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1</a>A&#41;&#46; He was admitted to the dermatology ward with the suspicion of pyoderma gangrenosum&#46; On examination he presented with a 15<span class="elsevierStyleHsp" style=""></span>cm infiltrated ulcerated plaque at the hypogastrium with satellite follicular pustules and nodules on the abdomen and the legs&#46; Inguinal lymph node enlargement was present&#46; Punch biopsies of the pustules and the ulceration were performed&#46; Examination showed intense perifollicular suppurative inflammation&#44; with the presence of neutrophils in the deep dermis and subcutaneous tissue&#46; Periodic acid Shiff &#40;PAS&#41; and Grocott staining showed the presence of fungal spores in the hair follicle &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41; and <span class="elsevierStyleItalic">Trichophyton mentagrophytes</span> was isolated from culture of the skin scrape with hair shaft&#46; He was treated with prednisolone 60<span class="elsevierStyleHsp" style=""></span>mg daily&#44; with gradual tapering&#44; and terbinafine 250<span class="elsevierStyleHsp" style=""></span>mg daily for 8 weeks with incremental improvement although residual hyperpigmentation remained&#46; His family had acquired a guinea pig some months before lesion onset and this was considered the likely source of the infection&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 2</span><p id="par0015" class="elsevierStylePara elsevierViewall">The second patient was a 23-year-old Caucasian man with a prosthetic right lower limb after amputation below the knee at the age of 5 years because of a malformation&#46; The patient was referred to our department because he developed painful follicular pustules in the right limb that impeded him from using his prosthesis&#46; Two months earlier&#44; he had been treated for tinea corporis at the same area with topical triamcinolone acetonide and econazole nitrate&#46; He presented with multiple follicular pustules and erythematous patches on the right lower limb&#46; He was diagnosed with bacterial folliculitis and treated with systemic Lymecycline 300<span class="elsevierStyleHsp" style=""></span>mg twice a day for 3 weeks without any improvement&#46; As the lesions progressed into painful nodules &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; the patient also developed malaise and low-grade fever&#46; His laboratory tests showed elevated C reactive protein 131<span class="elsevierStyleHsp" style=""></span>mg&#47;L and leucocytes 13&#46;9<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#46; A punch biopsy was performed and showed a deep folliculitis with PAS staining with fungal spores and hyphae in the hair shaft&#46; Fungal culture of the skin scrapes revealed <span class="elsevierStyleItalic">T&#46; mentagrophytes</span>&#46; He was treated with terbinafine 250<span class="elsevierStyleHsp" style=""></span>mg&#47;d for 6 weeks with significant improvement&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Majocchi granuloma &#40;MG&#41; is an unusual presentation of dermatophytosis&#46; It was first described by Majocchi in 1883 as &#8220;granulomatous skin infection due to dermatophytes commonly affecting healthy women exposed to trauma of the lower extremities&#46;&#8221;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;5</span></a> The predisposing factors for deep penetration by dermatophytes are scratching&#44; occlusion&#44; friction&#44; repeated shaving&#44; local treatment with topical corticosteroids&#44; and systemic immunosuppression&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Two forms of MG have been described&#44; a dermal perifollicular papular form which affects healthy individuals and the deep subcutaneous nodular form which usually occurs in immunocompromised patients such as organ transplant recipients&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The follicular invasion in MG is usually at the endothrix and <span class="elsevierStyleItalic">Trichophyton rubrum</span> is the most common dermatophyte associated with this condition&#44; but other dermatophytes such as <span class="elsevierStyleItalic">Trichophyton violaceum</span>&#44; <span class="elsevierStyleItalic">T&#46; mentagrophytes</span>&#44; <span class="elsevierStyleItalic">Epidermophyton floccosum</span>&#44; and <span class="elsevierStyleItalic">Microsporum canis</span> have also been described as agents causing infections in immunocompetent patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In order to survive in a more alkaline environment like the dermis&#44; the dermatophytes needs the keratinous material that provides a potent substrate for the organism&#46; Moreover the resulting cellular destruction and the inflammation increase the amounts of mucopolysaccharide acid&#44; so lowering the pH in the dermis and creating a more suitable dermal environment&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">It has been reported that <span class="elsevierStyleItalic">T&#46; mentagrophytes</span> can induce interleukin &#40;IL&#41;-8 and tumor necrosis factor &#40;TNF&#41; production by keratinocytes to chemoattract and activate neutrophils&#46; This may explain the fever and malaise that our patients developed during the course of the disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">There is no consensus on treatment but topical antifungals are ineffective because of the deep location of the infection&#46; The recommended treatments for MG are systemic antifungals such as itraconazole 200<span class="elsevierStyleHsp" style=""></span>mg daily or terbinafine 250<span class="elsevierStyleHsp" style=""></span>mg daily for 4&#8211;8 weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Our 2 cases share similarities in that they were immunocompetent patients who had been using topical potent steroids for long periods before developing the deep fungal infection&#46; The first patient contributed with local trauma by shaving the affected area and the second patient had a prosthesis that caused occlusion of the skin thus facilitating the dermatophytic penetration&#46; Both responded successfully to the same treatment with terbinafine&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion Majocchi granuloma is an uncommon dermatophytic infection that is difficult to identify because of its misleading clinical appearance&#46; This delays the correct diagnosis and treatment&#46; It is also important to highlight that the sample used for direct microscopy and culture should include the hair shaft due to the fungal predilection for the endothrix&#46; Biopsy with appropriate staining is the gold standard for the diagnosis&#46; This deep fungal infection should be well recognized among dermatologists and included in the differential diagnosis of infiltrated skin lesions that do not respond to conventional treatments&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors must have obtained the informed consent of the patients and&#47;or subjects mentioned in the article&#46; The author for correspondence must be in possession of this document&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflict of interests</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Majocchi granuloma is an uncommon deep follicular inflammation caused by dermatophytes and affects immunocompetent and immunocompromised patients&#46; The clinical findings overlap with other skin conditions such bacterial infections and inflammatory skin diseases&#44; thereby delaying correct diagnosis&#46; We describe 2 cases in immunocompetent patients&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El granuloma de Majocchi es una inflamaci&#243;n folicular profunda poco com&#250;n causada por dermatofitos que afecta a pacientes inmunocompetentes o inmunodeprimidos&#46; Los hallazgos cl&#237;nicos se mezclan con otras enfermedades cut&#225;neas tales como infecciones bacterianas o dermatopat&#237;as inflamatorias&#44; lo que retrasa el diagn&#243;stico acertado&#46; Se presentan 2 casos en pacientes inmunocompetentes&#46;</p></span>"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "V&#46; Ratajczak-Stefa&#324;ska"
                            1 => "M&#46; Kiedrowicz"
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                            3 => "M&#46; R&#243;zewicka"
                            4 => "D&#46; Mikulska"
                          ]
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                  ]
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                          "etal" => false
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "H&#46;R&#46; Cho"
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                    0 => array:2 [
                      "titulo" => "<span class="elsevierStyleItalic">Trichophyton mentagrophytes</span>-associated Majocchi&#39;s granuloma treated with cryotherapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Pietrzak"
                            1 => "K&#46; Tomasiewicz"
                            2 => "J&#46; Kanitakis"
                            3 => "T&#46; Paszkowski"
                            4 => "E&#46; Dybiec"
                            5 => "H&#46; Donica"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
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                      "doi" => "10.5603/19762"
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                        "fecha" => "2012"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
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                            1 => "B&#46;J&#46; Kullberg"
                            2 => "J&#46;W&#46;M&#46; Van der Meer"
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        "texto" => "<p id="par0075" class="elsevierStylePara elsevierViewall">We are indebted to Professor Carl Fredrik Wahlgren&#46;</p>"
        "vista" => "all"
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e-Case Report
Majocchis Granuloma Caused by Trichophyton mentagrophytes in 2 Immunocompetent Patients
Granuloma de Majocchi ocasionado por Trichophyton mentagrophytes en 2 pacientes inmunocompetentes
I. Trocoli Drakensjöa,
Autor para correspondencia
, I. Vassilakib, M. Bradleya
a Department of Dermatology at Karolinska University Hospital, Stockholm, Sweden
b Department Dermatopathology at Karolinska University Hospital, Stockholm, Sweden
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1</a>A&#41;&#46; He was admitted to the dermatology ward with the suspicion of pyoderma gangrenosum&#46; On examination he presented with a 15<span class="elsevierStyleHsp" style=""></span>cm infiltrated ulcerated plaque at the hypogastrium with satellite follicular pustules and nodules on the abdomen and the legs&#46; Inguinal lymph node enlargement was present&#46; Punch biopsies of the pustules and the ulceration were performed&#46; Examination showed intense perifollicular suppurative inflammation&#44; with the presence of neutrophils in the deep dermis and subcutaneous tissue&#46; Periodic acid Shiff &#40;PAS&#41; and Grocott staining showed the presence of fungal spores in the hair follicle &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41; and <span class="elsevierStyleItalic">Trichophyton mentagrophytes</span> was isolated from culture of the skin scrape with hair shaft&#46; He was treated with prednisolone 60<span class="elsevierStyleHsp" style=""></span>mg daily&#44; with gradual tapering&#44; and terbinafine 250<span class="elsevierStyleHsp" style=""></span>mg daily for 8 weeks with incremental improvement although residual hyperpigmentation remained&#46; His family had acquired a guinea pig some months before lesion onset and this was considered the likely source of the infection&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 2</span><p id="par0015" class="elsevierStylePara elsevierViewall">The second patient was a 23-year-old Caucasian man with a prosthetic right lower limb after amputation below the knee at the age of 5 years because of a malformation&#46; The patient was referred to our department because he developed painful follicular pustules in the right limb that impeded him from using his prosthesis&#46; Two months earlier&#44; he had been treated for tinea corporis at the same area with topical triamcinolone acetonide and econazole nitrate&#46; He presented with multiple follicular pustules and erythematous patches on the right lower limb&#46; He was diagnosed with bacterial folliculitis and treated with systemic Lymecycline 300<span class="elsevierStyleHsp" style=""></span>mg twice a day for 3 weeks without any improvement&#46; As the lesions progressed into painful nodules &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; the patient also developed malaise and low-grade fever&#46; His laboratory tests showed elevated C reactive protein 131<span class="elsevierStyleHsp" style=""></span>mg&#47;L and leucocytes 13&#46;9<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&#46; A punch biopsy was performed and showed a deep folliculitis with PAS staining with fungal spores and hyphae in the hair shaft&#46; Fungal culture of the skin scrapes revealed <span class="elsevierStyleItalic">T&#46; mentagrophytes</span>&#46; He was treated with terbinafine 250<span class="elsevierStyleHsp" style=""></span>mg&#47;d for 6 weeks with significant improvement&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Majocchi granuloma &#40;MG&#41; is an unusual presentation of dermatophytosis&#46; It was first described by Majocchi in 1883 as &#8220;granulomatous skin infection due to dermatophytes commonly affecting healthy women exposed to trauma of the lower extremities&#46;&#8221;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;5</span></a> The predisposing factors for deep penetration by dermatophytes are scratching&#44; occlusion&#44; friction&#44; repeated shaving&#44; local treatment with topical corticosteroids&#44; and systemic immunosuppression&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Two forms of MG have been described&#44; a dermal perifollicular papular form which affects healthy individuals and the deep subcutaneous nodular form which usually occurs in immunocompromised patients such as organ transplant recipients&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The follicular invasion in MG is usually at the endothrix and <span class="elsevierStyleItalic">Trichophyton rubrum</span> is the most common dermatophyte associated with this condition&#44; but other dermatophytes such as <span class="elsevierStyleItalic">Trichophyton violaceum</span>&#44; <span class="elsevierStyleItalic">T&#46; mentagrophytes</span>&#44; <span class="elsevierStyleItalic">Epidermophyton floccosum</span>&#44; and <span class="elsevierStyleItalic">Microsporum canis</span> have also been described as agents causing infections in immunocompetent patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In order to survive in a more alkaline environment like the dermis&#44; the dermatophytes needs the keratinous material that provides a potent substrate for the organism&#46; Moreover the resulting cellular destruction and the inflammation increase the amounts of mucopolysaccharide acid&#44; so lowering the pH in the dermis and creating a more suitable dermal environment&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">It has been reported that <span class="elsevierStyleItalic">T&#46; mentagrophytes</span> can induce interleukin &#40;IL&#41;-8 and tumor necrosis factor &#40;TNF&#41; production by keratinocytes to chemoattract and activate neutrophils&#46; This may explain the fever and malaise that our patients developed during the course of the disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">There is no consensus on treatment but topical antifungals are ineffective because of the deep location of the infection&#46; The recommended treatments for MG are systemic antifungals such as itraconazole 200<span class="elsevierStyleHsp" style=""></span>mg daily or terbinafine 250<span class="elsevierStyleHsp" style=""></span>mg daily for 4&#8211;8 weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Our 2 cases share similarities in that they were immunocompetent patients who had been using topical potent steroids for long periods before developing the deep fungal infection&#46; The first patient contributed with local trauma by shaving the affected area and the second patient had a prosthesis that caused occlusion of the skin thus facilitating the dermatophytic penetration&#46; Both responded successfully to the same treatment with terbinafine&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion Majocchi granuloma is an uncommon dermatophytic infection that is difficult to identify because of its misleading clinical appearance&#46; This delays the correct diagnosis and treatment&#46; It is also important to highlight that the sample used for direct microscopy and culture should include the hair shaft due to the fungal predilection for the endothrix&#46; Biopsy with appropriate staining is the gold standard for the diagnosis&#46; This deep fungal infection should be well recognized among dermatologists and included in the differential diagnosis of infiltrated skin lesions that do not respond to conventional treatments&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors must have obtained the informed consent of the patients and&#47;or subjects mentioned in the article&#46; The author for correspondence must be in possession of this document&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflict of interests</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Majocchi granuloma is an uncommon deep follicular inflammation caused by dermatophytes and affects immunocompetent and immunocompromised patients&#46; The clinical findings overlap with other skin conditions such bacterial infections and inflammatory skin diseases&#44; thereby delaying correct diagnosis&#46; We describe 2 cases in immunocompetent patients&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El granuloma de Majocchi es una inflamaci&#243;n folicular profunda poco com&#250;n causada por dermatofitos que afecta a pacientes inmunocompetentes o inmunodeprimidos&#46; Los hallazgos cl&#237;nicos se mezclan con otras enfermedades cut&#225;neas tales como infecciones bacterianas o dermatopat&#237;as inflamatorias&#44; lo que retrasa el diagn&#243;stico acertado&#46; Se presentan 2 casos en pacientes inmunocompetentes&#46;</p></span>"
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                            0 => "M&#46;G&#46; Netea"
                            1 => "B&#46;J&#46; Kullberg"
                            2 => "J&#46;W&#46;M&#46; Van der Meer"
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                        "tituloSerie" => "Clin Infect Dis"
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        "titulo" => "Acknowledgement"
        "texto" => "<p id="par0075" class="elsevierStylePara elsevierViewall">We are indebted to Professor Carl Fredrik Wahlgren&#46;</p>"
        "vista" => "all"
      ]
    ]
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Información del artículo
ISSN: 15782190
Idioma original: Inglés
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