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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Insect Bite-Like Reaction &#40;IBLR&#41; is a rare skin disorder&#44; which is associated with hematologic malignant neoplasms such as leukemia and malignant lymphoma&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Hematologic malignant neoplasms are derived from B cells in most cases&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We herein describe a rare case of IBLR in Anaplastic Large Cell Lymphoma &#40;ALCL&#41; patient&#44; a type of T-cell lymphoma&#46; To our knowledge&#44; this is the third report of IBLR associated with T-cell lymphoma&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">An 84-year-old male was diagnosed with ALK-negative ALCL and treated with chemotherapy &#40;a combination of pirarubicin&#44; cyclophosphamide&#44; vincristine&#44; and prednisolone&#41; in a hospital&#44; which produced complete remission&#46; Two years later&#44; he visited a clinic complaining of pruritic nodules on his hands and back&#46; Biopsy taken from a nodule on his hand revealed prominent lymphocytes in the epidermis&#44; around blood vessels and sweat glands in the dermis as well as diffuse eosinophil infiltration &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; and he was diagnosed with Prurigo Nodularis &#40;PN&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">He visited the same clinic again complaining of nodules with mild pruritus on both cheeks four months after the first visit &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Physical examination showed red or skin color circular nodules of 10&#8239;mm in diameter&#46; Laboratory tests showed anemia &#40;hemoglobin 10&#46;0&#8239;g&#47;dL&#41;&#44; normal levels of eosinophils &#40;688&#8239;&#181;L&#41;&#44; and slightly elevated levels of lactate dehydrogenase &#40;289 IU&#47;L&#41; and soluble interleukin-2 receptor &#40;750 U&#47;mL&#41;&#46; There was no data about serum IgE antibodies&#46; ALCL did not recur at that time&#46; A biopsy from one of the nodules revealed prominent infiltration of lymphocytes&#44; which were mostly CD4 positive non-neoplastic T cells&#44; and eosinophils mainly around blood vessels and sweat glands in the dermis and subcutaneous tissue &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The possibility of a recurrence of ALCL was excluded because CD30 positive neoplastic T-cells were not revealed&#46; He was diagnosed with IBLR&#46; Topical corticosteroid for one month led to the improvement of the skin lesions&#46; Epstein-Barr virus-encoded small RNA in situ hybridization was not detected in either specimen of PN or IBLR&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Skin eruptions are common in patients with hematologic malignant neoplasms&#46; Barzilai et al first reported a case of IBLR in which the patient presented with pruritic red papules&#44; nodules&#44; and plaques without insect bite&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> IBLR is also called &#8220;eosinophilic eruption of hematoproliferative disease&#8221;&#44; &#8220;exaggerated insect bite reaction&#8221;&#44; or &#8220;hypersensitivity to insect bite&#8221;&#46; Most cases of IBLR are associated with hematologic malignant neoplasms derived from B cells&#44; especially Chronic Lymphocytic Leukemia &#40;CLL&#41;&#46; Bairey et al&#46; reported 48 IBLR patients with CLL&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> According to their report&#44; IBLR usually appeared after the diagnosis of CLL&#44; while in 29&#37; of the patients&#44; IBLR appeared before the CLL diagnosis&#46; The mean duration of IBLR was 21&#46;5 months&#46; The common sites were lower limbs &#40;79&#37;&#41;&#44; upper limbs &#40;67&#37;&#41;&#44; and head and neck &#40;38&#37;&#41;&#46; Skin eruption of IBLR is clinically similar to that of PN&#44; but PN rarely occurs on the head and neck&#46; Histopathologically&#44; many lymphocytes and eosinophils infiltrate the upper and lower dermis and subcutaneous tissue of the IBLR lesional skin&#44; whereas these inflammatory cells mainly infiltrate the epidermis and upper dermis of the PN lesional skin&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> IBLR is a refractory skin disease and is treated with topical or oral corticosteroid&#44; antihistamine&#44; dapsone&#44; and phototherapy&#44; which however are little effective&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The exact pathogenesis of IBLR is still unknown&#46; IBLR has been defined as a disease with nonspecific cutaneous eruption&#44; in contrast to leukemia cutis&#44; which is associated with specific cutaneous lesions&#46; Bairey et al&#46; reported that IBLR was not related to the activity of CLL&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Similar eruptions have been reported in patients with human immunodeficiency virus infection and congenital agammaglobulinaemia&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> These past reports indicate that an altered immune reactivity probably plays a causative role in IBLR&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Infiltration of many eosinophils suggested a shift in the Th1&#47;Th2 balance toward Th2&#46; Simon et al&#46; reported that abnormal T-cell clones stimulate the production of eosinophilopoietic cytokines including IL-4 and IL-5&#44; which suggested that in our case IBLR was associated with ALCL&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In our case&#44; PN presented on the patient&#8217;s hands and back four months before the appearance of IBLR on his face&#46; ALCL did not recur when these skin diseases appeared&#46; Topical corticosteroids led to the rapid improvement of the IBLR eruption&#44; though IBLR is typically a refractory disease&#46; Biopsy specimens from the back &#40;PN&#41; and the cheek &#40;IBLR&#41; showed infiltration of many eosinophils and CD4 positive non-neoplastic T-cells &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 3</a>&#41;&#46; These histopathological findings suggest that our patient&#8217;s immune balance was shifted toward Th2&#44; which was probably associated with the pathogenesis of PN and IBLR in the present case&#46; To date&#44; 206 IBLR cases have been reported&#44; and only two cases were associated with hematologic malignant neoplasms of T-cell origin&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Therefore&#44; our case is the third report of IBLR associated with T-cell lymphoma&#46; However&#44; it is not yet clear why most IBLR cases are associated with hematologic malignant neoplasms derived from B cells&#46; The pathogenesis of IBLR should be further examined in future studies&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0035" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0040" class="elsevierStylePara elsevierViewall">Tatsuhiko Mori&#58; Designed the study&#59; performed the research and contributed to the analysis and interpretation of data&#59; wrote the initial draft of the manuscript&#59; read and approved the final version of the manuscript&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Kinuko Irie&#58; Performed the research and contributed to analysis and interpretation of data&#59; read and approved the final version of the manuscript&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Toshiyuki Yamamoto&#58; Designed the study&#59; assisted in the preparation of the manuscript&#59; read and approved the final version of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Case Letter
Insect bite-like reaction in a patient with T-cell lymphoma
Tatsuhiko Mori
Corresponding author
mtatsu@fmu.ac.jp

Corresponding author.
, Kinuko Irie, Toshiyuki Yamamoto
Department of Dermatology, Fukushima Medical University, Fukushima, Japan
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    "titulo" => "Insect bite-like reaction in a patient with T-cell lymphoma"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Insect Bite-Like Reaction &#40;IBLR&#41; is a rare skin disorder&#44; which is associated with hematologic malignant neoplasms such as leukemia and malignant lymphoma&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Hematologic malignant neoplasms are derived from B cells in most cases&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We herein describe a rare case of IBLR in Anaplastic Large Cell Lymphoma &#40;ALCL&#41; patient&#44; a type of T-cell lymphoma&#46; To our knowledge&#44; this is the third report of IBLR associated with T-cell lymphoma&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">An 84-year-old male was diagnosed with ALK-negative ALCL and treated with chemotherapy &#40;a combination of pirarubicin&#44; cyclophosphamide&#44; vincristine&#44; and prednisolone&#41; in a hospital&#44; which produced complete remission&#46; Two years later&#44; he visited a clinic complaining of pruritic nodules on his hands and back&#46; Biopsy taken from a nodule on his hand revealed prominent lymphocytes in the epidermis&#44; around blood vessels and sweat glands in the dermis as well as diffuse eosinophil infiltration &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; and he was diagnosed with Prurigo Nodularis &#40;PN&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">He visited the same clinic again complaining of nodules with mild pruritus on both cheeks four months after the first visit &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Physical examination showed red or skin color circular nodules of 10&#8239;mm in diameter&#46; Laboratory tests showed anemia &#40;hemoglobin 10&#46;0&#8239;g&#47;dL&#41;&#44; normal levels of eosinophils &#40;688&#8239;&#181;L&#41;&#44; and slightly elevated levels of lactate dehydrogenase &#40;289 IU&#47;L&#41; and soluble interleukin-2 receptor &#40;750 U&#47;mL&#41;&#46; There was no data about serum IgE antibodies&#46; ALCL did not recur at that time&#46; A biopsy from one of the nodules revealed prominent infiltration of lymphocytes&#44; which were mostly CD4 positive non-neoplastic T cells&#44; and eosinophils mainly around blood vessels and sweat glands in the dermis and subcutaneous tissue &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The possibility of a recurrence of ALCL was excluded because CD30 positive neoplastic T-cells were not revealed&#46; He was diagnosed with IBLR&#46; Topical corticosteroid for one month led to the improvement of the skin lesions&#46; Epstein-Barr virus-encoded small RNA in situ hybridization was not detected in either specimen of PN or IBLR&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Skin eruptions are common in patients with hematologic malignant neoplasms&#46; Barzilai et al first reported a case of IBLR in which the patient presented with pruritic red papules&#44; nodules&#44; and plaques without insect bite&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> IBLR is also called &#8220;eosinophilic eruption of hematoproliferative disease&#8221;&#44; &#8220;exaggerated insect bite reaction&#8221;&#44; or &#8220;hypersensitivity to insect bite&#8221;&#46; Most cases of IBLR are associated with hematologic malignant neoplasms derived from B cells&#44; especially Chronic Lymphocytic Leukemia &#40;CLL&#41;&#46; Bairey et al&#46; reported 48 IBLR patients with CLL&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> According to their report&#44; IBLR usually appeared after the diagnosis of CLL&#44; while in 29&#37; of the patients&#44; IBLR appeared before the CLL diagnosis&#46; The mean duration of IBLR was 21&#46;5 months&#46; The common sites were lower limbs &#40;79&#37;&#41;&#44; upper limbs &#40;67&#37;&#41;&#44; and head and neck &#40;38&#37;&#41;&#46; Skin eruption of IBLR is clinically similar to that of PN&#44; but PN rarely occurs on the head and neck&#46; Histopathologically&#44; many lymphocytes and eosinophils infiltrate the upper and lower dermis and subcutaneous tissue of the IBLR lesional skin&#44; whereas these inflammatory cells mainly infiltrate the epidermis and upper dermis of the PN lesional skin&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> IBLR is a refractory skin disease and is treated with topical or oral corticosteroid&#44; antihistamine&#44; dapsone&#44; and phototherapy&#44; which however are little effective&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The exact pathogenesis of IBLR is still unknown&#46; IBLR has been defined as a disease with nonspecific cutaneous eruption&#44; in contrast to leukemia cutis&#44; which is associated with specific cutaneous lesions&#46; Bairey et al&#46; reported that IBLR was not related to the activity of CLL&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Similar eruptions have been reported in patients with human immunodeficiency virus infection and congenital agammaglobulinaemia&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> These past reports indicate that an altered immune reactivity probably plays a causative role in IBLR&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Infiltration of many eosinophils suggested a shift in the Th1&#47;Th2 balance toward Th2&#46; Simon et al&#46; reported that abnormal T-cell clones stimulate the production of eosinophilopoietic cytokines including IL-4 and IL-5&#44; which suggested that in our case IBLR was associated with ALCL&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In our case&#44; PN presented on the patient&#8217;s hands and back four months before the appearance of IBLR on his face&#46; ALCL did not recur when these skin diseases appeared&#46; Topical corticosteroids led to the rapid improvement of the IBLR eruption&#44; though IBLR is typically a refractory disease&#46; Biopsy specimens from the back &#40;PN&#41; and the cheek &#40;IBLR&#41; showed infiltration of many eosinophils and CD4 positive non-neoplastic T-cells &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 3</a>&#41;&#46; These histopathological findings suggest that our patient&#8217;s immune balance was shifted toward Th2&#44; which was probably associated with the pathogenesis of PN and IBLR in the present case&#46; To date&#44; 206 IBLR cases have been reported&#44; and only two cases were associated with hematologic malignant neoplasms of T-cell origin&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Therefore&#44; our case is the third report of IBLR associated with T-cell lymphoma&#46; However&#44; it is not yet clear why most IBLR cases are associated with hematologic malignant neoplasms derived from B cells&#46; The pathogenesis of IBLR should be further examined in future studies&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0035" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0040" class="elsevierStylePara elsevierViewall">Tatsuhiko Mori&#58; Designed the study&#59; performed the research and contributed to the analysis and interpretation of data&#59; wrote the initial draft of the manuscript&#59; read and approved the final version of the manuscript&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Kinuko Irie&#58; Performed the research and contributed to analysis and interpretation of data&#59; read and approved the final version of the manuscript&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Toshiyuki Yamamoto&#58; Designed the study&#59; assisted in the preparation of the manuscript&#59; read and approved the final version of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Article information
ISSN: 03650596
Original language: English
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