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136 U&#47;L&#44; ALT&#58; 152 U&#47;L&#44; ALP&#58; 1821 U&#47;L&#44; GGT&#58; 907&#46;3 U&#47;L&#41;&#59; ultrasonography showed the liver at the upper limit of normality&#44; heterogeneous echotexture and areas of periportal hyperechogenicity&#59; magnetic resonance cholangiography and bone scintigraphy showed no alterations&#59; histopathology of the skin showed a lichenoid infiltrate of Langerhans cells with diffuse immunohistochemical positivity for CD1a and S100 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Thus&#44; the diagnosis of Langerhans cell histiocytosis &#40;LCH&#41; with seborrheic-like dermatitis lesions and liver involvement was established&#46; Oncological treatment was initiated with prednisone and vinblastine for 12 weeks&#44; with no improvement of skin lesions&#46; One month after the end of the induction phase&#44; with continuous lesions on the scalp&#44; a new histopathology analysis showed persistence of a lichenoid inflammatory infiltrate of Langerhans cells with diffuse positivity for CD1a&#44; whereas the ultrasonography showed hepatic infiltration and splenomegaly&#46; The continuation of chemotherapy with mercaptopurine&#44; prednisone and vinblastine for 12 months was indicated &#40;currently ongoing&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Historically&#44; LCH has been subdivided into four syndromes &#40;Letterer-Siwe&#44; Hand-Schuller-Christian&#44; eosinophilic granuloma&#44; and Hashimoto-Pritzker&#41;&#59; however&#44; current evidence indicates that not all cases fit into these categories&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Recently&#44; LCH has been redefined as an inflammatory myeloid neoplasia&#44; attributed to the activation of mutations in the mitogen-activated protein kinase &#40;MAPK&#41; pathway&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> with the <span class="elsevierStyleItalic">BRAF-V600E</span> gene mutation being the most prevalent one&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Clinically&#44; it is categorized by the involvement of one or multiple systems&#44; either unifocal or multifocal and the presence of involvement of organs at risk &#40;liver&#44; spleen and bone marrow&#41;&#44; which define the prognosis and therapeutic response&#46; Single-system LCH has an excellent prognosis&#44; whereas the multi-system form has a mortality risk that requires aggressive treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Although isolated skin disease is rare &#40;2&#37;&#41;&#44; cutaneous manifestations are the standard form of presentation in around 80&#37; of cases&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> being the most common in those younger than 2 years-old&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Seborrheic-like dermatitis&#44; erythematous papules&#44; and eczematous lesions are frequent&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> among others&#44; including petechiae&#44; purpura&#44; maculae&#44; hypopigmented or umbilicated papules&#44; nodules&#44; vesiculobullous lesions&#44; and pustules&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> predominantly on the scalp&#44; abdomen&#44; chest and intertriginous areas&#46; <a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The extracutaneous manifestations include lytic bone lesions&#44; diabetes insipidus&#44; growth hormone deficiency&#44; hepatosplenomegaly&#44; and lymphadenopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Liver involvement is seen exclusively in multi-system LCH&#44; presenting as isolated hepatomegaly and&#47;or liver function impairment and jaundice&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The histopathological analysis and positivity for CD1a&#44; S100&#44; and&#47;or CD207 &#40;Langerin&#41; in immunohistochemistry establishes the diagnosis&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Cutaneous manifestations of LCH are variable and may be similar to other prevalent dermatoses&#46; In the presence of intense and refractory seborrheic dermatitis-like condition&#44; LCH should be suspected&#44; and histopathological and multisystem involvement investigations are mandatory&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0025" 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="par0030" class="elsevierStylePara elsevierViewall">Daniela Antoniali&#58; Design and planning of the studied case&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied case&#59; review of the literature&#59; drafting and editing of the manuscript&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Helena Barbosa Lug&#227;o&#58; Approval of the final version of the manuscript&#59; drafting and editing of the manuscript&#59; participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied case&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Daniel Elias&#58; Approval of the final version of the manuscript&#59; drafting and editing of the manuscript&#59; participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied case&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Cacilda da Silva Souza&#58; Approval of the final version of the manuscript&#59; 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Case Letter
Seborrheic-like dermatitis and liver dysfunction in an infant: signs of Langerhans cell histiocytosis
Daniela Antoniali*, Helena Barbosa Lugão, Daniel Elias, Cacilda da Silva Souza
Dermatology Division, Department of Internal Medicine, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41;&#44; Erythematous-desquamative&#44; infiltrated lesions covered by hematic and meliceric crusts all over the scalp and the ear pinna&#46; &#40;B&#41;&#44; Coalescent erythematous papules under hematic and meliceric crusts&#44; extending from the temporal to the retroauricular region&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">This report describes the case of a one-year and five-months-old female child&#44; who had desquamation and pruritus on the scalp for 6 months&#44; with no response to topical corticosteroids and antifungal agents&#46; The physical examination showed weight and height deficit &#40;percentile 3 for height and 1 for weight&#41;&#59; coalescent papules under hematic and meliceric crusts&#44; on erythematous-desquamative skin on the scalp and the temporal and retroauricular regions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#59; ulcerated erythematous-infiltrated lesions on the left axilla and vulva and soft palate erosions&#46; The liver was hardened&#44; palpable five cm from the right costal margin&#46; There was no adenomegaly&#46; Complementary tests showed anemia &#40;Hb&#58; 9&#46;8&#8239;mg&#47;dL&#41;&#44; liver function tests alterations &#40;AST&#58; 136 U&#47;L&#44; ALT&#58; 152 U&#47;L&#44; ALP&#58; 1821 U&#47;L&#44; GGT&#58; 907&#46;3 U&#47;L&#41;&#59; ultrasonography showed the liver at the upper limit of normality&#44; heterogeneous echotexture and areas of periportal hyperechogenicity&#59; magnetic resonance cholangiography and bone scintigraphy showed no alterations&#59; histopathology of the skin showed a lichenoid infiltrate of Langerhans cells with diffuse immunohistochemical positivity for CD1a and S100 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Thus&#44; the diagnosis of Langerhans cell histiocytosis &#40;LCH&#41; with seborrheic-like dermatitis lesions and liver involvement was established&#46; Oncological treatment was initiated with prednisone and vinblastine for 12 weeks&#44; with no improvement of skin lesions&#46; One month after the end of the induction phase&#44; with continuous lesions on the scalp&#44; a new histopathology analysis showed persistence of a lichenoid inflammatory infiltrate of Langerhans cells with diffuse positivity for CD1a&#44; whereas the ultrasonography showed hepatic infiltration and splenomegaly&#46; The continuation of chemotherapy with mercaptopurine&#44; prednisone and vinblastine for 12 months was indicated &#40;currently ongoing&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Historically&#44; LCH has been subdivided into four syndromes &#40;Letterer-Siwe&#44; Hand-Schuller-Christian&#44; eosinophilic granuloma&#44; and Hashimoto-Pritzker&#41;&#59; however&#44; current evidence indicates that not all cases fit into these categories&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Recently&#44; LCH has been redefined as an inflammatory myeloid neoplasia&#44; attributed to the activation of mutations in the mitogen-activated protein kinase &#40;MAPK&#41; pathway&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> with the <span class="elsevierStyleItalic">BRAF-V600E</span> gene mutation being the most prevalent one&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Clinically&#44; it is categorized by the involvement of one or multiple systems&#44; either unifocal or multifocal and the presence of involvement of organs at risk &#40;liver&#44; spleen and bone marrow&#41;&#44; which define the prognosis and therapeutic response&#46; Single-system LCH has an excellent prognosis&#44; whereas the multi-system form has a mortality risk that requires aggressive treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Although isolated skin disease is rare &#40;2&#37;&#41;&#44; cutaneous manifestations are the standard form of presentation in around 80&#37; of cases&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> being the most common in those younger than 2 years-old&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Seborrheic-like dermatitis&#44; erythematous papules&#44; and eczematous lesions are frequent&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> among others&#44; including petechiae&#44; purpura&#44; maculae&#44; hypopigmented or umbilicated papules&#44; nodules&#44; vesiculobullous lesions&#44; and pustules&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> predominantly on the scalp&#44; abdomen&#44; chest and intertriginous areas&#46; <a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The extracutaneous manifestations include lytic bone lesions&#44; diabetes insipidus&#44; growth hormone deficiency&#44; hepatosplenomegaly&#44; and lymphadenopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Liver involvement is seen exclusively in multi-system LCH&#44; presenting as isolated hepatomegaly and&#47;or liver function impairment and jaundice&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The histopathological analysis and positivity for CD1a&#44; S100&#44; and&#47;or CD207 &#40;Langerin&#41; in immunohistochemistry establishes the diagnosis&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Cutaneous manifestations of LCH are variable and may be similar to other prevalent dermatoses&#46; In the presence of intense and refractory seborrheic dermatitis-like condition&#44; LCH should be suspected&#44; and histopathological and multisystem involvement investigations are mandatory&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0025" 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="par0030" class="elsevierStylePara elsevierViewall">Daniela Antoniali&#58; Design and planning of the studied case&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied case&#59; review of the literature&#59; drafting and editing of the manuscript&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Helena Barbosa Lug&#227;o&#58; Approval of the final version of the manuscript&#59; drafting and editing of the manuscript&#59; participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied case&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Daniel Elias&#58; Approval of the final version of the manuscript&#59; drafting and editing of the manuscript&#59; participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied case&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Cacilda da Silva Souza&#58; Approval of the final version of the manuscript&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied case&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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