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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Description</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 9-year-old Moldovan girl with no personal history of interest was referred from pediatrics for left vulvar hypertrophy that had developed over the preceding 6 months and had not responded to topical treatment with corticosteroids and antifungals&#46; The patient reported no local trauma and had not undergone abdominal surgery&#46; The hypertrophy was not accompanied by vaginal exudate and was completely asymptomatic&#46; The patient had maintained excellent general health at all times&#46; Physical examination revealed clear vulvar asymmetry&#46; The left labium majus was enlarged and perifollicular accentuation and mild scaling were evident&#46; No other local inflammatory signs or associated extragenital skin alterations were observed&#46; On palpation the affected area had a soft consistency similar to that of the contralateral labium majus&#46; No palpable subcutaneous lesions were detected&#46; Examination of the rest of the genital area revealed no findings of interest&#46; The patient was prepubertal &#40;Tanner stage I&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Soft tissue ultrasound showed an unencapsulated&#44; heterogeneous structure with poorly defined margins&#44; with increased vascularity in Doppler mode and no evidence of inguinal hernia &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; A T1-weighted magnetic resonance imaging study confirmed the aforementioned findings and ruled out the presence of focal lesions &#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><p id="par1025" class="elsevierStylePara elsevierViewall">What Is Your Diagnosis&#63;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Diagnosis</span><p id="par0015" class="elsevierStylePara elsevierViewall">Asymmetric hypertrophy of the left labium majus&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Comment</span><p id="par0020" class="elsevierStylePara elsevierViewall">Once underlying neoplastic and inflammatory processes had been ruled out&#44; the patient was diagnosed with asymmetric hypertrophy of the left labium majus based on clinical signs and radiological findings&#46; It was decided not to treat the patient&#46; The patient underwent repeated check-ups every 6 months consisting of a detailed physical examination and an ultrasound study&#46; No further alterations were detected within a year of the initial consultation&#46; Annual check-ups were scheduled during puberty until the patient reaches sexual maturity&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Asymmetric hypertrophy of the labium majus is rare&#44; although its incidence is likely underestimated due to misdiagnosis and a lack of familiarity with this condition&#46; Like asymmetric breast growth&#44; it is considered a physiological response to prepubertal hormonal variations&#46; Its detection is important in order to rule out more severe conditions&#46; The mean age of onset is 8&#46;3 years&#44; and most cases are unilateral&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Clinical signs consist of enlargement of the labium majus&#44; giving rise to a mass of the same consistency as the surrounding tissue with poorly defined borders&#59; no palpable solid or cystic lesions&#59; and normal skin&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It is not accompanied by systemic clinical signs and physical examination reveals no other alterations&#46; Diagnosis is based on clinical and radiological findings&#46; Biopsy may also be required in cases that are difficult to diagnose or have a prolonged course&#44; or if an underlying tumor is suspected&#46; The main histological findings are a marked proliferation of fibroblasts&#44; positive staining for estrogen receptor&#44; and an abundant extracellular matrix containing elements commonly found in normal vulvar tissue&#44; including adipocytes&#44; blood vessels&#44; and nerves&#46; Three typical radiological findings are described&#58; heterogeneity&#59; poorly defined borders&#59; and increased vascularity&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The differential diagnosis includes tumors such as mesenchymal tumors&#44; solitary mastocytoma of the vulva&#44; and aggressive angiomyxoma&#59; congenital vascular and lymphatic malformations&#59; infections such as schistosomiasis&#59; inguinal hernias&#59; Bartholin cyst&#59; and inflammatory processes such as granulomatous vulvitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4</span></a> In this case an underlying tumor was ruled out based on the results of the imaging studies&#44; in which the bluish coloration typical of vascular malformations was absent&#44; and the ultrasound examination&#44; which showed no compatible findings&#46; An infectious process was not suspected owing to the absence of local discomfort&#44; secretion&#44; and inflammation&#46; Inguinal hernia becomes more pronounced when standing&#44; and was ruled out by radiography&#46; Finally&#44; Bartholin cyst is rare in prepubertal children and granulomatous vulvitis has a recurrent course in the initial stages and is accompanied by progressive induration and&#44; usually&#44; erythema&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The prognosis is favorable&#58; this condition tends to stabilize and can resolve spontaneously at puberty&#46; Treatment is conservative&#46; Although there is no consensus on the frequency of follow-up examinations or the requisite additional tests&#44; Soyer et al&#46; propose close follow-up consisting of physical examination and skin ultrasound every 3 months during the prepubertal period and annually after puberty&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In patients with cosmetic and psychological repercussions&#44; the treatment of choice is surgery once the individual has reached full sexual development&#44; although the rate of recurrence is high&#46; Asymmetric hypertrophy of the labia minora is another recently described variant of normal genital anatomy that also occurs during puberty and&#44; due to its location&#44; tends to cause greater local discomfort&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Pediatricians and dermatologists should be familiar with these conditions in order to avoid unnecessary invasive diagnostic and therapeutic procedures&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "texto" => "<p id="par0040" class="elsevierStylePara elsevierViewall">The authors thank Dr&#46; Vanesa G&#243;mez Dermit of the Pediatric Radiology Department&#44; Marqu&#233;s de Valdecilla University Hospital&#46;</p>"
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Case for Diagnosis
Asymmetric Hypertrophy of the Labium Majus in a 9-Year-Old Girl
Hipertrofia asimétrica de labio mayor en una niña de 9 años
L. Reguero-del Cura
Autor para correspondencia
leandra.reguero@scsalud.es

Corresponding author.
, C. Durán-Vian, Í. Navarro-Fernández, A.E. López-Sundh, C. Gómez-Fernández
Servicio de Dermatología, Hospital Universitario Marqués de Valdecilla, Santander, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Description</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 9-year-old Moldovan girl with no personal history of interest was referred from pediatrics for left vulvar hypertrophy that had developed over the preceding 6 months and had not responded to topical treatment with corticosteroids and antifungals&#46; The patient reported no local trauma and had not undergone abdominal surgery&#46; The hypertrophy was not accompanied by vaginal exudate and was completely asymptomatic&#46; The patient had maintained excellent general health at all times&#46; Physical examination revealed clear vulvar asymmetry&#46; The left labium majus was enlarged and perifollicular accentuation and mild scaling were evident&#46; No other local inflammatory signs or associated extragenital skin alterations were observed&#46; On palpation the affected area had a soft consistency similar to that of the contralateral labium majus&#46; No palpable subcutaneous lesions were detected&#46; Examination of the rest of the genital area revealed no findings of interest&#46; The patient was prepubertal &#40;Tanner stage I&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Soft tissue ultrasound showed an unencapsulated&#44; heterogeneous structure with poorly defined margins&#44; with increased vascularity in Doppler mode and no evidence of inguinal hernia &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; A T1-weighted magnetic resonance imaging study confirmed the aforementioned findings and ruled out the presence of focal lesions &#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><p id="par1025" class="elsevierStylePara elsevierViewall">What Is Your Diagnosis&#63;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Diagnosis</span><p id="par0015" class="elsevierStylePara elsevierViewall">Asymmetric hypertrophy of the left labium majus&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Comment</span><p id="par0020" class="elsevierStylePara elsevierViewall">Once underlying neoplastic and inflammatory processes had been ruled out&#44; the patient was diagnosed with asymmetric hypertrophy of the left labium majus based on clinical signs and radiological findings&#46; It was decided not to treat the patient&#46; The patient underwent repeated check-ups every 6 months consisting of a detailed physical examination and an ultrasound study&#46; No further alterations were detected within a year of the initial consultation&#46; Annual check-ups were scheduled during puberty until the patient reaches sexual maturity&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Asymmetric hypertrophy of the labium majus is rare&#44; although its incidence is likely underestimated due to misdiagnosis and a lack of familiarity with this condition&#46; Like asymmetric breast growth&#44; it is considered a physiological response to prepubertal hormonal variations&#46; Its detection is important in order to rule out more severe conditions&#46; The mean age of onset is 8&#46;3 years&#44; and most cases are unilateral&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Clinical signs consist of enlargement of the labium majus&#44; giving rise to a mass of the same consistency as the surrounding tissue with poorly defined borders&#59; no palpable solid or cystic lesions&#59; and normal skin&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It is not accompanied by systemic clinical signs and physical examination reveals no other alterations&#46; Diagnosis is based on clinical and radiological findings&#46; Biopsy may also be required in cases that are difficult to diagnose or have a prolonged course&#44; or if an underlying tumor is suspected&#46; The main histological findings are a marked proliferation of fibroblasts&#44; positive staining for estrogen receptor&#44; and an abundant extracellular matrix containing elements commonly found in normal vulvar tissue&#44; including adipocytes&#44; blood vessels&#44; and nerves&#46; Three typical radiological findings are described&#58; heterogeneity&#59; poorly defined borders&#59; and increased vascularity&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The differential diagnosis includes tumors such as mesenchymal tumors&#44; solitary mastocytoma of the vulva&#44; and aggressive angiomyxoma&#59; congenital vascular and lymphatic malformations&#59; infections such as schistosomiasis&#59; inguinal hernias&#59; Bartholin cyst&#59; and inflammatory processes such as granulomatous vulvitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2&#44;4</span></a> In this case an underlying tumor was ruled out based on the results of the imaging studies&#44; in which the bluish coloration typical of vascular malformations was absent&#44; and the ultrasound examination&#44; which showed no compatible findings&#46; An infectious process was not suspected owing to the absence of local discomfort&#44; secretion&#44; and inflammation&#46; Inguinal hernia becomes more pronounced when standing&#44; and was ruled out by radiography&#46; Finally&#44; Bartholin cyst is rare in prepubertal children and granulomatous vulvitis has a recurrent course in the initial stages and is accompanied by progressive induration and&#44; usually&#44; erythema&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The prognosis is favorable&#58; this condition tends to stabilize and can resolve spontaneously at puberty&#46; Treatment is conservative&#46; Although there is no consensus on the frequency of follow-up examinations or the requisite additional tests&#44; Soyer et al&#46; propose close follow-up consisting of physical examination and skin ultrasound every 3 months during the prepubertal period and annually after puberty&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In patients with cosmetic and psychological repercussions&#44; the treatment of choice is surgery once the individual has reached full sexual development&#44; although the rate of recurrence is high&#46; Asymmetric hypertrophy of the labia minora is another recently described variant of normal genital anatomy that also occurs during puberty and&#44; due to its location&#44; tends to cause greater local discomfort&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Pediatricians and dermatologists should be familiar with these conditions in order to avoid unnecessary invasive diagnostic and therapeutic procedures&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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