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Analysis of a new biopsy specimen showed a superficial and deep perivascular lymphocytic infiltrate composed of mature cells and with no cytologic atypia &#40;CD4<span class="elsevierStyleSup">&#43;</span>&#44; CD2<span class="elsevierStyleSup">&#43;</span>&#44; and CD5<span class="elsevierStyleSup">&#43;</span> &#91;majority&#93;&#59; CD8<span class="elsevierStyleSup">&#43;</span>&#44; CD79<span class="elsevierStyleSup">&#43;</span>&#44; and CD20<span class="elsevierStyleSup">&#43;</span> &#91;minority&#93;&#59; occasional CD30<span class="elsevierStyleSup">&#43;</span>&#41; accompanied by histiocytes &#40;CD68<span class="elsevierStyleSup">&#43;</span>&#41; and plasma cells&#46; No epidermal or hypodermal abnormalities or mucin were observed&#46; Hydroxyurea and acetylsalicylic acid were suspended despite the low degree of suspected causality&#44; and treatment with doxycycline 100<span class="elsevierStyleHsp" style=""></span>mg&#47;d was prescribed for 2 months&#44; although the lesions did not resolve completely&#46; One year later&#44; the patient experienced a new outbreak of nodules and plaques on the upper and lower limbs&#46; Body hair&#44; sensitivity&#44; and sweating remained unaffected &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Examination of the biopsy revealed a superficial and deep histiocytic inflammatory infiltrate that tended to form interstitial granulomas in some areas and nodular granulomas in others &#40;no fibrinoid necrosis&#41;&#46; The granulomas were surrounded by mature lymphocytes &#40;CD4<span class="elsevierStyleSup">&#43;</span>&#44; CD8<span class="elsevierStyleSup">&#8211;</span>&#44; CD20<span class="elsevierStyleSup">&#8211;</span>&#44; and CD30<span class="elsevierStyleSup">&#8211;</span>&#41; with no cytologic atypia &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; No intracytoplasmic histiocytic bodies suggestive of leishmaniasis were observed&#46; Similarly&#44; no exogenous material was visible to the naked eye or under polarized light&#46; The results of Ziehl-Neelsen staining&#44; culture &#40;bacteria&#44; mycobacteria&#44; and fungi&#41;&#44; and serology testing &#40;human immunodeficiency virus and syphilis&#41; were negative&#46; The results for acute phase reactants and autoimmunity studies &#40;antinuclear antibodies&#44; anti&#8211;native DNA antibodies&#44; anti&#8211;extractable nuclear antigen antibodies&#44; and complement &#91;C3 and C4&#93;&#41; were normal&#46; Polymerase chain reaction was not performed to rule out leishmaniasis&#44; since the intermittent lesions resolved with corticosteroids or without treatment&#46; Once the diagnosis of granulomatous dermatitis had been confirmed&#44; the previously discontinued drugs were reintroduced&#44; with no worsening of the patient&#39;s condition&#46; At present&#44; the patient is stable with prednisone every 48<span class="elsevierStyleHsp" style=""></span>hours&#44; and&#44; while the infiltration has diminished&#44; it has not resolved&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Patient 2</span><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 74-year-old Spanish man who had never traveled outside Spain&#46; He had been diagnosed with refractory anemia with excess blasts type 1 a year previously and was referred with skin lesions accompanied by arthralgia and no signs of frank arthritis&#46; The lesions were erythematous plaques measuring 2-3<span class="elsevierStyleHsp" style=""></span>cm on his forehead&#44; neck&#44; and cheek&#46; Sensitivity&#44; body hair&#44; and sweating remained unaffected &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Three months earlier he had presented with similar lesions 1 month after the first cycle of therapy with azacytidine&#59; the lesions resolved completely with prednisone at 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#46; The skin biopsy revealed a superficial&#44; deep&#44; periadnexal perivascular inflammatory infiltrate consisting of mature lymphocytes without atypia accompanied by interstitial histiocytic granulomas &#40;no necrosis&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#44; scant eosinophils&#44; and multinucleated giant cells&#46; Vacuolar degeneration of the basement membrane and necrotic keratinocytes were observed in specific areas&#46; Standard microscopy and polarized light microscopy revealed no foreign bodies or intracytoplasmic bodies&#46; The results of culture and serology testing for syphilis and human immunodeficiency virus were negative&#46; Immunohistochemistry &#40;CD15 staining&#41; revealed few cells&#46; The results of direct immunofluorescence &#40;IgG&#44; IgM&#44; IgA&#44; C3&#44; and fibrinogen&#41; and Ziehl-Neelsen staining were also negative&#46; The blood workup was remarkable&#8212;other than for the patient&#39;s myelodysplasia&#8212;for levels of C-reactive protein &#40;16&#46;7<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; and the erythrocyte sedimentation rate &#40;88<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; All other parameters&#8212;antinuclear antibodies&#44; anti&#8211;native DNA antibodies&#44; anti&#8211;extractable nuclear antigen antibodies&#44; and complement &#40;C3&#44; and C4&#41;&#8212;were normal&#46; As in the previous case&#44; no molecular studies to rule out leishmaniasis were performed&#46; The lesions resolved without treatment after 1 month and did not reappear with subsequent cycles of azacytidine&#46; Three years later&#44; the myelodysplasia has progressed to acute myeloid leukemia&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">In 1993&#44; Vestey et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> reported the first 2 cases of granulomatous skin lesions associated with myelodysplastic syndrome&#59; the cases involved diffuse papular eruptions with histology of sarcoidosis in one case and granuloma annulare in the other&#46; Again in 1993&#44; Ackerman<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> first reported the pattern of IGD&#44; which in this case was associated with rheumatoid arthritis&#44; as a dermal infiltrate composed mainly of histiocytes distributed interstitially and in palisades around small bundles of degenerated collagen&#44; with scant or no mucin deposits and a limited number of eosinophils and neutrophils&#46; Katz<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> was the first to describe a cutaneous granulomatous eruption that differed from granuloma annulare&#44; sarcoidosis&#44; and IGD&#46; The eruption was described as a multinodular&#44; perivascular&#44; and periadnexal histiocytic infiltrate with small lymphocytes and plasma cells&#46; As in patient 2 &#40;see above&#41;&#44; this eruption involved medium-sized erythematous nodules &#40;1-5<span class="elsevierStyleHsp" style=""></span>cm&#41; on the face&#44; scalp&#44; and neck&#46; The author described the finding simply as a cutaneous granulomatous eruption&#46; The report was published because of the association between the eruption and myelodysplasia&#46; Aung et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> recently used the term NIGD to describe a case associated with myelodysplasia&#59; the case reported by Katz could be included under this term&#46; The case report described a large erythematous plaque covering the patient&#39;s arm and mimicking cellulitis&#44; followed by the appearance of 2 linear plaques on the elbow&#46; Cornejo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> performed a joint analysis of biopsy specimens from IGD and NIGD at different stages of development in lesions from the same patient with myelodysplasia&#59; the first corresponded to papular lesions and the second to nodules&#46; It is noteworthy that&#44; in this case&#44; a third biopsy specimen from a more disseminated phase of the patient&#39;s skin disease revealed that the granulomatous pattern merged with leukemia cutis &#40;cells with large myeloperoxidase-positive hyperchromatic nuclei&#41;&#46; Progression of leukemia was subsequently confirmed in bone marrow&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In addition to the clinical findings of a papular eruption&#44; nodules&#44; and a large plaque mimicking pyodermatitis reported to date&#44; attention should be drawn to the findings of Patsinakidis et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> who reported large urticariform and annular plaques on the thighs&#44; trunk&#44; and arms&#44; with biopsy-proven IGD in the context of myelodysplasia&#46; The most extensive disease was reported by Balin et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> who described histopathologically confirmed IGD in the form of plaques and papules coalescing on the trunk and limbs and covering 80&#37; of the total body surface&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the first case we report&#44; the biopsy specimens revealed various histopathological patterns developing in parallel&#44; thus demonstrating a histological spectrum within this reactive process&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The cases we report here are the first case in which NIGD is associated with PV and the seventh in which granulomatous dermatitis is associated with myelodysplasia in a broad context &#40;granuloma annulare&#44; sarcoidosis&#44; IGD&#44; and NIGD&#41;&#46; We feel that these cases should be brought together under the wider term granulomatous dermatitis&#44; which would include all the subtypes&#44; thus giving precedence to the fact that these granulomas are a reactive or paraneoplastic manifestation of hematologic disorders&#44; such as myelodysplasia and PV&#46; Therefore&#44; at least 1 complete blood count should be performed as part of the extension study in these patients&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical Disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of humans and animals</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that no tests were carried out in humans or animals for the purpose of this study&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Confidentiality of data</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data appear in this article&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Right to privacy and informed consent</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors obtained informed consent from the patients and&#47;or subjects referred to in this article&#46; This document is held by the corresponding author&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflicts of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            0 => "Dermatitis granulomatosa"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Granulomatous dermatitis has been associated with hematologic disorders&#44; including the myelodysplastic syndromes&#46; We describe the first case of granulomatous dermatitis associated with polycythemia vera&#44; presenting as large erythematous nodules mimicking panniculitis&#46; We also present the seventh case associated with myelodysplasia&#44; with erythematous plaques on the face and neck&#44; similar to a neutrophilic dermatosis&#46; We consider it particularly interesting for dermatologists to be aware of this dermatosis as a nonspecific manifestation of various hematologic disorders&#46; We suggest performing additional tests &#40;complete blood count&#41; to exclude the possibility that the skin manifestations are the initial sign of hematologic disease&#46; Furthermore&#44; we propose using the broader term&#44; granulomatous dermatitis&#44; to refer to these disorders as&#44; although there are more reports of interstitial forms&#44; cases with a more nodular presentation have also been published&#44; and the importance of the diagnosis derives not from the subtype but from the relationship with an underlying disease&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las dermatitis de patr&#243;n granulomatoso se han relacionado con trastornos hematol&#243;gicos&#44; entre ellos los s&#237;ndromes mielodispl&#225;sicos&#46; En este art&#237;culo se describe el primer caso de dermatitis granulomatosa asociado a policitemia vera&#44; en forma de grandes n&#243;dulos eritematosos simulando paniculitis&#44; y el s&#233;ptimo caso asociado a mielodisplasia&#44; con placas eritematosas en cara y cuello que recordaban a una dermatosis neutrof&#237;lica&#46; Consideramos de especial inter&#233;s para el dermat&#243;logo conocer esta dermatosis como manifestaci&#243;n no espec&#237;fica de diferentes trastornos hematol&#243;gicos&#44; y sugerimos la realizaci&#243;n de un estudio complementario &#40;hemograma&#41; en el caso de que la cl&#237;nica cut&#225;nea sea el comienzo&#46; Del mismo modo&#44; proponemos el t&#233;rmino m&#225;s amplio de dermatitis granulomatosas para denominarlas&#44; puesto que&#44; si bien las formas intersticiales son m&#225;s numerosas en la literatura&#44; tambi&#233;n se han publicado casos m&#225;s nodulares&#44; y la importancia de su diagn&#243;stico no radica en el subtipo sino en su relaci&#243;n con un trastorno subyacente&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Lozano-Masdemont B&#44; Baniandr&#233;s-Rodr&#237;guez O&#44; Parra-Blanco V&#44; Su&#225;rez-Fern&#225;ndez R&#46; Dermatitis granulomatosa como manifestaci&#243;n cut&#225;nea de trastornos hematol&#243;gicos&#58; primer caso asociado a policitemia vera y un nuevo caso asociado a mielodisplasia&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;e27&#8211;e32&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A&#44; Erythematous plaques on the outer surface of the arm&#46; B&#44; Similar lesions on the back&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A&#44; Round erythematous plaque with marked infiltration in the center of the nodule&#46; B&#44; Annular erythematous plaque on the other leg&#46; C&#44; Isolated plaque on the arm&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A&#44; Superficial and deep dermal inflammatory infiltrate &#40;hematoxylin-eosin&#44; original magnification&#44; &#215;4&#41;&#46; B&#44; Tendency to form interstitial granulomas in some areas&#44; with a more nodular appearance in others &#40;no fibrinoid necrosis&#41;&#44; surrounded by mature lymphocytes without cytologic atypia &#40;hematoxylin-eosin&#44; original magnification&#44; &#215;10&#41;&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A&#44; Superficial and deep perivascular and periadnexal inflammatory infiltrate &#40;hematoxylin-eosin&#44; original magnification&#44; &#215;4&#41;&#46; B&#44; Inflammatory infiltrate composed of mature lymphocytes and interstitial histiocytic granulomas&#44; without necrosis &#40;hematoxylin-eosin&#44; original magnification&#44; &#215;20&#41;&#46;</p>"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "A&#46;B&#46; Ackerman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:7 [
                        "editores" => "A&#46;B&#46;AckermanY&#46;GuoP&#46;VitaleA&#46;Patricia"
                        "paginaInicial" => "309"
                        "paginaFinal" => "312"
                        "edicion" => "1st ed"
                        "serieVolumen" => "Vol&#46; 3"
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                        "serieFecha" => "1993"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Interstitial granulomatous dermatitis&#58; A distinct entity with characteristic histological and clinical pattern"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46; Peroni"
                            1 => "C&#46; Colato"
                            2 => "D&#46; Schena"
                            3 => "P&#46; Gisondi"
                            4 => "G&#46; Girolomoni"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2133.2011.10727.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol"
                        "fecha" => "2012"
                        "volumen" => "166"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22059717"
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                    ]
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                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Interstitial granulomatous dermatitis secondary to acute promyelocytic leukemia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "D&#46;C Swing Jr&#46;"
                            1 => "D&#46;J&#46; Sheehan"
                            2 => "O&#46;P&#46; Sang&#252;eza"
                            3 => "R&#46;W&#46; Woodruff"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/DAD.0b013e318162af78"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Dermatopathol&#46;"
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            ]
            3 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Interstitial granulomatous dermatitis with arthritis accompanied by anaplastic large cell lymphoma"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
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Case Report
Granulomatous Dermatitis as a Cutaneous Manifestation of Hematologic Disorders: The First Case Associated With Polycythemia Vera and a New Case Associated With Myelodysplasia
Dermatitis granulomatosa como manifestación cutánea de trastornos hematológicos: primer caso asociado a policitemia vera y un nuevo caso asociado a mielodisplasia
B. Lozano-Masdemonta,
Autor para correspondencia
belenmasdemont@gmail.com

Corresponding author.
, O. Baniandrés-Rodrígueza, V. Parra-Blancob, R. Suárez-Fernándeza
a Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
b Servicio de Anatomía Patológica, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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    "titulo" => "Granulomatous Dermatitis as a Cutaneous Manifestation of Hematologic Disorders&#58; The First Case Associated With Polycythemia Vera and a New Case Associated With Myelodysplasia"
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        "titulo" => "Dermatitis granulomatosa como manifestaci&#243;n cut&#225;nea de trastornos hematol&#243;gicos&#58; primer caso asociado a policitemia vera y un nuevo caso asociado a mielodisplasia"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A&#44; Erythematous plaques on the outer surface of the arm&#46; B&#44; Similar lesions on the back&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Since it was first described in association with rheumatoid arthritis&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> interstitial granulomatous dermatitis &#40;IGD&#41; has been associated with hematologic diseases&#44;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#8211;4</span></a> specifically&#44; myelodysplastic syndromes&#44; which account for most cases&#46; Here&#44; we report the first case of noninterstitial granulomatous dermatitis &#40;NIGD&#41; associated with polycythemia vera &#40;PV&#41; and a new case of IGD associated with myelodysplasia&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Descriptions</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Patient 1</span><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 72-year-old Spanish woman who had never traveled outside Europe and had a history of PV that was being treated with hydroxyurea and acetylsalicylic acid&#46; She reported the onset of diffuse skin lesions 5 years after diagnosis of her hematologic disease&#46; The lesions consisted of 15-20 erythematous plaques measuring 1-3<span class="elsevierStyleHsp" style=""></span>cm on her back&#44; chest&#44; and the outer surface of both arms&#46; The diagnoses proposed were infection&#44; neutrophilic dermatosis&#44; and lupus tumidus &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The initial biopsy revealed a superficial and deep lymphocytic inflammatory infiltrate around the vessels&#44; follicles&#44; and adnexa&#44; with no mucin deposits&#46; The findings were compatible with a diagnosis of lupus tumidus&#46; The patient refused treatment with hydroxychloroquine&#46; The lesions eventually resolved without treatment&#44; although they did reappear&#46; Eighteen months later&#44; lesions similar to the original lesions and 4 large erythematous painless nodules appeared on both legs&#44; indicating lupus panniculitis&#46; Analysis of a new biopsy specimen showed a superficial and deep perivascular lymphocytic infiltrate composed of mature cells and with no cytologic atypia &#40;CD4<span class="elsevierStyleSup">&#43;</span>&#44; CD2<span class="elsevierStyleSup">&#43;</span>&#44; and CD5<span class="elsevierStyleSup">&#43;</span> &#91;majority&#93;&#59; CD8<span class="elsevierStyleSup">&#43;</span>&#44; CD79<span class="elsevierStyleSup">&#43;</span>&#44; and CD20<span class="elsevierStyleSup">&#43;</span> &#91;minority&#93;&#59; occasional CD30<span class="elsevierStyleSup">&#43;</span>&#41; accompanied by histiocytes &#40;CD68<span class="elsevierStyleSup">&#43;</span>&#41; and plasma cells&#46; No epidermal or hypodermal abnormalities or mucin were observed&#46; Hydroxyurea and acetylsalicylic acid were suspended despite the low degree of suspected causality&#44; and treatment with doxycycline 100<span class="elsevierStyleHsp" style=""></span>mg&#47;d was prescribed for 2 months&#44; although the lesions did not resolve completely&#46; One year later&#44; the patient experienced a new outbreak of nodules and plaques on the upper and lower limbs&#46; Body hair&#44; sensitivity&#44; and sweating remained unaffected &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Examination of the biopsy revealed a superficial and deep histiocytic inflammatory infiltrate that tended to form interstitial granulomas in some areas and nodular granulomas in others &#40;no fibrinoid necrosis&#41;&#46; The granulomas were surrounded by mature lymphocytes &#40;CD4<span class="elsevierStyleSup">&#43;</span>&#44; CD8<span class="elsevierStyleSup">&#8211;</span>&#44; CD20<span class="elsevierStyleSup">&#8211;</span>&#44; and CD30<span class="elsevierStyleSup">&#8211;</span>&#41; with no cytologic atypia &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; No intracytoplasmic histiocytic bodies suggestive of leishmaniasis were observed&#46; Similarly&#44; no exogenous material was visible to the naked eye or under polarized light&#46; The results of Ziehl-Neelsen staining&#44; culture &#40;bacteria&#44; mycobacteria&#44; and fungi&#41;&#44; and serology testing &#40;human immunodeficiency virus and syphilis&#41; were negative&#46; The results for acute phase reactants and autoimmunity studies &#40;antinuclear antibodies&#44; anti&#8211;native DNA antibodies&#44; anti&#8211;extractable nuclear antigen antibodies&#44; and complement &#91;C3 and C4&#93;&#41; were normal&#46; Polymerase chain reaction was not performed to rule out leishmaniasis&#44; since the intermittent lesions resolved with corticosteroids or without treatment&#46; Once the diagnosis of granulomatous dermatitis had been confirmed&#44; the previously discontinued drugs were reintroduced&#44; with no worsening of the patient&#39;s condition&#46; At present&#44; the patient is stable with prednisone every 48<span class="elsevierStyleHsp" style=""></span>hours&#44; and&#44; while the infiltration has diminished&#44; it has not resolved&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Patient 2</span><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 74-year-old Spanish man who had never traveled outside Spain&#46; He had been diagnosed with refractory anemia with excess blasts type 1 a year previously and was referred with skin lesions accompanied by arthralgia and no signs of frank arthritis&#46; The lesions were erythematous plaques measuring 2-3<span class="elsevierStyleHsp" style=""></span>cm on his forehead&#44; neck&#44; and cheek&#46; Sensitivity&#44; body hair&#44; and sweating remained unaffected &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Three months earlier he had presented with similar lesions 1 month after the first cycle of therapy with azacytidine&#59; the lesions resolved completely with prednisone at 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#46; The skin biopsy revealed a superficial&#44; deep&#44; periadnexal perivascular inflammatory infiltrate consisting of mature lymphocytes without atypia accompanied by interstitial histiocytic granulomas &#40;no necrosis&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#44; scant eosinophils&#44; and multinucleated giant cells&#46; Vacuolar degeneration of the basement membrane and necrotic keratinocytes were observed in specific areas&#46; Standard microscopy and polarized light microscopy revealed no foreign bodies or intracytoplasmic bodies&#46; The results of culture and serology testing for syphilis and human immunodeficiency virus were negative&#46; Immunohistochemistry &#40;CD15 staining&#41; revealed few cells&#46; The results of direct immunofluorescence &#40;IgG&#44; IgM&#44; IgA&#44; C3&#44; and fibrinogen&#41; and Ziehl-Neelsen staining were also negative&#46; The blood workup was remarkable&#8212;other than for the patient&#39;s myelodysplasia&#8212;for levels of C-reactive protein &#40;16&#46;7<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; and the erythrocyte sedimentation rate &#40;88<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; All other parameters&#8212;antinuclear antibodies&#44; anti&#8211;native DNA antibodies&#44; anti&#8211;extractable nuclear antigen antibodies&#44; and complement &#40;C3&#44; and C4&#41;&#8212;were normal&#46; As in the previous case&#44; no molecular studies to rule out leishmaniasis were performed&#46; The lesions resolved without treatment after 1 month and did not reappear with subsequent cycles of azacytidine&#46; Three years later&#44; the myelodysplasia has progressed to acute myeloid leukemia&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">In 1993&#44; Vestey et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> reported the first 2 cases of granulomatous skin lesions associated with myelodysplastic syndrome&#59; the cases involved diffuse papular eruptions with histology of sarcoidosis in one case and granuloma annulare in the other&#46; Again in 1993&#44; Ackerman<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> first reported the pattern of IGD&#44; which in this case was associated with rheumatoid arthritis&#44; as a dermal infiltrate composed mainly of histiocytes distributed interstitially and in palisades around small bundles of degenerated collagen&#44; with scant or no mucin deposits and a limited number of eosinophils and neutrophils&#46; Katz<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> was the first to describe a cutaneous granulomatous eruption that differed from granuloma annulare&#44; sarcoidosis&#44; and IGD&#46; The eruption was described as a multinodular&#44; perivascular&#44; and periadnexal histiocytic infiltrate with small lymphocytes and plasma cells&#46; As in patient 2 &#40;see above&#41;&#44; this eruption involved medium-sized erythematous nodules &#40;1-5<span class="elsevierStyleHsp" style=""></span>cm&#41; on the face&#44; scalp&#44; and neck&#46; The author described the finding simply as a cutaneous granulomatous eruption&#46; The report was published because of the association between the eruption and myelodysplasia&#46; Aung et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> recently used the term NIGD to describe a case associated with myelodysplasia&#59; the case reported by Katz could be included under this term&#46; The case report described a large erythematous plaque covering the patient&#39;s arm and mimicking cellulitis&#44; followed by the appearance of 2 linear plaques on the elbow&#46; Cornejo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> performed a joint analysis of biopsy specimens from IGD and NIGD at different stages of development in lesions from the same patient with myelodysplasia&#59; the first corresponded to papular lesions and the second to nodules&#46; It is noteworthy that&#44; in this case&#44; a third biopsy specimen from a more disseminated phase of the patient&#39;s skin disease revealed that the granulomatous pattern merged with leukemia cutis &#40;cells with large myeloperoxidase-positive hyperchromatic nuclei&#41;&#46; Progression of leukemia was subsequently confirmed in bone marrow&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In addition to the clinical findings of a papular eruption&#44; nodules&#44; and a large plaque mimicking pyodermatitis reported to date&#44; attention should be drawn to the findings of Patsinakidis et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> who reported large urticariform and annular plaques on the thighs&#44; trunk&#44; and arms&#44; with biopsy-proven IGD in the context of myelodysplasia&#46; The most extensive disease was reported by Balin et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> who described histopathologically confirmed IGD in the form of plaques and papules coalescing on the trunk and limbs and covering 80&#37; of the total body surface&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the first case we report&#44; the biopsy specimens revealed various histopathological patterns developing in parallel&#44; thus demonstrating a histological spectrum within this reactive process&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The cases we report here are the first case in which NIGD is associated with PV and the seventh in which granulomatous dermatitis is associated with myelodysplasia in a broad context &#40;granuloma annulare&#44; sarcoidosis&#44; IGD&#44; and NIGD&#41;&#46; We feel that these cases should be brought together under the wider term granulomatous dermatitis&#44; which would include all the subtypes&#44; thus giving precedence to the fact that these granulomas are a reactive or paraneoplastic manifestation of hematologic disorders&#44; such as myelodysplasia and PV&#46; Therefore&#44; at least 1 complete blood count should be performed as part of the extension study in these patients&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical Disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of humans and animals</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that no tests were carried out in humans or animals for the purpose of this study&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Confidentiality of data</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data appear in this article&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Right to privacy and informed consent</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors obtained informed consent from the patients and&#47;or subjects referred to in this article&#46; This document is held by the corresponding author&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflicts of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Granulomatous dermatitis has been associated with hematologic disorders&#44; including the myelodysplastic syndromes&#46; We describe the first case of granulomatous dermatitis associated with polycythemia vera&#44; presenting as large erythematous nodules mimicking panniculitis&#46; We also present the seventh case associated with myelodysplasia&#44; with erythematous plaques on the face and neck&#44; similar to a neutrophilic dermatosis&#46; We consider it particularly interesting for dermatologists to be aware of this dermatosis as a nonspecific manifestation of various hematologic disorders&#46; We suggest performing additional tests &#40;complete blood count&#41; to exclude the possibility that the skin manifestations are the initial sign of hematologic disease&#46; Furthermore&#44; we propose using the broader term&#44; granulomatous dermatitis&#44; to refer to these disorders as&#44; although there are more reports of interstitial forms&#44; cases with a more nodular presentation have also been published&#44; and the importance of the diagnosis derives not from the subtype but from the relationship with an underlying disease&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las dermatitis de patr&#243;n granulomatoso se han relacionado con trastornos hematol&#243;gicos&#44; entre ellos los s&#237;ndromes mielodispl&#225;sicos&#46; En este art&#237;culo se describe el primer caso de dermatitis granulomatosa asociado a policitemia vera&#44; en forma de grandes n&#243;dulos eritematosos simulando paniculitis&#44; y el s&#233;ptimo caso asociado a mielodisplasia&#44; con placas eritematosas en cara y cuello que recordaban a una dermatosis neutrof&#237;lica&#46; Consideramos de especial inter&#233;s para el dermat&#243;logo conocer esta dermatosis como manifestaci&#243;n no espec&#237;fica de diferentes trastornos hematol&#243;gicos&#44; y sugerimos la realizaci&#243;n de un estudio complementario &#40;hemograma&#41; en el caso de que la cl&#237;nica cut&#225;nea sea el comienzo&#46; Del mismo modo&#44; proponemos el t&#233;rmino m&#225;s amplio de dermatitis granulomatosas para denominarlas&#44; puesto que&#44; si bien las formas intersticiales son m&#225;s numerosas en la literatura&#44; tambi&#233;n se han publicado casos m&#225;s nodulares&#44; y la importancia de su diagn&#243;stico no radica en el subtipo sino en su relaci&#243;n con un trastorno subyacente&#46;</p></span>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A&#44; Erythematous plaques on the outer surface of the arm&#46; B&#44; Similar lesions on the back&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A&#44; Round erythematous plaque with marked infiltration in the center of the nodule&#46; B&#44; Annular erythematous plaque on the other leg&#46; C&#44; Isolated plaque on the arm&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A&#44; Superficial and deep dermal inflammatory infiltrate &#40;hematoxylin-eosin&#44; original magnification&#44; &#215;4&#41;&#46; B&#44; Tendency to form interstitial granulomas in some areas&#44; with a more nodular appearance in others &#40;no fibrinoid necrosis&#41;&#44; surrounded by mature lymphocytes without cytologic atypia &#40;hematoxylin-eosin&#44; original magnification&#44; &#215;10&#41;&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A&#44; Superficial and deep perivascular and periadnexal inflammatory infiltrate &#40;hematoxylin-eosin&#44; original magnification&#44; &#215;4&#41;&#46; B&#44; Inflammatory infiltrate composed of mature lymphocytes and interstitial histiocytic granulomas&#44; without necrosis &#40;hematoxylin-eosin&#44; original magnification&#44; &#215;20&#41;&#46;</p>"
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