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All had received multiple mosquito bites and presented with fever and a nonspecific erythematous maculopapular rash&#46; Zika virus infection was confirmed upon polymerase chain reaction &#40;PCR&#41; detection of viral nucleic acids in serum and urine&#46; All 3 patients progressed favorably&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Descriptions</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 1</span><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 25-year-old Spanish man who had returned to Spain from Martinique 7 days earlier&#46; He reported no symptoms during his stay except for numerous arthropod bites&#44; but attended our outpatient clinic with pruritic skin lesions on the upper half of his body that had developed 24<span class="elsevierStyleHsp" style=""></span>hours earlier together with fever and asthenia&#46; The patient&#39;s general condition was good&#44; and his temperature was 38&#46;3&#176;C&#46; He had a confluent erythematous maculopapular rash that predominantly affected the face &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; and trunk &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; There were scattered lesions on the lower limbs&#46; The results of a complete blood count &#40;CBC&#41; and tests of liver function&#44; coagulation&#44; and acute phase reactants &#40;C-reactive protein and procalcitonin&#41; were normal&#46; We prescribed treatment for symptoms and ordered tests for cytomegalovirus &#40;CMV&#41;&#44; Epstein-Barr virus &#40;EBV&#41;&#44; hepatitis A virus &#40;HAV&#41;&#44; hepatitis B virus &#40;HBV&#41;&#44; hepatitis C virus &#40;HCV&#41;&#44; human immunodeficiency virus &#40;HIV&#41;&#44; dengue virus&#44; chikungunya virus&#44; Zika virus&#44; <span class="elsevierStyleItalic">Rickettsia conorii</span>&#44; and syphilis&#46; The results of all tests were negative&#44; except for PCR for Zika virus&#44; which was detected in both serum and urine samples&#46; The patient recovered fully within a week&#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="par0020" class="elsevierStylePara elsevierViewall">The patient was a 31-year-old Spanish woman who had returned 2 days earlier from Santo Domingo in the Dominican Republic&#46; She reported no clinically relevant events except for arthropod bites&#44; but consulted us for a centrifugally distributed generalized cutaneous rash that had appeared abruptly 24&#160;hours earlier together with self-limiting diarrhea and a mild frontal headache&#46; The patient&#39;s general condition was good&#44; and her temperature was 37&#46;7&#176;C&#46; An erythematous maculopapular rash was observed on the cheeks&#44; the anterior and posterior aspects of the trunk&#44; the limbs&#44; and the palms &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Laboratory results &#40;CBC&#44; ionogram&#44; and tests of liver function&#44; coagulation&#44; and acute phase reactants&#41; were normal&#46; We prescribed treatment for symptoms&#46; The rash had resolved by a follow-up examination 24<span class="elsevierStyleHsp" style=""></span>hours later&#46; The results of microbiological tests for CMV&#44; EBV&#44; HAV&#44; HBV&#44; HCV&#44; HIV&#44; rubella and measles viruses&#44; dengue virus&#44; chikungunya virus&#44; Zika virus&#44; and syphilis were negative&#44; except for PCR detection of Zika virus in urine&#46; The patient recovered fully within 72<span class="elsevierStyleHsp" style=""></span>hours of onset&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Case 3</span><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was a 46-year-old Venezuelan man who lives in Spain&#46; He reported no clinically relevant events during his most recent visit to Venezuela&#44; except for numerous arthropod bites&#46; Two days after returning to Spain he consulted us for skin lesions in the upper half of his body that had appeared several hours earlier&#46; The rash was accompanied by fever&#44; general malaise&#44; pain on swallowing&#44; myalgia&#44; and small joint pain&#46; The patient&#39;s general condition was good&#44; and his temperature was 39&#46;5&#176;C&#46; He had mucosal dryness and bilateral conjunctival hyperemia &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41; together with a confluent erythematous maculopapular rash mainly on the face&#44; trunk&#44; and back and blanched when pressed with a glass slide&#46; The results of the CBC and liver function and coagulation tests were normal&#58; C-reactive protein&#44; 37&#46;0<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; procalcitonin&#44; 1&#46;27<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#46; Microbiology &#40;for CMV&#44; EBV&#44; HAV&#44; HBV&#44; HCV&#44; HIV&#44; chikungunya virus&#44; and syphilis&#41; results were negative but showed markers of a previous dengue virus infection&#46; The results of serology and blood PCR for Zika virus were negative&#46; Urine PCR produced a positive result for Zika virus&#46; The patient improved after 24<span class="elsevierStyleHsp" style=""></span>hours&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Zika virus is an arthropod-borne virus &#40;arbovirus&#41; &#40;genus <span class="elsevierStyleItalic">Flavivirus</span>&#44; family Flaviviridae&#41; that was first identified in Uganda in 1947&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> Transmission occurs via coexisting urban and sylvatic cycles and involves mosquito vectors of the genus <span class="elsevierStyleItalic">Aedes</span>&#46; Sexual&#44; vertical&#44; and blood-transfusion transmission have also been described&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Zika virus was limited to specific regions of Africa and Asia until 2007&#46; Since then&#44; the virus has spread unrestrained throughout the world&#46; The cases reported to date in Spain have been the result of infections acquired in other countries&#59; congenital and sexual transmission has been described<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">6&#44;7</span></a> &#40;HYPERLINK &#8220;<a id="intr0010" class="elsevierStyleInterRef" href="http://www.msssi.gob.es/profesionales/saludPublica/zika/casosDiagnosticados/home.htm''">http&#58;&#47;&#47;www&#46;msssi&#46;gob&#46;es&#47;profesionales&#47;saludPublica&#47;zika&#47;casosDiagnosticados&#47;home&#46;htm&#8221;</a>&#41;&#46; Zika virus infection can potentially have a substantial impact in Spain given the following factors&#58; 1&#41; Spain&#39;s thriving tourism industry&#59; 2&#41; the large number of Latin Americans resident here&#59; 3&#41; the presence along the Spanish Mediterranean coast of <span class="elsevierStyleItalic">Aedes albopictus</span>&#44; which could theoretically mediate autochthonous transmission after biting an individual infected abroad&#59; and 4&#41; the possibility of sexual transmission&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> Prompt diagnosis would allow optimization of clinical management&#44; improve the monitoring of severe cases&#44; and minimize the risk of potential autochthonous transmission&#46; Early detection in pregnant women is essential to detecting cases of congenital Zika virus infection&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Most patients &#40;75&#37;&#8211;80&#37;&#41; are asymptomatic&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> The remainder present with rash that is occasionally pruritic &#40;90&#37;&#41;&#44; fever &#40;65&#37;&#41;&#44; joint pain and inflammation &#40;65&#37;&#41;&#44; nonpurulent conjunctivitis &#40;55&#37;&#41;&#44; headache &#40;45&#37;&#41;&#44; and less frequently digestive symptoms &#40;10&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> In some cases Zika virus infection can be associated with neurological signs&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> The most important thing to remember about this disease is its ability to cause fetal malformations and miscarriage&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Although skin lesions are common in Zika infections&#44; they are not often illustrated in the literature&#46; The lesions are nonspecific and often difficult to distinguish from those caused by other arboviruses such as dengue and chikungunya viruses &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Furthermore&#44; coinfections with other tropical viruses can complicate diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> The rash caused by Zika virus consists of erythematous morbilliform or scarlatiniform macules and&#47;or papules that appear on the trunk or face 3 to 5 days after onset of the febrile phase&#46; In the cases we report the cutaneous manifestations resolved within 24<span class="elsevierStyleHsp" style=""></span>hours&#46; The differential diagnosis should include other infections such as rubella&#44; parvovirus&#44; measles&#44; dengue and chikungunya viruses&#44; leptospirosis&#44; and rickettsiosis&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> Zika virus infection can be distinguished from dengue and chikungunya infections by certain clinical signs&#46; Chikungunya virus causes characteristic polyarthralgia and joint pain and inflammation that can persist for months&#46; Auricular chondritis&#44; a highly characteristic symptom&#44; is sometimes present&#46; Dengue virus infections can be distinguished by the presence of intense myalgia and a purpuric rash predominantly affecting the lower limbs and dependent areas&#46; Zika virus infection usually causes low-grade fever and few systemic manifestations&#46; A definitive diagnosis is established by PCR detection of viral RNA in biological fluids during the acute phase of infection &#40;in blood for the first 5 days and in urine during 10 to 15 days&#41; and by the detection of immunoglobulin M antibodies by enzyme-linked immunosorbent assay or immunofluorescent antibody assay during the convalescent phase&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> Given the possibility of cross-reactions with other flaviviruses&#44; the results of these assays should be confirmed by virus neutralization testing&#46; Furthermore&#44; in patients who come from areas where other flaviviruses coexist with the Zika virus&#44; serum neutralization assays are required for a specific diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Given the current lack of any specific treatment or prophylaxis for Zika virus infection&#44; symptomatic treatment and vigilance to detect complications are necessary&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion&#44; early clinical suspicion of Zika virus infection can help minimize possible autochthonous transmission and optimize disease management&#46; Zika virus infection should therefore be included in the differential diagnosis in any case of nonspecific febrile rash and a compatible epidemiological history&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Ethical Disclosures</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Protection of human and animal subjects</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Data confidentiality</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that they followed their hospital&#39;s regulations regarding the publication of patient information&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Right to privacy and informed consent</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors obtained the informed consent of the patients referred to in this article&#46; The signed forms are in the possession of the corresponding author&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicts of Interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            0 => "Virus Zika"
            1 => "Piel"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Zika virus infection should be suspected in travelers or immigrants with the signs or symptoms of a viral infection &#40;rash&#44; fever&#44; joint pains&#44; conjunctivitis&#44; headache&#44; etc&#46;&#41; and a compatible epidemiological history&#46; Although cutaneous manifestations are among the most common clinical signs of Zika&#44; they are not specific and very few images are available&#46; We present 3 patients &#40;2 travelers and 1 immigrant&#41; in whom a rash was the presenting manifestation of Zika virus infection&#46; Prompt diagnosis optimizes outcomes in these patients&#44; improves the management of severe disease&#44; and minimizes the risk of local transmission by <span class="elsevierStyleItalic">Aedes albopictus</span>&#44; now a potential local vector for the virus due to its presence in areas along Spain&#39;s Mediterranean coast&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La infecci&#243;n por el virus Zika debe sospecharse en viajeros o inmigrantes con cl&#237;nica de viriasis &#40;exantema&#44; fiebre&#44; artralgias&#44; artritis&#44; conjuntivitis&#44; cefalea&#44; etc&#46;&#41; y una historia epidemiol&#243;gica compatible&#46; Aunque las manifestaciones cut&#225;neas se encuentran entre las m&#225;s frecuentes no son espec&#237;ficas y su iconograf&#237;a es escasa&#46; Presentamos 3 casos&#44; 2 viajeros y un inmigrante que comienzan con un exantema por virus Zika&#46; Alcanzar el diagn&#243;stico de forma r&#225;pida optimiza el manejo de estos pacientes&#44; mejora el control de los casos graves y permite minimizar una posible transmisi&#243;n aut&#243;ctona dado el riesgo que supone la presencia del <span class="elsevierStyleItalic">Aedes albopictus</span> como potencial vector transmisor de esta enfermedad en el litoral mediterr&#225;neo espa&#241;ol&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Cosano-Quero A&#44; Velasco-Tirado V&#44; Seco MPS&#44; Manzanedo-Bueno L&#44; Belhassen-Garc&#237;a M&#46; Virus Zika&#58; manifestaciones cut&#225;neas en 3 pacientes&#46; Actas Dermosifiliogr&#46; 2018&#59;109&#58;e13&#8211;e16&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Confluent erythematous papules on the forehead&#44; the dorsum of the nose&#44; and both cheeks 24<span class="elsevierStyleHsp" style=""></span>hours after initial appearance&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A&#44; Papular erythematous rash on the chest&#46; B&#44; Papular erythematous rash on the back&#46;</p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Edema and erythema of the malar region of the face</span>&nbsp;\t\t\t\t\t\t\n
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                  \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"><span class="elsevierStyleItalic">Submandibular and cervical lymphadenitis</span>&nbsp;\t\t\t\t\t\t\n
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                  \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"><span class="elsevierStyleHsp" style=""></span>Gingival bleeding&nbsp;\t\t\t\t\t\t\n
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