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syndrome essentially comprise fibrofolliculomas and&#47;or trichodiscomas that usually appear in individuals in their 20s or 30s&#46; Trichofolliculomas&#44; trichodiscomas&#44; and acrochordons&#8212;traditionally considered as the characteristic triad of Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#8212;appear to belong to the histopathologic and clinical spectrum of fibrofolliculoma&#46; Clinically&#44; these lesions are practically indistinguishable from one another and present as multiple whitish papules&#44; with a dome-shaped appearance&#44; a few millimeters in diameter&#44; located mainly on the nose&#44; forehead&#44; and cheeks&#44; although they can also appear on the neck and trunk &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Histologically&#44; fibrofolliculoma is typically vertical or perpendicular to the epidermis&#44; as it forms around a hair follicle&#46; It is characterized by the presence of long&#44; thin&#44; mantle-like epithelial cords&#44; which sometimes terminate in mature sebaceous glands&#44; with surrounding fibrovascular stroma containing a variable myxoid component &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Unlike fibrofolliculomas&#44; trichodiscomas are oriented horizontally&#44; that is&#44; parallel to the epidermis&#44; and are composed exclusively of stroma identical to that of fibrofolliculomas&#44; surrounded at the base by hair follicle units &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Trichodiscoma is considered a late form of fibrofolliculoma&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In addition to these characteristic lesions&#44; the presence of facial angiofibromas has occasionally been reported&#44; as has the involvement of oral mucosa in the form of multiple papules on the lips and buccal and gingival mucosa&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The fibrofolliculomas and trichodiscomas found in Birt&#8211;Hogg&#8211;Dub&#233; syndrome have features in common with the angiofibromas that occur in tuberous sclerosis complex&#46; Histologically&#44; the presence of a stroma with thicker collagen bundles&#44; along with stellate fibroblasts&#44; as well as the absence of the epithelial component&#44; are useful features for differentiating angiofibromas from fibrofolliculomas&#46; Analysis of immunoreactivity for CK15&#44; CD34&#44; and factor XIIIa is not very useful as it may occur in both types of lesion&#46; In Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#44; a mutation in the folliculin gene &#40;<span class="elsevierStyleItalic">FCLN</span>&#41; is associated with the development of multiple fibrofolliculomas and trichodiscomas&#44; whereas mutations in <span class="elsevierStyleItalic">TS1</span> and <span class="elsevierStyleItalic">TS2</span> are linked to the appearance of angiofibromas in the tuberous sclerosis complex&#46; Recent work has shown that both proteins could form part of the same mammalian target of rapamycin &#40;mTOR&#41; pathway&#44; responsible for the development of the characteristic skin lesions in both syndromes&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In fact&#44; the presence of fibrofolliculomas in patients with tuberous sclerosis or of angiofibromas in patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome has been very occasionally reported&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In addition&#44; patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome and those with tuberous sclerosis can present with lung and renal disease&#46; These similarities in clinical manifestations&#44; and the common histologic features in skin lesions&#44; are further evidence that genetic abnormalities arise in a common pathway&#46; In fact&#44; the results of a study conducted in <span class="elsevierStyleItalic">Schizosaccharomyces pombe</span>&#44; a unicellular eukaryotic yeast&#44; suggest that the genes responsible for Birt&#8211;Hogg&#8211;Dub&#233; syndrome and tuberous sclerosis both act via the mTOR pathway and lead to renal cell carcinoma&#44; skin cancer&#44; and pulmonary symptoms through mechanisms involving inappropriate inhibition in Birt&#8211;Hogg&#8211;Dub&#233; syndrome and activation in tuberous sclerosis&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Extracutaneous Manifestations</span><p id="par0020" class="elsevierStylePara elsevierViewall">In addition to skin lesions&#44; patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome may present a series of extracutaneous lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In recent years&#44; it has been shown that these patients are at a greater risk of developing renal cancer and spontaneous pneumothorax&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;11</span></a> In 1993&#44; Roth et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> described the first case of renal cancer in a patient with Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#46; Toro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> subsequently described Birt&#8211;Hogg&#8211;Dub&#233; syndrome as a marker of renal cancer&#46; Further studies providing confirmation have since been published&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;11&#8211;14</span></a> It was reported that patients with Birt&#8211;Hogg&#8211;Dub&#233; had a 7-fold higher risk of renal cancer&#44; with a predilection for men and an age of onset between 20 and 55 years&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Seven different autosomal dominant syndromes have been identified as having an association with renal cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> However&#44; unlike the other syndromes&#44; the presentation of renal lesions can be bilateral and multifocal in the case of Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#44; with 5 different histologic types&#58; oncocytic&#8211;chromophobe hybrid carcinoma &#40;50&#37;&#41;&#44; purely chromophobe carcinomas &#40;34&#37;&#41;&#44; purely oncocytic carcinomas &#40;5&#37;&#41;&#44; clear cell carcinomas &#40;3&#37;&#41;&#44; and papillary carcinomas &#40;2&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;14</span></a> The prevalence of renal tumors in patients with germline mutations in the <span class="elsevierStyleItalic">FLCN</span> gene varies from 6&#46;5&#37; to 34&#37; according to different studies&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> With regard to the risk of metastasis&#44; to date&#44; only 5 cases of distant metastases of renal cancer have been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Clinicopathologic studies showed that the renal tumors of these patients were of clear-cell&#44; tubulopapillary&#44; or papillary subtypes&#44; which account for a minority of subtypes in Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Up to 80&#37; of patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome have lung cysts&#44; which may be asymptomatic for years&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;11&#44;14&#8211;16</span></a> The number and size of the lesions varies from patient to patient&#44; ranging from small cysts to bullae measuring several centimeters across&#44; located mainly in the lung bases and at the subpleural level<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; A relationship between size and volume of the cysts and the risk of pneumothorax has been reported&#8212;the larger the volume the greater the risk&#46; The mean age of presentation is 38 years&#44; with no clear predilection for either sex&#46; Some studies suggest that male sex is a risk factor for spontaneous pneumothorax&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> whereas others report no such risk&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Among patients who present lung cysts&#44; approximately 20&#8211;30&#37; have a history of pneumothorax&#44; with a mean of 2 prior episodes&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In addition&#44; when patients with a history of pneumothorax are studied&#44; the vast majority have multiple cysts&#46; The right lung is more frequently affected&#44; although both lungs can be involved in up to 23&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#44; the risk of pneumothorax is 50 times greater than in the normal population&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The most frequent mutation in patients with a history of pneumothorax or lung lesions and Birt&#8211;Hogg&#8211;Dub&#233; syndrome is c&#46;1733ins&#47;delC located in exon 119&#46; Patients with certain mutations are at risk of developing larger and more numerous cystic lesions&#46; Thus&#44; the mutation in exon 9 confers a risk of developing a greater number of cysts&#44; whereas mutations in exon 9 and 12 are associated with larger cysts&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The pathophysiology of lung cysts is unknown but it may be that haploinsufficiency is enough to induce the development of these lesions&#44; as is the case in skin tumors&#46; In addition to the characteristic associations described above&#44; in patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#44; there have been reports of adenomas and colorectal polyps&#44; parotid oncocytomas&#44; parathyroid oncocytomas&#44; neural tumors&#44; trichoblastomas&#44; lipomas&#44; angiolipomas&#44; connective tissue abnormalities&#44; chorioretinopathy&#44; and nonrenal malignant neoplasms such as breast cancer&#44; colorectal cancer&#44; tonsil cancer&#44; and lung cancer&#44; and also skin cancers such as melanoma&#44; basal cell carcinoma&#44; squamous cell carcinoma&#44; dermatofibrosarcoma&#44; and leiomyosarcoma&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Despite these reports&#44; a significant association between Birt&#8211;Hogg&#8211;Dub&#233; syndrome and these neoplasms has not yet been demonstrated&#44; and further studies are needed&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Some authors maintain that carriers of the c&#46;1285dupC mutation have a greater risk of colon cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Genetic Basis</span><p id="par0030" class="elsevierStylePara elsevierViewall">In 2002&#44; the <span class="elsevierStyleItalic">FLCN</span> gene was identified as being associated with Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> This gene&#44; located on chromosome 17p11&#46;2 and comprising 14 exons&#44; encodes a 64<span class="elsevierStyleHsp" style=""></span>kDa protein&#44; folliculin&#44; which is expressed in most tissues including the skin and its appendages&#44; the lungs &#40;type 1 pneumocytes&#41; and the kidney &#40;distal nephron&#41;&#46; The exact function of this protein has not yet been elucidated&#44; but it seems to be implicated in the adenosine-monophosphate-activated protein kinase and mTOR pathways&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;20</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Although mutations can occur anywhere in the <span class="elsevierStyleItalic">FLCN</span> gene&#44; including exons and introns&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> to date 50&#37; of the mutations reported are frameshifts caused by insertions or deletions at the mutational hotspot in the cytosine 8 nucleotide of exon 11&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> Mutations 1285dupC &#40;previously described as c&#46;1733insC&#44; c&#46;1740dupC&#44; or c&#46;1277insC&#41; and c&#46;1285delC &#40;also described as c&#46;1733delC&#41; are the most frequently reported mutations in patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome and their family members&#46; The impact on protein transcription depends on the type of mutation &#40;base substitution&#44; nucleotide deletion or insertion&#44; or interference in messenger RNA splicing&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents the mutations described to date in the <span class="elsevierStyleItalic">FLCN</span> gene&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;16&#44;21&#8211;24</span></a> The loss of <span class="elsevierStyleItalic">FLCN</span> expression observed in almost all histologic subtypes of renal carcinoma implicates this gene in the pathogenesis of this type of tumor and provides further support for its function as a tumor suppressor gene&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> A second somatic mutation is necessary for renal cancer in patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome to develop&#59; this mutation leads to loss of mRNA expression of <span class="elsevierStyleItalic">FLCN</span> in these tumors&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;15&#44;23</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Contrary to what occurs in renal tumors&#44; no loss of heterozygosity has been detected in skin lesions and the level of <span class="elsevierStyleItalic">FLCN</span> mRNA expression is high&#44; although the reason for this is not known&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> These findings suggest that different mechanisms are implicated in the development of these skin tumors and renal cancers&#46; Further studies are therefore required to clarify the mechanisms implicated in skin lesions&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">To date&#44; no correlation between genotype and phenotype has been established&#44; and further studies are needed&#46; However&#44; some authors have observed a greater frequency of mutations in exon 11 in those patients with a history of pneumothorax&#44; as well as a relationship between mutations in exon 9 and 12 and the number and size&#44; respectively&#44; of lung cysts&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Other authors suggest that patients with the c&#46;1285delC mutation have a lower risk of developing renal cancer&#44; but further studies are necessary&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnosis</span><p id="par0050" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the current diagnostic criteria proposed by the European Birt&#8211;Hogg&#8211;Dub&#233; Consortium&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Of note is that&#44; although skin lesions are a warning sign for dermatologists&#44; they are not present in all patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#46; In fact&#44; not all patients present with the traditional triad of skin&#44; renal&#44; and lung disease&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Kunogi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> observed that up to 70&#37; of patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome and pneumothorax did not present with skin lesions or renal disorders&#46; Thus&#44; given the clinical variability of this syndrome&#44; it should be suspected not only in patients with characteristic skin lesions but also in those with extracutaneous lesions as described above&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The European Birt&#8211;Hogg&#8211;Dub&#233; Consortium has proposed a series of criteria that represent an indication for genetic study&#46; These include early-onset renal carcinoma &#40;&#60;50 years&#41;&#44; particularly if multifocal or bilateral and of characteristic histology &#40;chromophobe&#44; oncocytic&#44; or hybrid&#41;&#44; and when unexplained cystic lung disease or spontaneous pneumothorax is present&#44; especially in the case of bilateral disease and cysts located at the base of the lung&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> In addition&#44; those patients with a family history of pulmonary cystic disease&#44; spontaneous pneumothorax&#44; renal carcinoma&#44; or a combination of these conditions should also be considered as candidates for genetic study &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Thus&#44; in those patients whose only manifestation is lung or renal involvement&#44; detection of germline mutation in <span class="elsevierStyleItalic">FLCN</span> would help confirm diagnosis and allow genetic counseling&#46; Genetic counseling units are available in almost all autonomous regions of Spain&#44; and these can be consulted for requesting the genetic studies&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Differential Diagnosis</span><p id="par0060" class="elsevierStylePara elsevierViewall">Differential diagnosis in a patient with papular facial lesions should include other syndromes such as Cowden syndrome&#44; Brooke&#8211;Spiegler syndrome&#44; Rombo syndrome&#44; tuberous sclerosis&#44; and basaloid follicular hamartoma syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;27&#8211;33</span></a> Diagnosis is based on clinical features and histologic study&#46; <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> shows the principal features of each of these syndromes&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Familial spontaneous pneumothorax may occur in different hereditary processes&#46; Thus&#44; when faced with a patient with a family history of spontaneous pneumothorax and lung cysts&#44; the differential diagnosis should include other entities that may present with cystic changes in the lung parenchymya&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> These include &#945;1-antitrypsin deficiency&#44; Marfan syndrome&#44; Ehlers&#8211;Danlos syndrome&#44; lymphangioleiomyomatosis&#44; tuberous sclerosis&#44; Langerhans cell histiocytosis&#44; and cystic fibrosis&#46; Idiopathic pulmonary fibrosis&#44; <span class="elsevierStyleItalic">Pneumocystis jiroveci</span> infection&#44; lymphocytic interstitial pneumonia&#44; and septic embolism should also be included in the differential diagnosis&#46; The site of the lung cysts&#44; a family history of such cysts&#44; and the presence of other accompanying lesions&#44; particularly cutaneous ones&#44; can help guide the diagnosis&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Management of Patients With Birt&#8211;Hogg&#8211;Dub&#233; Syndrome</span><p id="par0070" class="elsevierStylePara elsevierViewall">As we have seen&#44; the clinical manifestations of Birt&#8211;Hogg&#8211;Dub&#233; syndrome are not just limited to skin lesions&#44; and other body systems can be involved&#46; The management of these patients should therefore be multidisciplinary and involve the cooperation of different specialists&#46; Diagnosis of skin lesions associated with this syndrome is based on clinical and histologic features&#46; An appropriate skin examination along with excision of a suspect lesion is necessary&#46; Treatment should be considered on esthetic grounds&#46; In addition to surgery&#44; the use of oral isotretinoin and treatment with carbon dioxide lasers and erbium&#58;YAG lasers have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;34&#44;35</span></a> Laser ablation is a useful treatment for other adnexal tumors&#46; Gambichler et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> described treatment of a patient with Birt&#8211;Hogg&#8211;Dub&#233; syndrome and skin lesions with an erbium&#58;YAG laser &#40;spot size 1&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#44; fluence 5<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span>&#44; pulse energy 340<span class="elsevierStyleHsp" style=""></span>mJ&#41;&#46; Subsequently&#44; in 2001&#44; Jacob and Dover<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> used a combination of carbon dioxide and erbium&#58;YAG lasers to treat a patient with similar lesions&#46; Currently&#44; van Steensel<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> is conducting a double-blind&#44; phase III study to assess the efficacy of topical rapamycin &#40;0&#46;25<span class="elsevierStyleHsp" style=""></span>mL of rapamycin&#44; 1<span class="elsevierStyleHsp" style=""></span>mg&#47;mL oral solution&#44; administered twice daily&#41; in the management of these lesions&#46; The results of this study will be available in the near future&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">As commented earlier&#44; patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome have a higher risk of developing renal cancer&#46; Those patients who are carriers of <span class="elsevierStyleItalic">FLCN</span> germline mutations and those patients who are at risk should be monitored closely&#46; There are no established guidelines for defining at which age to start&#44; the best screening approach&#44; or the frequency of follow-up visits&#46; As the age of onset of renal cancer is between 25 and 75 years&#44; the age for initiation of follow-up could be set at 20 years&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Ultrasound&#44; computed tomography &#40;CT&#41;&#44; and magnetic resonance imaging may be useful imaging techniques&#46; Some authors suggest using renal ultrasound and&#47;or abdominal CT on diagnosis and then every 3 or 5 years&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Staging in the event of diagnosis of renal cancer is no different to renal cancer in patients without the syndrome&#46; Once diagnosed&#44; treatment is usually surgical&#44; leaving as much renal parenchyma as possible with nephron-sparing techniques instead of radical nephrectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> In the event of metastases&#44; rapamycin analogs may be considered&#44; given the implication of the <span class="elsevierStyleItalic">FLCN</span> gene in regulating the mTOR pathway&#44; although more studies are needed to demonstrate benefit&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">With regard to the management of lung disease&#44; patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome may have a greater risk of pneumothorax when subjected to pressure changes&#44; for example&#44; during journeys in airplanes or aquatic activities such as diving&#46; It is not clear to what extent patients should be advised against undertaking such activities&#44; but the patient should be informed of the risk&#44; and also educated about the signs and symptoms that may appear&#46; There are insufficient data to support a clear association with smoking&#44; but a greater prevalence of renal cancer and pneumothorax has been observed in smokers&#44; and so patients should be advised to give up tobacco use&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Patients with a history of recurring pneumothorax or symptomatic lung disease should be referred to a lung specialist&#46; Chest X-ray or CT is useful for diagnosis of lung cysts&#44; but there are no universally accepted protocols for monitoring these lesions&#46; Treatment is similar to those patients who present with spontaneous pneumothorax not associated with the syndrome&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">With regard to the association between Birt&#8211;Hogg&#8211;Dub&#233; syndrome and colon cancer&#44; no specific indication has been reported for colonoscopy in these patients&#44; and the recommended management is the same as in the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Some authors suggest that this association could be mere coincidence given the frequency of colon cancer in the general population&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;38</span></a></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0090" class="elsevierStylePara elsevierViewall">In conclusion&#44; even though the warning signs for dermatologists are skin lesions with a histologically confirmed diagnosis such as fibrofolliculomas and trichodiscomas&#44; these are often absent&#46; Extracutaneous manifestations such as recurrent spontaneous pneumothorax or basal lung cysts&#44; as well as certain renal cancers&#44; along with genetic study&#44; can be used to establish a diagnosis of Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Funding</span><p id="par0095" class="elsevierStylePara elsevierViewall">This study was performed with the support of a grant &#40;<span class="elsevierStyleGrantNumber" refid="gs0005">AP-088&#47;11</span>&#41; for health research projects&#44; awarded by the <span class="elsevierStyleGrantSponsor" id="gs0005">Department of Health of the Autonomous Community of Valencia</span>&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Birt&#8211;Hogg&#8211;Dub&#233; syndrome is a rare autosomal dominant genodermatosis that is characterized by the presence of fibrofolliculomas and&#47;or trichodiscomas&#44; pulmonary cysts&#44; spontaneous pneumothorax&#44; and renal tumors&#46; The most common histological types found in renal tumors from patients with the syndrome are oncocytoma&#8211;chromophobe carcinoma hybrids and pure forms of chromophobe carcinoma&#44; oncocytic carcinoma&#44; and clear cell or papillary cell carcinoma&#46; The syndrome is linked to mutations in the FLCN gene&#44; which encodes folliculin and is preferentially expressed in the skin&#44; kidney&#44; and lung&#46; The syndrome can exhibit a high degree of clinical variability&#44; and the skin lesions that are a warning sign for dermatologists may be absent in up to 70&#37; of cases&#46; Consequently&#44; although skin lesions and mutations in FLCN are the main diagnostic criteria for Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#44; a diagnosis can be made based on noncutaneous manifestations&#44; with or without known family history of the syndrome&#44; even in the absence of histological confirmation of fibrofolliculomas or trichodiscomas&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El s&#237;ndrome de Birt&#8211;Hogg&#8211;Dub&#233; &#40;SBHD&#41; es una rara genodermatosis de herencia autos&#243;mica dominante caracterizada esencialmente por la presencia de fibrofoliculomas y&#47;o tricodiscomas&#44; quistes pulmonares&#44; neumot&#243;rax espont&#225;neos y c&#225;nceres renales&#44; siendo los tipos histol&#243;gicos m&#225;s frecuentes las formas h&#237;bridas de oncocitoma y carcinoma crom&#243;fobo o formas puras de carcinoma crom&#243;fobo&#44; oncoc&#237;tico&#44; de c&#233;lulas claras o papilar&#46; El gen implicado en este s&#237;ndrome&#44; FLCN&#44; codifica la foliculina&#44; que se expresa preferentemente a nivel cut&#225;neo&#44; renal y pulmonar&#46; Este s&#237;ndrome puede presentarse con una gran variabilidad cl&#237;nica&#44; y las lesiones cut&#225;neas que son el signo de alarma para los dermat&#243;logos pueden estar ausentes hasta en un 70&#37; de los casos&#46; As&#237;&#44; aunque las lesiones cut&#225;neas son&#44; junto con las mutaciones del gen FLCN&#44; los criterios mayores para el diagn&#243;stico del SBHD&#44; este diagn&#243;stico es posible incluso cuando no existe confirmaci&#243;n histol&#243;gica de fibrofoliculomas o tricodiscomas&#44; por las mencionadas manifestaciones extracut&#225;neas&#44; con o sin antecedentes familiares conocidos&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; L&#243;pez V&#44; et al&#46; Actualizaci&#243;n en el s&#237;ndrome Birt&#8211;Hogg&#8211;Dub&#233;&#46; Actas Dermosifiliogr&#46; 2012&#59;103&#58;198&#8211;206&#46;</p>"
      ]
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Trichodiscomas and fibrofolliculomas in a patient with Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#46;</p>"
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      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">c&#46;671&#95;672delc&#46;632&#95;633delAGinsCc&#46;689dupT&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</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">c&#46;871&#43;3&#95;c&#46;871&#43;4delGAinsTCCAGATc&#46;871&#43;13T&#62;Cc&#46;871&#43;16T&#62;A&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></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">c&#46;1062&#43;1G&#62;Ac&#46;1062&#43;2T&#62;Gc&#46;1062&#43;5G&#62;A&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">c&#46;1062&#43;6C&#62;Tc&#46;1062&#43;47G&#62;A&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></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t\ttop\n
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                  \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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">c&#46;1176&#43;31G&#62;Ac&#46;1176&#43;39G&#62;A&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">c&#46;1176&#43;68G&#62;Cc&#46;1176&#43;134G&#62;C&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">c&#46;1176&#43;179A&#62;Gc&#46;1177-165C&#62;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  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">c&#46;1198G&#62;Ac&#46;1215C&#62;Gc&#46;1252delC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">c&#46;1269C&#62;Tc&#46;1278C&#62;Tc&#46;1285delC&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">c&#46;1285dupCc&#46;1285C&#62;Tc&#46;1286dupA&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">c&#46;1300G&#62;Ac&#46;1300G&#62;Cc&#46;1300G&#62;T&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \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  " align="" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">c&#46;1301-7&#95;1304del11c&#46;1305delTc&#46;1318&#95;1334dupc&#46;1323delCinsGA&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="left" valign="\n
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                  \t\t\t\t">c&#46;1333G&#62;Ac&#46;1337&#95;1343dupc&#46;1340&#95;1346dupc&#46;1347&#95;1353dup&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">c&#46;1372dupc&#46;1379&#95;1380delc&#46;1389C&#62;G c&#46;1408&#95;1418del&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">c&#46;1426dupGc&#46;1429C&#62;Tc&#46;1844C&#62;G&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
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                  \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">c&#46;1432&#43;1G&#62;A&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">c&#46;1433-38A&#62;G&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">c&#46;1433-1G&#62;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="" valign="\n
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                  \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">13&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">c&#46;1433-1G&#62;Tc&#46;1487&#95;1490dup&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">c&#46;1522&#95;1524delc&#46;1523A&#62;G&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">c&#46;1528&#95;1530delc&#46;1533G&#62;A&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">c&#46;1533&#95;1536del&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">13i&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">c&#46;1538&#43;121C&#62;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="" 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="" 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="" 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></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">14&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">c&#46;1539&#95;1740delc&#46;1557delT&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">c&#46;1579C&#62;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">c&#46;1597C&#62;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">c&#46;1597&#95;1598del&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab182079.png"
              ]
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Germline Mutations in Birt&#8211;Hogg&#8211;Dub&#233; Syndrome&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patients should fulfill 1 major or 2 minor criteria for diagnosis of Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><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">Major Criteria</span>&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="elsevierStyleHsp" style=""></span>At least 5 fibrofolliculomas or trichodiscomas&#44; at least 1 confirmed histologically&#44; of adult onset&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="elsevierStyleHsp" style=""></span>Pathogenic germline mutation in <span class="elsevierStyleItalic">FLCN</span>&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="elsevierStyleVsp" style="height:0.5px"></span>&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">Minor Criteria</span>&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="elsevierStyleHsp" style=""></span>Multiple lung cysts&#58; basally located with no other apparent cause&#44; with or without spontaneous pneumothorax&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="elsevierStyleHsp" style=""></span>Renal cancer&#58; early onset &#40;&#60;50 years&#41;&#44; multifocal or bilateral renal cancer&#44; or renal cancer of characteristic histologic forms &#40;oncocytic-chromophobe hybrid histology&#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="elsevierStyleHsp" style=""></span>First-degree relative with Birt&#8211;Hogg&#8211;Dub&#233; syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab182082.png"
              ]
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Criteria Proposed by the European Birt&#8211;Hogg&#8211;Dub&#233; Consortium&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><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">Characteristic skin lesions &#40;fibrofolliculomas and&#47;or trichodiscomas&#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">Cystic lung disease with no apparent cause&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">Spontaneous primary pneumothorax&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">Renal cancer&#58; early onset &#40;&#60;50 years&#41;&#44; multifocal or bilateral renal cancer&#44; or renal cancer of characteristic histologic forms &#40;pure or oncocytic&#8211;chromophobe hybrid histology&#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">First-degree relative with any of the above characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab182080.png"
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            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Criteria for Requesting Genetic Study According to the European Birt&#8211;Hogg&#8211;Dub&#233; Consortium&#46;</p>"
        ]
      ]
      7 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; ADT&#44; autosomal dominant transmission&#59; GIT&#44; gastrointestinal tract&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                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">Disease&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">Transmission Pattern&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">Etiology&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">Age of Onset&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  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Clinical Features</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">Association With Cancer&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-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&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">Cutaneous&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">Extracutaneous&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&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">Cowden disease<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&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">ADT&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">PTEN</span> gene&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">20&#8211;30 years&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">Facial tricholemmomas &#40;around the mouth&#44; nose&#44; and ears&#41;Cobblestone-like papillomatous lesions in the oral cavity and on the lipsAcral keratosisSclerotic fibromas&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">MacrocephalyMental retardation&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">Breast&#58; Adenocarcinoma&#44; fibroadenoma&#44; and fibrocystic diseaseThyroid carcinomaHamartomatous polyps in GIT &#40;most frequently in the colon&#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">Tuberous sclerosis<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&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">ADT &#40;50&#8211;70&#37;&#41;New mutations&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">TSC1</span> &#40;hamartin&#41; and <span class="elsevierStyleItalic">TSC2</span> &#40;tuberin&#41; gene&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">Infancy&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">Facial angiofibromasFibrous plaque on the foreheadHypopigmented ash leaf&#44; polygonal&#44; confetti-like maculesLeathery plaquePeriungual fibromasCaf&#233;-au-lait stains&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">Endocrine&#58; early puberty&#44; hypothyroidismOcular&#58; retinal hamartomas&#44; achromic retinal plaquesSkeletalDentalPulmonaryRenal&#58; cystsNeurologicCardiac&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">Cardiac rhabdomyomaMultiple bilateral renal angiomyolipomas&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">Brooke&#8211;Spiegler syndrome and Rombo syndrome<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#8211;29</span></a>&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">ADT&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">CYLD1</span> gene &#40;Brooke&#8211;Spiegler syndrome&#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">Infancy&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">Brooke&#8211;Spiegler syndrome&#58; Trichoepitheliomas&#44; cylindromas&#44; and eccrine spiradenomasRombo syndrome&#58; atrophoderma vermiculatum&#44; milia&#44; hypertrichosis&#44; telangiectasias&#44; acral erythema&#44; trichoepitheliomas&#44; basal cell carcinomas&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Basal cell carcinoma&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">Badasoid follicular hamartoma syndrome<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&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">ADT&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">PTCH</span> gene&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">Birth-infancy&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">Basaloid follicular hamartomasDiffuse alopecia &#40;Brown&#8211;Crounse syndrome&#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">Myasthenia gravis marker&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></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">Birt&#8211;Hogg&#8211;Dub&#233; syndrome&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">ADT&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">FLCN</span> &#40;folliculin&#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">From 25 years onwards&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">TrichofolliculomasTrichodiscomasAcrochordonsFacial angiofibromasPapules in 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">Lung cystsPneumothorax&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">Renal cancer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Differential Diagnosis in a Patient With Facial Papular Lesions&#46;</p>"
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Novelties in Dermatology
Birt–Hogg–Dubé Syndrome: An Update
Actualización en el síndrome Birt–Hogg–Dubé
V. Lópeza,
Autor para correspondencia
veronica_17@live.com

Corresponding author.
, E. Jordáa, C. Monteagudob
a Fundación de Investigación Clínico de Valencia-INCLIVA, Hospital Clínico Universitario, Universidad de Valencia, Spain
b Servicio de Dermatología y Departamento de Anatomía Patológica, Hospital Clínico Universitario, Universidad de Valencia, Spain
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        "titulo" => "Actualizaci&#243;n en el s&#237;ndrome Birt&#8211;Hogg&#8211;Dub&#233;"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Histologic image of trichodiscoma &#40;hematoxylin&#8211;eosin&#44; original magnification 100&#215;&#41;&#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">In 1977&#44; Birt et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> described a series of patients with multiple papular skin-colored&#44; dome-shaped lesions located on the face&#44; neck&#44; and trunk&#46; Histologically&#44; these lesions corresponded to fibrofolliculomas&#44; trichodiscomas&#44; and soft fibromas&#46; This was the first description of what later came to be known as Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#44; a genodermatosis that exhibits autosomal dominant inheritance&#46; More than 20 years later&#44; its association with renal carcinoma and&#47;or pulmonary lesions was discovered&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical Features</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Skin Manifestations</span><p id="par0010" class="elsevierStylePara elsevierViewall">The skin manifestations of Birt&#8211;Hogg&#8211;Dub&#233; syndrome essentially comprise fibrofolliculomas and&#47;or trichodiscomas that usually appear in individuals in their 20s or 30s&#46; Trichofolliculomas&#44; trichodiscomas&#44; and acrochordons&#8212;traditionally considered as the characteristic triad of Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#8212;appear to belong to the histopathologic and clinical spectrum of fibrofolliculoma&#46; Clinically&#44; these lesions are practically indistinguishable from one another and present as multiple whitish papules&#44; with a dome-shaped appearance&#44; a few millimeters in diameter&#44; located mainly on the nose&#44; forehead&#44; and cheeks&#44; although they can also appear on the neck and trunk &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Histologically&#44; fibrofolliculoma is typically vertical or perpendicular to the epidermis&#44; as it forms around a hair follicle&#46; It is characterized by the presence of long&#44; thin&#44; mantle-like epithelial cords&#44; which sometimes terminate in mature sebaceous glands&#44; with surrounding fibrovascular stroma containing a variable myxoid component &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Unlike fibrofolliculomas&#44; trichodiscomas are oriented horizontally&#44; that is&#44; parallel to the epidermis&#44; and are composed exclusively of stroma identical to that of fibrofolliculomas&#44; surrounded at the base by hair follicle units &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Trichodiscoma is considered a late form of fibrofolliculoma&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In addition to these characteristic lesions&#44; the presence of facial angiofibromas has occasionally been reported&#44; as has the involvement of oral mucosa in the form of multiple papules on the lips and buccal and gingival mucosa&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The fibrofolliculomas and trichodiscomas found in Birt&#8211;Hogg&#8211;Dub&#233; syndrome have features in common with the angiofibromas that occur in tuberous sclerosis complex&#46; Histologically&#44; the presence of a stroma with thicker collagen bundles&#44; along with stellate fibroblasts&#44; as well as the absence of the epithelial component&#44; are useful features for differentiating angiofibromas from fibrofolliculomas&#46; Analysis of immunoreactivity for CK15&#44; CD34&#44; and factor XIIIa is not very useful as it may occur in both types of lesion&#46; In Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#44; a mutation in the folliculin gene &#40;<span class="elsevierStyleItalic">FCLN</span>&#41; is associated with the development of multiple fibrofolliculomas and trichodiscomas&#44; whereas mutations in <span class="elsevierStyleItalic">TS1</span> and <span class="elsevierStyleItalic">TS2</span> are linked to the appearance of angiofibromas in the tuberous sclerosis complex&#46; Recent work has shown that both proteins could form part of the same mammalian target of rapamycin &#40;mTOR&#41; pathway&#44; responsible for the development of the characteristic skin lesions in both syndromes&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In fact&#44; the presence of fibrofolliculomas in patients with tuberous sclerosis or of angiofibromas in patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome has been very occasionally reported&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In addition&#44; patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome and those with tuberous sclerosis can present with lung and renal disease&#46; These similarities in clinical manifestations&#44; and the common histologic features in skin lesions&#44; are further evidence that genetic abnormalities arise in a common pathway&#46; In fact&#44; the results of a study conducted in <span class="elsevierStyleItalic">Schizosaccharomyces pombe</span>&#44; a unicellular eukaryotic yeast&#44; suggest that the genes responsible for Birt&#8211;Hogg&#8211;Dub&#233; syndrome and tuberous sclerosis both act via the mTOR pathway and lead to renal cell carcinoma&#44; skin cancer&#44; and pulmonary symptoms through mechanisms involving inappropriate inhibition in Birt&#8211;Hogg&#8211;Dub&#233; syndrome and activation in tuberous sclerosis&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Extracutaneous Manifestations</span><p id="par0020" class="elsevierStylePara elsevierViewall">In addition to skin lesions&#44; patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome may present a series of extracutaneous lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In recent years&#44; it has been shown that these patients are at a greater risk of developing renal cancer and spontaneous pneumothorax&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;11</span></a> In 1993&#44; Roth et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> described the first case of renal cancer in a patient with Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#46; Toro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> subsequently described Birt&#8211;Hogg&#8211;Dub&#233; syndrome as a marker of renal cancer&#46; Further studies providing confirmation have since been published&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;11&#8211;14</span></a> It was reported that patients with Birt&#8211;Hogg&#8211;Dub&#233; had a 7-fold higher risk of renal cancer&#44; with a predilection for men and an age of onset between 20 and 55 years&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Seven different autosomal dominant syndromes have been identified as having an association with renal cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> However&#44; unlike the other syndromes&#44; the presentation of renal lesions can be bilateral and multifocal in the case of Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#44; with 5 different histologic types&#58; oncocytic&#8211;chromophobe hybrid carcinoma &#40;50&#37;&#41;&#44; purely chromophobe carcinomas &#40;34&#37;&#41;&#44; purely oncocytic carcinomas &#40;5&#37;&#41;&#44; clear cell carcinomas &#40;3&#37;&#41;&#44; and papillary carcinomas &#40;2&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;14</span></a> The prevalence of renal tumors in patients with germline mutations in the <span class="elsevierStyleItalic">FLCN</span> gene varies from 6&#46;5&#37; to 34&#37; according to different studies&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> With regard to the risk of metastasis&#44; to date&#44; only 5 cases of distant metastases of renal cancer have been reported&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Clinicopathologic studies showed that the renal tumors of these patients were of clear-cell&#44; tubulopapillary&#44; or papillary subtypes&#44; which account for a minority of subtypes in Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Up to 80&#37; of patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome have lung cysts&#44; which may be asymptomatic for years&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;11&#44;14&#8211;16</span></a> The number and size of the lesions varies from patient to patient&#44; ranging from small cysts to bullae measuring several centimeters across&#44; located mainly in the lung bases and at the subpleural level<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; A relationship between size and volume of the cysts and the risk of pneumothorax has been reported&#8212;the larger the volume the greater the risk&#46; The mean age of presentation is 38 years&#44; with no clear predilection for either sex&#46; Some studies suggest that male sex is a risk factor for spontaneous pneumothorax&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> whereas others report no such risk&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Among patients who present lung cysts&#44; approximately 20&#8211;30&#37; have a history of pneumothorax&#44; with a mean of 2 prior episodes&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In addition&#44; when patients with a history of pneumothorax are studied&#44; the vast majority have multiple cysts&#46; The right lung is more frequently affected&#44; although both lungs can be involved in up to 23&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#44; the risk of pneumothorax is 50 times greater than in the normal population&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The most frequent mutation in patients with a history of pneumothorax or lung lesions and Birt&#8211;Hogg&#8211;Dub&#233; syndrome is c&#46;1733ins&#47;delC located in exon 119&#46; Patients with certain mutations are at risk of developing larger and more numerous cystic lesions&#46; Thus&#44; the mutation in exon 9 confers a risk of developing a greater number of cysts&#44; whereas mutations in exon 9 and 12 are associated with larger cysts&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The pathophysiology of lung cysts is unknown but it may be that haploinsufficiency is enough to induce the development of these lesions&#44; as is the case in skin tumors&#46; In addition to the characteristic associations described above&#44; in patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#44; there have been reports of adenomas and colorectal polyps&#44; parotid oncocytomas&#44; parathyroid oncocytomas&#44; neural tumors&#44; trichoblastomas&#44; lipomas&#44; angiolipomas&#44; connective tissue abnormalities&#44; chorioretinopathy&#44; and nonrenal malignant neoplasms such as breast cancer&#44; colorectal cancer&#44; tonsil cancer&#44; and lung cancer&#44; and also skin cancers such as melanoma&#44; basal cell carcinoma&#44; squamous cell carcinoma&#44; dermatofibrosarcoma&#44; and leiomyosarcoma&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Despite these reports&#44; a significant association between Birt&#8211;Hogg&#8211;Dub&#233; syndrome and these neoplasms has not yet been demonstrated&#44; and further studies are needed&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Some authors maintain that carriers of the c&#46;1285dupC mutation have a greater risk of colon cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Genetic Basis</span><p id="par0030" class="elsevierStylePara elsevierViewall">In 2002&#44; the <span class="elsevierStyleItalic">FLCN</span> gene was identified as being associated with Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> This gene&#44; located on chromosome 17p11&#46;2 and comprising 14 exons&#44; encodes a 64<span class="elsevierStyleHsp" style=""></span>kDa protein&#44; folliculin&#44; which is expressed in most tissues including the skin and its appendages&#44; the lungs &#40;type 1 pneumocytes&#41; and the kidney &#40;distal nephron&#41;&#46; The exact function of this protein has not yet been elucidated&#44; but it seems to be implicated in the adenosine-monophosphate-activated protein kinase and mTOR pathways&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;20</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Although mutations can occur anywhere in the <span class="elsevierStyleItalic">FLCN</span> gene&#44; including exons and introns&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> to date 50&#37; of the mutations reported are frameshifts caused by insertions or deletions at the mutational hotspot in the cytosine 8 nucleotide of exon 11&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> Mutations 1285dupC &#40;previously described as c&#46;1733insC&#44; c&#46;1740dupC&#44; or c&#46;1277insC&#41; and c&#46;1285delC &#40;also described as c&#46;1733delC&#41; are the most frequently reported mutations in patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome and their family members&#46; The impact on protein transcription depends on the type of mutation &#40;base substitution&#44; nucleotide deletion or insertion&#44; or interference in messenger RNA splicing&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents the mutations described to date in the <span class="elsevierStyleItalic">FLCN</span> gene&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;16&#44;21&#8211;24</span></a> The loss of <span class="elsevierStyleItalic">FLCN</span> expression observed in almost all histologic subtypes of renal carcinoma implicates this gene in the pathogenesis of this type of tumor and provides further support for its function as a tumor suppressor gene&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> A second somatic mutation is necessary for renal cancer in patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome to develop&#59; this mutation leads to loss of mRNA expression of <span class="elsevierStyleItalic">FLCN</span> in these tumors&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;15&#44;23</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Contrary to what occurs in renal tumors&#44; no loss of heterozygosity has been detected in skin lesions and the level of <span class="elsevierStyleItalic">FLCN</span> mRNA expression is high&#44; although the reason for this is not known&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> These findings suggest that different mechanisms are implicated in the development of these skin tumors and renal cancers&#46; Further studies are therefore required to clarify the mechanisms implicated in skin lesions&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">To date&#44; no correlation between genotype and phenotype has been established&#44; and further studies are needed&#46; However&#44; some authors have observed a greater frequency of mutations in exon 11 in those patients with a history of pneumothorax&#44; as well as a relationship between mutations in exon 9 and 12 and the number and size&#44; respectively&#44; of lung cysts&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Other authors suggest that patients with the c&#46;1285delC mutation have a lower risk of developing renal cancer&#44; but further studies are necessary&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnosis</span><p id="par0050" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the current diagnostic criteria proposed by the European Birt&#8211;Hogg&#8211;Dub&#233; Consortium&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Of note is that&#44; although skin lesions are a warning sign for dermatologists&#44; they are not present in all patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#46; In fact&#44; not all patients present with the traditional triad of skin&#44; renal&#44; and lung disease&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Kunogi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> observed that up to 70&#37; of patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome and pneumothorax did not present with skin lesions or renal disorders&#46; Thus&#44; given the clinical variability of this syndrome&#44; it should be suspected not only in patients with characteristic skin lesions but also in those with extracutaneous lesions as described above&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The European Birt&#8211;Hogg&#8211;Dub&#233; Consortium has proposed a series of criteria that represent an indication for genetic study&#46; These include early-onset renal carcinoma &#40;&#60;50 years&#41;&#44; particularly if multifocal or bilateral and of characteristic histology &#40;chromophobe&#44; oncocytic&#44; or hybrid&#41;&#44; and when unexplained cystic lung disease or spontaneous pneumothorax is present&#44; especially in the case of bilateral disease and cysts located at the base of the lung&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> In addition&#44; those patients with a family history of pulmonary cystic disease&#44; spontaneous pneumothorax&#44; renal carcinoma&#44; or a combination of these conditions should also be considered as candidates for genetic study &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Thus&#44; in those patients whose only manifestation is lung or renal involvement&#44; detection of germline mutation in <span class="elsevierStyleItalic">FLCN</span> would help confirm diagnosis and allow genetic counseling&#46; Genetic counseling units are available in almost all autonomous regions of Spain&#44; and these can be consulted for requesting the genetic studies&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Differential Diagnosis</span><p id="par0060" class="elsevierStylePara elsevierViewall">Differential diagnosis in a patient with papular facial lesions should include other syndromes such as Cowden syndrome&#44; Brooke&#8211;Spiegler syndrome&#44; Rombo syndrome&#44; tuberous sclerosis&#44; and basaloid follicular hamartoma syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;27&#8211;33</span></a> Diagnosis is based on clinical features and histologic study&#46; <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> shows the principal features of each of these syndromes&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Familial spontaneous pneumothorax may occur in different hereditary processes&#46; Thus&#44; when faced with a patient with a family history of spontaneous pneumothorax and lung cysts&#44; the differential diagnosis should include other entities that may present with cystic changes in the lung parenchymya&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> These include &#945;1-antitrypsin deficiency&#44; Marfan syndrome&#44; Ehlers&#8211;Danlos syndrome&#44; lymphangioleiomyomatosis&#44; tuberous sclerosis&#44; Langerhans cell histiocytosis&#44; and cystic fibrosis&#46; Idiopathic pulmonary fibrosis&#44; <span class="elsevierStyleItalic">Pneumocystis jiroveci</span> infection&#44; lymphocytic interstitial pneumonia&#44; and septic embolism should also be included in the differential diagnosis&#46; The site of the lung cysts&#44; a family history of such cysts&#44; and the presence of other accompanying lesions&#44; particularly cutaneous ones&#44; can help guide the diagnosis&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Management of Patients With Birt&#8211;Hogg&#8211;Dub&#233; Syndrome</span><p id="par0070" class="elsevierStylePara elsevierViewall">As we have seen&#44; the clinical manifestations of Birt&#8211;Hogg&#8211;Dub&#233; syndrome are not just limited to skin lesions&#44; and other body systems can be involved&#46; The management of these patients should therefore be multidisciplinary and involve the cooperation of different specialists&#46; Diagnosis of skin lesions associated with this syndrome is based on clinical and histologic features&#46; An appropriate skin examination along with excision of a suspect lesion is necessary&#46; Treatment should be considered on esthetic grounds&#46; In addition to surgery&#44; the use of oral isotretinoin and treatment with carbon dioxide lasers and erbium&#58;YAG lasers have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;34&#44;35</span></a> Laser ablation is a useful treatment for other adnexal tumors&#46; Gambichler et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> described treatment of a patient with Birt&#8211;Hogg&#8211;Dub&#233; syndrome and skin lesions with an erbium&#58;YAG laser &#40;spot size 1&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#44; fluence 5<span class="elsevierStyleHsp" style=""></span>J&#47;cm<span class="elsevierStyleSup">2</span>&#44; pulse energy 340<span class="elsevierStyleHsp" style=""></span>mJ&#41;&#46; Subsequently&#44; in 2001&#44; Jacob and Dover<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> used a combination of carbon dioxide and erbium&#58;YAG lasers to treat a patient with similar lesions&#46; Currently&#44; van Steensel<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> is conducting a double-blind&#44; phase III study to assess the efficacy of topical rapamycin &#40;0&#46;25<span class="elsevierStyleHsp" style=""></span>mL of rapamycin&#44; 1<span class="elsevierStyleHsp" style=""></span>mg&#47;mL oral solution&#44; administered twice daily&#41; in the management of these lesions&#46; The results of this study will be available in the near future&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">As commented earlier&#44; patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome have a higher risk of developing renal cancer&#46; Those patients who are carriers of <span class="elsevierStyleItalic">FLCN</span> germline mutations and those patients who are at risk should be monitored closely&#46; There are no established guidelines for defining at which age to start&#44; the best screening approach&#44; or the frequency of follow-up visits&#46; As the age of onset of renal cancer is between 25 and 75 years&#44; the age for initiation of follow-up could be set at 20 years&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Ultrasound&#44; computed tomography &#40;CT&#41;&#44; and magnetic resonance imaging may be useful imaging techniques&#46; Some authors suggest using renal ultrasound and&#47;or abdominal CT on diagnosis and then every 3 or 5 years&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Staging in the event of diagnosis of renal cancer is no different to renal cancer in patients without the syndrome&#46; Once diagnosed&#44; treatment is usually surgical&#44; leaving as much renal parenchyma as possible with nephron-sparing techniques instead of radical nephrectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> In the event of metastases&#44; rapamycin analogs may be considered&#44; given the implication of the <span class="elsevierStyleItalic">FLCN</span> gene in regulating the mTOR pathway&#44; although more studies are needed to demonstrate benefit&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">With regard to the management of lung disease&#44; patients with Birt&#8211;Hogg&#8211;Dub&#233; syndrome may have a greater risk of pneumothorax when subjected to pressure changes&#44; for example&#44; during journeys in airplanes or aquatic activities such as diving&#46; It is not clear to what extent patients should be advised against undertaking such activities&#44; but the patient should be informed of the risk&#44; and also educated about the signs and symptoms that may appear&#46; There are insufficient data to support a clear association with smoking&#44; but a greater prevalence of renal cancer and pneumothorax has been observed in smokers&#44; and so patients should be advised to give up tobacco use&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Patients with a history of recurring pneumothorax or symptomatic lung disease should be referred to a lung specialist&#46; Chest X-ray or CT is useful for diagnosis of lung cysts&#44; but there are no universally accepted protocols for monitoring these lesions&#46; Treatment is similar to those patients who present with spontaneous pneumothorax not associated with the syndrome&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">With regard to the association between Birt&#8211;Hogg&#8211;Dub&#233; syndrome and colon cancer&#44; no specific indication has been reported for colonoscopy in these patients&#44; and the recommended management is the same as in the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Some authors suggest that this association could be mere coincidence given the frequency of colon cancer in the general population&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;38</span></a></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0090" class="elsevierStylePara elsevierViewall">In conclusion&#44; even though the warning signs for dermatologists are skin lesions with a histologically confirmed diagnosis such as fibrofolliculomas and trichodiscomas&#44; these are often absent&#46; Extracutaneous manifestations such as recurrent spontaneous pneumothorax or basal lung cysts&#44; as well as certain renal cancers&#44; along with genetic study&#44; can be used to establish a diagnosis of Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Funding</span><p id="par0095" class="elsevierStylePara elsevierViewall">This study was performed with the support of a grant &#40;<span class="elsevierStyleGrantNumber" refid="gs0005">AP-088&#47;11</span>&#41; for health research projects&#44; awarded by the <span class="elsevierStyleGrantSponsor" id="gs0005">Department of Health of the Autonomous Community of Valencia</span>&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            2 => "Neumot&#243;rax espont&#225;neo"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Birt&#8211;Hogg&#8211;Dub&#233; syndrome is a rare autosomal dominant genodermatosis that is characterized by the presence of fibrofolliculomas and&#47;or trichodiscomas&#44; pulmonary cysts&#44; spontaneous pneumothorax&#44; and renal tumors&#46; The most common histological types found in renal tumors from patients with the syndrome are oncocytoma&#8211;chromophobe carcinoma hybrids and pure forms of chromophobe carcinoma&#44; oncocytic carcinoma&#44; and clear cell or papillary cell carcinoma&#46; The syndrome is linked to mutations in the FLCN gene&#44; which encodes folliculin and is preferentially expressed in the skin&#44; kidney&#44; and lung&#46; The syndrome can exhibit a high degree of clinical variability&#44; and the skin lesions that are a warning sign for dermatologists may be absent in up to 70&#37; of cases&#46; Consequently&#44; although skin lesions and mutations in FLCN are the main diagnostic criteria for Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#44; a diagnosis can be made based on noncutaneous manifestations&#44; with or without known family history of the syndrome&#44; even in the absence of histological confirmation of fibrofolliculomas or trichodiscomas&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El s&#237;ndrome de Birt&#8211;Hogg&#8211;Dub&#233; &#40;SBHD&#41; es una rara genodermatosis de herencia autos&#243;mica dominante caracterizada esencialmente por la presencia de fibrofoliculomas y&#47;o tricodiscomas&#44; quistes pulmonares&#44; neumot&#243;rax espont&#225;neos y c&#225;nceres renales&#44; siendo los tipos histol&#243;gicos m&#225;s frecuentes las formas h&#237;bridas de oncocitoma y carcinoma crom&#243;fobo o formas puras de carcinoma crom&#243;fobo&#44; oncoc&#237;tico&#44; de c&#233;lulas claras o papilar&#46; El gen implicado en este s&#237;ndrome&#44; FLCN&#44; codifica la foliculina&#44; que se expresa preferentemente a nivel cut&#225;neo&#44; renal y pulmonar&#46; Este s&#237;ndrome puede presentarse con una gran variabilidad cl&#237;nica&#44; y las lesiones cut&#225;neas que son el signo de alarma para los dermat&#243;logos pueden estar ausentes hasta en un 70&#37; de los casos&#46; As&#237;&#44; aunque las lesiones cut&#225;neas son&#44; junto con las mutaciones del gen FLCN&#44; los criterios mayores para el diagn&#243;stico del SBHD&#44; este diagn&#243;stico es posible incluso cuando no existe confirmaci&#243;n histol&#243;gica de fibrofoliculomas o tricodiscomas&#44; por las mencionadas manifestaciones extracut&#225;neas&#44; con o sin antecedentes familiares conocidos&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; L&#243;pez V&#44; et al&#46; Actualizaci&#243;n en el s&#237;ndrome Birt&#8211;Hogg&#8211;Dub&#233;&#46; Actas Dermosifiliogr&#46; 2012&#59;103&#58;198&#8211;206&#46;</p>"
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">c&#46;871&#43;3&#95;c&#46;871&#43;4delGAinsTCCAGATc&#46;871&#43;13T&#62;Cc&#46;871&#43;16T&#62;A&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">c&#46;871&#43;36G&#62;Ac&#46;871&#43;204A&#62;G&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="left" valign="\n
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                  \t\t\t\t">c&#46;887C&#62;Ac&#46;890&#95;893del&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="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">c&#46;1021delCc&#46;1378&#95;1405dup&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
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">c&#46;1062&#43;1G&#62;Ac&#46;1062&#43;2T&#62;Gc&#46;1062&#43;5G&#62;A&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">c&#46;1062&#43;6C&#62;Tc&#46;1062&#43;47G&#62;A&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">c&#46;1063-172C&#62;Gc&#46;1063-117C&#62;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">c&#46;1063-10&#95;1065delc&#46;1063-2A&#62;G&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">10&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">c&#46;1063&#95;1065delc&#46;1063-2A&#62;G&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">c&#46;1076delC&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">c&#46;1127G&#62;A&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">c&#46;1156&#95;1175del&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">10i&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">c&#46;1176&#43;31G&#62;Ac&#46;1176&#43;39G&#62;A&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">c&#46;1176&#43;68G&#62;Cc&#46;1176&#43;134G&#62;C&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">c&#46;1176&#43;179A&#62;Gc&#46;1177-165C&#62;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">c&#46;1177-5&#95;1177-3delc&#46;1177-2A&#62;G&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">11&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">c&#46;1198G&#62;Ac&#46;1215C&#62;Gc&#46;1252delC&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">c&#46;1269C&#62;Tc&#46;1278C&#62;Tc&#46;1285delC&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">c&#46;1285dupCc&#46;1285C&#62;Tc&#46;1286dupA&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">c&#46;1300G&#62;Ac&#46;1300G&#62;Cc&#46;1300G&#62;T&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">11i&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">c&#46;1301-59C&#62;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="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \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
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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
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                  \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">12&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">c&#46;1301-7&#95;1304del11c&#46;1305delTc&#46;1318&#95;1334dupc&#46;1323delCinsGA&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">c&#46;1333G&#62;Ac&#46;1337&#95;1343dupc&#46;1340&#95;1346dupc&#46;1347&#95;1353dup&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">c&#46;1372dupc&#46;1379&#95;1380delc&#46;1389C&#62;G c&#46;1408&#95;1418del&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">c&#46;1426dupGc&#46;1429C&#62;Tc&#46;1844C&#62;G&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">12i&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">c&#46;1432&#43;1G&#62;A&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">c&#46;1433-38A&#62;G&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">c&#46;1433-1G&#62;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="" 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></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">13&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">c&#46;1433-1G&#62;Tc&#46;1487&#95;1490dup&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">c&#46;1522&#95;1524delc&#46;1523A&#62;G&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">c&#46;1528&#95;1530delc&#46;1533G&#62;A&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">c&#46;1533&#95;1536del&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">13i&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">c&#46;1538&#43;121C&#62;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="" 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="" 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="" 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></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">14&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">c&#46;1539&#95;1740delc&#46;1557delT&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">c&#46;1579C&#62;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">c&#46;1597C&#62;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">c&#46;1597&#95;1598del&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab182079.png"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Germline Mutations in Birt&#8211;Hogg&#8211;Dub&#233; Syndrome&#46;</p>"
        ]
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      5 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
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          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patients should fulfill 1 major or 2 minor criteria for diagnosis of Birt&#8211;Hogg&#8211;Dub&#233; syndrome&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Major Criteria</span>&nbsp;\t\t\t\t\t\t\n
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                  \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="elsevierStyleHsp" style=""></span>At least 5 fibrofolliculomas or trichodiscomas&#44; at least 1 confirmed histologically&#44; of adult onset&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="elsevierStyleHsp" style=""></span>Pathogenic germline mutation in <span class="elsevierStyleItalic">FLCN</span>&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="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
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                  \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">Minor Criteria</span>&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="elsevierStyleHsp" style=""></span>Multiple lung cysts&#58; basally located with no other apparent cause&#44; with or without spontaneous pneumothorax&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="elsevierStyleHsp" style=""></span>Renal cancer&#58; early onset &#40;&#60;50 years&#41;&#44; multifocal or bilateral renal cancer&#44; or renal cancer of characteristic histologic forms &#40;oncocytic-chromophobe hybrid histology&#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="elsevierStyleHsp" style=""></span>First-degree relative with Birt&#8211;Hogg&#8211;Dub&#233; syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab182082.png"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Criteria Proposed by the European Birt&#8211;Hogg&#8211;Dub&#233; Consortium&#46;</p>"
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        "mostrarDisplay" => false
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><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">Characteristic skin lesions &#40;fibrofolliculomas and&#47;or trichodiscomas&#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">Cystic lung disease with no apparent cause&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">Spontaneous primary pneumothorax&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">Renal cancer&#58; early onset &#40;&#60;50 years&#41;&#44; multifocal or bilateral renal cancer&#44; or renal cancer of characteristic histologic forms &#40;pure or oncocytic&#8211;chromophobe hybrid histology&#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">First-degree relative with any of the above characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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      ]
      7 => array:7 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; ADT&#44; autosomal dominant transmission&#59; GIT&#44; gastrointestinal tract&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                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">Disease&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">Transmission Pattern&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">Etiology&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">Age of Onset&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  " colspan="2" align="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Clinical Features</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">Association With Cancer&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-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&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">Cutaneous&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">Extracutaneous&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&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">Cowden disease<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&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">ADT&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">PTEN</span> gene&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">20&#8211;30 years&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">Facial tricholemmomas &#40;around the mouth&#44; nose&#44; and ears&#41;Cobblestone-like papillomatous lesions in the oral cavity and on the lipsAcral keratosisSclerotic fibromas&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">MacrocephalyMental retardation&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">Breast&#58; Adenocarcinoma&#44; fibroadenoma&#44; and fibrocystic diseaseThyroid carcinomaHamartomatous polyps in GIT &#40;most frequently in the colon&#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">Tuberous sclerosis<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&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">ADT &#40;50&#8211;70&#37;&#41;New mutations&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">TSC1</span> &#40;hamartin&#41; and <span class="elsevierStyleItalic">TSC2</span> &#40;tuberin&#41; gene&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">Infancy&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">Facial angiofibromasFibrous plaque on the foreheadHypopigmented ash leaf&#44; polygonal&#44; confetti-like maculesLeathery plaquePeriungual fibromasCaf&#233;-au-lait stains&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">Endocrine&#58; early puberty&#44; hypothyroidismOcular&#58; retinal hamartomas&#44; achromic retinal plaquesSkeletalDentalPulmonaryRenal&#58; cystsNeurologicCardiac&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">Cardiac rhabdomyomaMultiple bilateral renal angiomyolipomas&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">Brooke&#8211;Spiegler syndrome and Rombo syndrome<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#8211;29</span></a>&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">ADT&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">CYLD1</span> gene &#40;Brooke&#8211;Spiegler syndrome&#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">Infancy&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">Brooke&#8211;Spiegler syndrome&#58; Trichoepitheliomas&#44; cylindromas&#44; and eccrine spiradenomasRombo syndrome&#58; atrophoderma vermiculatum&#44; milia&#44; hypertrichosis&#44; telangiectasias&#44; acral erythema&#44; trichoepitheliomas&#44; basal cell carcinomas&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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Basal cell carcinoma&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">Badasoid follicular hamartoma syndrome<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&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">ADT&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">PTCH</span> gene&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">Birth-infancy&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">Basaloid follicular hamartomasDiffuse alopecia &#40;Brown&#8211;Crounse syndrome&#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">Myasthenia gravis marker&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></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">Birt&#8211;Hogg&#8211;Dub&#233; syndrome&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">ADT&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">FLCN</span> &#40;folliculin&#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">From 25 years onwards&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">TrichofolliculomasTrichodiscomasAcrochordonsFacial angiofibromasPapules in 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">Lung cystsPneumothorax&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">Renal cancer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab182081.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Differential Diagnosis in a Patient With Facial Papular Lesions&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:38 [
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "A&#46;R&#46; Birt"
                            1 => "G&#46;R&#46; Hogg"
                            2 => "W&#46;J&#46; Dub&#233;"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
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            1 => array:3 [
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            2 => array:3 [
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                  "host" => array:1 [
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            ]
            3 => array:3 [
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                        0 => array:2 [
                          "etal" => false
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            ]
            4 => array:3 [
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                  "contribucion" => array:1 [
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                            0 => "J&#46; Schaffer"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
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                      "Revista" => array:6 [
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            5 => array:3 [
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                  "contribucion" => array:1 [
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                        0 => array:2 [
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
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            6 => array:3 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "N&#46; Kluger"
                            1 => "S&#46; Giraud"
                            2 => "I&#46; Coupier"
                            3 => "M&#46; Avril"
                            4 => "O&#46; Dereure"
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
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                      "Revista" => array:6 [
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                        "volumen" => "162"
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