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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We report the case of an elderly man with a granulomatous variant of chronic pigmented purpura who presented with papular lesions on the lower legs&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 78-year-old Japanese man complained of asymptomatic eruptions of 2 years&#8217; duration on his lower legs&#46; He had no history of systemic granulomatous disease and had not taken any drugs&#46; Physical examination showed a number of purpuric papular lesions on both shins &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A and B&#41;&#46; The lesions were tiny&#44; ranging from the size of a pinhead to 5<span class="elsevierStyleHsp" style=""></span>mm&#44; and were both isolated and arranged in clusters&#46; Laboratory data&#44; which included blood cell counts&#44; biochemical liver and renal function tests&#44; and lipid&#44; cholesterol&#44; and triglyceride levels were normal&#46; Histologic examination revealed extravasation of red blood cells&#44; hemosiderin deposition&#44; and dense inflammatory cell infiltration in the upper dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; The infiltrate was composed of mononuclear cells&#44; histiocytes&#44; and giant cells &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#44; and immunohistochemistry revealed a number of CD3<span class="elsevierStyleSup">&#43;</span> T cells&#44; with a predominance of CD4<span class="elsevierStyleSup">&#43;</span> cells&#46; There were also CD8<span class="elsevierStyleSup">&#43;</span> T cells scattered among the granulomatous lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#8211;E&#41; and abundant CD68<span class="elsevierStyleSup">&#43;</span> cells at the periphery of the cellular infiltrates &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>F&#41;&#46; Vasculitis was not observed&#46; Special stains for microorganisms were all negative&#46; The purpuric lesions were resistant to treatment with topical corticosteroids&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Several cases of granulomatous pigmented purpura have been described since the entity was first reported by Saito and Matsuoka&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Most of the cases have involved Asian people&#44; but there have been few reports from Japan&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Although the clinical features described in the original report included lichen aureus-like brown coalesced hemorrhagic papules on the dorsum of the feet&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> additional features such as macules&#44; papules&#44; plaques&#44; and pigmentation have been reported&#46; Apart from the typical clinical features of chronic pigmented purpura&#44; our patient also had a number of papular lesions on both shins&#44; similarly to a previously reported case&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> The age of the patients with granulomatous pigmented purpura described in the literature ranges from 22 to 78 years old &#40;present case&#41;&#44; with disease duration varying from 2 months to 20 years&#46; In addition to the lower extremities&#44; there have also been rare reports of lesions on the wrists&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> forearms&#44; and lower back&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In our case&#44; histologic features showed dense cellular infiltrates composed of lymphocytes and histiocytes in the upper dermis&#46; CD4<span class="elsevierStyleSup">&#43;</span> cells were predominant among the CD3<span class="elsevierStyleSup">&#43;</span> T cells&#44; C&#44; and CD68<span class="elsevierStyleSup">&#43;</span> histiocytes surrounded the cellular infiltrates in the upper dermis&#46; What triggered the granulomatous reaction is not clear&#44; but the long-term chronic course may have had a role&#46; Hyperlipidemia has been reported in several cases&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> and other studies have suggested that lipid microdroplets may induce an inflammatory reaction of the microvasculature&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Drugs have also been suggested as possible triggers and have been implicated as causative factors of pigmented purpura&#46; In addition&#44; there have been reports of an association with antinuclear antibody and rheumatoid factor positivity&#44; and regulatory T cells were attributed a possible role in the induction of granulomatous changes in pigmented purpura in a patient with Sj&#246;gren syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> In our case&#44; associations with systemic autoimmune diseases&#44; hyperlipidemia&#44; and drug intake were all ruled out&#46; Further studies are necessary to investigate the triggering events and etiology of granulomatous reactions in pigmented purpura&#46;</p></span>"
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Case and Research Letter
Granulomatous Variant of Pigmented Purpura
Variante granulomatosa de púrpura pigmentada
H. Hakenoshita, T. Yamamoto
Autor para correspondencia
toyamade@fmu.ac.jp

Corresponding author.
Department of Dermatology, Shirakawa Kosei General Hospital, and Fukushima Medical University, Fukushima, Japan
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We report the case of an elderly man with a granulomatous variant of chronic pigmented purpura who presented with papular lesions on the lower legs&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 78-year-old Japanese man complained of asymptomatic eruptions of 2 years&#8217; duration on his lower legs&#46; He had no history of systemic granulomatous disease and had not taken any drugs&#46; Physical examination showed a number of purpuric papular lesions on both shins &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A and B&#41;&#46; The lesions were tiny&#44; ranging from the size of a pinhead to 5<span class="elsevierStyleHsp" style=""></span>mm&#44; and were both isolated and arranged in clusters&#46; Laboratory data&#44; which included blood cell counts&#44; biochemical liver and renal function tests&#44; and lipid&#44; cholesterol&#44; and triglyceride levels were normal&#46; Histologic examination revealed extravasation of red blood cells&#44; hemosiderin deposition&#44; and dense inflammatory cell infiltration in the upper dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; The infiltrate was composed of mononuclear cells&#44; histiocytes&#44; and giant cells &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#44; and immunohistochemistry revealed a number of CD3<span class="elsevierStyleSup">&#43;</span> T cells&#44; with a predominance of CD4<span class="elsevierStyleSup">&#43;</span> cells&#46; There were also CD8<span class="elsevierStyleSup">&#43;</span> T cells scattered among the granulomatous lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#8211;E&#41; and abundant CD68<span class="elsevierStyleSup">&#43;</span> cells at the periphery of the cellular infiltrates &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>F&#41;&#46; Vasculitis was not observed&#46; Special stains for microorganisms were all negative&#46; The purpuric lesions were resistant to treatment with topical corticosteroids&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Several cases of granulomatous pigmented purpura have been described since the entity was first reported by Saito and Matsuoka&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Most of the cases have involved Asian people&#44; but there have been few reports from Japan&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Although the clinical features described in the original report included lichen aureus-like brown coalesced hemorrhagic papules on the dorsum of the feet&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> additional features such as macules&#44; papules&#44; plaques&#44; and pigmentation have been reported&#46; Apart from the typical clinical features of chronic pigmented purpura&#44; our patient also had a number of papular lesions on both shins&#44; similarly to a previously reported case&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> The age of the patients with granulomatous pigmented purpura described in the literature ranges from 22 to 78 years old &#40;present case&#41;&#44; with disease duration varying from 2 months to 20 years&#46; In addition to the lower extremities&#44; there have also been rare reports of lesions on the wrists&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> forearms&#44; and lower back&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In our case&#44; histologic features showed dense cellular infiltrates composed of lymphocytes and histiocytes in the upper dermis&#46; CD4<span class="elsevierStyleSup">&#43;</span> cells were predominant among the CD3<span class="elsevierStyleSup">&#43;</span> T cells&#44; C&#44; and CD68<span class="elsevierStyleSup">&#43;</span> histiocytes surrounded the cellular infiltrates in the upper dermis&#46; What triggered the granulomatous reaction is not clear&#44; but the long-term chronic course may have had a role&#46; Hyperlipidemia has been reported in several cases&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> and other studies have suggested that lipid microdroplets may induce an inflammatory reaction of the microvasculature&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Drugs have also been suggested as possible triggers and have been implicated as causative factors of pigmented purpura&#46; In addition&#44; there have been reports of an association with antinuclear antibody and rheumatoid factor positivity&#44; and regulatory T cells were attributed a possible role in the induction of granulomatous changes in pigmented purpura in a patient with Sj&#246;gren syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> In our case&#44; associations with systemic autoimmune diseases&#44; hyperlipidemia&#44; and drug intake were all ruled out&#46; Further studies are necessary to investigate the triggering events and etiology of granulomatous reactions in pigmented purpura&#46;</p></span>"
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