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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A healthy 9-year-old girl presented with an acute onset of painful vulvar ulcers and dysuria&#46; Physical examination of genital mucosa showed well-defined deep ulcers with a fibrinous center and elevated red borders on the labia majora &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Ulcers were large over 1 centimeter in diameter&#44; in a mirror pattern&#46; She reported a high fever up to 38&#44;5&#8239;&#176;C&#44; odynophagia&#44; congestion&#44; and malaise one week before&#46; Serological tests were negative for herpes simplex virus&#44; Epstein Barr virus&#44; cytomegalovirus&#44; human immunodeficiency virus &#40;HIV&#41;&#44; and venereal disease research laboratory &#40;VDRL&#41;&#46; Autoimmune tests were negative for antinuclear and anti-DNA antibodies&#46; Complete blood tests and urine samples were normal&#46; Hormone tests such as estradiol&#44; prolactin&#44; follicle-stimulating hormone &#40;FSH&#41;&#44; and luteinizing hormone &#40;LH&#41; were all normal for her age&#46; The diagnosis of Lipsch&#252;tz ulcer was made&#46; The patient was started on topical anesthetic cream and the ulcers had total recovery after two weeks&#44; with no scarring&#46; She has not presented new episodes at one-year follow-up&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Lipsch&#252;tz ulcer&#44; also known as reactive non-sexually related acute genital ulcers&#44; is a very uncommon clinical entity that typically occurs in sexually inactive young women&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is characterized by an abrupt onset&#44; intense local pain&#44; and dysuria&#46; Its morphology is variable&#44; often presenting as &#8216;kissing ulcers&#8217; with a symmetric appearance on opposite sides of the vulva&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> Also&#44; necrotic ulcers with important oedema and erythema of the labia and inguinal lymphadenopathy have been described&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4</span></a> The ulcers can be single or multiple with raised&#44; sharply demarcated borders&#46; Most of them are often covered with gray exudate or a gray-black eschar&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Typically&#44; ulcers are located on the labia minora&#44; but they can also be found on the labia majora&#44; perineum&#44; and in the lower vagina&#46; It affects mainly adolescents and young women&#44; and it is uncommon for children&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Lipsch&#252;tz ulcer is usually preceded by flu-like symptoms&#46; Its etiology and pathogenesis are still unknown&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> Although&#44; some viruses or bacteria have been associated with this entity &#40;Epstein-Barr virus&#44; Mycoplasma and influenza A infection&#41;&#46; The pathogenic mechanism is unclear&#44; but a reactive process triggered by a distant infection with deposition of immune complex in the dermal vessels causing micro-thrombosis&#44; and eventually leading to deep&#44; necrotizing&#44; painful ulcers is suspected&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The diagnosis is made by exclusion&#44; after ruling out other causes of genital ulcerations&#46; Differential diagnosis includes ulcers of venereal and non-venereal origin&#44; auto-immune diseases&#44; trauma&#44; and malignant tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The treatment is mainly symptomatic&#44; with spontaneous resolution within 2&#8210;6 weeks and without recurrences in most cases&#46; Due to its self-limited evolution&#44; local care is sufficient&#46; Topical anesthetic&#44; topical corticosteroids&#44; and oral analgesics are usually indicated&#46; On the other hand&#44; if the patient has severe pain or malaise&#44; hospitalization is indicated&#44; so systemic steroids and broad-spectrum antibiotics are recommended&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Lipsch&#252;tz ulcer is a challenge in clinical practice&#44; it is usually under-diagnosed or misdiagnosed&#46; Furthermore&#44; there is high anxiety and confusion for patients and their families as the diagnosis of the herpes simplex virus is often presumptively made&#46; Therefore&#44; the authors highlight to keep in mind this unusual diagnosis especially in a young girl or adolescent with acute genital ulcers&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0030" class="elsevierStylePara elsevierViewall">This article was funded by the <span class="elsevierStyleGrantSponsor" id="gs0005">Universidad de La Frontera</span> &#91;<span class="elsevierStyleGrantNumber" refid="gs0005">DI13-0051</span>&#93;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0035" class="elsevierStylePara elsevierViewall">Fabiola Schafer&#58; Approval of the final version of the manuscript&#46;&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; participation in study design&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Rodrigo Miranda&#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; participation in study design&#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="par0045" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Case Letter
Acute genital ulcers in a young girl: a clinical challenge: Lipschütz ulcer
Fabiola Schafera,
Autor para correspondência
fdschafe@gmail.com

Corresponding author.
, Rodrigo Mirandab
a Department of Medical Specialties, School of Medicine, Universidad de La Frontera, Temuco, Chile
b Department of Internal Medicine, School of Medicine, Universidad de La Frontera, Temuco, Chile
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A healthy 9-year-old girl presented with an acute onset of painful vulvar ulcers and dysuria&#46; Physical examination of genital mucosa showed well-defined deep ulcers with a fibrinous center and elevated red borders on the labia majora &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Ulcers were large over 1 centimeter in diameter&#44; in a mirror pattern&#46; She reported a high fever up to 38&#44;5&#8239;&#176;C&#44; odynophagia&#44; congestion&#44; and malaise one week before&#46; Serological tests were negative for herpes simplex virus&#44; Epstein Barr virus&#44; cytomegalovirus&#44; human immunodeficiency virus &#40;HIV&#41;&#44; and venereal disease research laboratory &#40;VDRL&#41;&#46; Autoimmune tests were negative for antinuclear and anti-DNA antibodies&#46; Complete blood tests and urine samples were normal&#46; Hormone tests such as estradiol&#44; prolactin&#44; follicle-stimulating hormone &#40;FSH&#41;&#44; and luteinizing hormone &#40;LH&#41; were all normal for her age&#46; The diagnosis of Lipsch&#252;tz ulcer was made&#46; The patient was started on topical anesthetic cream and the ulcers had total recovery after two weeks&#44; with no scarring&#46; She has not presented new episodes at one-year follow-up&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Lipsch&#252;tz ulcer&#44; also known as reactive non-sexually related acute genital ulcers&#44; is a very uncommon clinical entity that typically occurs in sexually inactive young women&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is characterized by an abrupt onset&#44; intense local pain&#44; and dysuria&#46; Its morphology is variable&#44; often presenting as &#8216;kissing ulcers&#8217; with a symmetric appearance on opposite sides of the vulva&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> Also&#44; necrotic ulcers with important oedema and erythema of the labia and inguinal lymphadenopathy have been described&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4</span></a> The ulcers can be single or multiple with raised&#44; sharply demarcated borders&#46; Most of them are often covered with gray exudate or a gray-black eschar&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Typically&#44; ulcers are located on the labia minora&#44; but they can also be found on the labia majora&#44; perineum&#44; and in the lower vagina&#46; It affects mainly adolescents and young women&#44; and it is uncommon for children&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Lipsch&#252;tz ulcer is usually preceded by flu-like symptoms&#46; Its etiology and pathogenesis are still unknown&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> Although&#44; some viruses or bacteria have been associated with this entity &#40;Epstein-Barr virus&#44; Mycoplasma and influenza A infection&#41;&#46; The pathogenic mechanism is unclear&#44; but a reactive process triggered by a distant infection with deposition of immune complex in the dermal vessels causing micro-thrombosis&#44; and eventually leading to deep&#44; necrotizing&#44; painful ulcers is suspected&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The diagnosis is made by exclusion&#44; after ruling out other causes of genital ulcerations&#46; Differential diagnosis includes ulcers of venereal and non-venereal origin&#44; auto-immune diseases&#44; trauma&#44; and malignant tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The treatment is mainly symptomatic&#44; with spontaneous resolution within 2&#8210;6 weeks and without recurrences in most cases&#46; Due to its self-limited evolution&#44; local care is sufficient&#46; Topical anesthetic&#44; topical corticosteroids&#44; and oral analgesics are usually indicated&#46; On the other hand&#44; if the patient has severe pain or malaise&#44; hospitalization is indicated&#44; so systemic steroids and broad-spectrum antibiotics are recommended&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Lipsch&#252;tz ulcer is a challenge in clinical practice&#44; it is usually under-diagnosed or misdiagnosed&#46; Furthermore&#44; there is high anxiety and confusion for patients and their families as the diagnosis of the herpes simplex virus is often presumptively made&#46; Therefore&#44; the authors highlight to keep in mind this unusual diagnosis especially in a young girl or adolescent with acute genital ulcers&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0030" class="elsevierStylePara elsevierViewall">This article was funded by the <span class="elsevierStyleGrantSponsor" id="gs0005">Universidad de La Frontera</span> &#91;<span class="elsevierStyleGrantNumber" refid="gs0005">DI13-0051</span>&#93;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0035" class="elsevierStylePara elsevierViewall">Fabiola Schafer&#58; Approval of the final version of the manuscript&#46;&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; participation in study design&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Rodrigo Miranda&#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; participation in study design&#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="par0045" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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