Case for Diagnosis
Multiple Acquired Hypopigmented Nodules on the Anterior Chest
Nódulos múltiples hipopigmentados adquiridos en la cara anterior del tórax
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Quintana-Codina, G. Melé-Ninot, C. Santonja" "autores" => array:3 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Quintana-Codina" "email" => array:1 [ 0 => "mquintanacodina@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" => "G." "apellidos" => "Melé-Ninot" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Santonja" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitari Sagrat Cor, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nódulos múltiples hipopigmentados adquiridos en la cara anterior del tórax" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 338 "Ancho" => 450 "Tamanyo" => 16708 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 52-year-old man with a personal history of vitiligo came to our clinic for assessment of multiple asymptomatic lesions on his upper chest that had first appeared 4 years earlier.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed 6 soft, oval, hypopigmented, subcutaneous lesions. No follicular component was present but mild friction-induced erythema, without induration, was observed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Additional Tests</span><p id="par0015" class="elsevierStylePara elsevierViewall">Dermoscopy showed only achromic macules coinciding with each of the nodules.</p><p id="par0020" class="elsevierStylePara elsevierViewall">High-frequency ultrasound imaging (18<span class="elsevierStyleHsp" style=""></span>MHz, Esaote MyLab<span class="elsevierStyleSup">TM</span>25Gold) of 2 contiguous lesions revealed 2 oval foci of thickening and decreased dermal echogenicity that had a solid appearance and were pushing up the epidermis. No sonographic abnormalities of the dermal surface were observed between the 2 foci (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Color Doppler ultrasound showed no sign of vascular flow in the lesions. The other lesions had a similar echostructure.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Histologic examination of a punch biopsy specimen revealed the absence of melanocytes in the basal layer of the epidermis and multiple thin fascicles of smooth muscle fibers oriented in various directions in the middle dermis (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">What Is Your Diagnosis?</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Multiple acquired smooth muscle hamartoma (SMH) with vitiligo hypopigmentation.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinical Course and Treatment</span><p id="par0035" class="elsevierStylePara elsevierViewall">One lesion was surgically removed at the patient's request. The other nodules have remained stable over time.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Comment</span><p id="par0040" class="elsevierStylePara elsevierViewall">SMH is a rare, benign entity that is slightly more common in men and typically presents as a single congenital lesion; the acquired form is exceptional.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Unlike congenital SMH, the acquired form often does not present hypertrichosis, hyperpigmentation, and pseudo Darier sign. Moreover, while congenital SMH tends to be located on the lumbosacral region and the proximal parts of the limbs, acquired SMH tends to appear on the trunk, neck, upper limbs, vulva, and scrotum.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">SMH is mainly diagnosed clinically, although histologic examination may be essential, especially when the clinical presentation is atypical, as in the case of our patient. Histologically, SMH is characterized by the proliferation in the dermis of bundles of smooth muscle oriented in various directions and intermixed with collagen bundles. These bundles, which may or may not be connected to hair follicles, are revealed by histochemical staining with Masson trichrome stain; immunohistochemical techniques such as smooth muscle actin and desmin may also give positive results. Epidermal changes such as acanthosis, papillomatosis, and hypermelanosis can be observed in some cases.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3,4</span></a> Koizumi et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> described CD34-positive dendritic cells in the vicinity of muscle cell bundles in the dermis and interpreted this as a characteristic finding with possible pathogenic implications.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The differential diagnosis is extensive and includes Becker nevus, solitary mastocytoma, connective tissue nevus, and eruptive leiomyoma, among other entities.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,4</span></a> Most authors consider Becker nevus and SMH to be polar forms of a spectrum of entities. At one end of the spectrum is Becker nevus, characterized by the predominance of epidermal changes such as hyperpigmentation and hypertrichosis, while at the other end is SMH, characterized by the predominance of smooth muscle cell proliferation over epidermal changes.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Ultrasound findings for this entity are nonspecific, so differential diagnosis must include other soft-tissue tumors with clinical and sonographic similarities, such as dermatofibroma, granuloma annulare, multiple piloleiomyoma, and spontaneous keloids, among other entities. In some cases, we may find differential characteristics that can point to a diagnosis, such as the peripheral hypoechoic lines in dermatofibromas and the hyperechoic linear fibrillar pattern in keloids. However, histopathologic information is often necessary in order to establish a definitive diagnosis.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion, we have presented an exceptional case of multiple acquired SMH with vitiligo hypopigmentation, probably caused by an isotopic phenomenon. The clinical presentation of SMH in our patient was atypical due to the hypopigmentation, the absence of hypertrichosis, and the multiple lesions, making it necessary to carry out a histopathologic study to confirm the clinical diagnosis. We have also described for the first time the sonographic characteristics of this rare entity. Soft-tissue tumors are a large, heterogeneous group of rare tumors—hence the paucity of information about their sonographic characteristics. We believe that computer-aided diagnostic systems will someday make it easier to distinguish between malignant and benign tumors using high-frequency ultrasound.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of Interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:3 [ "identificador" => "sec0015" "titulo" => "Additional Tests" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical Course and Treatment" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Comment" ] ] ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 4 => array:2 [ "identificador" => "xack370107" "titulo" => "Acknowledgments" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Quintana-Codina M, Melé-Ninot G, Santonja C. Nódulos múltiples hipopigmentados adquiridos en la cara anterior del tórax. Actas Dermosifiliogr. 2018;109:743–744.</p>" ] ] "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 338 "Ancho" => 450 "Tamanyo" => 16708 ] ] ] 1 => array:6 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 530 "Ancho" => 750 "Tamanyo" => 47646 ] ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 263 "Ancho" => 350 "Tamanyo" => 35318 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>40.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Non-congenital smooth muscle hamartoma: 3 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.P. 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Jemec" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:6 [ "titulo" => "Dermatologic ultrasound with clinical and histologic correlations" "fecha" => "2013" "paginaInicial" => "177" "paginaFinal" => "181" "editorial" => "Springer" "editorialLocalizacion" => "New York" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack370107" "titulo" => "Acknowledgments" "texto" => "<p id="par0075" class="elsevierStylePara elsevierViewall">We would like to thank Dr. Luis Requena Caballero of the dermatology department at Hospital Universitario Fundación Jiménez Díaz.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010900000008/v1_201810020631/S1578219018302610/v1_201810020631/en/main.assets" "Apartado" => array:4 [ "identificador" => "6154" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case for Diagnosis" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010900000008/v1_201810020631/S1578219018302610/v1_201810020631/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219018302610?idApp=UINPBA000044" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 8 | 9 | 17 |
| 2024 Octubre | 64 | 45 | 109 |
| 2024 Septiembre | 79 | 27 | 106 |
| 2024 Agosto | 95 | 51 | 146 |
| 2024 Julio | 82 | 36 | 118 |
| 2024 Junio | 81 | 28 | 109 |
| 2024 Mayo | 82 | 37 | 119 |
| 2024 Abril | 77 | 34 | 111 |
| 2024 Marzo | 99 | 28 | 127 |
| 2024 Febrero | 83 | 32 | 115 |
| 2024 Enero | 66 | 38 | 104 |
| 2023 Diciembre | 73 | 17 | 90 |
| 2023 Noviembre | 95 | 21 | 116 |
| 2023 Octubre | 82 | 26 | 108 |
| 2023 Septiembre | 71 | 38 | 109 |
| 2023 Agosto | 41 | 18 | 59 |
| 2023 Julio | 69 | 33 | 102 |
| 2023 Junio | 57 | 27 | 84 |
| 2023 Mayo | 58 | 28 | 86 |
| 2023 Abril | 79 | 25 | 104 |
| 2023 Marzo | 66 | 31 | 97 |
| 2023 Febrero | 44 | 42 | 86 |
| 2023 Enero | 43 | 33 | 76 |
| 2022 Diciembre | 53 | 51 | 104 |
| 2022 Noviembre | 22 | 28 | 50 |
| 2022 Octubre | 25 | 29 | 54 |
| 2022 Septiembre | 24 | 32 | 56 |
| 2022 Agosto | 29 | 31 | 60 |
| 2022 Julio | 30 | 40 | 70 |
| 2022 Junio | 24 | 33 | 57 |
| 2022 Mayo | 26 | 37 | 63 |
| 2022 Abril | 67 | 39 | 106 |
| 2022 Marzo | 57 | 52 | 109 |
| 2022 Febrero | 49 | 27 | 76 |
| 2022 Enero | 71 | 54 | 125 |
| 2021 Diciembre | 43 | 45 | 88 |
| 2021 Noviembre | 55 | 46 | 101 |
| 2021 Octubre | 39 | 57 | 96 |
| 2021 Septiembre | 35 | 40 | 75 |
| 2021 Agosto | 74 | 43 | 117 |
| 2021 Julio | 84 | 39 | 123 |
| 2021 Junio | 35 | 27 | 62 |
| 2021 Mayo | 48 | 50 | 98 |
| 2021 Abril | 158 | 87 | 245 |
| 2021 Marzo | 56 | 54 | 110 |
| 2021 Febrero | 68 | 42 | 110 |
| 2021 Enero | 46 | 44 | 90 |
| 2020 Diciembre | 41 | 47 | 88 |
| 2020 Noviembre | 45 | 35 | 80 |
| 2020 Octubre | 22 | 19 | 41 |
| 2020 Septiembre | 45 | 25 | 70 |
| 2020 Agosto | 40 | 21 | 61 |
| 2020 Julio | 22 | 21 | 43 |
| 2020 Junio | 38 | 38 | 76 |
| 2020 Mayo | 23 | 29 | 52 |
| 2020 Abril | 20 | 9 | 29 |
| 2020 Marzo | 19 | 12 | 31 |
| 2020 Febrero | 1 | 0 | 1 |
| 2019 Mayo | 0 | 0 | 0 |
| 2019 Abril | 1 | 0 | 1 |
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