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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A&#44; Macules and hyperpigmented plaques in the hand&#46; B&#44; Subepidermal blister containing abundant polymorphonuclear cells &#40;hematoxylin-eosin&#44; &#215;<span class="elsevierStyleHsp" style=""></span>200&#41;&#46;<span class="elsevierStyleHsp" style=""></span>C&#44; Linear deposit in the basement membrane of C3 in direct immunofluorescence&#46; D&#44; Weak marking of IgG class antibodies directed against the dermal side of the blister in indirect immunofluorescence of salt-split skin &#40;sodium chloride 1<span class="elsevierStyleHsp" style=""></span>M&#41; &#40;antibody dilution 1&#47;10&#41;&#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">Anti-p200 pemphigoid is an autoimmune subepidermal blistering disease first described by Zillikens et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> in 1996 in a 54-year-old man&#46; The patient presented with generalized bullae associated with IgG antibodies directed against a 200<span class="elsevierStyleHsp" style=""></span>kDa protein located in the lamina lucida of the basement membrane&#46; Subsequently&#44; 91 additional cases have been reported and the actual incidence is unknown&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the first 2 cases in Spain&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Histories</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 1</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 65-year-old man presented with a history of Horton arteritis treated with low-dose oral corticosteroids and bullous pemphigoid &#40;BP&#41; diagnosed 3 years earlier in another hospital&#46; He attended our department with a new episode of pruriginous lesions&#46; Physical examination showed tense bullae and urticarial plaques predominantly on the legs&#44; with isolated lesions on the trunk&#46; There was no mucosal involvement&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Biopsy of the lesioned skin showed subepidermal bullae and an inflammatory infiltrate composed of neutrophils throughout the basement membrane &#40;BM&#41;&#44; with papillary microabscesses of neutrophils and some foci of eosinophilic spongiosis&#46; Direct immunofluorescence &#40;IF&#41; revealed linear deposits of C3 and IgG in the BM&#46; Circulating immunoglobulin &#40;Ig&#41; G antibodies directed against the dermal part of the BM were detected in indirect IF of salt-split skin &#40;sodium chloride 1<span class="elsevierStyleHsp" style=""></span>M&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Anti-BP180 and anti-collagen <span class="elsevierStyleSmallCaps">vii</span> antibodies were negative with enzyme-linked immunosorbent assay &#40;ELISA&#41;&#46; An immunoblot of extracts of human skin&#44; performed according to previously described methods&#44; detected IgG antibodies directed against a 200<span class="elsevierStyleHsp" style=""></span>kDa protein &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> Treatment was initiated with topical clobetasol according to a regimen for moderate to severe BP&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> and the prednisone dose &#40;10<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41; was maintained for arteritis&#44; with good response&#46; The patient had a new episode of blistering on reducing the dose of oral corticosteroids to 5<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#46; The prednisone dose was increased to 20<span class="elsevierStyleHsp" style=""></span>mg&#47;d and dapsone 50<span class="elsevierStyleHsp" style=""></span>mg&#47;d was added&#46; Clinical improvement was seen&#46; Finally&#44; the patient remained free of lesions with dapsone 75<span class="elsevierStyleHsp" style=""></span>mg&#47;d and prednisone 7&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Case 2</span><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was a 43-year-old man with history of plaque psoriasis who&#44; 18 months earlier&#44; coinciding with a stressful event&#44; had experienced an episode of tense bullae on the face&#44; scalp&#44; genitals&#44; and groin&#44; with no mucosal involvement&#46; He was treated with prednisone at a dose of 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#44; with remission of the lesions&#46; Subsequently&#44; he presented with a new episode of lesions&#44; for which he received treatment with ciclosporin &#40;without success&#41; in another center&#46; He finally responded to high doses of dapsone &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The physical examination on his first visit showed multiple erythematous scaling plaques on the trunk and limbs&#44; corresponding to psoriasis lesions&#44; along with macules and hyperpigmented plaques predominantly on the arms&#46; Skin biopsy showed subepidermal bullae with abundant polymorphonuclear cells and microabscesses of neutrophils in dermal papillae&#46; The results of direct and indirect IF and anti-BP180 and anti-collagen <span class="elsevierStyleSmallCaps">vii</span> ELISA were identical to those described for the first patient &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; Immunohistochemical study for collagen <span class="elsevierStyleSmallCaps">iv</span> of the paraffin block was also performed&#44; and in contrast to the first patient&#44; intense marking of the blister floor was observed &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46; Immunoblotting confirmed diagnosis of anti-p200 pemphigoid &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Given that the lesions had practically remitted with dapsone 200<span class="elsevierStyleHsp" style=""></span>mg&#47;d and that the patient tolerated treatment poorly due to asthenia&#44; the dose was tapered progressively until discontinuation&#46; During this time&#44; the isolated appearance of blisters resolved with potent topical corticosteroids&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Anti-p200 pemphigoid is a recently described blistering disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;2&#44;5&#44;6</span></a> Patients are usually middle-aged adults &#40;&#60;<span class="elsevierStyleHsp" style=""></span>65<span class="elsevierStyleHsp" style=""></span>years&#41; with tense bullae and generalized urticarial pruriginous plaques&#44; with clinical characteristics similar to BP or the inflammatory form of epidermolysis bullosa acquisita &#40;EBA&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5&#44;6</span></a> Mucosal lesions are observed in approximately 20&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5&#44;6</span></a> The bullae usually resolve without leaving scars or milia&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5</span></a> A high prevalence of psoriasis has been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5&#8211;7</span></a> Some cases have been associated with drugs &#40;penicillin&#41; or psoralen and ultraviolet A radiation phototherapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">6&#44;8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Characteristic histopathological findings include presence of subepidermal blisters&#44; accompanied by an inflammatory infiltrate in the superficial dermis&#44; which is usually neutrophilic and less often eosinophilic&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5&#44;6&#44;9</span></a> Occasionally&#44; microabscesses of neutrophils in dermal papillae and neutrophilic or eosinophilic spongiosis can be observed&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5&#44;6&#44;9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Direct immunofluorescence &#40;IF&#41; reveals linear deposits of C3 and IgG in the BM&#46; Indirect IF of salt-split skin &#40;sodium chloride 1<span class="elsevierStyleHsp" style=""></span>M&#41; shows circulating IgG antibodies directed against the dermal side of the blister&#44; although deposits have occasionally been observed on both sides&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;2&#44;5&#44;6&#44;9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Diagnosis is established with an immunoblot of extracts of human skin&#44; in which the serum of patients reacts to a 200<span class="elsevierStyleHsp" style=""></span>kDa protein&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;2&#44;5</span></a> In 25&#37; of cases&#44; weaker reactivity has been observed with other antigens&#44; such as BP180&#44; BP230&#44; or laminin 332&#46; This observation may be explained by intermolecular expansion of epitopes&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5&#44;6&#44;10</span></a> Immunoblotting is a complex technique that is available in only a few laboratories&#46; This has probably limited the diagnosis in some cases of anti-p200 pemphigoid&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Immunohistochemical study of the components of the BM in biopsies of blisters recently fixed in paraffin can usually locate collagen <span class="elsevierStyleSmallCaps">iv</span> &#40;which labels the dense lamina&#41; on the dermal side of the blister&#44; thereby assisting diagnosis if immunoblotting is not available&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Currently&#44; large gaps still remain in our knowledge of the pathogenesis of anti-p200 pemphigoid&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> The p200 antigen is a noncollagen protein localized at the interface between the lamina lucida and the lamina densa of the BM&#46; Recently&#44; laminin gamma-1 has been identified as the autoantigen in 90&#37; of cases&#44; with an epitope localized in residue 246 of the carboxy terminal domain&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5&#44;7&#44;11</span></a> However&#44; all attempts to demonstrate the pathogenicity of antibodies directed against the carboxy terminal domain of laminin gamma-1 have failed&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">12&#8211;14</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Differential diagnosis should include other subepidermal blistering diseases with C3 deposits and&#47;or linear IgG in direct IF&#44; mainly BP and EBA&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5</span></a> Indirect IF of salt-split skin &#40;or direct IF of split skin when circulating antibodies are not detected&#41; enables us to distinguish the entity from BP but not from EBA&#46; In these cases&#44; immunohistochemistry for collagen <span class="elsevierStyleSmallCaps">iv</span> is a simple technique that enables us to differentiate anti-p200 pemphigoid from EBA&#58; collagen <span class="elsevierStyleSmallCaps">iv</span> would be present in the blister floor in the former case and in the roof of the blister in the latter case&#46; However&#44; this technique may not be informative in cases of intense inflammatory infiltrate&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> These findings are not pathognomic and to establish an unequivocal diagnosis&#44; immunoblotting or even more complex techniques such as immunoprecipitation are required&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5&#44;7</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">With regard to treatment&#44; the regimens proposed for BP are as follows&#58; potent topical corticosteroids&#44; prednisone 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg as monotherapy or in combination with dapsone &#40;1&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5&#44;15</span></a> The outcome after treatment is variable&#44; but response is usually rapid and favorable to immunosuppressants&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In conclusion&#44; we present the first 2 cases of anti-p200 pemphigoid described in Spain and have characterized the lesions clinically&#44; pathologically&#44; and immunologically&#46; Given the difficult techniques required for diagnosis&#44; it is likely that anti-p200 pemphigoid is underdiagnosed&#44; with cases erroneously classified as BP or EBA&#46; Differential diagnosis with respect to EBA is particularly important as both entities differ substantially in terms of management and prognosis&#46; We propose immunohistochemistry with collagen <span class="elsevierStyleSmallCaps">iv</span> of lesioned skin&#44; combining it with the usual IF techniques&#44; as a simple and accessible tool for differential diagnosis with EAA&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical Responsibilities</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of human and animal subjects</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Confidentiality of data</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that they have followed their hospital&#39;s protocol on the publication of data concerning patients&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Right to privacy and informed consent</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors obtained the informed consent of patients and&#47;or subjects mentioned in this article&#46; The informed consent form is located in the archives of the corresponding author&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Funding</span><p id="par0100" class="elsevierStylePara elsevierViewall">The study was partially funded with Research Project PI 09&#47;1410 &#40;J&#46; Herrero&#41;&#44; with cofunding from FEDER&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicts of Interest</span><p id="par0105" 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">Anti-p200 pemphigoid is a rare autoimmune subepidermal blistering disease characterized by the presence of circulating immunoglobulin G antibodies directed against laminin gamma-1&#44; a 200-kDa protein located in the lamina lucida of the basement membrane&#46; We review the clinical&#44; histopathological and immunological characteristics of the first 2 cases described in Spain&#46; Anti-p200 pemphigoid shares histopathological and immunopathological findings with epidermolysis bullosa acquisita&#44; the main entity in the differential diagnosis&#46; However&#44; its management follows the same guidelines as those used for bullous pemphigoid&#46; The diagnosis is confirmed by immunoblotting&#44; which is a complex technique available in few centers&#46; We propose the immunohistochemical detection of collagen type <span class="elsevierStyleSmallCaps">IV</span> on the floor of the blister&#44; combined with standard immunofluorescence techniques&#44; as a simple&#44; accessible alternative to differentiate anti-p200 pemphigoid from epidermolysis bullosa acquisita&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El penfigoide anti-p200 es una enfermedad ampollosa subepid&#233;rmica autoinmune infrecuente&#44; asociada a la presencia de anticuerpos circulantes de tipo IgG dirigidos frente a la laminina gamma-1&#44; una prote&#237;na de 200<span class="elsevierStyleHsp" style=""></span>kDa localizada en la l&#225;mina l&#250;cida de la membrana basal&#46; Revisamos las caracter&#237;sticas cl&#237;nicas&#44; histopatol&#243;gicas e inmunol&#243;gicas de los 2 primeros casos descritos en Espa&#241;a&#46; El penfigoide anti-p200 comparte hallazgos histopatol&#243;gicos e inmunopatol&#243;gicos con la epiderm&#243;lisis ampollosa adquirida&#44; su principal diagn&#243;stico diferencial&#46; Sin embargo&#44; su manejo sigue las mismas pautas descritas para el penfigoide ampolloso&#46; El diagn&#243;stico se confirma mediante <span class="elsevierStyleItalic">inmunoblot</span>&#44; una t&#233;cnica compleja y accesible en pocos centros&#46; Proponemos la detecci&#243;n mediante inmunohistoqu&#237;mica del col&#225;geno <span class="elsevierStyleSmallCaps">iv</span> en el suelo de la ampolla&#44; combin&#225;ndola con las t&#233;cnicas habituales de inmunofluorescencia&#44; como alternativa sencilla y disponible&#44; para diferenciarlo de la epiderm&#243;lisis ampollosa adquirida&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Garc&#237;a-D&#237;ez I&#44; Mart&#237;nez-Escala ME&#44; Ishii N&#44; Hashimoto T&#44; Galy JMM&#44; Pujol RM&#44; et al&#46; Descripci&#243;n de 2 casos de penfigoide anti-p200&#46; Utilidad de una t&#233;cnica inmunohistoqu&#237;mica sencilla en el diagn&#243;stico diferencial con otras enfermedades ampollosas autoinmunes&#46; Actas Dermosifiliogr&#46; 2017&#59;108&#58;e1&#8211;e5&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A and B&#44; Tense bullae on an urticarial base located on the knee and ankle&#46; C&#44; Neutrophilic infiltrate with some eosinophils throughout the basement membrane&#44; with formation of papillary microabscesses &#40;hematoxylin-eosin &#215;<span class="elsevierStyleHsp" style=""></span>200&#41;&#46; D&#44; Presence of IgG class antibodies directed against the dermal side of the blister in indirect immunofluorescence of salt-split skin &#40;sodium chloride 1<span class="elsevierStyleHsp" style=""></span>M&#41; &#40;1&#47;40 antibody dilution&#41;&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Immunoblot technique performed with dermal extracts of human skin&#44; obtained by splitting skin with ethylenediamine tetraacetic acid and submitting to electrophoresis on SDS-polyacrylamide gel&#44; as per the Laemmli method &#40;left&#41; as well as immunoblotting with recombinant laminin 332 &#40;right&#41;&#46; As shown in the left panel &#40;dermal extracts of human skin&#41;&#44; sera of patients 1 and 2 &#40;corresponding to columns 3 and 4&#44; respectively&#41; show a band at 200<span class="elsevierStyleHsp" style=""></span>kDa&#44; corresponding to the same band present in the serum of another patient with anti-p200 pemphigoid &#40;column 2&#41;&#46; This band is not present in the serum of a patient with epidermolysis bullosa acquisita &#40;column 1&#41;&#44; but a band is present at 290<span class="elsevierStyleHsp" style=""></span>kDa&#44; corresponding to collagen <span class="elsevierStyleSmallCaps">vii</span>&#46; In the right panel &#40;recombinant laminin 332&#41;&#44; the recombinant protein is not detected in the sera of patients 1 and 2 &#40;columns 3 and 4&#44; respectively&#41; and the serum from healthy control &#40;column 2&#41;&#44; whereas the serum of a patient with anti-laminin 332 pemphigoid &#40;column 1&#41; has several bands at 165&#44; 145&#44; 140&#44; and 105 140<span class="elsevierStyleHsp" style=""></span>kDa&#44; corresponding to the &#945;3&#44; &#946;3&#44; and &#947;2 chains of laminin 332&#44; respectively&#46;</p>"
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        "titulo" => "Acknowledgments"
        "texto" => "<p id="par0110" class="elsevierStylePara elsevierViewall">We would like to express our gratitude to Dr&#46; Mar&#237;a Teresa Fern&#225;ndez Figueras and Dr&#46; Josep Palou Aymerich&#44; for their valuable collaboration by donating blocks of paraffin from patients for new sections to enable immunohistochemical study with collagen <span class="elsevierStyleSmallCaps">iv&#46;</span></p>"
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e-Case Report
Usefulness of a Simple Immunohistochemical Staining Technique to Differentiate Anti-p200 Pemphigoid From Other Autoimmune Blistering Diseases: A Report of 2 Cases
Descripción de 2 casos de penfigoide anti-p200. Utilidad de una técnica inmunohistoquímica sencilla en el diagnóstico diferencial con otras enfermedades ampollosas autoinmunes
I. García-Díeza,
Autor para correspondencia
, M.E. Martínez-Escalaa, N. Ishiib, T. Hashimotob, J.M. Mascaró Galyc, R.M. Pujola, J.E. Herrero-Gonzáleza
a Departamento de Dermatología, Hospital del Mar, Parc de Salut Mar, Institut Hospital del Mar d’Investigacions Mèdiques, Barcelona, Spain
b Departamento de Dermatología, Facultad de Medicina de la Universidad de Kurume, Fukuoka, Japan
c Departamento de Dermatología, Hospital Clínic, Barcelona, Spain
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        "titulo" => "Descripci&#243;n de 2 casos de penfigoide anti-p200&#46; Utilidad de una t&#233;cnica inmunohistoqu&#237;mica sencilla en el diagn&#243;stico diferencial con otras enfermedades ampollosas autoinmunes"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A&#44; Macules and hyperpigmented plaques in the hand&#46; B&#44; Subepidermal blister containing abundant polymorphonuclear cells &#40;hematoxylin-eosin&#44; &#215;<span class="elsevierStyleHsp" style=""></span>200&#41;&#46;<span class="elsevierStyleHsp" style=""></span>C&#44; Linear deposit in the basement membrane of C3 in direct immunofluorescence&#46; D&#44; Weak marking of IgG class antibodies directed against the dermal side of the blister in indirect immunofluorescence of salt-split skin &#40;sodium chloride 1<span class="elsevierStyleHsp" style=""></span>M&#41; &#40;antibody dilution 1&#47;10&#41;&#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">Anti-p200 pemphigoid is an autoimmune subepidermal blistering disease first described by Zillikens et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> in 1996 in a 54-year-old man&#46; The patient presented with generalized bullae associated with IgG antibodies directed against a 200<span class="elsevierStyleHsp" style=""></span>kDa protein located in the lamina lucida of the basement membrane&#46; Subsequently&#44; 91 additional cases have been reported and the actual incidence is unknown&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the first 2 cases in Spain&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Histories</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 1</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 65-year-old man presented with a history of Horton arteritis treated with low-dose oral corticosteroids and bullous pemphigoid &#40;BP&#41; diagnosed 3 years earlier in another hospital&#46; He attended our department with a new episode of pruriginous lesions&#46; Physical examination showed tense bullae and urticarial plaques predominantly on the legs&#44; with isolated lesions on the trunk&#46; There was no mucosal involvement&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Biopsy of the lesioned skin showed subepidermal bullae and an inflammatory infiltrate composed of neutrophils throughout the basement membrane &#40;BM&#41;&#44; with papillary microabscesses of neutrophils and some foci of eosinophilic spongiosis&#46; Direct immunofluorescence &#40;IF&#41; revealed linear deposits of C3 and IgG in the BM&#46; Circulating immunoglobulin &#40;Ig&#41; G antibodies directed against the dermal part of the BM were detected in indirect IF of salt-split skin &#40;sodium chloride 1<span class="elsevierStyleHsp" style=""></span>M&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Anti-BP180 and anti-collagen <span class="elsevierStyleSmallCaps">vii</span> antibodies were negative with enzyme-linked immunosorbent assay &#40;ELISA&#41;&#46; An immunoblot of extracts of human skin&#44; performed according to previously described methods&#44; detected IgG antibodies directed against a 200<span class="elsevierStyleHsp" style=""></span>kDa protein &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> Treatment was initiated with topical clobetasol according to a regimen for moderate to severe BP&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> and the prednisone dose &#40;10<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41; was maintained for arteritis&#44; with good response&#46; The patient had a new episode of blistering on reducing the dose of oral corticosteroids to 5<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#46; The prednisone dose was increased to 20<span class="elsevierStyleHsp" style=""></span>mg&#47;d and dapsone 50<span class="elsevierStyleHsp" style=""></span>mg&#47;d was added&#46; Clinical improvement was seen&#46; Finally&#44; the patient remained free of lesions with dapsone 75<span class="elsevierStyleHsp" style=""></span>mg&#47;d and prednisone 7&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Case 2</span><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was a 43-year-old man with history of plaque psoriasis who&#44; 18 months earlier&#44; coinciding with a stressful event&#44; had experienced an episode of tense bullae on the face&#44; scalp&#44; genitals&#44; and groin&#44; with no mucosal involvement&#46; He was treated with prednisone at a dose of 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#44; with remission of the lesions&#46; Subsequently&#44; he presented with a new episode of lesions&#44; for which he received treatment with ciclosporin &#40;without success&#41; in another center&#46; He finally responded to high doses of dapsone &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The physical examination on his first visit showed multiple erythematous scaling plaques on the trunk and limbs&#44; corresponding to psoriasis lesions&#44; along with macules and hyperpigmented plaques predominantly on the arms&#46; Skin biopsy showed subepidermal bullae with abundant polymorphonuclear cells and microabscesses of neutrophils in dermal papillae&#46; The results of direct and indirect IF and anti-BP180 and anti-collagen <span class="elsevierStyleSmallCaps">vii</span> ELISA were identical to those described for the first patient &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; Immunohistochemical study for collagen <span class="elsevierStyleSmallCaps">iv</span> of the paraffin block was also performed&#44; and in contrast to the first patient&#44; intense marking of the blister floor was observed &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46; Immunoblotting confirmed diagnosis of anti-p200 pemphigoid &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Given that the lesions had practically remitted with dapsone 200<span class="elsevierStyleHsp" style=""></span>mg&#47;d and that the patient tolerated treatment poorly due to asthenia&#44; the dose was tapered progressively until discontinuation&#46; During this time&#44; the isolated appearance of blisters resolved with potent topical corticosteroids&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Anti-p200 pemphigoid is a recently described blistering disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;2&#44;5&#44;6</span></a> Patients are usually middle-aged adults &#40;&#60;<span class="elsevierStyleHsp" style=""></span>65<span class="elsevierStyleHsp" style=""></span>years&#41; with tense bullae and generalized urticarial pruriginous plaques&#44; with clinical characteristics similar to BP or the inflammatory form of epidermolysis bullosa acquisita &#40;EBA&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5&#44;6</span></a> Mucosal lesions are observed in approximately 20&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5&#44;6</span></a> The bullae usually resolve without leaving scars or milia&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5</span></a> A high prevalence of psoriasis has been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5&#8211;7</span></a> Some cases have been associated with drugs &#40;penicillin&#41; or psoralen and ultraviolet A radiation phototherapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">6&#44;8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Characteristic histopathological findings include presence of subepidermal blisters&#44; accompanied by an inflammatory infiltrate in the superficial dermis&#44; which is usually neutrophilic and less often eosinophilic&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5&#44;6&#44;9</span></a> Occasionally&#44; microabscesses of neutrophils in dermal papillae and neutrophilic or eosinophilic spongiosis can be observed&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5&#44;6&#44;9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Direct immunofluorescence &#40;IF&#41; reveals linear deposits of C3 and IgG in the BM&#46; Indirect IF of salt-split skin &#40;sodium chloride 1<span class="elsevierStyleHsp" style=""></span>M&#41; shows circulating IgG antibodies directed against the dermal side of the blister&#44; although deposits have occasionally been observed on both sides&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;2&#44;5&#44;6&#44;9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Diagnosis is established with an immunoblot of extracts of human skin&#44; in which the serum of patients reacts to a 200<span class="elsevierStyleHsp" style=""></span>kDa protein&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;2&#44;5</span></a> In 25&#37; of cases&#44; weaker reactivity has been observed with other antigens&#44; such as BP180&#44; BP230&#44; or laminin 332&#46; This observation may be explained by intermolecular expansion of epitopes&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5&#44;6&#44;10</span></a> Immunoblotting is a complex technique that is available in only a few laboratories&#46; This has probably limited the diagnosis in some cases of anti-p200 pemphigoid&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Immunohistochemical study of the components of the BM in biopsies of blisters recently fixed in paraffin can usually locate collagen <span class="elsevierStyleSmallCaps">iv</span> &#40;which labels the dense lamina&#41; on the dermal side of the blister&#44; thereby assisting diagnosis if immunoblotting is not available&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Currently&#44; large gaps still remain in our knowledge of the pathogenesis of anti-p200 pemphigoid&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> The p200 antigen is a noncollagen protein localized at the interface between the lamina lucida and the lamina densa of the BM&#46; Recently&#44; laminin gamma-1 has been identified as the autoantigen in 90&#37; of cases&#44; with an epitope localized in residue 246 of the carboxy terminal domain&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5&#44;7&#44;11</span></a> However&#44; all attempts to demonstrate the pathogenicity of antibodies directed against the carboxy terminal domain of laminin gamma-1 have failed&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">12&#8211;14</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Differential diagnosis should include other subepidermal blistering diseases with C3 deposits and&#47;or linear IgG in direct IF&#44; mainly BP and EBA&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5</span></a> Indirect IF of salt-split skin &#40;or direct IF of split skin when circulating antibodies are not detected&#41; enables us to distinguish the entity from BP but not from EBA&#46; In these cases&#44; immunohistochemistry for collagen <span class="elsevierStyleSmallCaps">iv</span> is a simple technique that enables us to differentiate anti-p200 pemphigoid from EBA&#58; collagen <span class="elsevierStyleSmallCaps">iv</span> would be present in the blister floor in the former case and in the roof of the blister in the latter case&#46; However&#44; this technique may not be informative in cases of intense inflammatory infiltrate&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> These findings are not pathognomic and to establish an unequivocal diagnosis&#44; immunoblotting or even more complex techniques such as immunoprecipitation are required&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5&#44;7</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">With regard to treatment&#44; the regimens proposed for BP are as follows&#58; potent topical corticosteroids&#44; prednisone 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg as monotherapy or in combination with dapsone &#40;1&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5&#44;15</span></a> The outcome after treatment is variable&#44; but response is usually rapid and favorable to immunosuppressants&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;5</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In conclusion&#44; we present the first 2 cases of anti-p200 pemphigoid described in Spain and have characterized the lesions clinically&#44; pathologically&#44; and immunologically&#46; Given the difficult techniques required for diagnosis&#44; it is likely that anti-p200 pemphigoid is underdiagnosed&#44; with cases erroneously classified as BP or EBA&#46; Differential diagnosis with respect to EBA is particularly important as both entities differ substantially in terms of management and prognosis&#46; We propose immunohistochemistry with collagen <span class="elsevierStyleSmallCaps">iv</span> of lesioned skin&#44; combining it with the usual IF techniques&#44; as a simple and accessible tool for differential diagnosis with EAA&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical Responsibilities</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of human and animal subjects</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Confidentiality of data</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that they have followed their hospital&#39;s protocol on the publication of data concerning patients&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Right to privacy and informed consent</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors obtained the informed consent of patients and&#47;or subjects mentioned in this article&#46; The informed consent form is located in the archives of the corresponding author&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Funding</span><p id="par0100" class="elsevierStylePara elsevierViewall">The study was partially funded with Research Project PI 09&#47;1410 &#40;J&#46; Herrero&#41;&#44; with cofunding from FEDER&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicts of Interest</span><p id="par0105" 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">Anti-p200 pemphigoid is a rare autoimmune subepidermal blistering disease characterized by the presence of circulating immunoglobulin G antibodies directed against laminin gamma-1&#44; a 200-kDa protein located in the lamina lucida of the basement membrane&#46; We review the clinical&#44; histopathological and immunological characteristics of the first 2 cases described in Spain&#46; Anti-p200 pemphigoid shares histopathological and immunopathological findings with epidermolysis bullosa acquisita&#44; the main entity in the differential diagnosis&#46; However&#44; its management follows the same guidelines as those used for bullous pemphigoid&#46; The diagnosis is confirmed by immunoblotting&#44; which is a complex technique available in few centers&#46; We propose the immunohistochemical detection of collagen type <span class="elsevierStyleSmallCaps">IV</span> on the floor of the blister&#44; combined with standard immunofluorescence techniques&#44; as a simple&#44; accessible alternative to differentiate anti-p200 pemphigoid from epidermolysis bullosa acquisita&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El penfigoide anti-p200 es una enfermedad ampollosa subepid&#233;rmica autoinmune infrecuente&#44; asociada a la presencia de anticuerpos circulantes de tipo IgG dirigidos frente a la laminina gamma-1&#44; una prote&#237;na de 200<span class="elsevierStyleHsp" style=""></span>kDa localizada en la l&#225;mina l&#250;cida de la membrana basal&#46; Revisamos las caracter&#237;sticas cl&#237;nicas&#44; histopatol&#243;gicas e inmunol&#243;gicas de los 2 primeros casos descritos en Espa&#241;a&#46; El penfigoide anti-p200 comparte hallazgos histopatol&#243;gicos e inmunopatol&#243;gicos con la epiderm&#243;lisis ampollosa adquirida&#44; su principal diagn&#243;stico diferencial&#46; Sin embargo&#44; su manejo sigue las mismas pautas descritas para el penfigoide ampolloso&#46; El diagn&#243;stico se confirma mediante <span class="elsevierStyleItalic">inmunoblot</span>&#44; una t&#233;cnica compleja y accesible en pocos centros&#46; Proponemos la detecci&#243;n mediante inmunohistoqu&#237;mica del col&#225;geno <span class="elsevierStyleSmallCaps">iv</span> en el suelo de la ampolla&#44; combin&#225;ndola con las t&#233;cnicas habituales de inmunofluorescencia&#44; como alternativa sencilla y disponible&#44; para diferenciarlo de la epiderm&#243;lisis ampollosa adquirida&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Garc&#237;a-D&#237;ez I&#44; Mart&#237;nez-Escala ME&#44; Ishii N&#44; Hashimoto T&#44; Galy JMM&#44; Pujol RM&#44; et al&#46; Descripci&#243;n de 2 casos de penfigoide anti-p200&#46; Utilidad de una t&#233;cnica inmunohistoqu&#237;mica sencilla en el diagn&#243;stico diferencial con otras enfermedades ampollosas autoinmunes&#46; Actas Dermosifiliogr&#46; 2017&#59;108&#58;e1&#8211;e5&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Immunoblot technique performed with dermal extracts of human skin&#44; obtained by splitting skin with ethylenediamine tetraacetic acid and submitting to electrophoresis on SDS-polyacrylamide gel&#44; as per the Laemmli method &#40;left&#41; as well as immunoblotting with recombinant laminin 332 &#40;right&#41;&#46; As shown in the left panel &#40;dermal extracts of human skin&#41;&#44; sera of patients 1 and 2 &#40;corresponding to columns 3 and 4&#44; respectively&#41; show a band at 200<span class="elsevierStyleHsp" style=""></span>kDa&#44; corresponding to the same band present in the serum of another patient with anti-p200 pemphigoid &#40;column 2&#41;&#46; This band is not present in the serum of a patient with epidermolysis bullosa acquisita &#40;column 1&#41;&#44; but a band is present at 290<span class="elsevierStyleHsp" style=""></span>kDa&#44; corresponding to collagen <span class="elsevierStyleSmallCaps">vii</span>&#46; In the right panel &#40;recombinant laminin 332&#41;&#44; the recombinant protein is not detected in the sera of patients 1 and 2 &#40;columns 3 and 4&#44; respectively&#41; and the serum from healthy control &#40;column 2&#41;&#44; whereas the serum of a patient with anti-laminin 332 pemphigoid &#40;column 1&#41; has several bands at 165&#44; 145&#44; 140&#44; and 105 140<span class="elsevierStyleHsp" style=""></span>kDa&#44; corresponding to the &#945;3&#44; &#946;3&#44; and &#947;2 chains of laminin 332&#44; respectively&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A&#44; Macules and hyperpigmented plaques in the hand&#46; B&#44; Subepidermal blister containing abundant polymorphonuclear cells &#40;hematoxylin-eosin&#44; &#215;<span class="elsevierStyleHsp" style=""></span>200&#41;&#46;<span class="elsevierStyleHsp" style=""></span>C&#44; Linear deposit in the basement membrane of C3 in direct immunofluorescence&#46; D&#44; Weak marking of IgG class antibodies directed against the dermal side of the blister in indirect immunofluorescence of salt-split skin &#40;sodium chloride 1<span class="elsevierStyleHsp" style=""></span>M&#41; &#40;antibody dilution 1&#47;10&#41;&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Immunohistochemical study with collagen <span class="elsevierStyleSmallCaps">iv</span>&#44; showing staining of the dermal part of the blister&#44; thus demonstrating that the collagen is above the lamina densa&#44; as well as the wall of dermal vessels &#40;collagen <span class="elsevierStyleSmallCaps">iv</span> &#215;<span class="elsevierStyleHsp" style=""></span>200&#41;&#46;</p>"
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        "texto" => "<p id="par0110" class="elsevierStylePara elsevierViewall">We would like to express our gratitude to Dr&#46; Mar&#237;a Teresa Fern&#225;ndez Figueras and Dr&#46; Josep Palou Aymerich&#44; for their valuable collaboration by donating blocks of paraffin from patients for new sections to enable immunohistochemical study with collagen <span class="elsevierStyleSmallCaps">iv&#46;</span></p>"
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Información del artículo
ISSN: 15782190
Idioma original: Inglés
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