e- Case Report
Juvenile Dermatomyositis: Key Roles of Muscle Magnetic Resonance Imaging and Early Aggressive Treatment
La resonancia magnética muscular y el tratamiento agresivo precoz, claves en la dermatomiositis juvenil
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García del Pozo, C. Martín de Hijas, L. Íñiguez de Onzoño" "autores" => array:3 [ 0 => array:2 [ "nombre" => "M.C." "apellidos" => "García del Pozo" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Martín de Hijas" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Íñiguez de Onzoño" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731017304970" "doi" => "10.1016/j.ad.2017.01.023" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731017304970?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219018301641?idApp=UINPBA000044" "url" => "/15782190/0000010900000006/v1_201808010420/S1578219018301641/v1_201808010420/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1578219018301823" "issn" => "15782190" "doi" => "10.1016/j.adengl.2018.05.022" "estado" => "S300" "fechaPublicacion" => "2018-07-01" "aid" => "1814" "copyright" => "Elsevier España, S.L.U. and AEDV" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2018;109:e37-41" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3 "formatos" => array:2 [ "HTML" => 1 "PDF" => 2 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">e- Case Report</span>" "titulo" => "Reflectance Confocal Microscopy: A Promising Tool to Identify Malignancy in Melanocytic Lesions Exhibiting a Dermoscopic Island" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e37" "paginaFinal" => "e41" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Microscopia confocal de reflectancia: una herramienta útil para diagnosticar malignidad en lesiones melanocíticas que presenten el signo de la isla" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1891 "Ancho" => 2167 "Tamanyo" => 552888 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Clinical, dermoscopy, reflectance confocal microscopy (RCM), and histology findings. A, Light brown nevus (4<span class="elsevierStyleHsp" style=""></span>mm) in the lumbar region with asymmetry and a hyperpigmented area. B, Dermoscopic island: dermoscopy reveals a homogenous reticular pattern within which lies an area of eccentric hyperpigmention with a distinct, atypical reticular pattern. C, RCM image showing isolated atypical round cells (arrows), atypical cells forming nests (circles), and papillae with poorly defined contours (asterisks). D, Proliferation of large atypical melanocytes with prominent, hyperchromatic nucleoli corresponding to the dermoscopic island (hematoxylin-eosin, original magnification ×100).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Elosua-González, R. Gamo-Villegas, U. Floristán-Muruzábal, F. Pinedo-Moraleda, J.L. López-Estebaranz" "autores" => array:5 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Elosua-González" ] 1 => array:2 [ "nombre" => "R." 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Corral-Magaña, A.F. Bauzá-Alonso, M.M. Escudero-Góngora, L. Lacruz, A. Martín-Santiago" "autores" => array:5 [ 0 => array:4 [ "nombre" => "O." "apellidos" => "Corral-Magaña" "email" => array:1 [ 0 => "oricmag@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A.F." "apellidos" => "Bauzá-Alonso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M.M." "apellidos" => "Escudero-Góngora" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Lacruz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "A." "apellidos" => "Martín-Santiago" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Son Espases, Palma de Mallorca, España" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Pediatría, Hospital Universitario Son Espases, Palma de Mallorca, España" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La resonancia magnética muscular y el tratamiento agresivo precoz, claves en la dermatomiositis juvenil" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1849 "Ancho" => 2500 "Tamanyo" => 213748 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance imaging (MRI) findings. A, Patient #1. Whole-body muscle MRI. Increased intensity in STIR (short tau inversion recovery) sequence of buttock region and vastus lateralis, consistent with muscle edema, a sign of muscle inflammation. Integration of this finding confirmed the diagnosis of juvenile dermatomyositis. B, Patient #4. MRI of shoulder muscle. Increased signal from right deltoids and fascia in association with a small quantity of liquid in the subacromial bursa. C, patient #5. Whole-body muscle MRI after initiation of treatment. Note the hypointense calcinosis cutis plaque in the right low lumbar region (*).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Juvenile dermatomyositis is an uncommon autoimmune systemic connective tissue disease. Despite its low prevalence, it accounts for 85% of all idiopathic inflammatory myopathies in children, and incidence rates vary between 2 and 4 cases per 1 million children depending on the series.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> Clinically, juvenile dermatomyositis is characterized by muscle weakness and distinctive cutaneous manifestations, which tend to occur as the presenting symptom. On occasions, the disease may affect other organs, such as the gastrointestinal tract, the heart, the lungs, the kidneys, and the eyes.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> Other complications, such as lipotrophy and calcinosis, may appear in late stages of disease, but they have become less common since the introduction of early intensive treatment. Diagnosis of juvenile dermatomyositis has traditionally been based on the criteria published by Bohan and Peter in 1975, but muscle biopsy is gradually being replaced by muscle magnetic resonance imaging (MRI), which is a noninvasive procedure that offers high sensitivity and performs better than muscle biopsy in terms of false negatives as it is not affected by the patchy distribution of disease.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3–5</span></a> In view of these advantages, several groups have proposed incorporating muscle MRI findings into diagnostic and follow-up criteria.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,5,6</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Objectives</span><p id="par0010" class="elsevierStylePara elsevierViewall">We performed a retrospective chart review of patients diagnosed with juvenile dermatomyositis at our hospital between January 1999 and December 2015. Our aims were to assess disease course and complications in patients treated with early intensive therapy and to evaluate the use of MRI rather than biopsy for detecting muscle involvement.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0015" class="elsevierStylePara elsevierViewall">We studied 5 patients (4 boys and 1 girl) with a mean age at diagnosis of 10.4 years (range, 8-12 years). Time to diagnosis ranged from 2 months to 3 years. All the patients developed the characteristic cutaneous manifestations first. These preceded the onset of muscle involvement by periods ranging from 2 weeks to 3 years. The shortest time to diagnosis was observed in the 2 patients who presented with skin complaints (patients #2 and #4). The physical examination revealed Gottron papules and malar rash in patient #2 and Gottron papules, heliotrope erythema, and psoriasiform plaques on the scalp in #patient 4 (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The presenting manifestation in the other 3 patients was muscle weakness. All the patients had cutaneous manifestations, the most common of which were Gottron papules/the Gottron sign (present in 5/5 patients), heliotrope erythema (4/5), malar rash (4/5) and periungual telangiectasias (3/5) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The 5 patients had proximal muscle weakness, elevated levels of 1 or more muscle enzymes (alanine aminotransferase, aspartate aminotransferase, creatine kinase, aldolase), and muscle MRI findings consistent with myositis in the upper and lower limbs (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The electromyogram, performed in 4 patients, showed a myogenic pattern in the biceps and/or quadriceps. Two patients had positive antinuclear antibodies with low titers (1/160). None of the patients underwent muscle biopsy and a skin biopsy was performed in all cases (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The starting treatment in 3 patients consisted of oral systemic corticosteroids 1<span class="elsevierStyleHsp" style=""></span>mg/kg/d or intravenous corticosteroids at two 500-mg pulses combined with oral methotrexate 15<span class="elsevierStyleHsp" style=""></span>mg/wk and hydroxychloroquine 200<span class="elsevierStyleHsp" style=""></span>mg/d. Another patient was treated with oral prednisone 1<span class="elsevierStyleHsp" style=""></span>mg/kg/d combined with ciclosporin and 6 boluses of intravenous immunoglobulin (IVIG). The last patient, who had mild muscle involvement, was treated with oral methotrexate 15<span class="elsevierStyleHsp" style=""></span>mg and hydroxychloroquine 200<span class="elsevierStyleHsp" style=""></span>mg combined with topical corticosteroids and tacrolimus. No systemic corticosteroids were administered. Four patients relapsed during follow-up and received different treatments (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Four patients are currently asymptomatic. Two are not receiving any treatment, 1 is receiving subcutaneous methotrexate 15<span class="elsevierStyleHsp" style=""></span>mg/wk and hydroxychloroquine 200<span class="elsevierStyleHsp" style=""></span>mg/d, and the other is receiving once-daily hydroxychloroquine 200<span class="elsevierStyleHsp" style=""></span>mg as monotherapy (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). None of the patients developed serious complications or organ involvement and just 1 developed calcinosis cutis in the form of a single plaque in the lumbar region 3 years after diagnosis.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">We have presented 5 cases of juvenile dermatomyositis with cutaneous and muscle manifestations but no involvement of the visceral organs. The ratio of male to female patients was 4:1. This rate contrasts with reports of higher proportions of girls in larger series.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,2,7,8</span></a> The mean age at diagnosis was 10.4 years and the mean time to diagnosis was 11.25 months. These figures are similar to those described in the literature<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2,7,8</span></a> and indicate that diagnosis is often delayed in patients with juvenile dermatomyositis.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Diagnosis was established in all 5 patients on the basis of cutaneous and/or muscle involvement, elevated levels of 1 of more muscle enzymes, an electromyogram showing a myogenic pattern, and abnormal muscle MRI findings. A muscle biopsy was not needed in any of the cases. While not pathognomonic, edema in T1- and STIR (short tau inversion recovery) MRI sequences has been described as a specific feature of idiopathic inflammatory myopathies and juvenile dermatomyositis. Barsotti et al.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> reported that muscle edema had a sensitivity of 92.3% and a specificity of 83.3% for the diagnosis of inflammatory myopathies. Degree of edema on the MRI has also been found to correlate with levels of disease activity.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3,5,9</span></a> The pelvis offers the greatest yield in muscle MRI, followed by the buttocks, the vastus medialis and lateralis, and the shoulders, thorax, and neck.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> Several authors have called for the use of whole-body MRI as the imaging test of choice because early involvement of the muscle in the above locations may not be clinically detectable.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3,9</span></a> Detection of muscle edema by whole-body MRI in these and other locations would enable the early detection of asymptomatic disease, even in patients without elevated muscle enzymes or with a negative muscle biopsy result.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3,5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Muscle biopsy can produce false-negative results in juvenile dermatomyositis due to the patchy distribution of disease. Muscle MRI, by contrast, examines the entire muscle area. It, therefore, offers greater sensitivity and, where necessary, can help in the selection of an appropriate muscle biopsy site.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3,9</span></a> It also has high sensitivity for the detection of recurrence during follow-up, as it can show signs of disease activity in patients with normal muscle enzyme levels.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Like other authors,<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,3,9–12</span></a> we believe that muscle MRI is a valuable diagnostic and follow-up tool for juvenile dermatomyositis. It is safe, sensitive, and noninvasive and can be used instead of muscle biopsy in most patients. Several authors have proposed using muscle MRI as an additional diagnostic tool for juvenile dermatomyositis and the procedure is currently used by different working groups to evaluate and monitor inflammatory myopathies.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,3,4,9,12</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Four of the 5 patients in our series showed excellent progress over a follow-up period of 4 to 12 years, and they are all currently asymptomatic and free of sequelae. The fifth patient was diagnosed and treated at a hospital in Ecuador for 3 years before being referred to our hospital with calcinosis cutis presenting as a small plaque. The plaque probably developed because the patient did not receive early aggressive treatment. Calcinosis has been linked to the presence of persistent inflammatory activity, and many authors have shown that early initiation of intensive treatment can prevent later complications.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">7,8,13</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Although the prognosis of juvenile dermatomyositis has improved, early initiation of aggressive treatment and long-term follow up are still necessary as the disease runs an unpredictable course.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="par0060" class="elsevierStylePara elsevierViewall">We have presented 5 cases of juvenile dermatomyositis, 4 of which were associated with excellent outcomes. These favorable results are consistent with reports in the literature and are probably thanks to the early initiation of intensive therapy.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,6,8,11,14</span></a> Just 1 patient developed calcinosis cutis and this was possibly due to late initiation of nonaggressive therapy.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Dermatologists have an important role in diagnosing juvenile dermatomyositis<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> and muscle MRI is a safe, sensitive, noninvasive test for detecting and monitoring muscle involvement.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical Disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of humans and animals</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that no tests were carried out in humans or animals for the purpose of this study.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Confidentiality of data</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that they have followed their hospital's protocol on the publication of data concerning patients.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Right to privacy and informed consent</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that no private patient data appear in this article.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflicts of Interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1066840" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1014583" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1066839" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1014582" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Objectives" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of humans and animals" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of Interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1014583" "palabras" => array:3 [ 0 => "Juvenile dermatomyositis" 1 => "Muscle magnetic resonance" 2 => "Early treatment" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1014582" "palabras" => array:3 [ 0 => "Dermatomiositis juvenil" 1 => "Resonancia magnética muscular" 2 => "Tratamiento precoz" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Juvenile dermatomyositis is a rare systemic connective tissue disease with onset during childhood. It presents clinically with proximal muscle weakness and characteristic skin involvement. Diagnosis is based on the Bohan and Peter criteria, though many authors are now substituting biopsy with muscle magnetic resonance imaging (MRI) for both diagnosis and follow-up. Without intensive early treatment, complications such as calcinosis cutis and lipodystrophy can develop in the chronic phases of the disease. Early recognition is therefore key to management. We present a series of 5 patients who were diagnosed with Juvenile dermatomyositis on muscle MRI without undergoing muscle biopsy and who received early treatment. We draw attention to the usefulness of muscle MRI for the diagnosis of muscle involvement and to the importance of early initiation of intensive treatment to prevent complications.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La dermatomiositis juvenil es una conectivopatía sistémica infrecuente de aparición en la edad pediátrica. Clínicamente se caracteriza por la presencia de debilidad muscular proximal con afectación cutánea característica. El diagnóstico de la enfermedad se realiza mediante los criterios de Bohan y Peter, si bien recientemente numerosos autores están sustituyendo la realización de biopsia muscular por la resonancia magnética muscular (RMM) para el diagnóstico y seguimiento de la enfermedad.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">En fases crónicas de la enfermedad, y sin un tratamiento precoz intensivo, pueden aparecer complicaciones como la calcinosis cutánea o la lipoatrofia, por lo que el reconocimiento temprano de la enfermedad es clave en el manejo.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Presentamos una serie de 5 pacientes diagnosticados de dermatomiositis juvenil mediante RMM sin realizarse biopsia muscular y tratados de forma temprana. Resaltamos la utilidad de la RMM en el diagnóstico de la enfermedad muscular y la importancia de instaurar el tratamiento de forma precoz e intensiva para prevenir las complicaciones.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Corral-Magaña O, Bauzá-Alonso AF, Escudero-Góngora MM, Lacruz L, Martín-Santiago A. La resonancia magnética muscular y el tratamiento agresivo precoz, claves en la dermatomiositis juvenil. Actas Dermosifiliogr. 2018;109:e42–e46.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1849 "Ancho" => 2500 "Tamanyo" => 213748 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance imaging (MRI) findings. A, Patient #1. Whole-body muscle MRI. Increased intensity in STIR (short tau inversion recovery) sequence of buttock region and vastus lateralis, consistent with muscle edema, a sign of muscle inflammation. Integration of this finding confirmed the diagnosis of juvenile dermatomyositis. B, Patient #4. MRI of shoulder muscle. Increased signal from right deltoids and fascia in association with a small quantity of liquid in the subacromial bursa. C, patient #5. Whole-body muscle MRI after initiation of treatment. Note the hypointense calcinosis cutis plaque in the right low lumbar region (*).</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: Abs, antibodies; ANA, antinuclear antibodies; CC, calcinosis cutis; DIF, direct immunofluorescence; F, female; GP, Gottron papules; HE, heliotrope erythema; LL, lower limbs; M, male; MR, malar rash; MRI, muscle magnetic resonance imaging; Neg, negative; PHS, photosensitivity; PP, psoriasiform plaques; PT, periungual telangiectasias; UL, upper limbs.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age at Diagnosis, y \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time to Diagnosis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">First Symptom \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Presenting Complaint \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cutaneous Manifestations \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Muscle Weakness \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Abs<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Biopsy \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MRI \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24<span class="elsevierStyleHsp" style=""></span>mo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cutaneous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Weakness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HE, GP, PT, MR, \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Scapula and pelvis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hyperkeratosis, parakeratosis, perivascular lymphocytic infiltrate, mucin, negative DIF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Edema in paraspinal and upper and lower limb muscles \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3<span class="elsevierStyleHsp" style=""></span>wk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cutaneous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Skin lesion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GP, MR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Scapula \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ANAs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hyperkeratosis, perivascular infiltrate, negative keratinocytes, mucin, fibrinogen with DIF<br> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Scapular muscle edema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cutaneous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Weakness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HE, GP, PT, MR, PHS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pelvis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ANAs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ulceration, parakeratosis, perivascular lymphocytic infiltrate, vascular dilation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pelvic girdle muscle edema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.5<span class="elsevierStyleHsp" style=""></span>mo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cutaneous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Skin lesion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HE, GP, PT, PP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Scapula \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hyperkeratosis, papillary dermis edema, perivascular lymphocytic infiltrate, vascular dilation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right deltoid edema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24<span class="elsevierStyleHsp" style=""></span>mo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cutaneous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Weakness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HE, GP, MR, CC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Scapula and pelvis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not available (performed at other hospital) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Proximal muscle atrophy in upper and lower limbs \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1819474.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">The following antibodies were determined: ANA, Jo1, SSA/Ro/SSB/La, U1RNP, Sm, Scl70, Mi-2, Ku, Pm-Scl, SRP, antisynthetases.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Clinical Characteristics of Patients.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: CORT, corticosteroids; CICLO, ciclosporin; MTX, methotrexate; HCQ, hydrochloroquine; IVIG, intravenous immunoglobulin; mPDN, methylprednisone; PDN, prednisone; TAC, tacrolimus.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CORT \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MTX \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HCQ \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TAC \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IVIG \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CICLO \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. of Relapses/Treatment \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Follow-up Duration, y \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 pulses mPDN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15<span class="elsevierStyleHsp" style=""></span>mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">200<span class="elsevierStyleHsp" style=""></span>mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1/PDN, IVIG, MTX \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral PDN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 boluses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2/deflazacort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral PDN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15<span class="elsevierStyleHsp" style=""></span>mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">200<span class="elsevierStyleHsp" style=""></span>mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1/tacrolimus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Topical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15<span class="elsevierStyleHsp" style=""></span>mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">200<span class="elsevierStyleHsp" style=""></span>mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Topical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral PDN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15<span class="elsevierStyleHsp" style=""></span>mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">200<span class="elsevierStyleHsp" style=""></span>mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 bolus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1/PDN, MTX, HCQ, IVIG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1819476.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Initial Treatment.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: CORT, corticosteroids; CICLO, ciclosporin; MTX, methotrexate; HCQ, hydrochloroquine; IVIG, intravenous immunoglobulin; PDN, prednisone; TAC, tacrolimus.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CORT \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MTX \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HCQ \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TAC \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IVIG \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CICLO \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Current Situation \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PDN 30<span class="elsevierStyleHsp" style=""></span>mg 5 mo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15<span class="elsevierStyleHsp" style=""></span>mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">200<span class="elsevierStyleHsp" style=""></span>mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 boluses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Under treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tapering regimen \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">200<span class="elsevierStyleHsp" style=""></span>mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Stable with treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tapering regimen \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">200<span class="elsevierStyleHsp" style=""></span>mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Topical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20<span class="elsevierStyleHsp" style=""></span>mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">200<span class="elsevierStyleHsp" style=""></span>mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 boluses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Stable with treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1819475.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Maintenance Treatment.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An update on juvenile dermatomyositis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "V. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 14 | 8 | 22 |
| 2024 Octubre | 73 | 45 | 118 |
| 2024 Septiembre | 81 | 35 | 116 |
| 2024 Agosto | 134 | 49 | 183 |
| 2024 Julio | 102 | 38 | 140 |
| 2024 Junio | 90 | 31 | 121 |
| 2024 Mayo | 80 | 32 | 112 |
| 2024 Abril | 85 | 38 | 123 |
| 2024 Marzo | 76 | 33 | 109 |
| 2024 Febrero | 67 | 33 | 100 |
| 2024 Enero | 60 | 23 | 83 |
| 2023 Diciembre | 83 | 16 | 99 |
| 2023 Noviembre | 93 | 30 | 123 |
| 2023 Octubre | 83 | 35 | 118 |
| 2023 Septiembre | 70 | 30 | 100 |
| 2023 Agosto | 54 | 17 | 71 |
| 2023 Julio | 81 | 33 | 114 |
| 2023 Junio | 62 | 23 | 85 |
| 2023 Mayo | 85 | 28 | 113 |
| 2023 Abril | 73 | 28 | 101 |
| 2023 Marzo | 73 | 30 | 103 |
| 2023 Febrero | 68 | 41 | 109 |
| 2023 Enero | 45 | 41 | 86 |
| 2022 Diciembre | 62 | 49 | 111 |
| 2022 Noviembre | 36 | 27 | 63 |
| 2022 Octubre | 38 | 31 | 69 |
| 2022 Septiembre | 33 | 48 | 81 |
| 2022 Agosto | 33 | 38 | 71 |
| 2022 Julio | 40 | 33 | 73 |
| 2022 Junio | 45 | 17 | 62 |
| 2022 Mayo | 70 | 49 | 119 |
| 2022 Abril | 96 | 39 | 135 |
| 2022 Marzo | 90 | 47 | 137 |
| 2022 Febrero | 58 | 28 | 86 |
| 2022 Enero | 61 | 44 | 105 |
| 2021 Diciembre | 46 | 49 | 95 |
| 2021 Noviembre | 58 | 45 | 103 |
| 2021 Octubre | 48 | 61 | 109 |
| 2021 Septiembre | 36 | 47 | 83 |
| 2021 Agosto | 45 | 44 | 89 |
| 2021 Julio | 66 | 41 | 107 |
| 2021 Junio | 63 | 50 | 113 |
| 2021 Mayo | 46 | 63 | 109 |
| 2021 Abril | 104 | 99 | 203 |
| 2021 Marzo | 75 | 42 | 117 |
| 2021 Febrero | 94 | 52 | 146 |
| 2021 Enero | 43 | 45 | 88 |
| 2020 Diciembre | 54 | 38 | 92 |
| 2020 Noviembre | 59 | 36 | 95 |
| 2020 Octubre | 42 | 20 | 62 |
| 2020 Septiembre | 53 | 41 | 94 |
| 2020 Agosto | 58 | 24 | 82 |
| 2020 Julio | 29 | 22 | 51 |
| 2020 Junio | 58 | 54 | 112 |
| 2020 Mayo | 27 | 26 | 53 |
| 2020 Abril | 39 | 17 | 56 |
| 2020 Marzo | 24 | 20 | 44 |
| 2020 Febrero | 1 | 0 | 1 |
| 2018 Septiembre | 1 | 2 | 3 |
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