span class="elsevierStyleItalic">Tinea capitis</span> en mujeres de edad avanzada&#58; descripci&#243;n de 4 caso&#46; Actas Dermosifiliogr&#46;2012&#59;103&#58;144-148&#46;</p>"
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        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Case 1&#46; Alopecic plaque with desquamation 3 months after onset&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Case 2&#46; Erythematous&#44; alopecic plaque with crusts and pustules on the cranial vertex&#46; Fungal culture was positive for <span class="elsevierStyleItalic">Trichophyton rubrum</span>&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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            "Tamanyo" => 200649
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Case 4&#46; Inflammatory&#44; crusted plaque on the patient&#39;s scalp&#46; Fungal culture was positive for <span class="elsevierStyleItalic">Trichophyton mentagrophytes</span>&#46;</p>"
        ]
      ]
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        "etiqueta" => "Table 1"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">DM&#58; diabetes mellitus&#59; HT&#58; hypertension&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Case No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">History&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Site&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Prior Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Delay in Diagnosis&#44; mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Culture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Clinical Findings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Clinical Course&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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"><span class="elsevierStyleBold">1</span>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&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">None of interest&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">Back&#44; neck&#44; and scalp&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">Eczema&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&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"><span class="elsevierStyleItalic">Trichophyton tonsurans</span>&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">Annular plaque&#44; desquamation&#44; and alopecia&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">Itraconazole &#40;3 months&#41;&#44; terbinafine &#40;1 month&#41;&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">Complete remission &#40;16 weeks&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleBold">2</span>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&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">DM&#44; HT&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">Scalp&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">Eczema&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&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"><span class="elsevierStyleItalic">Trichophyton rubrum</span>&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">Erythematous plaque with alopecia on the cranial vertex with pustules and crusts&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">Itraconazole&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">Complete remission &#40;6 weeks&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleBold">3</span>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&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">None of interest&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">Scalp&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">None&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;5&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"><span class="elsevierStyleItalic">Trichophyton tonsurans</span>&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">Hyperkeratotic alopecic tumoral growth on the back of the head&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">Terbinafine&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">Complete remission &#40;8 weeks&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleBold">4</span>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72&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">None of interest&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">Scalp&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">Bacterial infection&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&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"><span class="elsevierStyleItalic">Trichophyton mentagrophytes</span>&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">Hyperkeratotic plaque with suppuration&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">Itraconazole&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">Remission &#40;5 weeks&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Summary of the 4 clinical cases&#46;</p>"
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Case Report
Tinea Capitis in Elderly Women: A Report of 4 Cases
Tinea capitis en mujeres de edad avanzada: descripción de 4 casos
L. Morell
Autor para correspondencia
laiamorell@hotmail.com

Corresponding author.
, M.J. Fuente, A. Boada, J.M. Carrascosa, C. Ferrándiz
Servicio de Dermatología, Hospital Universitari Germans Trias i Pujol, Badalona, (Barcelona), Spain
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        "titulo" => "<span class="elsevierStyleItalic">Tinea capitis</span> en mujeres de edad avanzada&#58; descripci&#243;n de 4 casos"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Case 4&#46; Inflammatory&#44; crusted plaque on the patient&#39;s scalp&#46; Fungal culture was positive for <span class="elsevierStyleItalic">Trichophyton mentagrophytes</span>&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Tinea capitis was thought to be found almost exclusively in children<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> and most commonly caused by <span class="elsevierStyleItalic">Microsporum audouinii</span> or <span class="elsevierStyleItalic">Microsporum canis&#46;</span><a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;7</span></a> In recent years&#44; however&#44; the epidemiological profile of the disease has changed in terms of both incidence and causative agents&#44; and its prevalence has increased in adult patients&#44; especially elderly women&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;7</span></a> In order to correctly diagnose and manage tinea capitis&#44; physicians need to be familiar with the clinical signs of the disease in elderly patients&#44; as well as the therapeutic responses seen in this age group&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present 4 cases of tinea capitis in elderly women with atypical clinical manifestations and pathogens &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; All 4 cases were diagnosed in the dermatology department of our hospital in the past 6 months&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Descriptions</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Description 1</span><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 71-year-old woman who presented with hair loss and pruritic lesions on her back and scalp&#46; The symptoms had first appeared 3 months earlier&#46; The patient had been diagnosed with eczema and had received treatment with topical corticosteroids for several months&#46; The pruritus had decreased slightly&#44; but the alopecia had progressively worsened&#46; The patient had not been in contact with animals&#46; Physical examination revealed a scaly&#44; erythematous annular plaque covering the neck and the upper third of the back&#46; A large alopecic plaque with abundant whitish desquamation was present on the scalp &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; and hair fell out easily with traction&#46; Skin-scale and hair samples were collected for direct microscopic examination using the potassium hydroxide technique&#44; which revealed hyphae&#44; and for culture&#44; which was positive for <span class="elsevierStyleItalic">Trichophyton tonsurans</span>&#46; Oral treatment with itraconazole &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; resulted in marked improvement in the lesions at 1 month&#46; After that&#44; however&#44; improvement slowed&#44; despite the fact that the patient reported taking the drugs correctly&#46; Clinical symptoms persisted and cultures were still positive 7 months after the start of treatment&#46; The treatment was therefore changed to oral terbinafine &#40;250<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#44; which resulted in complete resolution within 1 month&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Description 2</span><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was a 65-year-old woman who presented with slightly pruritic scalp lesions that had appeared 3 months earlier&#46; During the preceding 3 months&#44; she had received treatment with topical corticosteroids&#44; antibiotics&#44; and ciclopirox olamine shampoo&#44; but her condition had not improved&#46; The patient had not been in contact with animals or with people who had similar lesions&#46; Physical examination revealed an erythematous&#44; partially alopecic plaque on the cranial vertex characterized by superficial crusts and pustules &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Histopathologic examination of the biopsy specimen revealed clear evidence of folliculitis and a granulomatous foreign-body reaction&#46; The bacterial culture was negative and <span class="elsevierStyleItalic">Trichophyton rubrum</span> colonies were isolated in the fungal culture&#46; Oral treatment with itraconazole &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; was initiated and the clinical and microbiologic symptoms resolved completely after 6 weeks&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Description 3</span><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was a 69-year-old woman who presented with a crusted tumoral growth on her scalp that had appeared 6 weeks earlier&#46; She had received no prior topical or systemic treatment&#46; Physical examination revealed a crusted lesion on the back of the head&#46; The crust concealed fleshy exophytic granulation tissue&#46; Fungal culture was positive for <span class="elsevierStyleItalic">T tonsurans</span>&#46; Eight weeks after oral treatment with terbinafine &#40;250<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; was initiated&#44; there was still some evidence of scarring alopecia but no signs of inflammation&#44; desquamation&#44; or traction hair loss&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Description 4</span><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was a 72-year-old woman who presented with a 3-week history of 2 crusted&#44; inflammatory lesions on her scalp&#46; She had completed a 3-day treatment with topical corticosteroids and oral cloxacillin&#46; The perilesional erythema had resolved but the rest of the lesion had not improved&#46; The patient had no fever or other symptoms&#46; Physical examination revealed one crusted lesion on the left parietal-temporal region of the scalp &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; and another on the forehead&#46; The crust was removed from the lesion on the forehead&#44; revealing an eroded surface with suppuration at various points&#46; Regional lymph nodes were enlarged and palpable&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Although an initial biopsy showed nonspecific changes&#44; a second histologic study revealed the presence of mixed dermal infiltration with numerous eosinophils&#44; as well as spores and filaments inside the follicles&#46; These findings&#44; together with positive culture results&#44; allowed us to establish a diagnosis of <span class="elsevierStyleItalic">Trichophyton mentagrophytes</span> infection&#46; Oral treatment with itraconazole &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41; was initiated&#46; The symptoms improved slowly&#44; resolving completely within 35 days of the start of treatment&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">This case series shows that scalp ringworm in elderly patients is relatively common and often presents with atypical clinical characteristics&#46; Low clinical suspicion can lead to inappropriate empiric treatments that delay diagnosis and complicate the therapeutic response&#46;Tinea capitis is usually seen in children between the ages of 3 and 7&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Although the disease was once thought to be rare in adulthood&#44; a growing number of authors have reported an increase in tinea capitis among adults&#44; particularly menopausal and elderly women&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Factors that may favor the development of the disease at this age include hormonal changes&#44; the use of certain hair-care products&#44; and using the services of hair salons&#44; which can be a source of infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In most of the cases that have been reported&#44; including our own case series&#44; diagnosis was delayed&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This delay is probably due to both the rarity of this infection in adults and its atypical clinical manifestations&#44; which can be confused with inflammatory processes such as seborrheic dermatitis or psoriasis&#46; Atypical manifestations seem to be more common in patients infected with <span class="elsevierStyleItalic">T tonsurans</span> &#40;as in 2 of our cases&#41;&#44; who often present either diffuse desquamation with mild alopecia and lesions suggestive of seborrheic dermatitis or pustular inflammatory lesions and associated regional lymphadenopathy&#44; a clinical picture that can lead to an incorrect diagnosis of bacterial infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5&#44;8&#44;9</span></a> Although <span class="elsevierStyleItalic">M canis</span> remains the most common causative agent of tinea capitis in southern Europe&#44; with a prevalence greater than 80&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> the epidemiology of these infections has changed considerably in recent years&#46; A growing number of cases have been attributed to the following species&#58; <span class="elsevierStyleItalic">T mentagrophytes</span>&#44; <span class="elsevierStyleItalic">Trichophyton verrucosum</span>&#44; <span class="elsevierStyleItalic">T tonsurans</span>&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;10&#44;11</span></a> and <span class="elsevierStyleItalic">T rubrum&#46;</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Specifically in Barcelona&#44; <span class="elsevierStyleItalic">T mentagrophytes</span><a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> has been highly prevalent&#44; whereas <span class="elsevierStyleItalic">T tonsurans</span> is the species most frequently isolated in the United States&#44; the United Kingdom&#44; and Canada&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;13&#44;14</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">These changes are attributable to many factors&#44; in particular the rise of travel to endemic areas and the migratory flows from the Southern to the Northern hemisphere&#46; In addition to facilitating contagion&#44; migration has also helped to spread species endemic to Africa and Asia&#8211;generally anthropophilic fungi&#8211;to urban areas in Europe&#44; especially neighborhoods where immigrants make up a high percentage of the population&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11&#44;14</span></a> In keeping with what seems to be the current trend for this disease&#44; the species found in our 4 patients&#8211;all city dwellers&#8211;were anthropophilic&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">It should be noted that fungal culture was essential to either confirming the clinical suspicion or redirecting the diagnosis in all 4 cases&#46; Fungal culture should therefore be used routinely in cases of desquamative conditions of the scalp that involve pruritus or an inflammatory appearance&#44; especially in elderly patients whose symptoms do not respond satisfactorily to the prescribed treatment&#46; It should also be emphasized that patients with fungal infections of the skin are often referred to a specialist&#8211;as 3 of the patients in this series were&#8211;after receiving treatment with topical corticosteroids&#44; which mask the clinical presentation and further modify the patient&#39;s response&#44; or with azole shampoos&#44; which do not resolve the process but can affect the sensitivity of diagnostic tests&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The diversity of the treatments prescribed in this series can be explained by the preferences of the various physicians caring for the different patients&#46; Although griseofulvin remains&#44; for some authors&#44; the treatment of choice for scalp ringworm in children and adults&#44; both terbinafine and itraconazole are considered acceptable alternatives &#40;the latter in particular for cases caused by fungi of the genus <span class="elsevierStyleItalic">Trichophyton</span>&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">It should be noted that the disease&#39;s apparent resistance to itraconazole&#8211;a drug considered effective against tinea capitis&#8211;in the case of the first patient may be associated with failure to follow the prescribed regimen strictly&#46; Moreover&#44; in most of the cases in the literature reporting a good response&#44; the dose recommended is 200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; although some authors recommend a dose of 5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#46; The recommended dose in the first patient in this series would therefore be between 300 and 400<span class="elsevierStyleHsp" style=""></span>mg&#47;day as the patient weighed approximately 65<span class="elsevierStyleHsp" style=""></span>kg&#46; No resistance to itraconazole has been reported in cases of scalp ringworm caused by <span class="elsevierStyleItalic">T tonsurans</span>&#46; Itraconazole resistance has been reported&#44; however&#44; in cases caused by <span class="elsevierStyleItalic">T mentagrophytes</span> &#40;in Latin America&#41;&#44; and cases caused by <span class="elsevierStyleItalic">T tonsurans</span> have shown resistance to fluconazole&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;18</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In conclusion&#44; the differential diagnosis of any scaly and&#47;or inflammatory skin condition in elderly patients&#44; including those with alopecia&#44; should include tinea capitis&#44; and fungal cultures should be performed routinely in cases of suboptimal response to anti-inflammatory treatments&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare&#46;</p></span></span>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Tinea capitis is a condition usually found only in children&#46; However&#44; its epidemiological profile has changed in recent decades&#44; with regard to age at onset and the causative microorganisms&#46; We report the cases of 4 women over 65 years of age diagnosed with tinea capitis&#46; One presented plaques of alopecia with desquamation and the other 3 developed crusted inflammatory lesions&#46; Cultures were positive for <span class="elsevierStyleItalic">Trichophyton tonsurans</span> &#40;2 patients&#41;&#44; <span class="elsevierStyleItalic">Trichophyton rubrum</span>&#44; and <span class="elsevierStyleItalic">Trichophyton mentagrophytes</span>&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The relative rarity of tinea capitis in the elderly and the frequently atypical presentation in this age group can delay diagnosis&#44; leading to irreversible sequelae and increasing the risk of contagion&#46; Fungal culture should be included in the study of persistent&#44; atypical dermatoses of the scalp&#44; particularly in the elderly&#46;</p>"
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        "resumen" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La <span class="elsevierStyleItalic">tinea capitis</span> se ha considerado cl&#225;sicamente como un proceso casi exclusivo de la infancia&#46; Sin embargo&#44; en las &#250;ltimas d&#233;cadas se han observado algunos cambios en su perfil epidemiol&#243;gico&#44; tanto en lo que concierne a las edades de presentaci&#243;n como a los agentes responsables&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se describen los casos de 4 mujeres mayores de 65 a&#241;os diagnosticadas de <span class="elsevierStyleItalic">tinea capitis</span>&#46; Una de ellas presentaba placas alop&#233;cicas con descamaci&#243;n&#44; mientras que en las otras tres las lesiones eran inflamatorias y costrosas&#46; Los cultivos fueron positivos para <span class="elsevierStyleItalic">Trichophyton tonsurans</span> &#40;2 pacientes&#41;&#44; <span class="elsevierStyleItalic">Trichophyton rubrum</span> y <span class="elsevierStyleItalic">Trichophyton mentagrophytes</span>&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La relativa infrecuencia de la <span class="elsevierStyleItalic">tinea capitis</span> en la edad avanzada y&#44; por otra parte&#44; su frecuente atipicidad cl&#237;nica condicionan un diagn&#243;stico tard&#237;o&#44; circunstancia que puede condicionar secuelas irreversibles e incrementa la posibilidad de contagios&#46; El cultivo f&#250;ngico deber&#237;a incorporarse en el estudio de las dermatosis del cuero cabelludo de curso at&#237;pico y persistente&#44; especialmente en individuos de edad avanzada&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Morell L&#44; et al&#46; <span class="elsevierStyleItalic">Tinea capitis</span> en mujeres de edad avanzada&#58; descripci&#243;n de 4 caso&#46; Actas Dermosifiliogr&#46;2012&#59;103&#58;144-148&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Case 1&#46; Alopecic plaque with desquamation 3 months after onset&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Case 2&#46; Erythematous&#44; alopecic plaque with crusts and pustules on the cranial vertex&#46; Fungal culture was positive for <span class="elsevierStyleItalic">Trichophyton rubrum</span>&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Case 4&#46; Inflammatory&#44; crusted plaque on the patient&#39;s scalp&#46; Fungal culture was positive for <span class="elsevierStyleItalic">Trichophyton mentagrophytes</span>&#46;</p>"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Delay in Diagnosis&#44; mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Culture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Clinical Findings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Clinical Course&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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"><span class="elsevierStyleBold">1</span>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&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">None of interest&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">Back&#44; neck&#44; and scalp&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">Eczema&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&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"><span class="elsevierStyleItalic">Trichophyton tonsurans</span>&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">Annular plaque&#44; desquamation&#44; and alopecia&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">Itraconazole &#40;3 months&#41;&#44; terbinafine &#40;1 month&#41;&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">Complete remission &#40;16 weeks&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleBold">2</span>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&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">DM&#44; HT&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">Scalp&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">Eczema&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&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"><span class="elsevierStyleItalic">Trichophyton rubrum</span>&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">Erythematous plaque with alopecia on the cranial vertex with pustules and crusts&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">Itraconazole&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">Complete remission &#40;6 weeks&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleBold">3</span>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&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">None of interest&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">Scalp&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">None&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;5&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"><span class="elsevierStyleItalic">Trichophyton tonsurans</span>&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">Hyperkeratotic alopecic tumoral growth on the back of the head&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">Terbinafine&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">Complete remission &#40;8 weeks&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><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"><span class="elsevierStyleBold">4</span>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72&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">None of interest&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">Scalp&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">Bacterial infection&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&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"><span class="elsevierStyleItalic">Trichophyton mentagrophytes</span>&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">Hyperkeratotic plaque with suppuration&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">Itraconazole&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">Remission &#40;5 weeks&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Summary of the 4 clinical cases&#46;</p>"
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      "titulo" => "References"
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        0 => array:2 [
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                            0 => "E&#46;M&#46; Higgins"
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                          "etal" => false
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                            0 => "B&#46; Havlickova"
                            1 => "V&#46;A&#46; Czaika"
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                          "etal" => false
                          "autores" => array:3 [
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                            2 => "R&#46; Arenas"
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                      ]
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                  ]
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                          "etal" => false
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