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who presents a two-year history of the appearance of four painful&#44; slow-growing lesions in the limbs and abdomen&#44; associated with low back pain&#46; The physical examination showed well defined subcutaneous nodules&#44; mobile&#44; of a rubbery consistency and very painful&#44; located in the left forearm &#40;1&#8239;&#215;&#8239;1&#46;5&#8239;cm&#41;&#44; abdomen &#40;0&#46;5&#8239;&#215;&#8239;0&#46;5&#8239;cm&#41;&#44; left thigh &#40;1&#8239;&#215;&#8239;0&#46;5&#8239;cm&#41;&#44; and one of larger size and linear shape on the dorsum of the right hand &#40;2&#8239;&#215;&#8239;1&#8239;cm&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Within the relevant laboratory&#44; 2&#44;200 leukocytes&#44; 920 lymphocytes&#44; with CD4 of 6 cells&#47;mcL and a viral load of 36&#44;600 copies are reported&#46; In the magnetic resonance imaging &#40;MRI&#41; of the contrasted spine&#44; an extensive epidural infiltration with foraminal involvement of T4-T5&#44; T7&#44; T11&#44; and T12 with compression and displacement of the spinal cord is evident &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; A biopsy of one of the skin lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; and of the epidural mass &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41; were taken with findings similar to histology&#44; finding a positive fusocellular neoplasm for H-caldesmon and smooth muscle actin &#40;SMA&#41; a diagnosis of smooth muscle tumor&#46; Subsequently&#44; an <span class="elsevierStyleItalic">in situ</span> hybridization study was performed for the detection of the Epstein-Barr virus encoding region &#40;EBER&#41;&#44; which was positive &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">The relationship between smooth muscle tumors and immunosuppression was first documented in 1970 by Pritzker et al&#46;&#44; 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which promotes cell proliferation and tumor formation&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The diagnosis is made based on physical examination&#44; radiology&#44; and findings in the histological and immunohistochemical study&#59; it is confirmed with <span class="elsevierStyleItalic">in situ</span> hybridization study for the detection of the Epstein-Barr virus&#44; as was done in the representative case&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The presence of these lesions in the central nervous system has been associated with a worse prognosis&#59; regarding treatment&#44; there are some case reports of reversal of the neoplasms with the improvement of immunosuppression&#44; surgical resection for isolated lesions have been published&#44; and the use of radiotherapy and chemotherapy such as sirolimus&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However&#44; most reports are in patients without HIV infection and the results have not been completely satisfactory&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;10</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Financial support</span><p id="par0050" 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="par0030" class="elsevierStylePara elsevierViewall">Estefania Galeano-Piedrahita&#58; Approval of the final version of the manuscript&#59; study conception and planning&#59; preparation and writing of the manuscript&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; intellectual participation in propaedeutic and&#47;or therapeutic conduct of studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Ana Maria Maya Rico&#58; Approval of the final version of the manuscript&#59; study conception and planning&#59; preparation and writing of the manuscript&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; intellectual participation in propaedeutic and&#47;or therapeutic conduct of studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Ana Cristina Ruiz Su&#225;rez&#58; Approval of the final version of the manuscript&#59; study conception and planning&#59; preparation and writing of the manuscript&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; intellectual participation in propaedeutic and&#47;or therapeutic conduct of studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Andrea Laverde Walter&#58; Approval of the final version of the manuscript&#59; study conception and planning&#59; preparation and writing of the manuscript&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; intellectual participation in propaedeutic and&#47;or therapeutic conduct of studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Case Report
Cutaneous smooth muscle tumors associated with Epstein-Barr virus in an adult patient with HIV
Estefania Galeano-Piedrahita
Autor para correspondência
estefaniadermatologia@gmail.com

Corresponding author.
, Ana Maria Maya Rico, Ana Cristina Ruiz Suárez, Andrea Laverde Walter
Dermatology Service, CES University, Medellín, Antioquia, Colombia
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who presents a two-year history of the appearance of four painful&#44; slow-growing lesions in the limbs and abdomen&#44; associated with low back pain&#46; The physical examination showed well defined subcutaneous nodules&#44; mobile&#44; of a rubbery consistency and very painful&#44; located in the left forearm &#40;1&#8239;&#215;&#8239;1&#46;5&#8239;cm&#41;&#44; abdomen &#40;0&#46;5&#8239;&#215;&#8239;0&#46;5&#8239;cm&#41;&#44; left thigh &#40;1&#8239;&#215;&#8239;0&#46;5&#8239;cm&#41;&#44; and one of larger size and linear shape on the dorsum of the right hand &#40;2&#8239;&#215;&#8239;1&#8239;cm&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Within the relevant laboratory&#44; 2&#44;200 leukocytes&#44; 920 lymphocytes&#44; with CD4 of 6 cells&#47;mcL and a viral load of 36&#44;600 copies are reported&#46; In the magnetic resonance imaging &#40;MRI&#41; of the contrasted spine&#44; an extensive epidural infiltration with foraminal involvement of T4-T5&#44; T7&#44; T11&#44; and T12 with compression and displacement of the spinal cord is evident &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; A biopsy of one of the skin lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; and of the epidural mass &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41; were taken with findings similar to histology&#44; finding a positive fusocellular neoplasm for H-caldesmon and smooth muscle actin &#40;SMA&#41; a diagnosis of smooth muscle tumor&#46; Subsequently&#44; an <span class="elsevierStyleItalic">in situ</span> hybridization study was performed for the detection of the Epstein-Barr virus encoding region &#40;EBER&#41;&#44; which was positive &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">The relationship between smooth muscle tumors and immunosuppression was first documented in 1970 by Pritzker et al&#46;&#44; 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most reports are in patients without HIV infection and the results have not been completely satisfactory&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;10</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Financial support</span><p id="par0050" 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="par0030" class="elsevierStylePara elsevierViewall">Estefania Galeano-Piedrahita&#58; Approval of the final version of the manuscript&#59; study conception and planning&#59; preparation and writing of the manuscript&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; intellectual participation in propaedeutic and&#47;or therapeutic conduct of studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Ana Maria Maya Rico&#58; Approval of the final version of the manuscript&#59; study conception and planning&#59; preparation and writing of the manuscript&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; intellectual participation in propaedeutic and&#47;or therapeutic conduct of studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Ana Cristina Ruiz Su&#225;rez&#58; Approval of the final version of the manuscript&#59; study conception and planning&#59; preparation and writing of the manuscript&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; intellectual participation in propaedeutic and&#47;or therapeutic conduct of studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Andrea Laverde Walter&#58; Approval of the final version of the manuscript&#59; study conception and planning&#59; preparation and writing of the manuscript&#59; data collection&#44; analysis&#44; and interpretation&#59; effective participation in research orientation&#59; intellectual participation in propaedeutic and&#47;or therapeutic conduct of studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Epstein Barr virus-associated smooth muscle tumors are an uncommon neoplasm that occurs in immunosuppressed patients of any age&#46; Usually&#44; it presents as multifocal tumors mainly in the spinal cord&#44; epidural region&#44; gastrointestinal tract and liver&#44; upper respiratory tract and skin&#44; the latest with few cases reported in the literature and related with human immunodeficiency virus infection and acquired immune deficiency syndrome&#46; The authors present the first case of a Colombian adult patient with human immunodeficiency virus infection and multifocal Epstein Barr virus-associated smooth muscle tumors in the skin and epidural region&#44; confirmed by histopathology&#44; immunohistochemistry and in situ hybridization studies&#46;</p></span>"
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