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Serology for syphilis&#44; hepatitis B and C viruses&#44; and HIV was negative&#46; The Mantoux test was negative&#46; Chest x-ray showed no significant changes of interest&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">A skin biopsy taken from an urticarial plaque showed a lymphocytic and eosinophilic dermal infiltrate with focal changes at the dermoepidermal interface &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2A</a>&#41;&#46; A biopsy was also taken from a blister&#44; revealing a subepidermal blister associated with a lymphocytic and eosinophilic dermal infiltrate &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2B</a>&#41;&#46; Direct immunofluorescence of healthy perilesional skin was positive&#44; showing linear deposits of IgG and C3 at the dermoepidermal junction with a U-serrated pattern &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2C</a>&#41;&#46; Indirect immunofluorescence on 1<span class="elsevierStyleHsp" style=""></span>M sodium chloride-separated skin showed the presence of circulating antibasement membrane zone antibodies bound on the epidermal side&#44; at a titer of 1&#58;80&#46; Autoimmune studies were positive for circulating antibasement membrane antibodies against antigens BP-180 and BP-230 detected using the immunoblot technique on the patient&#39;s serum mixed with human epidermal extracts&#46; Other antibodies studied &#40;Sm&#44; RNP&#44; Ro&#44; La&#44; Scl-70&#44; Jo-1&#44; DNAd&#44; antidesmogleins&#44; collagen <span class="elsevierStyleSmallCaps">VII</span>&#44; antidesmocollins&#41; were negative&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">With a diagnosis of BP&#44; treatment was initiated with oral prednisone&#44; 90<span class="elsevierStyleHsp" style=""></span>mg&#47;d &#40;1&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#41;&#44; combined with azathioprine&#44; 100<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#46; Two weeks after starting treatment&#44; the patient presented a progressive clinical improvement&#44; and the dose of prednisone was gradually reduced&#46; At the 6-month follow-up&#44; the patient was stable&#44; with no clinical recurrence&#44; and remained on treatment with prednisone&#44; 20<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#44; and azathioprine&#44; 100<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#59; residual postinflammatory hyperpigmentation and milia-like cysts were observed&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The cutaneous manifestations of BP can be atypical and highly polymorphous&#44; and may or may not include the tense blisters characteristic of this entity&#46; A number of atypical presentations have been described<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;3</span></a>&#58; nonbullous&#44; papular&#44; eczematous&#44; nodular&#44; vesicular&#44; annular erythema-like&#44; erythema multiforme-like&#44; erythrodermic&#44; dyshydrosiform&#44; vegetative&#44; lichen planus pemphogoides&#44; infantile&#44; physical agent-induced&#44; drug-induced&#44; and localized &#40;pretibial&#44; vulvar&#44; peristomal&#44; umbilical&#44; postradiotherapy&#44; paralyzed-limb&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Erythema multiforme-like BP is a rare variant&#44; with only 8 cases reported in the literature &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#8211;9</span></a> including 5 women and 3 men aged between 16 and 80 years&#46; Suspected triggering factors include orf virus infection&#44; furosemide&#44; citalopram&#44; thioridazine&#44; flupentixol&#44; amoxicillin&#44; and penicillin&#46; Lesions have been most common on the trunk and flexor surfaces of the limbs&#44; although they can arise on any area of skin&#44; including the palms and soles and the mucosas&#46; The clinical findings in all cases included manifestations of erythema multiforme and bullous pemphigoid&#44; and the diagnosis was confirmed by the immunopathology findings&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Our case was unusual&#44; with early cutaneous manifestations suggestive of erythema multiforme&#44; with centrifugally enlarging erythematous plaques on acral areas and on the extensor surfaces of the limbs&#44; associated with focal histologic changes at the interface and subepidermal edema&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">BP must be considered in the differential diagnosis in patients with a diffuse erythema multiforme-like skin rash who develop erythematous or urticarial plaques with peripheral blisters&#44; producing an annular or polycyclic morphology&#46; A high level of clinical and histologic suspicion is required&#46; The diagnosis is confirmed by positive direct and indirect immunofluorescence&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;3</span></a></p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Imbern&#243;n-Moya A&#44; Aguilar A&#44; Burgos F&#44; Gallego M&#193;&#46; Penfigoide ampolloso tipo eritema multiforme&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;690&#8211;692&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A&#44; Annular and polycyclic erythematous plaques with tense peripheral blisters on both thighs&#46; B&#44; Detail of the same lesions&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A&#44; Vacuolization of the basal layer of the epidermis with no clear evidence of vesicles or blisters&#44; and the presence of a superficial and deep dermal inflammatory infiltrate with lymphocytes and occasional eosinophils&#46; Hematoxylin and eosin&#44; original magnification<span class="elsevierStyleHsp" style=""></span>&#215;20&#46; B&#44; Subepidermal blister containing fibrin and abundant eosinophils&#44; and a dermal infiltrate of lymphocytes and eosinophils&#46; Marked subepidermal edema is observed close to the blister with early separation of the dermoepidermal junction&#46; Hematoxylin and eosin&#44; original magnification<span class="elsevierStyleHsp" style=""></span>&#215;20&#46;<span class="elsevierStyleHsp" style=""></span>C&#44; Positive direct immunofluorescence with linear deposits of immunoglobulin G and C3 at the dermoepidermal junction&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age&#44; y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Suspected Etiologic Factor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Site of the Lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mucosal Involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Involvement of the Palms and Soles&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alian et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Orf virus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trunk&#44; limbs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Park et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Amlodipine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trunk&#44; limbs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hirano et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Furosemide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Face&#44; neck&#44; flexor surface of the limbs&#44; trunk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hayakawa and Shiohara<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Extensor surface of the limbs&#44; back&#44; buttocks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mehravaran et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Citalopram<br>Thioridazine<br>Flupentixol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Flexor surface of the limbs&#44; neckline&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Alcalay et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Amoxicillin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Face&#44; neck&#44; trunk&#44; limbs</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Yes &#40;oral&#44; nasal&#44; anogenital&#44; ocular&#41;</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Yes</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Penicillin G procaine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Penicillin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Description of the Published Cases of Erythema Multiforme-like Bullous Pemphigoid&#46;</p>"
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    ]
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
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            0 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "P&#46; Bernard"
                            1 => "L&#46; Borradori"
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                  "host" => array:1 [
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                        "titulo" => "Dermatology"
                        "paginaInicial" => "475"
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                        "edicion" => "3rd ed&#46;"
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                            0 => "E&#46; Cozzani"
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                          ]
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              "identificador" => "bib0070"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Amlodipine-associated bullous pemphigoid with erythema multiforme-likeclinical features"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "K&#46;Y&#46; Park"
                            1 => "B&#46;J&#46; Kim"
                            2 => "M&#46;N&#46; Kim"
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                  "host" => array:1 [
                    0 => array:2 [
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                        "fecha" => "2011"
                        "volumen" => "50"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21506992"
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Case and Research Letters
Erythema Multiforme-Like Bullous Pemphigoid
Penfigoide ampolloso tipo eritema multiforme
A. Imbernón-Moyaa,
Autor para correspondencia
adrian_imber88@hotmail.com

Corresponding author.
, A. Aguilara, F. Burgosb, M.Á. Gallegoa
a Servicio de Dermatología, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
b Servicio de Anatomía Patológica, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
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            "entidad" => "Servicio de Anatom&#237;a Patol&#243;gica&#44; Hospital Universitario Severo Ochoa&#44; Legan&#233;s&#44; Madrid&#44; Spain"
            "etiqueta" => "b"
            "identificador" => "aff0010"
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    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Penfigoide ampolloso tipo eritema multiforme"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A&#44; Vacuolization of the basal layer of the epidermis with no clear evidence of vesicles or blisters&#44; and the presence of a superficial and deep dermal inflammatory infiltrate with lymphocytes and occasional eosinophils&#46; Hematoxylin and eosin&#44; original magnification<span class="elsevierStyleHsp" style=""></span>&#215;20&#46; B&#44; Subepidermal blister containing fibrin and abundant eosinophils&#44; and a dermal infiltrate of lymphocytes and eosinophils&#46; Marked subepidermal edema is observed close to the blister with early separation of the dermoepidermal junction&#46; Hematoxylin and eosin&#44; original magnification<span class="elsevierStyleHsp" style=""></span>&#215;20&#46;<span class="elsevierStyleHsp" style=""></span>C&#44; Positive direct immunofluorescence with linear deposits of immunoglobulin G and C3 at the dermoepidermal junction&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Bullous pemphigoid &#40;BP&#41; is the most common chronic autoimmune subepidermal bullous dermatosis&#44; occurring mainly in the elderly&#46; It is characterized clinically by a pruritic polymorphous skin rash that typically arises on the abdomen&#44; the flexor surfaces of the limbs&#44; the neck&#44; axillas&#44; and groin&#46; Initially the lesions are often excoriated&#44; erythematous&#44; eczematous&#44; and&#47;or urticarial&#46; Blisters usually then develop on normal or erythematous skin&#44; giving rise to crusted erosive areas that heal without scarring&#46; The diagnosis is confirmed by the demonstration of deposits of immunoglobulin &#40;Ig&#41; G or of the C3 component of complement on the epidermal basement membrane&#44; and the presence in the serum of circulating IgG antibasement membrane zone antibodies against antigens BP-180 and BP-230&#46; Numerous variants of BP have been described&#44; with a broad spectrum of clinical manifestations&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 32-year-old woman&#44; with skin phototype <span class="elsevierStyleSmallCaps">VI</span>&#44; with no personal or family history of interest&#44; was seen in dermatology outpatients for the appearance of a highly pruritic&#44; widespread skin rash that had developed 3 weeks earlier&#46; The patient was not taking any medication or using topical products&#44; had not been sunbathing&#44; and reported no associated systemic symptoms&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">On physical examination&#44; she presented a good general state of health&#46; Examination of the skin revealed multiple well-defined&#44; confluent&#44; edematous erythematous plaques with centrifugal growth&#44; with tense peripheral vesicles and blisters containing a clear fluid&#44; producing a polycyclic&#44; annular morphology &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1&#44; A and B</a>&#41;&#46; The skin lesions affected the face&#44; neck&#44; trunk&#44; and limbs&#44; including the dorsum of the hands and feet&#46; No lesions were observed on the palms&#44; soles&#44; mucosas&#44; nails&#44; or scalp&#46; The Nikolsky and Asboe-Hansen signs were negative&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Laboratory tests including routine biochemistry&#44; urinalysis&#44; coagulation studies&#44; antinuclear antibodies&#44; antitransglutaminase antibodies&#44; serum electrophoresis&#44; and immunoglobulin and complement levels were normal or negative&#46; The only findings of interest were a white cell count of 20<span class="elsevierStyleHsp" style=""></span>000 cells&#47;&#956;L with eosinophilia of 6000 cells&#47;&#956;l&#44; and elevation of the erythrocyte sedimentation rate &#40;35<span class="elsevierStyleHsp" style=""></span>mm in the first hour&#41;&#46; Serology for syphilis&#44; hepatitis B and C viruses&#44; and HIV was negative&#46; The Mantoux test was negative&#46; Chest x-ray showed no significant changes of interest&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">A skin biopsy taken from an urticarial plaque showed a lymphocytic and eosinophilic dermal infiltrate with focal changes at the dermoepidermal interface &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2A</a>&#41;&#46; A biopsy was also taken from a blister&#44; revealing a subepidermal blister associated with a lymphocytic and eosinophilic dermal infiltrate &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2B</a>&#41;&#46; Direct immunofluorescence of healthy perilesional skin was positive&#44; showing linear deposits of IgG and C3 at the dermoepidermal junction with a U-serrated pattern &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2C</a>&#41;&#46; Indirect immunofluorescence on 1<span class="elsevierStyleHsp" style=""></span>M sodium chloride-separated skin showed the presence of circulating antibasement membrane zone antibodies bound on the epidermal side&#44; at a titer of 1&#58;80&#46; Autoimmune studies were positive for circulating antibasement membrane antibodies against antigens BP-180 and BP-230 detected using the immunoblot technique on the patient&#39;s serum mixed with human epidermal extracts&#46; Other antibodies studied &#40;Sm&#44; RNP&#44; Ro&#44; La&#44; Scl-70&#44; Jo-1&#44; DNAd&#44; antidesmogleins&#44; collagen <span class="elsevierStyleSmallCaps">VII</span>&#44; antidesmocollins&#41; were negative&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">With a diagnosis of BP&#44; treatment was initiated with oral prednisone&#44; 90<span class="elsevierStyleHsp" style=""></span>mg&#47;d &#40;1&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#41;&#44; combined with azathioprine&#44; 100<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#46; Two weeks after starting treatment&#44; the patient presented a progressive clinical improvement&#44; and the dose of prednisone was gradually reduced&#46; At the 6-month follow-up&#44; the patient was stable&#44; with no clinical recurrence&#44; and remained on treatment with prednisone&#44; 20<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#44; and azathioprine&#44; 100<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#59; residual postinflammatory hyperpigmentation and milia-like cysts were observed&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The cutaneous manifestations of BP can be atypical and highly polymorphous&#44; and may or may not include the tense blisters characteristic of this entity&#46; A number of atypical presentations have been described<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;3</span></a>&#58; nonbullous&#44; papular&#44; eczematous&#44; nodular&#44; vesicular&#44; annular erythema-like&#44; erythema multiforme-like&#44; erythrodermic&#44; dyshydrosiform&#44; vegetative&#44; lichen planus pemphogoides&#44; infantile&#44; physical agent-induced&#44; drug-induced&#44; and localized &#40;pretibial&#44; vulvar&#44; peristomal&#44; umbilical&#44; postradiotherapy&#44; paralyzed-limb&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Erythema multiforme-like BP is a rare variant&#44; with only 8 cases reported in the literature &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#8211;9</span></a> including 5 women and 3 men aged between 16 and 80 years&#46; Suspected triggering factors include orf virus infection&#44; furosemide&#44; citalopram&#44; thioridazine&#44; flupentixol&#44; amoxicillin&#44; and penicillin&#46; Lesions have been most common on the trunk and flexor surfaces of the limbs&#44; although they can arise on any area of skin&#44; including the palms and soles and the mucosas&#46; The clinical findings in all cases included manifestations of erythema multiforme and bullous pemphigoid&#44; and the diagnosis was confirmed by the immunopathology findings&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Our case was unusual&#44; with early cutaneous manifestations suggestive of erythema multiforme&#44; with centrifugally enlarging erythematous plaques on acral areas and on the extensor surfaces of the limbs&#44; associated with focal histologic changes at the interface and subepidermal edema&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">BP must be considered in the differential diagnosis in patients with a diffuse erythema multiforme-like skin rash who develop erythematous or urticarial plaques with peripheral blisters&#44; producing an annular or polycyclic morphology&#46; A high level of clinical and histologic suspicion is required&#46; The diagnosis is confirmed by positive direct and indirect immunofluorescence&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;3</span></a></p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Imbern&#243;n-Moya A&#44; Aguilar A&#44; Burgos F&#44; Gallego M&#193;&#46; Penfigoide ampolloso tipo eritema multiforme&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;690&#8211;692&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A&#44; Annular and polycyclic erythematous plaques with tense peripheral blisters on both thighs&#46; B&#44; Detail of the same lesions&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A&#44; Vacuolization of the basal layer of the epidermis with no clear evidence of vesicles or blisters&#44; and the presence of a superficial and deep dermal inflammatory infiltrate with lymphocytes and occasional eosinophils&#46; Hematoxylin and eosin&#44; original magnification<span class="elsevierStyleHsp" style=""></span>&#215;20&#46; B&#44; Subepidermal blister containing fibrin and abundant eosinophils&#44; and a dermal infiltrate of lymphocytes and eosinophils&#46; Marked subepidermal edema is observed close to the blister with early separation of the dermoepidermal junction&#46; Hematoxylin and eosin&#44; original magnification<span class="elsevierStyleHsp" style=""></span>&#215;20&#46;<span class="elsevierStyleHsp" style=""></span>C&#44; Positive direct immunofluorescence with linear deposits of immunoglobulin G and C3 at the dermoepidermal junction&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age&#44; y&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Suspected Etiologic Factor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Site of the Lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mucosal Involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Involvement of the Palms and Soles&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alian et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Orf virus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trunk&#44; limbs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Park et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Amlodipine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Trunk&#44; limbs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hirano et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Furosemide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Face&#44; neck&#44; flexor surface of the limbs&#44; trunk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hayakawa and Shiohara<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Extensor surface of the limbs&#44; back&#44; buttocks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mehravaran et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Citalopram<br>Thioridazine<br>Flupentixol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Flexor surface of the limbs&#44; neckline&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Alcalay et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Amoxicillin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Face&#44; neck&#44; trunk&#44; limbs</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Yes &#40;oral&#44; nasal&#44; anogenital&#44; ocular&#41;</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Yes</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Penicillin G procaine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Penicillin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Description of the Published Cases of Erythema Multiforme-like Bullous Pemphigoid&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
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            0 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pemphigoid Group"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "P&#46; Bernard"
                            1 => "L&#46; Borradori"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:5 [
                        "titulo" => "Dermatology"
                        "paginaInicial" => "475"
                        "paginaFinal" => "482"
                        "edicion" => "3rd ed&#46;"
                        "serieFecha" => "2012"
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            1 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Atypical presentations of bullous pemphigoid&#58; Clinical and immunopathological aspects"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "E&#46; Cozzani"
                            1 => "G&#46; Gasparini"
                            2 => "M&#46; Burlando"
                            3 => "F&#46; Drago"
                            4 => "A&#46; Parodi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
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