Case and Research Letter
Lichenoid Graft-vs-Host Disease With Exclusively Cutaneous Involvement After Liver Transplant
Enfermedad injerto contra huésped liquenoide tras trasplante hepático con afectación exclusivamente cutánea
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Placas eritematovioláceas liquenoides distribuidas sobre los miembros inferiores. B). Detalle de placas liquenoides con componente necrótico en el dorso del pie. C). Pápulas blanquecinas dispuestas en empedrado en la mucosa yugal.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Sanz-Bueno, G. Pérez-Rial, M. Castellanos, F. Vanaclocha" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Sanz-Bueno" ] 1 => array:2 [ "nombre" => "G." "apellidos" => "Pérez-Rial" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Castellanos" ] 3 => array:2 [ "nombre" => "F." 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Recurrence of psoriasis 30 weeks after initiation of ustekinumab (PASI, 9.8). B, Patient 1. PASI 75 after combining 17 sessions of narrowband UV-B therapy (12.9<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span>) with ustekinumab (PASI, 2.1). PASI indicates Psoriasis Area and Severity Index.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Soro Martínez, I. Belinchón Romero, M.P. Arribas Granados" "autores" => array:3 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Soro Martínez" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Belinchón Romero" ] 2 => array:2 [ "nombre" => "M.P." 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Respuesta al tratamiento combinado con crioterapia y terbinafina" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 650 "Ancho" => 976 "Tamanyo" => 81953 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Firm contiguous plaques with crusted areas on a erythematous base and a larger area with a scar-like appearance.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Bassas-Vila, M.J. Fuente, R. Guinovart, C. Ferrándiz" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Bassas-Vila" ] 1 => array:2 [ "nombre" => "M.J." "apellidos" => "Fuente" ] 2 => array:2 [ "nombre" => "R." 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Sanz-Bueno, G. Pérez-Rial, M. Castellanos, F. Vanaclocha" "autores" => array:4 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Sanz-Bueno" "email" => array:1 [ 0 => "jsanzbueno@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "G." "apellidos" => "Pérez-Rial" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Castellanos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "F." "apellidos" => "Vanaclocha" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina del Aparato Digestivo, Hospital Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Enfermedad injerto contra huésped liquenoide tras trasplante hepático con afectación exclusivamente cutánea" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1050 "Ancho" => 1400 "Tamanyo" => 529635 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Hyperkeratosis with parakeratosis, vacuolization of the basal layer of the epidermis, necrosis of keratinocytes and lymphocytic infiltrate in the dermis (hematoxylin-eosin, original magnification ×10). B, Detail of histologic image showing hair follicle with keratinocyte necrosis (hematoxylin-eosin, original magnification ×40).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">While graft-vs-host disease (GVHD) is a common complication in bone marrow transplantation, it is rare in liver transplantation, with an estimated incidence of around 1% or 2%.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Since GVHD was first described in a liver-transplant recipient in 1988,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> approximately 80 cases have been reported and the vast majority of these have been acute cases. We present a case of chronic lichenoid GVHD in a liver-transplant recipient that presented with exclusively cutaneous involvement and mixed chimerism observed in skin but not peripheral blood samples.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient, a 70-year-old man, had undergone a cadaveric liver transplant for cirrhosis due to hepatitis C virus infection. The crossmatch results were negative. The HLA of the donor was *1 A*68 B*39 B*39 DRB1*17 DRB1 *17 while that of the recipient was A*1 A*1 B*35 B*78 DRB1*13 DRB1*13. The patient was started on immunosuppressive treatment with tacrolimus and prednisone and was also prescribed ranitidine for gastric protection. On day 16 posttransplant, he developed an asymptomatic centrifugal maculopapular rash. The blood test results were normal and serology for cytomegalovirus, Epstein-Barr virus, and parvovirus B19 were negative for acute infection. A drug-induced reaction was therefore suspected and the skin biopsy findings were consistent with this hypothesis. Ranitidine was identified as the most probable cause and withdrawn; prednisone doses were increased to 1<span class="elsevierStyleHsp" style=""></span>mg/kg/d, but no improvement was observed. A liver biopsy showed nonspecific inflammation and there was no evidence of rejection or GVHD. The patient's condition continued to worsen over the weeks. On day 122, multiple lichenoid plaques with a necrotic component covered a large area of his body (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B) and there were also whitish papules in a cobblestone pattern on the oral mucosa (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). Repeated skin biopsies showed interface dermatitis, a perivascular infiltrate in the dermis, and necrosis of keratinocytes in the epidermis and hair follicle (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Analysis of peripheral blood was negative for chimerism, but mixed chimerism (90% donor cells) was detected in the affected skin. Following the diagnosis of GVHD, immunosuppressive therapy was intensified; the patient was administered prednisone 1.5<span class="elsevierStyleHsp" style=""></span>mg/kg/d and tacrolimus to maintain blood levels at 10-12<span class="elsevierStyleHsp" style=""></span>ng/mL, but lesions continue to appear. The patient did not develop diarrhea, cytopenia, or any other systemic symptoms during the course of the disease, and we therefore did not test for GVHD in other organs. On day 180, the patient died of disseminated invasive aspergillosis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Chronic GVHD typically appears either de novo or following recovery from acute GVHD. Only Yilmaz et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> described a similar case to ours, in which acute GVHD progressed to chronic GVHD without a quiescent phase. It is difficult to determine the incidence of acute and chronic GVHD as their clinical and histologic findings overlap<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and the chronological criterion that establishes that acute GVHD occurs within 100 days of transplantation and that chronic GVHD occurs afterwards is insufficient. Lymphoid cells in the transplanted liver are responsible for the immune attack on the host's tissues. The skin, bone marrow, and digestive system are the most common targets. Unlike the situation with hematopoietic cell transplantation, the liver is not a target in this case as it is the engrafted organ. The lymphocytes reach peak levels a week after transplantation, but then become undetectable in the recipient's blood.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The coexistence of donor and host cell populations is known as mixed chimerism and it has been associated with the development of GVHD. Chimerism is detected by polymerase chain reaction, which is a highly sensitive method that can detect donor polymorphisms in host tissue with a sensitivity of up to 0.1%.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In our patient, we tested peripheral blood for chimerism on 2 separate occasions, but the results were negative. We did, however, observe a high rate of donor lymphocytes in lesional skin, suggesting an attack by the immune system. To our knowledge, this is the first time these cells have been described in target tissue without also being present in peripheral blood. We do not know if earlier tests would have detected lymphocytes in peripheral blood, that is, before they had reached the tissues. Cutaneous involvement has been reported in most cases of chronic GVHD in the literature (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), but only 3 of these described a lichenoid pattern.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4,7</span></a> Chimerism in the skin was not tested in any of the cases. Diagnosis of GVHD after liver transplantation is frequently delayed because the condition is rare and has nonspecific signs and symptoms that may be confused with those seen in drug-induced reactions or viral infections. Furthermore, the histology findings are practically indistinguishable from those seen in drug-induced reactions, particularly in the early stages of disease. We would like to stress that chimerism testing in both peripheral blood and affected tissue is a valuable diagnostic tool in GVHD, a potentially fatal disease.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sanz-Bueno J, Pérez-Rial G, Castellanos M, Vanaclocha F. Enfermedad injerto contra huésped liquenoide tras trasplante hepático con afectación exclusivamente cutánea. Actas Dermosifiliogr. 2014;105:198–200.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 896 "Ancho" => 1300 "Tamanyo" => 262076 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Erythematous violaceous lichenoid plaques covering the patient's legs. B, Detail of lichenoid plaques with a necrotic component on the dorsal aspect of the foot. C, Whitish papules arranged in a cobblestone pattern on the oral mucosa.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1050 "Ancho" => 1400 "Tamanyo" => 529635 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Hyperkeratosis with parakeratosis, vacuolization of the basal layer of the epidermis, necrosis of keratinocytes and lymphocytic infiltrate in the dermis (hematoxylin-eosin, original magnification ×10). B, Detail of histologic image showing hair follicle with keratinocyte necrosis (hematoxylin-eosin, original magnification ×40).</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: F, female; M, male; PB, peripheral blood.</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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Age \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">Sex \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">Onset \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Clinical Manifestations \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">Chimerism \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">Course \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">Whitington et al.,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> 1996 \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">9 mo \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">F \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="elsevierStyleHsp" style=""></span>60 d \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">Hematologic, cutaneous \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">Yes, PB \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">Chronic \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">Pinna et al.,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> 1999 \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">8 mo \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">F \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="elsevierStyleHsp" style=""></span>330 d \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">Intestinal \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">Yes, PB \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">Recovery \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="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \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">8 mo \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">M \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="elsevierStyleHsp" style=""></span>230 d \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">FeverIntestinalHematologicCutaneous \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">Yes, PB \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">Recovery \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">Dunn et al.,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> 2001 \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">10 mo \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">F \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="elsevierStyleHsp" style=""></span>6 y \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">IntestinalCutaneous \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">Yes, PB \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">Recovery \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">Nemoto et al.,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> 2003 \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">50 y \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">F \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="elsevierStyleHsp" style=""></span>114 d \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">Cutaneous \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">Yes, PB \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">Recovery \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">Walling et al.,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> 2004 \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">60 y \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">M \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="elsevierStyleHsp" style=""></span>70 d \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">Cutaneous \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">Yes, PB \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">Recovery \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">Yilmaz et al.,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> 2012 \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">49 y \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">M \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="elsevierStyleHsp" style=""></span>50 d \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">CutaneousFeverIntestinalHematologic \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">Not tested \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">Deceased \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab465402.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Characteristics of Chronic Graft-vs-Host Disease After Liver Transplantation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Graft vs host disease after liver transplantation: A new approach is needed" "autores" => 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 10 | 12 | 22 |
| 2024 Octubre | 80 | 41 | 121 |
| 2024 Septiembre | 87 | 27 | 114 |
| 2024 Agosto | 122 | 52 | 174 |
| 2024 Julio | 78 | 48 | 126 |
| 2024 Junio | 79 | 36 | 115 |
| 2024 Mayo | 65 | 41 | 106 |
| 2024 Abril | 85 | 16 | 101 |
| 2024 Marzo | 77 | 36 | 113 |
| 2024 Febrero | 80 | 27 | 107 |
| 2024 Enero | 41 | 25 | 66 |
| 2023 Diciembre | 72 | 21 | 93 |
| 2023 Noviembre | 69 | 26 | 95 |
| 2023 Octubre | 80 | 22 | 102 |
| 2023 Septiembre | 83 | 35 | 118 |
| 2023 Agosto | 48 | 20 | 68 |
| 2023 Julio | 74 | 35 | 109 |
| 2023 Junio | 60 | 25 | 85 |
| 2023 Mayo | 54 | 29 | 83 |
| 2023 Abril | 55 | 22 | 77 |
| 2023 Marzo | 44 | 27 | 71 |
| 2023 Febrero | 36 | 28 | 64 |
| 2023 Enero | 44 | 36 | 80 |
| 2022 Diciembre | 49 | 35 | 84 |
| 2022 Noviembre | 22 | 32 | 54 |
| 2022 Octubre | 25 | 20 | 45 |
| 2022 Septiembre | 38 | 38 | 76 |
| 2022 Agosto | 18 | 45 | 63 |
| 2022 Julio | 34 | 35 | 69 |
| 2022 Junio | 28 | 24 | 52 |
| 2022 Mayo | 37 | 34 | 71 |
| 2022 Abril | 44 | 35 | 79 |
| 2022 Marzo | 59 | 51 | 110 |
| 2022 Febrero | 46 | 27 | 73 |
| 2022 Enero | 69 | 38 | 107 |
| 2021 Diciembre | 43 | 32 | 75 |
| 2021 Noviembre | 40 | 47 | 87 |
| 2021 Octubre | 39 | 50 | 89 |
| 2021 Septiembre | 44 | 42 | 86 |
| 2021 Agosto | 34 | 42 | 76 |
| 2021 Julio | 38 | 30 | 68 |
| 2021 Junio | 32 | 35 | 67 |
| 2021 Mayo | 41 | 34 | 75 |
| 2021 Abril | 92 | 24 | 116 |
| 2021 Marzo | 46 | 18 | 64 |
| 2021 Febrero | 86 | 30 | 116 |
| 2021 Enero | 39 | 13 | 52 |
| 2020 Diciembre | 55 | 12 | 67 |
| 2020 Noviembre | 32 | 17 | 49 |
| 2020 Octubre | 33 | 17 | 50 |
| 2020 Septiembre | 38 | 12 | 50 |
| 2020 Agosto | 29 | 11 | 40 |
| 2020 Julio | 34 | 15 | 49 |
| 2020 Junio | 56 | 24 | 80 |
| 2020 Mayo | 28 | 18 | 46 |
| 2020 Abril | 32 | 16 | 48 |
| 2020 Marzo | 34 | 18 | 52 |
| 2020 Febrero | 4 | 2 | 6 |
| 2020 Enero | 4 | 2 | 6 |
| 2019 Diciembre | 8 | 3 | 11 |
| 2019 Noviembre | 4 | 2 | 6 |
| 2019 Octubre | 0 | 2 | 2 |
| 2019 Septiembre | 8 | 0 | 8 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 6 | 25 | 31 |
| 2019 Mayo | 4 | 7 | 11 |
| 2019 Abril | 2 | 5 | 7 |
| 2019 Marzo | 2 | 6 | 8 |
| 2019 Febrero | 2 | 2 | 4 |
| 2019 Enero | 15 | 2 | 17 |
| 2018 Diciembre | 0 | 2 | 2 |
| 2018 Noviembre | 3 | 2 | 5 |
| 2018 Octubre | 3 | 1 | 4 |
| 2018 Septiembre | 3 | 0 | 3 |
| 2018 Marzo | 1 | 0 | 1 |
| 2018 Febrero | 33 | 3 | 36 |
| 2018 Enero | 44 | 5 | 49 |
| 2017 Diciembre | 44 | 6 | 50 |
| 2017 Noviembre | 34 | 3 | 37 |
| 2017 Octubre | 33 | 4 | 37 |
| 2017 Septiembre | 37 | 2 | 39 |
| 2017 Agosto | 53 | 4 | 57 |
| 2017 Julio | 52 | 11 | 63 |
| 2017 Junio | 57 | 13 | 70 |
| 2017 Mayo | 55 | 8 | 63 |
| 2017 Abril | 56 | 12 | 68 |
| 2017 Marzo | 46 | 15 | 61 |
| 2017 Febrero | 33 | 7 | 40 |
| 2017 Enero | 35 | 4 | 39 |
| 2016 Diciembre | 42 | 13 | 55 |
| 2016 Noviembre | 66 | 7 | 73 |
| 2016 Octubre | 92 | 7 | 99 |
| 2016 Septiembre | 157 | 10 | 167 |
| 2016 Agosto | 51 | 5 | 56 |
| 2016 Julio | 36 | 6 | 42 |
| 2016 Junio | 15 | 6 | 21 |
| 2016 Mayo | 6 | 6 | 12 |
| 2016 Abril | 3 | 2 | 5 |
| 2016 Marzo | 2 | 0 | 2 |
| 2016 Febrero | 8 | 1 | 9 |
| 2016 Enero | 10 | 1 | 11 |
| 2015 Diciembre | 5 | 2 | 7 |
| 2015 Noviembre | 5 | 2 | 7 |
| 2015 Octubre | 11 | 1 | 12 |
| 2015 Septiembre | 8 | 0 | 8 |
| 2015 Agosto | 6 | 1 | 7 |
| 2015 Julio | 90 | 9 | 99 |
| 2015 Junio | 40 | 3 | 43 |
| 2015 Mayo | 61 | 6 | 67 |
| 2015 Abril | 28 | 3 | 31 |
| 2015 Marzo | 58 | 0 | 58 |
| 2015 Febrero | 44 | 2 | 46 |
| 2015 Enero | 29 | 3 | 32 |
| 2014 Diciembre | 36 | 2 | 38 |
| 2014 Noviembre | 38 | 4 | 42 |
| 2014 Octubre | 35 | 1 | 36 |
| 2014 Septiembre | 32 | 2 | 34 |
| 2014 Agosto | 25 | 2 | 27 |
| 2014 Julio | 33 | 5 | 38 |
| 2014 Junio | 40 | 4 | 44 |
| 2014 Mayo | 39 | 6 | 45 |
| 2014 Abril | 40 | 8 | 48 |
| 2014 Marzo | 13 | 4 | 17 |
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