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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 5-year-old boy was seen for recurring nodules on the forehead that had appeared 6 months earlier &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Physical examination revealed the presence of various skin-colored nodules with a stony consistency&#46; The nodules were asymptomatic and showed a tendency to spontaneously involute without scarring&#46; No fever or associated neurological or systemic signs were observed&#46; The boy&#39;s family reported no history of trauma&#44; insect bites&#44; or recent travel&#46; The results of laboratory tests&#44; including a complete blood count and biochemistry profile&#44; were normal&#46; The results of serology for antinuclear antibodies&#44; rheumatoid factor&#44; and complement were within normal ranges&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">High-frequency ultrasound &#40;12&#8239;MHz&#41; revealed the presence of multiple&#44; poorly defined hypoechoic nodules in the subcutaneous cellular tissue&#44; surrounded by a hyperechoic ring and joined by a thin hyperechoic line &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A and B&#41;&#46; Neither calvarial involvement nor the presence of any internal communication were observed on ultrasound&#46; Doppler mode showed weak color uptake&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">An incisional biopsy was performed and subsequent histology &#40;hematoxylin-eosin&#41; showed a normal epidermis with deep&#44; predominantly lymphohistiocytic infiltrate in the subcutaneous cell tissue &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#46; The infiltrate was organized into palisade granulomas with central necrobiosis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#41;&#46;</p><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="par0025" class="elsevierStylePara elsevierViewall">Subcutaneous granuloma annulare &#40;SGA&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Comments</span><p id="par0030" class="elsevierStylePara elsevierViewall">SGA&#44; also known as deep granuloma annulare&#44; is a rare subtype of granuloma annulare&#46; It occurs almost exclusively in children of less than 10 years of age&#44; but has been described anecdotally in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It presents clinically as single or multiple skin-colored nodules with a characteristic stony consistency&#46; The most frequently affected areas are the pretibial region&#44; the forearms&#44; and the feet&#46; Scalp involvement is not uncommon and the presence of multiple lesions is characteristic&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> SGA is a benign process with a tendency towards spontaneous involution&#46; Recurrence is reported in 30&#37; to 75&#37; of cases&#46; Although the etiology and pathogenesis of SGA are not fully described&#44; proposed precipitating factors include trauma and insect bites&#46; These could trigger delayed hypersensitivity reaction mediated by T lymphocytes&#44; inducing a panniculitis-like inflammatory response&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Characteristic histological findings include a deep granulomatous infiltrate composed of lymphocytes and histiocytes arranged in a palisade&#44; a central area of necrobiosis&#44; and the presence of mucin&#46; Because the histological features of SGA resemble those of rheumatoid nodules &#40;RN&#41;&#44; these lesions are also referred to as pseudorheumatoid nodules of childhood&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> The 2 conditions differ&#44; especially in terms of the clinical picture&#58; SGA mainly occurs in healthy children without rheumatoid arthritis &#40;RA&#41;&#44; whereas RN appear in patients with a history of RA&#44; usually on extensor surfaces or areas predisposed to trauma&#46; Although the association of SGA with RA has been ruled out&#44; the relationship between SGA and diabetes mellitus remains a topic of debate&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The differential diagnosis of SGA primarily includes arthropod bites&#44; juvenile self-resolving mucinosis&#44; and subcutaneous juvenile xanthogranuloma&#46; However&#44; due to the stony consistency of the nodules&#44; SGA can also be confused with exostosis&#44; osteoma cutis&#44; pilomatrixoma&#44; and calcinosis cutis&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Skin ultrasound has been proposed as a key technique for the diagnosis of SGA&#44; and avoids the need for more invasive methods such as skin biopsy&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The characteristic ultrasound image of SGA is a heterogeneous hypoechoic nodule located in the subcutaneous cellular tissue&#44; surrounded by a hyperechoic ring&#44; with a negative Doppler signal&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">When considering treatment options&#44; the benign nature of SGA and its tendency to resolve spontaneously should be taken into account&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Surgical excision is not recommended&#44; given the high rates of recurrence&#46; Treatment of SGA with topical corticosteroids&#44; oral thalidomide&#44; and local heat therapy has been described&#44; without consistent responses&#44; and therefore follow-up and clinical observation are recommended in most cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Funding</span><p id="par0050" class="elsevierStylePara elsevierViewall">No funding was received for this study&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case for Diagnosis
Recurring Nodules on the Forehead of a 5-year-old Boy
Nódulos recurrentes en la región frontal de un niño de cinco años
H. Iznardo Ruiza, J.M. Mir-Bonaféb, J.F. Mir-Bonaféa,
Autor para correspondencia
joanmirbonafe@gmail.com

Corresponding author.
a Servicio de Dermatología, Hospital de la Sant Creu i Sant Pau, Barcelona, Spain
b Servicio de Dermatología, Clínica Juaneda, Palma de Mallorca, 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 5-year-old boy was seen for recurring nodules on the forehead that had appeared 6 months earlier &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Physical examination revealed the presence of various skin-colored nodules with a stony consistency&#46; The nodules were asymptomatic and showed a tendency to spontaneously involute without scarring&#46; No fever or associated neurological or systemic signs were observed&#46; The boy&#39;s family reported no history of trauma&#44; insect bites&#44; or recent travel&#46; The results of laboratory tests&#44; including a complete blood count and biochemistry profile&#44; were normal&#46; The results of serology for antinuclear antibodies&#44; rheumatoid factor&#44; and complement were within normal ranges&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">High-frequency ultrasound &#40;12&#8239;MHz&#41; revealed the presence of multiple&#44; poorly defined hypoechoic nodules in the subcutaneous cellular tissue&#44; surrounded by a hyperechoic ring and joined by a thin hyperechoic line &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A and B&#41;&#46; Neither calvarial involvement nor the presence of any internal communication were observed on ultrasound&#46; Doppler mode showed weak color uptake&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">An incisional biopsy was performed and subsequent histology &#40;hematoxylin-eosin&#41; showed a normal epidermis with deep&#44; predominantly lymphohistiocytic infiltrate in the subcutaneous cell tissue &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A&#41;&#46; The infiltrate was organized into palisade granulomas with central necrobiosis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>B&#41;&#46;</p><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="par0025" class="elsevierStylePara elsevierViewall">Subcutaneous granuloma annulare &#40;SGA&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Comments</span><p id="par0030" class="elsevierStylePara elsevierViewall">SGA&#44; also known as deep granuloma annulare&#44; is a rare subtype of granuloma annulare&#46; It occurs almost exclusively in children of less than 10 years of age&#44; but has been described anecdotally in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It presents clinically as single or multiple skin-colored nodules with a characteristic stony consistency&#46; The most frequently affected areas are the pretibial region&#44; the forearms&#44; and the feet&#46; Scalp involvement is not uncommon and the presence of multiple lesions is characteristic&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> SGA is a benign process with a tendency towards spontaneous involution&#46; Recurrence is reported in 30&#37; to 75&#37; of cases&#46; Although the etiology and pathogenesis of SGA are not fully described&#44; proposed precipitating factors include trauma and insect bites&#46; These could trigger delayed hypersensitivity reaction mediated by T lymphocytes&#44; inducing a panniculitis-like inflammatory response&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Characteristic histological findings include a deep granulomatous infiltrate composed of lymphocytes and histiocytes arranged in a palisade&#44; a central area of necrobiosis&#44; and the presence of mucin&#46; Because the histological features of SGA resemble those of rheumatoid nodules &#40;RN&#41;&#44; these lesions are also referred to as pseudorheumatoid nodules of childhood&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> The 2 conditions differ&#44; especially in terms of the clinical picture&#58; SGA mainly occurs in healthy children without rheumatoid arthritis &#40;RA&#41;&#44; whereas RN appear in patients with a history of RA&#44; usually on extensor surfaces or areas predisposed to trauma&#46; Although the association of SGA with RA has been ruled out&#44; the relationship between SGA and diabetes mellitus remains a topic of debate&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The differential diagnosis of SGA primarily includes arthropod bites&#44; juvenile self-resolving mucinosis&#44; and subcutaneous juvenile xanthogranuloma&#46; However&#44; due to the stony consistency of the nodules&#44; SGA can also be confused with exostosis&#44; osteoma cutis&#44; pilomatrixoma&#44; and calcinosis cutis&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Skin ultrasound has been proposed as a key technique for the diagnosis of SGA&#44; and avoids the need for more invasive methods such as skin biopsy&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The characteristic ultrasound image of SGA is a heterogeneous hypoechoic nodule located in the subcutaneous cellular tissue&#44; surrounded by a hyperechoic ring&#44; with a negative Doppler signal&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">When considering treatment options&#44; the benign nature of SGA and its tendency to resolve spontaneously should be taken into account&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Surgical excision is not recommended&#44; given the high rates of recurrence&#46; Treatment of SGA with topical corticosteroids&#44; oral thalidomide&#44; and local heat therapy has been described&#44; without consistent responses&#44; and therefore follow-up and clinical observation are recommended in most cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Funding</span><p id="par0050" class="elsevierStylePara elsevierViewall">No funding was received for this study&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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