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erythrocyte sedimentation rate&#44; 15<span class="elsevierStyleHsp" style=""></span>mm&#59; biochemistry with aspartate aminotransferase&#44; 22<span class="elsevierStyleHsp" style=""></span>IU&#47;L&#59; alanine aminotransferase&#44; 20<span class="elsevierStyleHsp" style=""></span>IU&#47;L&#59; ferritin&#44; 1148<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#59; and C-reactive protein&#44; 13&#46;7<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; Antinuclear antibodies&#44; rheumatoid factor&#44; microbial serology&#44; and blood and urine cultures were all negative&#46; Complement&#44; immunoglobulin&#44; and protein levels were normal&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">What Is Your diagnosis&#63;</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0015" class="elsevierStylePara elsevierViewall">Adult-onset Still disease&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical Course and Treatment</span><p id="par0020" class="elsevierStylePara elsevierViewall">The findings were compatible with a diagnosis of adult-onset Still disease &#40;AOSD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> The patient was started on naproxen 500<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h and a tapering course of prednisone 20<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#46; He showed initial improvement&#44; but the disease flared up again when the corticosteroid doses were reduced&#46; Methotrexate 10<span class="elsevierStyleHsp" style=""></span>mg&#47;wk was added to the treatment&#46; At the time of writing&#44; after a year of follow-up&#44; the patient has achieved good clinical control of the disease with prednisone 5<span class="elsevierStyleHsp" style=""></span>mg&#47;d and methotrexate 2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;wk&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Comment</span><p id="par0025" class="elsevierStylePara elsevierViewall">AOSD is an uncommon disease described by Bywaters in 1971&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> It was recently classified as a polygenic autoinflammatory disease&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> It generally appears between the third and sixth decade of life and is more common in women&#46; 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Remarkable findings in the blood tests are leukocytosis&#44; hyperferritinemia&#44; and elevated liver enzymes&#46; Antinuclear antibodies and rheumatoid factor are negative&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3&#44;4</span></a> There may also be high levels of interleukin &#40;IL&#41; 6&#44; tumor necrosis factor&#44; interferon-&#947;&#44; and IL-8&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Although ferritin levels have low specificity and specificity&#44; they generally exceed 1000<span class="elsevierStyleHsp" style=""></span>ng&#47;mL and correlate with disease activity&#46; They typically return to normal on remission of the disease<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> and they may even predict a chronic course&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> Glycosylated ferritin is a more specific marker&#46; Levels of the kinase protein MAP4K3 might be correlated with disease activity and may even have a pathogenic role<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">AOSD can be divided into 2 main phenotypes&#44; systemic-onset AOSD and articular AOSD&#44; based on disease course and cytokine profile&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Complications are rare<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> but can include hepatitis&#44; pleuritis&#44; pneumonitis&#44; and carditis&#46; More serious complications are macrophage activation syndrome and disseminated intravascular coagulation&#44; both of which have a high mortality&#46; In 1 series&#44; 14&#46;8&#37; of patients developed severe complications<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> and female sex was the greatest risk factor&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;3</span></a> Pancytopenia and respiratory distress syndrome should raise suspicion of the possibility of macrophage activation syndrome&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The treatment for OASD is based on experiences with individual patients and&#47;or small series&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Pharmacologic treatments include nonsteroidal anti-inflammatory drugs&#44; corticosteroids&#44; methotrexate&#44; hydroxychloroquine&#44; leflunomide&#44; azathioprine&#44; ciclosporin&#44; penicillamine&#44; and tacrolimus&#46; Biologic drugs have also been used in severe&#44; refractory cases and include infliximab&#44; etanercept&#44; adalimumab&#44; anakinra&#44; and tocilizumab&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of Interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case for Diagnosis
Máculas evanescentes en tronco y extremidades
Fleeting Macules on the Trunk and Limbs
M.Á. Flores-Terrya,
Autor para correspondencia
miguelterry85@hotmail.com

Corresponding author.
, M. Franco-Muñóza, J.A. Garrido-Martína, N. Villasanti-Rivasb
a Servicio de Dermatología, Hospital General Universitario de Ciudad Real, Ciudad Real, España
b Servicio de Anatomía Patológica, Hospital General Universitario de Ciudad Real, Ciudad Real, España
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and arthritis affecting the joints of his right shoulder and left knee and ankle&#46; No enlargement was noticed in the axillary or inguinal lymph nodes or in the liver or spleen&#46; Skin biopsy showed a normal epidermis with a superficial perivascular lymphohistiocytic dermal infiltrate with neutrophils&#46; No other abnormal findings were observed &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Additional Tests</span><p id="par0010" class="elsevierStylePara elsevierViewall">Complete blood count with leukocytes&#44; 13<span class="elsevierStyleHsp" style=""></span>300<span class="elsevierStyleHsp" style=""></span>leukocytes&#47;&#956;L &#40;segment&#44; 83&#46;7&#37;&#41;&#59; erythrocyte sedimentation rate&#44; 15<span class="elsevierStyleHsp" style=""></span>mm&#59; biochemistry with aspartate aminotransferase&#44; 22<span class="elsevierStyleHsp" style=""></span>IU&#47;L&#59; alanine aminotransferase&#44; 20<span class="elsevierStyleHsp" style=""></span>IU&#47;L&#59; ferritin&#44; 1148<span class="elsevierStyleHsp" style=""></span>ng&#47;mL&#59; and C-reactive protein&#44; 13&#46;7<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; Antinuclear antibodies&#44; rheumatoid factor&#44; microbial serology&#44; and blood and urine cultures were all negative&#46; Complement&#44; immunoglobulin&#44; and protein levels were normal&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">What Is Your diagnosis&#63;</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0015" class="elsevierStylePara elsevierViewall">Adult-onset Still disease&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical Course and Treatment</span><p id="par0020" class="elsevierStylePara elsevierViewall">The findings were compatible with a diagnosis of adult-onset Still disease &#40;AOSD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> The patient was started on naproxen 500<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h and a tapering course of prednisone 20<span class="elsevierStyleHsp" style=""></span>mg&#47;d&#46; He showed initial improvement&#44; but the disease flared up again when the corticosteroid doses were reduced&#46; Methotrexate 10<span class="elsevierStyleHsp" style=""></span>mg&#47;wk was added to the treatment&#46; At the time of writing&#44; after a year of follow-up&#44; the patient has achieved good clinical control of the disease with prednisone 5<span class="elsevierStyleHsp" style=""></span>mg&#47;d and methotrexate 2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;wk&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Comment</span><p id="par0025" class="elsevierStylePara elsevierViewall">AOSD is an uncommon disease described by Bywaters in 1971&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> It was recently classified as a polygenic autoinflammatory disease&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> It generally appears between the third and sixth decade of life and is more common in women&#46; Its pathophysiology and triggers remain unclear&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> although several theories have been proposed&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> including infections&#44; which would largely act as viral &#8220;activators&#8221;&#46; A number of genetic markers &#40;HLA DRB1&#42;1201&#44; 1501&#44; B35&#44; DR2&#44; DR5&#41; have also been implicated&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Clinically&#44; the disease is characterized by a fever that spikes in the evening&#44; an evanescent salmon-colored maculopapular rash&#44; arthritis&#44; enlarged lymph nodes&#44; and&#47;or hepatosplenomegaly&#46; The differential diagnosis should include numerous entities such as urticaria&#44; vasculitis&#44; drug eruptions&#44; Sweet syndrome&#44; and hematologic tumors&#46; The hallmark histopathologic finding is a perivascular lymphohistiocytic dermal infiltrate with neutrophils&#46; Remarkable findings in the blood tests are leukocytosis&#44; hyperferritinemia&#44; and elevated liver enzymes&#46; Antinuclear antibodies and rheumatoid factor are negative&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3&#44;4</span></a> There may also be high levels of interleukin &#40;IL&#41; 6&#44; tumor necrosis factor&#44; interferon-&#947;&#44; and IL-8&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Although ferritin levels have low specificity and specificity&#44; they generally exceed 1000<span class="elsevierStyleHsp" style=""></span>ng&#47;mL and correlate with disease activity&#46; They typically return to normal on remission of the disease<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> and they may even predict a chronic course&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> Glycosylated ferritin is a more specific marker&#46; Levels of the kinase protein MAP4K3 might be correlated with disease activity and may even have a pathogenic role<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">AOSD can be divided into 2 main phenotypes&#44; systemic-onset AOSD and articular AOSD&#44; based on disease course and cytokine profile&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Complications are rare<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> but can include hepatitis&#44; pleuritis&#44; pneumonitis&#44; and carditis&#46; More serious complications are macrophage activation syndrome and disseminated intravascular coagulation&#44; both of which have a high mortality&#46; In 1 series&#44; 14&#46;8&#37; of patients developed severe complications<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> and female sex was the greatest risk factor&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;3</span></a> Pancytopenia and respiratory distress syndrome should raise suspicion of the possibility of macrophage activation syndrome&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The treatment for OASD is based on experiences with individual patients and&#47;or small series&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Pharmacologic treatments include nonsteroidal anti-inflammatory drugs&#44; corticosteroids&#44; methotrexate&#44; hydroxychloroquine&#44; leflunomide&#44; azathioprine&#44; ciclosporin&#44; penicillamine&#44; and tacrolimus&#46; Biologic drugs have also been used in severe&#44; refractory cases and include infliximab&#44; etanercept&#44; adalimumab&#44; anakinra&#44; and tocilizumab&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of Interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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