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2</a>&#41;&#44; vessels with a predominantly lymphocytic inflammatory infiltrate in the deep reticular dermis and the presence of fibrin &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; in the lumen&#46; Masson&#8217;s trichrome staining showed the amorphous material stained in red&#44; characterizing the aspect of a &#8220;fibrin ring&#8221; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The Verhoeff staining method showed elastic fibers close to the lumen and interspersed in the &#8220;fibrin ring&#8221;&#44; characterizing arteries&#44; with a histopathological picture of LTA &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Laboratory tests such as ANA&#44; anti-DNA&#44; anticardiolipin antibody&#44; Antibodies to Extractable Nuclear Antigens &#40;anti-ENA&#41;&#44; Anti-Neutrophil Cytoplasmic Antibodies &#40;ANCA&#41;&#44; complement&#44; cryoglobulins&#44; Erythrocyte Sedimentation Rate &#40;ESR&#41;&#44; as well as general exams and liver and kidney function tests were normal&#46; Arterial and venous Doppler ultrasound assessment disclosed venous insufficiency in the left lower limb&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Three short cycles of prednisone &#40;0&#46;5&#8239;mg&#47;kg&#47;day&#41; were administered and 50&#8239;mg&#47;day of dapsone was started&#44; gradually increasing the dose to 150&#8239;mg&#47;day&#46; However&#44; the patient developed spontaneous ulcers in the lower limbs&#46; Dapsone was discontinued and azathioprine 100&#8239;mg&#47;day was introduced&#44; in addition to 20&#8239;mg&#47;day of prednisone and maintenance of local care&#44; with ulcer healing and pain relief in one month&#46; After 5 months of follow-up&#44; new lesions appeared&#44; and an increase in the dose of azathioprine to 250&#8239;mg was prescribed&#44; finally showing a good clinical response &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">LTA was first described as a macular arteritis in 2003&#44; by Fein et al&#46;&#44; after the report of three female patients with an asymptomatic hyperpigmented macular eruption&#44; with no consistent association with serological abnormalities or autoimmune diseases of the connective tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Histopathologically&#44; it was characterized as a lymphocytic arteritis in the reticular dermis and hypodermis&#44; with luminal occlusion&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Subsequently&#44; Lee et al&#46; suggested the term LTA&#44; due to the heterogeneity of clinical presentation with the same histopathological alterations&#46; Its association with Cutaneous Polyarteritis Nodosa &#40;cPAN&#41; has been debated since the entity was described&#44; and there is no consensus in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Ishibashi and Chen described arteritis alterations in patients with cPAN as a four-stage process &#40;acute&#44; subacute&#44; under repair&#44; and healed&#41;&#46; In the subacute stage&#44; concentric fibrinoid necrosis of the intima and polymorphous inflammatory infiltrate comprising not only neutrophils&#44; but also lymphocytes and histiocytes have been described&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Classically&#44; LTA is associated with a dense lymphocytic infiltrate and a luminal fibrin ring&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Although there is no consensus in the literature&#44; some authors believe that LTA is a latent form or a final stage of PAN&#44; or even a different entity&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> No association with this condition has been observed so far in our patient&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">As for the clinical picture&#44; hyperchromic macules in the lower limbs and&#44; more rarely&#44; in the upper limbs are observed&#44; especially in women over 40 years old&#44; in addition to livedo racemosa&#47;reticularis or nodules&#44; reinforcing the clinical similarity to PAN&#46; The reported patient was in the age range compatible with the previously described cases&#44; with maculae and ulcers&#44; but without livedo or nodules&#46; Moreover&#44; the patient also had poor local circulation&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3&#44;8&#44;9</span></a> LTA can be associated with thrombophilic alterations&#44; such as increased antiphospholipid antibodies and anticardiolipin antibodies&#44; increased antinuclear antibodies&#44; in addition to elevated ESR&#44; findings not observed in the described case&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Due to the scarcity of cases in the literature&#44; there is still no consensus regarding the therapeutic options for this new entity&#46; There are reports of treatment with prednisone alone or in combination with cyclophosphamide&#44; atovaquone&#44; pentoxifylline&#44; aspirin&#47;doxycycline&#44; dapsone&#44; or narrow-band ultraviolet light B &#40;NBUVB&#41;&#44; in addition to reports of improvement in untreated lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5&#44;9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">After a literature review&#44; two LTA reports were found&#44; showing ulcers in the lower limbs&#44; which were histopathologically compatible with the diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> Llamas-Velasco et al&#46; described a case of a 25-year-old woman without venous insufficiency signs and symptoms&#44; who developed a non-traumatic ulcer on the lower limbs with an LTA-compatible biopsy&#44; which showed clinical improvement after 42 months of treatment with pentoxifylline and prednisone&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The authors believe the ulcer was caused by ischemic damage&#44; secondary to the presence of a chronic lymphocytic vascular lesion&#44; associated with local conditions&#44; such as poor collateral blood circulation or increased venous pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In the present case&#44; the biopsy was performed on a macular lesion&#44; which developed into an ulcer after the procedure and Doppler ultrasound assessment showed venous insufficiency&#44; which could indicate an ulcerous lesion secondary to stasis&#59; however&#44; one can also speculate it was an atypical evolution of arteritis&#44; as it was painful and healed with immunosuppressive therapy&#44; in addition to the fact that venous insufficiency has already been implicated in the literature as a possible etiopathogenic factor of LTA&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Clinically&#44; differentiation from cPAN is also possible&#44; where painful ulcerated lesions are more characteristic and their resolution depends on aggressive immunosuppressive treatment&#46; In this case&#44; the differentiation was histopathological&#44; but one cannot rule out the association between the two conditions&#44; previously mentioned as being possibly associated&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The present report describes a rare case of a middle-aged Caucasian woman with painful ulcerations&#44; which may be another clinical presentation of LTA or represent an atypical progression of this condition&#46; Moreover&#44; this condition usually has an indolent course with variable response to treatment&#44; sometimes showing improvement without any treatment&#44; unlike the reported patient&#44; who only responded after several months of 250&#8239;mg&#47;day of azathioprine&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors&#8217; contributions</span><p id="par0075" class="elsevierStylePara elsevierViewall">Jessica Shen Tsy Wu Kim&#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; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Valeria Romero Godofredo&#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; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Milvia Maria Sim&#245;es e Silva Enokihara&#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="par0090" class="elsevierStylePara elsevierViewall">M&#244;nica Ribeiro de Azevedo Vasconcellos&#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; intellectual participation in the propaedeutic and&#47; or therapeutic conduct of the 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="par0095" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Lymphocytic thrombophilic arteritis is a recently described entity&#44; histopathologically characterized by lymphocytic vasculitis that affects the arterioles of the dermo-hypodermic junction&#44; associated with deposition of fibrin and a luminal fibrin ring&#46; A 49-year-old female patient presented with achromic maculae and a well-defined ulcer on the medial aspect of the left lower limb&#46; The biopsy showed intense inflammatory infiltrate in the papillary dermis with a predominance of lymphocytes&#44; and medium-caliber vessels surrounded by mononuclear infiltrates in the deep reticular dermis&#46; Masson&#8217;s trichrome staining showed intense destruction of the muscle layer of the vascular wall and a fibrin ring&#46; Good clinical response was attained with azathioprine&#46; The authors believe that the ulceration might be another clinical presentation or represent an atypical progression of this condition&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article&#58; Kim JSTW&#44; Godofredo VR&#44; Enokihara MMSS&#44; Vasconcellos MRA&#46; Lymphocytic thrombophilic arteritis with lower-limb ulcers&#46; An Bras Dermatol&#46; 2021&#59;96&#58;315&#8211;8&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Department of Dermatology&#44; Universidade Federal de S&#227;o Paulo&#44; S&#227;o Paulo&#44; SP&#44; Brazil&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Achromic maculae with well-defined edges&#44; Milian&#8217;s white atrophy&#44; erythematous maculae&#44; and an ulcer measuring 1&#46;5&#8239;cm in diameter&#44; on the medial aspect of the left lower limb&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In the papillary dermis&#44; intense inflammatory infiltrate with a predominance of lymphocytes is shown&#44; without compromising the epidermis&#46; In the deep reticular dermis&#44; medium-caliber vessels surrounded by mononuclear infiltrates are shown &#40;Hematoxylin &#38; eosin&#44; &#215;40&#41;&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The use of Masson&#8217;s trichrome staining shows that the destruction of the vascular wall and muscle layer was intense&#44; since no smooth muscle fiber stained in red is observed&#44; and the amorphous material in the lumen is stained red&#44; characterizing the aspect of &#8220;fibrin ring&#8221; &#40;Masson&#8217;s trichrome&#44; &#215;400&#41;&#46;</p>"
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Case Report
Lymphocytic thrombophilic arteritis with lower-limb ulcers
Jessica Shen Tsy Wu Kima,
Autor para correspondência
jessicastwu@gmail.com

Corresponding author.
, Valeria Romero Godofredoa, Milvia Maria Simões e Silva Enokiharaa,b, Mônica Ribeiro de Azevedo Vasconcellosa
a Department of Dermatology, Universidade Federal de São Paulo, São Paulo, SP, Brazil
b Department of Pathology, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Using Verhoeff&#39;s method for elastic fibers&#44; it can be observed that elastic fibers are found close to the lumen and interspersed with the &#8220;fibrin ring&#8221;&#44; suggesting that these vessels are arteries and characterizing the histological picture of lymphocytic thrombophilic arteritis &#40;Verhoeff&#44; &#215;400&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Lymphocytic thrombophilic arteritis &#40;LTA&#41;&#44; or macular lymphocytic arteritis&#44; is a recently described entity&#44; histopathologically characterized by lymphocytic vasculitis that affects arterioles of the dermo-hypodermic junction&#44; associated with the deposition of fibrin and a luminal fibrin ring&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> We describe a case of LTA with ulcers in the lower limbs&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A previously healthy 49-year-old female patient started to show erythematous maculae on her lower limbs 17 months ago and had been followed at our service for 11 months&#46; She had been treated at another service with prednisone 0&#46;5&#8239;mg&#47;kg&#47;&#47;day for a short period after a skin biopsy&#44; which resulted in the development of an ulcer&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">At the examination&#44; she had well-defined achromic maculae&#44; compatible with Milian&#8217;s white atrophy and erythematous maculae&#44; in addition to an ulcer measuring 1&#46;5&#8239;cm in diameter&#44; with well-defined and erythematous edges with a fibrinous bottom&#44; on the medial aspect of the left lower limb &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">We chose not to perform a new biopsy due to the patient&#8217;s poor circulation status&#46; A review of the initial biopsy showed intense lymphocytic inflammatory infiltrate in the papillary dermis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; vessels with a predominantly lymphocytic inflammatory infiltrate in the deep reticular dermis and the presence of fibrin &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; in the lumen&#46; Masson&#8217;s trichrome staining showed the amorphous material stained in red&#44; characterizing the aspect of a &#8220;fibrin ring&#8221; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The Verhoeff staining method showed elastic fibers close to the lumen and interspersed in the &#8220;fibrin ring&#8221;&#44; characterizing arteries&#44; with a histopathological picture of LTA &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Laboratory tests such as ANA&#44; anti-DNA&#44; anticardiolipin antibody&#44; Antibodies to Extractable Nuclear Antigens &#40;anti-ENA&#41;&#44; Anti-Neutrophil Cytoplasmic Antibodies &#40;ANCA&#41;&#44; complement&#44; cryoglobulins&#44; Erythrocyte Sedimentation Rate &#40;ESR&#41;&#44; as well as general exams and liver and kidney function tests were normal&#46; Arterial and venous Doppler ultrasound assessment disclosed venous insufficiency in the left lower limb&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Three short cycles of prednisone &#40;0&#46;5&#8239;mg&#47;kg&#47;day&#41; were administered and 50&#8239;mg&#47;day of dapsone was started&#44; gradually increasing the dose to 150&#8239;mg&#47;day&#46; However&#44; the patient developed spontaneous ulcers in the lower limbs&#46; Dapsone was discontinued and azathioprine 100&#8239;mg&#47;day was introduced&#44; in addition to 20&#8239;mg&#47;day of prednisone and maintenance of local care&#44; with ulcer healing and pain relief in one month&#46; After 5 months of follow-up&#44; new lesions appeared&#44; and an increase in the dose of azathioprine to 250&#8239;mg was prescribed&#44; finally showing a good clinical response &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">LTA was first described as a macular arteritis in 2003&#44; by Fein et al&#46;&#44; after the report of three female patients with an asymptomatic hyperpigmented macular eruption&#44; with no consistent association with serological abnormalities or autoimmune diseases of the connective tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Histopathologically&#44; it was characterized as a lymphocytic arteritis in the reticular dermis and hypodermis&#44; with luminal occlusion&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Subsequently&#44; Lee et al&#46; suggested the term LTA&#44; due to the heterogeneity of clinical presentation with the same histopathological alterations&#46; Its association with Cutaneous Polyarteritis Nodosa &#40;cPAN&#41; has been debated since the entity was described&#44; and there is no consensus in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Ishibashi and Chen described arteritis alterations in patients with cPAN as a four-stage process &#40;acute&#44; subacute&#44; under repair&#44; and healed&#41;&#46; In the subacute stage&#44; concentric fibrinoid necrosis of the intima and polymorphous inflammatory infiltrate comprising not only neutrophils&#44; but also lymphocytes and histiocytes have been described&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Classically&#44; LTA is associated with a dense lymphocytic infiltrate and a luminal fibrin ring&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Although there is no consensus in the literature&#44; some authors believe that LTA is a latent form or a final stage of PAN&#44; or even a different entity&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> No association with this condition has been observed so far in our patient&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">As for the clinical picture&#44; hyperchromic macules in the lower limbs and&#44; more rarely&#44; in the upper limbs are observed&#44; especially in women over 40 years old&#44; in addition to livedo racemosa&#47;reticularis or nodules&#44; reinforcing the clinical similarity to PAN&#46; The reported patient was in the age range compatible with the previously described cases&#44; with maculae and ulcers&#44; but without livedo or nodules&#46; Moreover&#44; the patient also had poor local circulation&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3&#44;8&#44;9</span></a> LTA can be associated with thrombophilic alterations&#44; such as increased antiphospholipid antibodies and anticardiolipin antibodies&#44; increased antinuclear antibodies&#44; in addition to elevated ESR&#44; findings not observed in the described case&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Due to the scarcity of cases in the literature&#44; there is still no consensus regarding the therapeutic options for this new entity&#46; There are reports of treatment with prednisone alone or in combination with cyclophosphamide&#44; atovaquone&#44; pentoxifylline&#44; aspirin&#47;doxycycline&#44; dapsone&#44; or narrow-band ultraviolet light B &#40;NBUVB&#41;&#44; in addition to reports of improvement in untreated lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5&#44;9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">After a literature review&#44; two LTA reports were found&#44; showing ulcers in the lower limbs&#44; which were histopathologically compatible with the diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> Llamas-Velasco et al&#46; described a case of a 25-year-old woman without venous insufficiency signs and symptoms&#44; who developed a non-traumatic ulcer on the lower limbs with an LTA-compatible biopsy&#44; which showed clinical improvement after 42 months of treatment with pentoxifylline and prednisone&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The authors believe the ulcer was caused by ischemic damage&#44; secondary to the presence of a chronic lymphocytic vascular lesion&#44; associated with local conditions&#44; such as poor collateral blood circulation or increased venous pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In the present case&#44; the biopsy was performed on a macular lesion&#44; which developed into an ulcer after the procedure and Doppler ultrasound assessment showed venous insufficiency&#44; which could indicate an ulcerous lesion secondary to stasis&#59; however&#44; one can also speculate it was an atypical evolution of arteritis&#44; as it was painful and healed with immunosuppressive therapy&#44; in addition to the fact that venous insufficiency has already been implicated in the literature as a possible etiopathogenic factor of LTA&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Clinically&#44; differentiation from cPAN is also possible&#44; where painful ulcerated lesions are more characteristic and their resolution depends on aggressive immunosuppressive treatment&#46; In this case&#44; the differentiation was histopathological&#44; but one cannot rule out the association between the two conditions&#44; previously mentioned as being possibly associated&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The present report describes a rare case of a middle-aged Caucasian woman with painful ulcerations&#44; which may be another clinical presentation of LTA or represent an atypical progression of this condition&#46; Moreover&#44; this condition usually has an indolent course with variable response to treatment&#44; sometimes showing improvement without any treatment&#44; unlike the reported patient&#44; who only responded after several months of 250&#8239;mg&#47;day of azathioprine&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors&#8217; contributions</span><p id="par0075" class="elsevierStylePara elsevierViewall">Jessica Shen Tsy Wu Kim&#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; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Valeria Romero Godofredo&#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; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Milvia Maria Sim&#245;es e Silva Enokihara&#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="par0090" class="elsevierStylePara elsevierViewall">M&#244;nica Ribeiro de Azevedo Vasconcellos&#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; intellectual participation in the propaedeutic and&#47; or therapeutic conduct of the 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="par0095" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Lymphocytic thrombophilic arteritis is a recently described entity&#44; histopathologically characterized by lymphocytic vasculitis that affects the arterioles of the dermo-hypodermic junction&#44; associated with deposition of fibrin and a luminal fibrin ring&#46; A 49-year-old female patient presented with achromic maculae and a well-defined ulcer on the medial aspect of the left lower limb&#46; The biopsy showed intense inflammatory infiltrate in the papillary dermis with a predominance of lymphocytes&#44; and medium-caliber vessels surrounded by mononuclear infiltrates in the deep reticular dermis&#46; Masson&#8217;s trichrome staining showed intense destruction of the muscle layer of the vascular wall and a fibrin ring&#46; Good clinical response was attained with azathioprine&#46; The authors believe that the ulceration might be another clinical presentation or represent an atypical progression of this condition&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article&#58; Kim JSTW&#44; Godofredo VR&#44; Enokihara MMSS&#44; Vasconcellos MRA&#46; Lymphocytic thrombophilic arteritis with lower-limb ulcers&#46; An Bras Dermatol&#46; 2021&#59;96&#58;315&#8211;8&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Achromic maculae with well-defined edges&#44; Milian&#8217;s white atrophy&#44; erythematous maculae&#44; and an ulcer measuring 1&#46;5&#8239;cm in diameter&#44; on the medial aspect of the left lower limb&#46;</p>"
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                      "titulo" => "Three cases of lymphocytic thrombophilic arteritis presenting with an annular eruption"
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                          "autores" => array:6 [
                            0 => "R&#46;I&#46; Kelly"
                            1 => "E&#46; Wee"
                            2 => "C&#46; Tancharoen"
                            3 => "M&#46;M&#46; Tam"
                            4 => "S&#46; Balta"
                            5 => "R&#46;A&#46; Williams"
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                        "tituloSerie" => "Australas J Dermatol&#46;"
                        "fecha" => "2018"
                        "volumen" => "59"
                        "paginaInicial" => "e127"
                        "paginaFinal" => "e132"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28752544"
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                    0 => array:2 [
                      "titulo" => "Lymphocytic thrombophilic arteritis&#58; a newly described medium-sizes vessel arteritis of the skin"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46;S&#46; Lee"
                            1 => "S&#46; Kossard"
                            2 => "M&#46;A&#46; McGrath"
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                      "doi" => "10.1001/archderm.144.9.1175"
                      "Revista" => array:6 [
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