Case Report
Exuberant case of erythema elevatum diutinum in a patient infected with HIV and hepatitis B virus
Sayuri Aparecida Hirayamaa,
, Cezar Arthur Tavares Pinheirob, Isabelle Maffei Guarentic, Danise Senna Oliveiraa
Corresponding author
a Department of General Medicine, Teaching Hospital, Universidade Federal de Pelotas, Pelotas, RS, Brazil
b HIV/AIDS Specialized Care Service, Universidade Federal de Pelotas, Pelotas, RS, Brazil
c Empresa Brasileira de Serviços Hospitalares, Teaching Hospital, Universidade Federal de Pelotas, Pelotas, RS, Brazil
Read
6159
Timeswas read the article
3053
Total PDF
3106
Total HTML
Share statistics
array:24 [ "pii" => "S0365059620300271" "issn" => "03650596" "doi" => "10.1016/j.abd.2019.02.013" "estado" => "S300" "fechaPublicacion" => "2020-03-01" "aid" => "134" "copyright" => "Sociedade Brasileira de Dermatologia" "copyrightAnyo" => "2020" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by/4.0/" "subdocumento" => "crp" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "pt" => array:19 [ "pii" => "S2666275220300783" "issn" => "26662752" "doi" => "10.1016/j.abdp.2019.02.013" "estado" => "S300" "fechaPublicacion" => "2020-03-01" "aid" => "134" "copyright" => "Sociedade Brasileira de Dermatologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by/4.0/" "subdocumento" => "crp" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "pt" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Caso Clínico</span>" "titulo" => "Caso exuberante de eritema <span class="elsevierStyleItalic">elevatum diutinum</span> em paciente infectado pelo HIV e pelo vírus da hepatite B" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => "pt" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "200" "paginaFinal" => "202" ] ] "contieneResumen" => array:1 [ "pt" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 685 "Ancho" => 905 "Tamanyo" => 76707 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Lesões nodulares acastanhadas nos joelhos.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sayuri Aparecida Hirayama, Cezar Arthur Tavares Pinheiro, Isabelle Maffei Guarenti, Danise Senna Oliveira" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Sayuri Aparecida" "apellidos" => "Hirayama" ] 1 => array:2 [ "nombre" => "Cezar Arthur Tavares" "apellidos" => "Pinheiro" ] 2 => array:2 [ "nombre" => "Isabelle Maffei" "apellidos" => "Guarenti" ] 3 => array:2 [ "nombre" => "Danise Senna" "apellidos" => "Oliveira" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0365059620300271" "doi" => "10.1016/j.abd.2019.02.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620300271?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275220300783?idApp=UINPBA00008Z" "url" => "/26662752/0000009500000002/v1_202005231807/S2666275220300783/v1_202005231807/pt/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S0365059620300234" "issn" => "03650596" "doi" => "10.1016/j.abd.2019.02.012" "estado" => "S300" "fechaPublicacion" => "2020-03-01" "aid" => "130" "copyright" => "Sociedade Brasileira de Dermatologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by/4.0/" "subdocumento" => "crp" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3 "formatos" => array:2 [ "EPUB" => 1 "PDF" => 2 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "PsAPASH: a rare and recent autoinflammatory syndrome associated with hidradenitis suppurativa" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "203" "paginaFinal" => "206" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1430 "Ancho" => 1074 "Tamanyo" => 161357 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Lesions suggestive of pyoderma gangrenosum in the left breast: ulcers with violaceous and undermined borders.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Raissa de Lima Gadelha, Renata da Silveira Rodrigues Paiva, Esther Bastos Palitot, Joanne Elizabeth Ferraz da Costa" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Raissa de Lima" "apellidos" => "Gadelha" ] 1 => array:2 [ "nombre" => "Renata da Silveira Rodrigues" "apellidos" => "Paiva" ] 2 => array:2 [ "nombre" => "Esther Bastos" "apellidos" => "Palitot" ] 3 => array:2 [ "nombre" => "Joanne Elizabeth Ferraz da" "apellidos" => "Costa" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S2666275220300564" "doi" => "10.1016/j.abdp.2019.02.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275220300564?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620300234?idApp=UINPBA00008Z" "url" => "/03650596/0000009500000002/v1_202004180640/S0365059620300234/v1_202004180640/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0365059620300258" "issn" => "03650596" "doi" => "10.1016/j.abd.2019.09.026" "estado" => "S300" "fechaPublicacion" => "2020-03-01" "aid" => "132" "copyright" => "Sociedade Brasileira de Dermatologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by/4.0/" "subdocumento" => "fla" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Investigation</span>" "titulo" => "High rate of sensitization to Kathon CG, detected by patch tests in patients with suspected allergic contact dermatitis" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "194" "paginaFinal" => "199" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 598 "Ancho" => 2167 "Tamanyo" => 73385 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Location and frequency of lesions in patients with positive tests (percentage).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Eliane Aparecida Silva, Marcia Regina Miras Bosco, Rejane Rojas Lozano, Ana Carla Pereira Latini, Vânia Nieto Brito de Souza" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Eliane Aparecida" "apellidos" => "Silva" ] 1 => array:2 [ "nombre" => "Marcia Regina Miras" "apellidos" => "Bosco" ] 2 => array:2 [ "nombre" => "Rejane Rojas" "apellidos" => "Lozano" ] 3 => array:2 [ "nombre" => "Ana Carla Pereira" "apellidos" => "Latini" ] 4 => array:2 [ "nombre" => "Vânia Nieto Brito de" "apellidos" => "Souza" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S266627522030076X" "doi" => "10.1016/j.abdp.2019.09.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S266627522030076X?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620300258?idApp=UINPBA00008Z" "url" => "/03650596/0000009500000002/v1_202004180640/S0365059620300258/v1_202004180640/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Exuberant case of erythema elevatum diutinum in a patient infected with HIV and hepatitis B virus" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "200" "paginaFinal" => "202" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Sayuri Aparecida Hirayama, Cezar Arthur Tavares Pinheiro, Isabelle Maffei Guarenti, Danise Senna Oliveira" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Sayuri Aparecida" "apellidos" => "Hirayama" "email" => array:1 [ 0 => "sayuri.hirayama@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Cezar Arthur Tavares" "apellidos" => "Pinheiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Isabelle Maffei" "apellidos" => "Guarenti" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Danise Senna" "apellidos" => "Oliveira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of General Medicine, Teaching Hospital, Universidade Federal de Pelotas, Pelotas, RS, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "HIV/AIDS Specialized Care Service, Universidade Federal de Pelotas, Pelotas, RS, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Empresa Brasileira de Serviços Hospitalares, Teaching Hospital, Universidade Federal de Pelotas, Pelotas, RS, Brazil" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 884 "Ancho" => 1207 "Tamanyo" => 313146 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Anatomopathological examination of the skin biopsy demonstrating neutrophilic dermatitis, with marked leukocytoclasia and presence of fibrotic nodules surrounding the neutrophilic infiltrate, compatible with leukocytoclastic vasculitis (Hematoxylin & eosin, ×40).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Erythema elevatum diutinum (EED) is a distinct form of cutaneous leukocytoclastic vasculitis, first recorded in 1878 by Hutchinson and later in 1879 by Bury. It was officially named by Radcliff-Crocker and Williams in 1892<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> (apud Jose SK, 2016, p. 81). It occurs predominantly in adults from 40 to 60 years, being slightly more prevalent in men.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Although its pathogenesis is still unknown, it is believed that immune complexes are deposited on the wall of venules and other vessels by continuous antigen stimulation or other infections. Therefore, EED is associated with hematological, autoimmune, neoplastic, and infectious diseases, such as human immunodeficiency virus (HIV) infection and hepatitis. This deposition of immune complexes leads to activation of the complement cascade <span class="elsevierStyleItalic">via</span> IL-8, with neutrophil chemotaxis, releasing lysozymes, collagenases, myeloperoxidases, and hydrolases that induce fibrin deposition and cholesterol crystals in the capillaries and venules, leading to damage.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">This condition is characterized by papules, plaques, and nodules on the extensor surfaces of extremities, with a predilection for hands, feet, elbows, knees, and Achilles tendons, while sometimes being observed on the face and ears. These lesions occur symmetrically and bilaterally; they are initially soft and erythematous or purpuric, with occasional ulceration. Over time, lesions may develop with hypo- or hyperchromia in the event of regression. The nodular form is rarer, usually occurring in patients with HIV infection. Pruritus and burning pain in the lesions may be observed, as well as arthralgias and ocular alterations, such as nodular scleritis, panuveitis, autoimmune keratolysis, and peripheral keratitis.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The authors describe the case of a patient infected with HIV and hepatitis B virus (HBV) presenting with leukocytoclastic vasculitis diagnosed by biopsy of skin lesions.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">This was a 43-year-old black male patient with a 16-year history of HIV infection who was using lamivudine<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>tenofovir<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>lopinavir/ritonavir (viral load 25,000<span class="elsevierStyleHsp" style=""></span>copies/mL and CD4 count of 39<span class="elsevierStyleHsp" style=""></span>cells/mm<span class="elsevierStyleSup">3</span>). Three years before, a single and nodular lesion had appeared in the right calcaneus; others lesions on the extensor face of the left lower limb and left elbow were observed in subsequent months. All lesions were itchy and progressed in number and size over time. Physical examination disclosed symmetrically distributed erythematous-xanthochromic nodules on the knees and elbows, and linear plaques and erythematous-violaceous nodules on the ankles, toes, and plantar region (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). The patient denied visual alterations and arthralgias. In this hospitalization, the patient was diagnosed with neurotoxoplasmosis, pneumocystosis, and hepatitis B (HbsAg, total anti HBC, and HBEAg reagents with AST/TGO<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>U/L and ALT/TGP<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>U/L). Due to suspicion of tuberous xanthoma, a lipid profile was requested, which was normal. Kaposi's sarcoma was also suspected. Biopsies of two of the lesions were performed. The anatomopathological examination demonstrated neutrophilic dermatitis with marked leukocytoclasia and presence of fibrotic nodules surrounding the neutrophilic infiltrate (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Clinical and pathological correlation indicated EED. Treatment with dapsone 100<span class="elsevierStyleHsp" style=""></span>mg/day was initiated, which resolved the lesions within seven months (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">The diagnosis of EED is clinical and histopathological; in the early stages, the latter presents leukocytoclastic vasculitis with polymorphonuclear cells, macrophages, and histiocytes in the dermis, and in the late stage, granulation tissue, fibrosis, vascular proliferation, lymphohistiocytic inflammatory infiltrate, and focal areas containing neutrophils with leukocytoclasia. In the late stage, intra- and extracellular lipids (cholesterol deposits), although rare, may be observed. The differential diagnosis in the early phase may be Sweet's syndrome, pyoderma gangrenosum, facial granuloma, drug-induced rash, erythema multiforme, cutaneous porphyria, and bullous pemphigoid. In the late stage, the differential diagnosis considers dermatofibroma, fibromatosis, necrobiotic xanthogranuloma, and tuberous xanthoma. In patients with HIV infection, Kaposi's sarcoma and bacillary angiomatosis should also be considered.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The first choice of treatment is dapsone.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Alternatives are colchicine, tetracyclines, niacinamide, and systemic corticosteroids such as prednisolone.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Topical betamethasone may also be used. New therapies with 5% topical dapsone and plasmapheresis have been described.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> In the late stage of the disease, there is little response to dapsone, given the predominant fibrosis. In this case, intralesional corticosteroids or lesion excision are the treatments of choice<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> The disease has a prolonged duration, with reports of spontaneous resolution ranging from five to ten years.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Relapse may occur after dapsone discontinuation.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the literature, approximately 25 cases of EED and HIV infection have been described,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> one of which in Brazil,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> and three cases of HIV/HBV/EED co-occurrence.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> EED is most commonly seen in patients with a CD4 count<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>cells/mm<span class="elsevierStyleSup">3</span>, and both immunosuppression and antigen-antibody reactions caused by HIV and HBV are believed to be the triggering factors of this disease. Nonetheless, in the study by Muratori et al.,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> in four out of five patients with HIV infection, the triggering factor was streptococcal infection. In these patients, the nodular form is the most prevalent,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> and the palmoplantar region may be involved, as in the present case. Differential diagnosis should include bacillary angiomatosis, Kaposi's sarcoma, and rheumatoid nodules.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The present case is relevant, due to the few reports of EED/HIV/HBV patients in the literature. It is common to find skin lesions in immunosuppressed patients, which may suggest diseases of various etiologies. Thus, histopathological confirmation is essential to establish the diagnosis, the stage of the disease, and guide treatment.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Financial support</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Authors’ contributions</span><p id="par0045" class="elsevierStylePara elsevierViewall">Sayuri Aparecida Hirayama: Approval of the final version of the manuscript; conception and planning of the study; elaboration and writing of the manuscript; obtaining, analyzing, and interpreting the data; critical review of the literature; critical review of the manuscript.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Cezar Arthur Tavares Pinheiro: Preparation and writing of the manuscript; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical review of the manuscript.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Isabelle Maffei Guarenti: Approval of the final version of the manuscript; effective participation in research orientation; critical review of the manuscript.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Danise Senna Oliveira: Intellectual participation in propaedeutic and/or therapeutic conduct of studied cases.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1327246" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1223475" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 5 => array:2 [ "identificador" => "sec0025" "titulo" => "Financial support" ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Authors’ contributions" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 8 => array:2 [ "identificador" => "xack458176" "titulo" => "<span class="elsevierStyleBold">Acknowledgements</span>" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-08-02" "fechaAceptado" => "2019-02-27" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1223475" "palabras" => array:5 [ 0 => "Cutaneous" 1 => "Hepatitis B virus" 2 => "HIV" 3 => "Leukocytoclastic" 4 => "Vasculitis" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythema elevatum diutinum is a small vessel vasculitis which is benign, rare, and chronic. It is clinically characterized by violaceous, brown, or yellowish plaques, nodules, and papules. It has been associated with autoimmune, infectious, and neoplastic processes. The following case describes a patient with hepatitis B virus and human immunodeficiency virus with CD4 count<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">3</span>, HIV-seropositive for 16 years, and diagnosed with hepatitis B virus at the hospital. The patient was treated with oral dapsone 100<span class="elsevierStyleHsp" style=""></span>mg/day, showing regression after seven months of treatment. The authors found three cases in the literature of association of erythema elevatum diutinum, human immunodeficiency virus, and hepatitis B virus.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Hirayama SA, Pinheiro CAT, Guarenti IM, Oliveira DS. Exuberant case of erythema elevatum diutinum in a patient infected with HIV and hepatitis B virus. An Bras Dermatol. 2020;95:200–2.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Teaching Hospital of the Universidade Federal de Pelotas, Pelotas, RS, Brazil.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 834 "Ancho" => 1207 "Tamanyo" => 105961 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Medial aspect of right foot and lateral aspect of left foot with erythematous-brown plaques.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 913 "Ancho" => 1207 "Tamanyo" => 116387 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Brownish nodular lesions on the knees.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 884 "Ancho" => 1207 "Tamanyo" => 313146 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Anatomopathological examination of the skin biopsy demonstrating neutrophilic dermatitis, with marked leukocytoclasia and presence of fibrotic nodules surrounding the neutrophilic infiltrate, compatible with leukocytoclastic vasculitis (Hematoxylin & eosin, ×40).</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 668 "Ancho" => 1207 "Tamanyo" => 152107 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Lateral aspect of right foot after seven months of treatment, showing lesions regression.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Erythema elevatum diutinum in acquired immune deficiency syndrome: can it be an immune reconstitution inflammatory syndrome?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.K. Jose" 1 => "Y.S. Marfatia" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/0253-7184.180287" "Revista" => array:6 [ "tituloSerie" => "Indian J Sex Transm Dis AIDS" "fecha" => "2016" "volumen" => "37" "paginaInicial" => "81" "paginaFinal" => "84" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27190420" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0060" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical and surgical therapeutic approach in Erythema Elevatum Diutinum – case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L.H. Zacaron" 1 => "J.C. Gonçalves" 2 => "V.M. Curty" 3 => "D. Acri" 4 => "A.M. Lima" 5 => "R.B.C.J. Martins" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1590/abd1806-4841.20132150" "Revista" => array:6 [ "tituloSerie" => "An Bras Dermatol" "fecha" => "2013" "volumen" => "88" "paginaInicial" => "15" "paginaFinal" => "18" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24346869" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0065" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Erythema elevatum diutinum: an atypical presentation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.E.G. Meléndez" 1 => "S.A.M. Cabriales" 2 => "K. Eichelmann" 3 => "M.G. Flores" 4 => "J.O. Candiani" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/MAJ.0000000000000397" "Revista" => array:6 [ "tituloSerie" => "Am J Med Sci" "fecha" => "2015" "volumen" => "349" "paginaInicial" => "374" "paginaFinal" => "375" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25521326" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0070" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A case of erythema elevatum diutinum with pancytopenia: focus on dapsone-induced hematologic side effects and colchicine as a safe treatment option" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "E. Kocatürk" 1 => "B. Memet" 2 => "I.O. Topal" 3 => "T. Yüksel" 4 => "P.K. Ülkümen" 5 => "U. Kızıltaç" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Drugs Dermatol" "fecha" => "2015" "volumen" => "14" "paginaInicial" => "1090" "paginaFinal" => "1092" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26461818" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0075" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Successful surgical treatment of advanced erythema elevatum diutinum" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.R. Rinard" 1 => "R.C. Mahabir" 2 => "J.F. Greene" 3 => "P. Grothaus" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/229255031001800111" "Revista" => array:6 [ "tituloSerie" => "Can J Plast Surg" "fecha" => "2010" "volumen" => "18" "paginaInicial" => "28" "paginaFinal" => "30" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21358872" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0080" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Erythema elevatum diutinum: a case report and review of literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "V. Doktor" 1 => "A. Hadi" 2 => "A. Hadi" 3 => "R. Phelps" 4 => "H. Goodheart" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/ijd.14169" "Revista" => array:6 [ "tituloSerie" => "Int J Dermatol" "fecha" => "2019" "volumen" => "58" "paginaInicial" => "408" "paginaFinal" => "415" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30074624" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0085" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Erythema elevatum diutinum as a first clinical manifestation for diagnosing HIV infection: case history" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "P.A. Rover" 1 => "C. Bittencourt" 2 => "M.P. Discacciati" 3 => "M.C. Zaniboni" 4 => "L.H. Arruda" 5 => "M.L. Cintra" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1590/s1516-31802005000400009" "Revista" => array:6 [ "tituloSerie" => "Sao Paulo Med J" "fecha" => "2005" "volumen" => "123" "paginaInicial" => "201" "paginaFinal" => "203" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16389420" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0090" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Erythema elevatum diutinum in human immunodeficiency virus-infected patients-report of a case and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "F. Dronda" 1 => "A. González-López" 2 => "M. Lecona" 3 => "C. Barros" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2230.1996.tb00069.x" "Revista" => array:6 [ "tituloSerie" => "Clin Exp Dermatol" "fecha" => "1996" "volumen" => "21" "paginaInicial" => "222" "paginaFinal" => "225" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8914367" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0095" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Erythema elevatum diutinum and HIV infection: a report of five cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. Muratori" 1 => "C. Carrera" 2 => "A. Gorani" 3 => "E. Alessi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1046/j.1365-2133.1999.02988.x" "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "1999" "volumen" => "141" "paginaInicial" => "335" "paginaFinal" => "338" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10468812" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0100" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nodular erythema elevatum diutinum mimicking Kaposi's sarcoma in a human immunodeficiency virus infected patient" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "G.R. Rao" 1 => "R. Joshi" 2 => "A.P. Prasad" 3 => "A. Amareswar" 4 => "S. Sandhya" 5 => "M. Sridevi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/0019-5154.143527" "Revista" => array:6 [ "tituloSerie" => "Indian J Dermatol" "fecha" => "2014" "volumen" => "59" "paginaInicial" => "592" "paginaFinal" => "594" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25484391" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack458176" "titulo" => "<span class="elsevierStyleBold">Acknowledgements</span>" "texto" => "<p id="par0075" class="elsevierStylePara elsevierViewall">The authors would like to thank Dr. Isabella Roque Miclos, a resident in Clinical Medicine at the Universidade Federal de Pelotas.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/03650596/0000009500000002/v1_202004180640/S0365059620300271/v1_202004180640/en/main.assets" "Apartado" => array:4 [ "identificador" => "80638" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Report" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009500000002/v1_202004180640/S0365059620300271/v1_202004180640/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620300271?idApp=UINPBA00008Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 15 | 9 | 24 |
| 2024 October | 99 | 86 | 185 |
| 2024 September | 101 | 88 | 189 |
| 2024 August | 134 | 98 | 232 |
| 2024 July | 120 | 124 | 244 |
| 2024 June | 109 | 74 | 183 |
| 2024 May | 103 | 58 | 161 |
| 2024 April | 119 | 90 | 209 |
| 2024 March | 100 | 83 | 183 |
| 2024 February | 80 | 86 | 166 |
| 2024 January | 52 | 56 | 108 |
| 2023 December | 62 | 69 | 131 |
| 2023 November | 72 | 83 | 155 |
| 2023 October | 55 | 99 | 154 |
| 2023 September | 65 | 70 | 135 |
| 2023 August | 50 | 35 | 85 |
| 2023 July | 50 | 30 | 80 |
| 2023 June | 55 | 45 | 100 |
| 2023 May | 51 | 21 | 72 |
| 2023 April | 50 | 14 | 64 |
| 2023 March | 95 | 45 | 140 |
| 2023 February | 73 | 34 | 107 |
| 2023 January | 41 | 28 | 69 |
| 2022 December | 57 | 24 | 81 |
| 2022 November | 96 | 56 | 152 |
| 2022 October | 67 | 57 | 124 |
| 2022 September | 48 | 58 | 106 |
| 2022 August | 48 | 60 | 108 |
| 2022 July | 46 | 63 | 109 |
| 2022 June | 46 | 52 | 98 |
| 2022 May | 40 | 51 | 91 |
| 2022 April | 39 | 49 | 88 |
| 2022 March | 40 | 60 | 100 |
| 2022 February | 29 | 26 | 55 |
| 2022 January | 53 | 71 | 124 |
| 2021 December | 38 | 48 | 86 |
| 2021 November | 53 | 60 | 113 |
| 2021 October | 55 | 88 | 143 |
| 2021 September | 38 | 65 | 103 |
| 2021 August | 48 | 55 | 103 |
| 2021 July | 41 | 47 | 88 |
| 2021 June | 39 | 98 | 137 |
| 2021 May | 73 | 120 | 193 |
| 2021 April | 140 | 225 | 365 |
| 2021 March | 45 | 53 | 98 |
| 2021 February | 21 | 20 | 41 |
| 2021 January | 12 | 15 | 27 |
| 2020 December | 20 | 18 | 38 |
| 2020 November | 19 | 14 | 33 |
| 2020 October | 25 | 15 | 40 |
| 2020 September | 16 | 7 | 23 |
| 2020 August | 11 | 5 | 16 |
| 2020 July | 15 | 6 | 21 |
| 2020 June | 18 | 22 | 40 |
| 2020 May | 15 | 16 | 31 |
| 2020 April | 4 | 4 | 8 |
Show all
