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smaller&#44; plaque was located in the left parieto-occipital region and presented similar ultrasound characteristics&#46; This plaque was 0&#46;6<span class="elsevierStyleHsp" style=""></span>cm wide&#44; 0&#46;3<span class="elsevierStyleHsp" style=""></span>cm thick&#44; and 0&#46;8<span class="elsevierStyleHsp" style=""></span>cm long&#46; The other 2 plaques revealed similar ultrasound characteristics and were located in the left occipital region and were between 0&#46;8 and 1&#46;2<span class="elsevierStyleHsp" style=""></span>cm wide&#44; between 0&#46;3 and 0&#46;7<span class="elsevierStyleHsp" style=""></span>cm thick&#44; and between 0&#46;8 and 1&#46;1<span class="elsevierStyleHsp" style=""></span>cm long&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">No involvement of the cartilage&#44; muscle&#44; or underlying bone was observed&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Case 2</span><p id="par0045" class="elsevierStylePara elsevierViewall">A 23-year-old woman with no past history of interest consulted for lesions on the right pinna that had been present for 6 months and were associated with occasional otorrhagia and sensitivity of the ear canal&#46; Physical examination revealed multiple sessile papules with a smooth surface and a maximum diameter of 0&#46;5<span class="elsevierStyleHsp" style=""></span>cm in the pinna&#44; including the ear canal and earlobe&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Color Doppler ultrasound imaging revealed multiple hypoechogenic plaques with reasonably well defined edges and diffusely hypervascular&#44; polypoid&#44; exophytic&#44; hypoechogenic pseudonodular formations located in the epidermal&#44; dermal and superficial subcutaneous planes&#59; the plaques were between 1&#46;8 and 7&#46;4<span class="elsevierStyleHsp" style=""></span>mm wide&#44; between 1&#46;4 and 7&#46;1<span class="elsevierStyleHsp" style=""></span>mm thick&#44; and between 2 and 5<span class="elsevierStyleHsp" style=""></span>mm long and showed low-velocity arteries&#46; In the clinical examination&#44; these lesions appeared to be separate&#59; however&#44; communicating vascular pathways between the foci were observed in the dermis&#46; No involvement of the ear cartilage was found&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Case 3</span><p id="par0055" class="elsevierStylePara elsevierViewall">A 25-year-old previously healthy man consulted for lesions in the region of the left year that had appeared 8 months earlier and were associated with occasional pruritus&#46; Physical examination revealed multiple sessile papules and nodules with a smooth surface and a maximum diameter of 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm in the left pinna&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Color Doppler ultrasound imaging revealed multiple diffusely hypervascular dermal and superficial subcutaneous hypoechogenic pseudonodular plaques with reasonably well defined edges&#59; some of the plaques presented an exophytic appearance with dermal thickening and&#44; to a lesser extent&#44; epidermal and subcutaneous thickening&#46; These formations formed a cuff surrounding the ear cartilage without compromising it and were between 3&#46;0 and 19&#46;3<span class="elsevierStyleHsp" style=""></span>mm wide&#44; between 4&#46;2 and 10&#46;6<span class="elsevierStyleHsp" style=""></span>cm thick&#44; and between 4&#46;0 and 14&#46;6<span class="elsevierStyleHsp" style=""></span>mm long&#46; The intralesional blood vessels showed arterial flows of medium to low velocity&#46; The left superficial temporal artery was located 2<span class="elsevierStyleHsp" style=""></span>mm ventrally to the aforementioned formations&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Histology</span><p id="par0065" class="elsevierStylePara elsevierViewall">The histology in these cases showed foci of epidermal hyperplasia&#44; proliferation of capillaries and blood vessels with walls of medium thickness covered by epithelioid endothelium and with intracytoplasmic vacuoles&#44; surrounded by a fibrous stroma with abundant lymphocytic and eosinophilic infiltrate in the dermis and epidermis compatible with ALHE &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">This series of cases shows a form of ultrasound presentation different from what has been reported previously and knowledge of this form of presentation may allow for improved clinical and ultrasound discrimination from other skin lesions &#40;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6</span></a>&#41;&#46; Moreover&#44; the use of ultrasound imaging may help to confirm this entity in cases with multiple lesions&#44; as in Case 1&#44; which would avoid unnecessary biopsies and allow for noninvasive management&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Color Doppler imaging provides important anatomical data in ALHE&#44; such as depth&#44; involvement of deep tissue planes&#44; such as cartilage&#44; muscle&#44; bone&#44; and external orifices such as the ear canal&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2&#44;3</span></a> It also makes it possible to determine the distance to high-risk structures&#44; such as periauricular vessels with high blood flow&#44; such as the superficial temporal artery&#44; which was very close to the lesions in one of the cases reported&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The finding of subclinical vascular involvement of the dermis in Case 2 is an interesting finding&#44; as it makes it possible to understand how this entity is extended&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The differential diagnosis may include other types of angiomatous or glomangiomatous lesions&#44; which usually present different ultrasound characteristics&#44; often a single&#44; more nodular&#44; hypoechogenic&#44; hypervascular&#44; dermal-subcutaneous lesion &#40;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7&#44;8</span></a>&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Unlike vascular malformations&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> ALHE lesions show no tubules or internal anechogenic lacunae in the ultrasound examination and in comparison with the hypervascular variants of pilomatrixoma&#44; ALHE lesions do not present internal hyperechogenic foci with a calcified appearance &#40;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a>&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In comparison with other types of vascular tumor such as kaposiform hemangioendothelioma or angiomyxoma&#44; the latter show less defined edges and a more heterogeneous dermal and subcutaneous echostructure&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Another lesion that may be included in the ultrasound differential diagnosis is pyogenic granuloma&#44; which typically presents as a single hypervascular&#44; exophytic&#44; hypoechogenic&#44; polypoid lesion and does not appear as a plaque&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Angiosarcoma usually presents in ultrasound examinations as a single hypervascular&#44; hypoechogenic dermal and subcutaneous lesion with poorly defined&#44; irregular or lobular edges&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In conclusion&#44; color Doppler ultrasound is a tool that can support the diagnosis of ALHE&#44; and knowledge of its forms of ultrasound presentation will make it possible to improve the accuracy of the diagnosis and follow-up of the course of these cases&#44; as well as avoiding multiple biopsies&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of Interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "xres1187729"
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        1 => array:2 [
          "identificador" => "xpalclavsec1107576"
          "titulo" => "Keywords"
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          "titulo" => "Clinical and Ultrasound Evaluations"
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              "titulo" => "Case 1"
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              "titulo" => "Case 2"
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              "identificador" => "sec0025"
              "titulo" => "Case 3"
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          "clase" => "keyword"
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          "palabras" => array:8 [
            0 => "Angiolymphoid hyperplasia"
            1 => "Angiolymphoid hyperplasia ultrasound"
            2 => "Angiolymphoid hyperplasia ultrasonography"
            3 => "Angiolymphoid hyperplasia with eosinophilia"
            4 => "Dermatologic ultrasound"
            5 => "Skin ultrasound"
            6 => "Vascular tumors"
            7 => "Ear pinna ultrasound"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:8 [
            0 => "Hiperplasia angiolinfoide"
            1 => "Hiperplasia angiolinfoide ecograf&#237;a"
            2 => "Hiperplasia angiolinfoide ultrasonido"
            3 => "Hiperplasia angiolinfoide con eosinofilia"
            4 => "Ultrasonido dermatol&#243;gico"
            5 => "Ultrasonido piel"
            6 => "Tumores vasculares"
            7 => "Ecograf&#237;a pabell&#243;n auricular"
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Angiolymphoid hyperplasia with eosinophilia &#40;ALHE&#41; is a benign vascular proliferation characterized by solitary or multiple angiomatous lesions&#46; It is most common in young or middle-aged women&#44; and the lesions typically affect the head and neck&#44; showing a particular predilection for the periauricular region&#46; The differential diagnosis in patients with ALHE is broad and includes both benign and malignant conditions&#46; We report on a series of cases of periauricular ALHE in which ultrasound imaging revealed an hypervascular&#44; pseudonodular and plaque-like morphology with clinical and histologic correlations&#46; It also evidenced vascular communication between lesions that appeared to be separate on clinical examination&#46; Familiarity with such ultrasound presentations could help to improve diagnostic accuracy and facilitate disease monitoring in patients with ALHE&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La hiperplasia angiolinfoide con eosinofilia &#40;HALE&#41; es una proliferaci&#243;n vascular benigna caracterizada por lesiones angiomatosas solitarias o m&#250;ltiples&#44; que se presentan m&#225;s frecuentemente en mujeres j&#243;venes o de mediana edad&#44; en cabeza y cuello&#44; con predilecci&#243;n por la regi&#243;n periauricular&#46; Esta enfermedad plantea un diagn&#243;stico diferencial extenso&#44; tanto con lesiones benignas como malignas&#44; por lo que la posibilidad de tener una herramienta diagn&#243;stica no invasiva como la ecograf&#237;a puede ser de utilidad&#46; Presentamos una serie de casos de HALE con morfolog&#237;a ecogr&#225;fica &#171;en placa pseudonodular hipervascular&#187; de localizaci&#243;n periauricular&#44; con correlaci&#243;n cl&#237;nica e histol&#243;gica&#46; Se demostr&#243; comunicaci&#243;n vascular ecogr&#225;fica entre lesiones que parec&#237;an cl&#237;nicamente separadas&#46; El conocimiento de esta forma de presentaci&#243;n ecogr&#225;fica podr&#237;a contribuir a mejorar la precisi&#243;n del diagn&#243;stico y seguimiento evolutivo de estos casos&#46;</p></span>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Wortsman X&#44; Yagnam M&#44; Carre&#241;o L&#46; Morfolog&#237;a Ecogr&#225;fica en Placa Pseudonodular Hipervascular en Hiperplasia Angiolinfoide&#46; Actas Dermosifiliogr&#46; 2019&#59;110&#58;303&#8211;307&#46;</p>"
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            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0055"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A-D&#41;&#44; Clinical presentations in ALHE&#46; Confluent erythematous&#44; sessile papules and nodules&#44; some of which form plaques&#46; A&#41;&#44; Case 1&#59; B&#41;&#44; Case 2&#59; C&#41;&#44; Dermatoscopy of Case 2&#59; and D&#41;&#44; Case 3&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A-F&#41;&#44; Ultrasound en ALHE&#46; A&#41;&#44; Grayscale imaging and D&#41;&#44; Color Doppler imaging of Case 1&#59; B&#41;&#44; Grayscale imaging and E&#41;&#44; B-Flow ultrasound &#40;General Electric Health Systems&#41; of Case 2&#59; C&#41;&#44; Grayscale imaging and F&#41;&#44; Color Doppler imaging of Case 3&#46; Multiple diffusely hypervascular hypoechogenic dermal and superficial subcutaneous plaques with reasonably well defined edges&#44; showing pseudonodular areas that raise and crease the epidermis&#44; some with a polypoid exophytic appearance and with areas of epidermal&#44; dermal and surface subcutaneous thickening&#46; Note the vascular communication between the lesions in D-F&#44; which was subclinical in Case 2 &#40;B and E&#41; and note that the superficial temporal artery &#40;T&#41; is near the lesion in F&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A and B&#41;&#44; Histology in ALHE&#46; Hematoxylin&#8211;eosin&#58; A&#41;&#44; &#215;20&#59; B&#41;&#44; &#215;400&#46; Dermal proliferation of capillaries and blood vessels with walls of medium thickness with epithelioid endothelium and intracytoplasmic vacuoles&#44; abundant lymphocytic and eosinophilic infiltrate surrounded by a fibrous stroma and mild epidermal hyperplasia&#46;</p>"
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                  \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">Cases&nbsp;\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&nbsp;\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&#44; y&nbsp;\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">Location&nbsp;\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">Blood-Vessel Thickness&#44; mm&nbsp;\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">Systolic Peak&#44; cm&#47;s&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Behind ear&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1-1&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Parieto-occipital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;4-0&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Occipital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;5-1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pinna&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;5-0&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;1&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pinna&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;5-2&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Brief Comunication
Hypervascular Pseudonodular Plaque-Like Ultrasound Morphology in Angiolymphoid Hyperplasia
Morfología Ecográfica en Placa Pseudonodular Hipervascular en Hiperplasia Angiolinfoide
X. Wortsmana,b,
Autor para correspondencia
xworts@yahoo.com

Corresponding author.
, M. Yagnamb, L. Carreñoc
a Instituto de Investigación y Diagnóstico por Imágenes en Piel y Tejidos Blandos-IDIEP, Santiago, Chile
b Departamento de Dermatología, Facultad de Medicina, Universidad de Chile, Santiago, Chile
c Sección de Dermatopatología, Departamento de Anatomía Patológica, Hospital Clínico Universidad de Chile, Universidad de Chile, Santiago, Chile
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Angiolymphoid hyperplasia with eosinophilia &#40;ALHE&#41; is a chronic benign vascular proliferation of uncertain origin&#44; with an extensive differential diagnosis that includes other benign and malignant subcutaneous lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Color Doppler ultrasound is a noninvasive diagnostic technique that is increasingly common in dermatology&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2&#8211;4</span></a> To date&#44; there are 2 reports in the literature of the use of ultrasonography in ALHE&#59; both cases are of single lesions with hypervascularized nodular morphology&#44; one in the dermis of the chin&#44; which the authors describe as having the appearance of a ball of wool&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> and the other of mixed echostructure under the skin of the arm&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We report 3 histologically confirmed cases of periauricular ALHE&#44; with ultrasound morphology that showed multiple hypervascular pseudonodular plaques in different locations than those reported previously&#46; The description of these findings may contribute to increasing knowledge of the forms of ultrasound presentation of this disease and thus improve noninvasive diagnosis of the entity&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical and Ultrasound Evaluations</span><p id="par0020" class="elsevierStylePara elsevierViewall">The reported cases were managed following the published recommendations of the guidelines for performing dermatologic ultrasonography and the medical ethics standards of the Declaration of Helsinki&#46; The patients provided consent for the publication of their images and clinical data &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#44; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; and Video&#44; <a class="elsevierStyleCrossRef" href="#sec0055">supplementary material&#44; Video 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 1</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 51-year-old previously healthy woman consulted for a lesion behind the left ear that had appeared a year earlier and had grown gradually&#44; associated with pruritus and occasional bleeding&#46; The physical examination revealed an erythematous multinodular tumor behind the left ear&#59; the tumor measured 6&#46;5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>cm and was painless to the touch&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Color Doppler ultrasound revealed 4 periauricular focal areas with a diffuse&#44; hypervascular&#44; hypoechogenic pseudonodular plaque-like morphology&#44; with reasonably well defined edges and characterized by thickening and reduction of the echogenicity of the dermis&#44; discrete undulation&#44; and epidermal thickening and increased superficial subcutaneous echogenicity with prominent arteries of medium to low velocity&#46; The largest plaque was located behind the left ear and measured 3&#46;9<span class="elsevierStyleHsp" style=""></span>cm on the transverse axis&#44; 0&#46;8<span class="elsevierStyleHsp" style=""></span>cm in thickness&#44; and 5<span class="elsevierStyleHsp" style=""></span>cm on the longitudinal axis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The second&#44; smaller&#44; plaque was located in the left parieto-occipital region and presented similar ultrasound characteristics&#46; This plaque was 0&#46;6<span class="elsevierStyleHsp" style=""></span>cm wide&#44; 0&#46;3<span class="elsevierStyleHsp" style=""></span>cm thick&#44; and 0&#46;8<span class="elsevierStyleHsp" style=""></span>cm long&#46; The other 2 plaques revealed similar ultrasound characteristics and were located in the left occipital region and were between 0&#46;8 and 1&#46;2<span class="elsevierStyleHsp" style=""></span>cm wide&#44; between 0&#46;3 and 0&#46;7<span class="elsevierStyleHsp" style=""></span>cm thick&#44; and between 0&#46;8 and 1&#46;1<span class="elsevierStyleHsp" style=""></span>cm long&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">No involvement of the cartilage&#44; muscle&#44; or underlying bone was observed&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Case 2</span><p id="par0045" class="elsevierStylePara elsevierViewall">A 23-year-old woman with no past history of interest consulted for lesions on the right pinna that had been present for 6 months and were associated with occasional otorrhagia and sensitivity of the ear canal&#46; Physical examination revealed multiple sessile papules with a smooth surface and a maximum diameter of 0&#46;5<span class="elsevierStyleHsp" style=""></span>cm in the pinna&#44; including the ear canal and earlobe&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Color Doppler ultrasound imaging revealed multiple hypoechogenic plaques with reasonably well defined edges and diffusely hypervascular&#44; polypoid&#44; exophytic&#44; hypoechogenic pseudonodular formations located in the epidermal&#44; dermal and superficial subcutaneous planes&#59; the plaques were between 1&#46;8 and 7&#46;4<span class="elsevierStyleHsp" style=""></span>mm wide&#44; between 1&#46;4 and 7&#46;1<span class="elsevierStyleHsp" style=""></span>mm thick&#44; and between 2 and 5<span class="elsevierStyleHsp" style=""></span>mm long and showed low-velocity arteries&#46; In the clinical examination&#44; these lesions appeared to be separate&#59; however&#44; communicating vascular pathways between the foci were observed in the dermis&#46; No involvement of the ear cartilage was found&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Case 3</span><p id="par0055" class="elsevierStylePara elsevierViewall">A 25-year-old previously healthy man consulted for lesions in the region of the left year that had appeared 8 months earlier and were associated with occasional pruritus&#46; Physical examination revealed multiple sessile papules and nodules with a smooth surface and a maximum diameter of 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm in the left pinna&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Color Doppler ultrasound imaging revealed multiple diffusely hypervascular dermal and superficial subcutaneous hypoechogenic pseudonodular plaques with reasonably well defined edges&#59; some of the plaques presented an exophytic appearance with dermal thickening and&#44; to a lesser extent&#44; epidermal and subcutaneous thickening&#46; These formations formed a cuff surrounding the ear cartilage without compromising it and were between 3&#46;0 and 19&#46;3<span class="elsevierStyleHsp" style=""></span>mm wide&#44; between 4&#46;2 and 10&#46;6<span class="elsevierStyleHsp" style=""></span>cm thick&#44; and between 4&#46;0 and 14&#46;6<span class="elsevierStyleHsp" style=""></span>mm long&#46; The intralesional blood vessels showed arterial flows of medium to low velocity&#46; The left superficial temporal artery was located 2<span class="elsevierStyleHsp" style=""></span>mm ventrally to the aforementioned formations&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Histology</span><p id="par0065" class="elsevierStylePara elsevierViewall">The histology in these cases showed foci of epidermal hyperplasia&#44; proliferation of capillaries and blood vessels with walls of medium thickness covered by epithelioid endothelium and with intracytoplasmic vacuoles&#44; surrounded by a fibrous stroma with abundant lymphocytic and eosinophilic infiltrate in the dermis and epidermis compatible with ALHE &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">This series of cases shows a form of ultrasound presentation different from what has been reported previously and knowledge of this form of presentation may allow for improved clinical and ultrasound discrimination from other skin lesions &#40;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6</span></a>&#41;&#46; Moreover&#44; the use of ultrasound imaging may help to confirm this entity in cases with multiple lesions&#44; as in Case 1&#44; which would avoid unnecessary biopsies and allow for noninvasive management&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Color Doppler imaging provides important anatomical data in ALHE&#44; such as depth&#44; involvement of deep tissue planes&#44; such as cartilage&#44; muscle&#44; bone&#44; and external orifices such as the ear canal&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2&#44;3</span></a> It also makes it possible to determine the distance to high-risk structures&#44; such as periauricular vessels with high blood flow&#44; such as the superficial temporal artery&#44; which was very close to the lesions in one of the cases reported&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The finding of subclinical vascular involvement of the dermis in Case 2 is an interesting finding&#44; as it makes it possible to understand how this entity is extended&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The differential diagnosis may include other types of angiomatous or glomangiomatous lesions&#44; which usually present different ultrasound characteristics&#44; often a single&#44; more nodular&#44; hypoechogenic&#44; hypervascular&#44; dermal-subcutaneous lesion &#40;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7&#44;8</span></a>&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Unlike vascular malformations&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> ALHE lesions show no tubules or internal anechogenic lacunae in the ultrasound examination and in comparison with the hypervascular variants of pilomatrixoma&#44; ALHE lesions do not present internal hyperechogenic foci with a calcified appearance &#40;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a>&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In comparison with other types of vascular tumor such as kaposiform hemangioendothelioma or angiomyxoma&#44; the latter show less defined edges and a more heterogeneous dermal and subcutaneous echostructure&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Another lesion that may be included in the ultrasound differential diagnosis is pyogenic granuloma&#44; which typically presents as a single hypervascular&#44; exophytic&#44; hypoechogenic&#44; polypoid lesion and does not appear as a plaque&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Angiosarcoma usually presents in ultrasound examinations as a single hypervascular&#44; hypoechogenic dermal and subcutaneous lesion with poorly defined&#44; irregular or lobular edges&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In conclusion&#44; color Doppler ultrasound is a tool that can support the diagnosis of ALHE&#44; and knowledge of its forms of ultrasound presentation will make it possible to improve the accuracy of the diagnosis and follow-up of the course of these cases&#44; as well as avoiding multiple biopsies&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of Interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Wortsman X&#44; Yagnam M&#44; Carre&#241;o L&#46; Morfolog&#237;a Ecogr&#225;fica en Placa Pseudonodular Hipervascular en Hiperplasia Angiolinfoide&#46; Actas Dermosifiliogr&#46; 2019&#59;110&#58;303&#8211;307&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A-D&#41;&#44; Clinical presentations in ALHE&#46; Confluent erythematous&#44; sessile papules and nodules&#44; some of which form plaques&#46; A&#41;&#44; Case 1&#59; B&#41;&#44; Case 2&#59; C&#41;&#44; Dermatoscopy of Case 2&#59; and D&#41;&#44; Case 3&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A-F&#41;&#44; Ultrasound en ALHE&#46; A&#41;&#44; Grayscale imaging and D&#41;&#44; Color Doppler imaging of Case 1&#59; B&#41;&#44; Grayscale imaging and E&#41;&#44; B-Flow ultrasound &#40;General Electric Health Systems&#41; of Case 2&#59; C&#41;&#44; Grayscale imaging and F&#41;&#44; Color Doppler imaging of Case 3&#46; Multiple diffusely hypervascular hypoechogenic dermal and superficial subcutaneous plaques with reasonably well defined edges&#44; showing pseudonodular areas that raise and crease the epidermis&#44; some with a polypoid exophytic appearance and with areas of epidermal&#44; dermal and surface subcutaneous thickening&#46; Note the vascular communication between the lesions in D-F&#44; which was subclinical in Case 2 &#40;B and E&#41; and note that the superficial temporal artery &#40;T&#41; is near the lesion in F&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A and B&#41;&#44; Histology in ALHE&#46; Hematoxylin&#8211;eosin&#58; A&#41;&#44; &#215;20&#59; B&#41;&#44; &#215;400&#46; Dermal proliferation of capillaries and blood vessels with walls of medium thickness with epithelioid endothelium and intracytoplasmic vacuoles&#44; abundant lymphocytic and eosinophilic infiltrate surrounded by a fibrous stroma and mild epidermal hyperplasia&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">51&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Parieto-occipital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;4-0&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Occipital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;5-1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\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&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pinna&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;5-0&#46;9&nbsp;\t\t\t\t\t\t\n
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