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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 65-year-old diabetic female with poor metabolic control &#40;HbA1c 14&#46;9&#37;&#41; presented with a two-month history of pruriginous lesions on the trunk and extremities&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">On physical examination&#44; multiple umbilicated&#44; hyperpigmented papules with a central keratotic plug were observed &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#44; as well as inguinal and cervical lymphadenopathies measuring up to 2<span class="elsevierStyleHsp" style=""></span>cm in diameter&#46; Mucous membranes were unaffected&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Laboratory tests revealed mild anemia with mild eosinophilia &#40;hemoglobin 10&#46;9<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; 940<span class="elsevierStyleHsp" style=""></span>eosinophils&#47;mL&#41;&#44; elevated erythrocyte sedimentation rate &#40;93<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#41;&#44; and elevated lactate dehydrogenase &#40;1000<span class="elsevierStyleHsp" style=""></span>units&#47;L&#41;&#46;</p></span><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0011">What is your diagnosis&#63;</span><p id="par0020" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a&#41;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Prurigo nodularis</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b&#41;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Lichenoid drug eruption</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c&#41;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Lymphomatoid papulosis</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Perforating dermatosis</p></li></ul></p><p id="par0045" class="elsevierStylePara elsevierViewall">Skin biopsy showed a cup-shaped depression of the epidermis&#44; with an overlying keratin plug containing collagen fibers&#44; keratinous debris&#44; and inflammatory cells on H&#38;E stained sections&#46; Van Gieson staining demonstrated vertically oriented collagen fibers extruding through the epidermis &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The patient was treated with antihistamines and triamcinolone&#46; A secondary study for a myeloproliferative neoplasm was negative&#59; she was referred to an endocrinologist to improve metabolic management&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Reactive perforating collagenosis &#40;RPC&#41; is a rare disease in the spectrum of perforating dermatoses&#44; showing epidermal perforation and transepidermal elimination of collagen and&#47;or elastic fibers as histologic features&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">RPC may be classified into hereditary and acquired forms&#46; The hereditary type appears in early childhood and is genetically determined by autosomal inheritance&#44; whereas the acquired form &#40;ARPC&#41; accompanies systemic diseases&#44; most commonly diabetes mellitus &#40;DM&#41; and chronic kidney disease &#40;CKD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However&#44; ARPC has also been associated with both myeloproliferative and solid neoplasms&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Clinically&#44; the disease presents with erythematous and&#47;or hyperpigmented papules&#44; plaques&#44; and nodules&#46; Lesions present a central umbilicated or crateriform hyperkeratotic plug&#44; are intensely pruritic&#44; and the Koebner phenomenon is observed&#46; After healing&#44; atrophic&#44; hypo- or hyperpigmented scars are common&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> These lesions appear in areas of superficial trauma and are most likely due to itching&#46; In diabetic patients&#44; vasculopathy of the dermis has been proposed as a synergistic factor&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The palmoplantar region&#44; intertriginous areas&#44; and mucous membranes are generally unaffected&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;6</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">RPC is a clinical diagnosis that requires histopathological confirmation&#44; and its features depend on the stage of the disease&#46; 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What is your diagnosis?
Case for diagnosis. Hyperpigmented and excoriated papules and nodules in a diabetic patient
Catalina Hasbúna, Mauricio Sandovalb,
Autor para correspondência
masando1@uc.cl

Corresponding author.
, Sergio González-Bombardierec
a School of Medicine, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
b Department of Dermatology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
c Department of Pathology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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940<span class="elsevierStyleHsp" style=""></span>eosinophils&#47;mL&#41;&#44; elevated erythrocyte sedimentation rate &#40;93<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#41;&#44; and elevated lactate dehydrogenase &#40;1000<span class="elsevierStyleHsp" style=""></span>units&#47;L&#41;&#46;</p></span><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0011">What is your diagnosis&#63;</span><p id="par0020" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a&#41;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Prurigo nodularis</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b&#41;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Lichenoid drug eruption</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c&#41;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Lymphomatoid papulosis</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Perforating dermatosis</p></li></ul></p><p id="par0045" class="elsevierStylePara elsevierViewall">Skin biopsy showed a cup-shaped depression of the epidermis&#44; with an overlying keratin plug containing collagen fibers&#44; keratinous debris&#44; and inflammatory cells on H&#38;E stained sections&#46; Van Gieson staining demonstrated vertically oriented collagen fibers extruding through the epidermis &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The patient was treated with antihistamines and triamcinolone&#46; A secondary study for a myeloproliferative neoplasm was negative&#59; she was referred to an endocrinologist to improve metabolic management&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Reactive perforating collagenosis &#40;RPC&#41; is a rare disease in the spectrum of perforating dermatoses&#44; showing epidermal perforation and transepidermal elimination of collagen and&#47;or elastic fibers as histologic features&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">RPC may be classified into hereditary and acquired forms&#46; The hereditary type appears in early childhood and is genetically determined by autosomal inheritance&#44; whereas the acquired form &#40;ARPC&#41; accompanies systemic diseases&#44; most commonly diabetes mellitus &#40;DM&#41; and chronic kidney disease &#40;CKD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However&#44; ARPC has also been associated with both myeloproliferative and solid neoplasms&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Clinically&#44; the disease presents with erythematous and&#47;or hyperpigmented papules&#44; 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especially in the context of DM and CKD&#46; However&#44; even in this scenario&#44; when clinical suspicion for an associated neoplasm is high&#44; a basic study for internal malignancies must be performed&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Financial support</span><p id="par0085" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Authors&#8217; contributions</span><p id="par0090" class="elsevierStylePara elsevierViewall">Catalina Hasb&#250;n&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Mauricio Sandoval&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; intellectual participation in propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the manuscript&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Sergio Gonz&#225;lez-Bombardiere&#58; Approval of the final version of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; intellectual participation in propaedeutic&#47;therapeutic conduct of the studied cases&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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