Letter - Clinical
Case for diagnosis. Multiple infiltrated plaques in a patient with human immunodeficiency virus and hepatitis C co-infection: lichen myxedematosus
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Placas infiltradas múltiplas em paciente com coinfecção pelo vírus da imunodeficiência humana e da hepatite C: lichen myxedematosus" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "398" "paginaFinal" => "400" ] ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1113 "Ancho" => 1675 "Tamanyo" => 235232 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Pápulas eritematosas e esbranquiçadas no dorso superior e cervical posterior.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Nathalia Hoffmann Guarda, Renan Rangel Bonamigo, Renata Heck" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Nathalia Hoffmann" "apellidos" => "Guarda" ] 1 => array:2 [ "nombre" => "Renan Rangel" "apellidos" => "Bonamigo" ] 2 => array:2 [ "nombre" => "Renata" "apellidos" => "Heck" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0365059623000041" "doi" => "10.1016/j.abd.2021.10.017" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059623000041?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275223000310?idApp=UINPBA00008Z" "url" => "/26662752/0000009800000003/v3_202305121556/S2666275223000310/v3_202305121556/pt/main.assets" ] ] "itemSiguiente" => array:18 [ "pii" => "S0365059623000028" "issn" => "03650596" "doi" => "10.1016/j.abd.2021.05.026" "estado" => "S300" "fechaPublicacion" => "2023-05-01" "aid" => "703" "copyright" => "Sociedade Brasileira de Dermatologia" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter - Clinical</span>" "titulo" => "Papulopustular infantile acne treated with oral isotretinoin" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "400" "paginaFinal" => "402" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1743 "Ancho" => 2508 "Tamanyo" => 331683 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Infantile acne treated with oral isotretinoin. (A/B) One year after the end of treatment with oral isotretinoin, the patient shows residual normochromic scars.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Grasielle Silva Santos, Mayra Ianhez, Hélio Amante Miot" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Grasielle Silva" "apellidos" => "Santos" ] 1 => array:2 [ "nombre" => "Mayra" "apellidos" => "Ianhez" ] 2 => array:2 [ "nombre" => "Hélio Amante" "apellidos" => "Miot" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S2666275223000280" "doi" => "10.1016/j.abdp.2023.02.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275223000280?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059623000028?idApp=UINPBA00008Z" "url" => "/03650596/0000009800000003/v3_202305121633/S0365059623000028/v3_202305121633/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0365059623000089" "issn" => "03650596" "doi" => "10.1016/j.abd.2022.04.010" "estado" => "S300" "fechaPublicacion" => "2023-05-01" "aid" => "707" "copyright" => "Sociedade Brasileira de Dermatologia" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter - Clinical</span>" "titulo" => "Morphea after SARS-CoV2 vaccine" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "396" "paginaFinal" => "398" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1551 "Ancho" => 2508 "Tamanyo" => 419305 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Symmetrical, whitish, ivory, xerotic and sclerotic plaques, with a diameter ≥3 cm. 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Multiple infiltrated plaques in a patient with human immunodeficiency virus and hepatitis C co-infection: lichen myxedematosus" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "398" "paginaFinal" => "400" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Nathalia Hoffmann Guarda, Renan Rangel Bonamigo, Renata Heck" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Nathalia Hoffmann" "apellidos" => "Guarda" "email" => array:1 [ 0 => "hofgan@pitt.edu" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Renan Rangel" "apellidos" => "Bonamigo" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Renata" "apellidos" => "Heck" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Sanitary Dermatology Outpatient Clinic, Secretaria de Saúde do Estado do Rio Grande do Sul, Porto Alegre, RS, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1045 "Ancho" => 1675 "Tamanyo" => 186374 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythematous, confluent plaques with an infiltrated appearance, in the gluteal region, bilaterally.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">This report describes the case of a 45-year-old male patient, smoker, diagnosed with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection three years before. He was undergoing regular treatment with antiretroviral therapy (ritonavir, tenofovir and atazanavir), and had an undetectable viral load, with a CD4 cell count of 534 cells/mm<span class="elsevierStyleSup">3</span>, but without treatment for hepatitis C. He complained of cutaneous lesions with two years of evolution, and significant worsening in the last months, with local pruritus. On examination, erythematous, infiltrated papules and plaques were observed in the gluteal region bilaterally, as well as in the left abdominal, cervical and upper dorsal regions (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1–3</a>). He underwent laboratory tests that showed AST (aspartate aminotransferase) of 82 U/L, ALT (alanine aminotransferase) of 115 U/L, GGT (gamma-glutamyl transferase) of 131 U/L, alkaline phosphatase of 83 U/L, total bilirubin of 1.28 mg/dL, and fasting glucose of 103 mg/dL. Other laboratory tests within normal limits included: Hb,15.3 g/dL; leukocytes, 5800 mm<span class="elsevierStyleSup">3</span>; platelets, 205,000 mm<span class="elsevierStyleSup">3</span>; TSH, 2.51 IU/mL; free T4 1.08 µg/dL; Cr 0.79 mg/dL; non-reactive ANA (antinuclear antibody), non-reactive rheumatoid factor, proteinogram with no monoclonal peaks. A skin biopsy was performed, which showed abundant mucin deposits in the upper and middle dermis (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">What’s your diagnosis?</span><p id="par0010" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a)</span><p id="par0015" class="elsevierStylePara elsevierViewall">Lichen amyloidosus;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b)</span><p id="par0020" class="elsevierStylePara elsevierViewall">Lichen myxedematosus;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c)</span><p id="par0025" class="elsevierStylePara elsevierViewall">Eruptive collagenoma;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d)</span><p id="par0030" class="elsevierStylePara elsevierViewall">Granuloma annulare.</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">The diagnosis of lichen myxedematosus was confirmed through clinical-pathological correlation. The patient was instructed to maintain antiretroviral therapy and to start treatment for hepatitis C.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Lichen myxedematous (LM) is a rare, chronic subtype of mucinosis that clinically manifests as papules, nodules, or plaques restricted to the skin. It is characterized by fibroblast proliferation, with varying degrees of fibrosis, and mucin deposition in the dermis, in the absence of thyroid disease.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> Its etiopathogenesis is unknown; however, it is known that a variety of clinical conditions have been associated with LM, such as HIV infection, HCV, and exposure to chemicals such as L-tryptophan.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The current classification of mucinoses was proposed by Rongioletti et al. and divides the papular mucinoses into scleromyxedema, a variant with systemic involvement and associated with paraproteinemia, and localized papular LM. Localized LM is divided into 5 subtypes: discrete papular mucinosis, persistent acral papular mucinosis, self-healing cutaneous mucinosis, juvenile papular mucinosis, and nodular papular mucinosis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6</span></a> Atypical cases with the overlapping of subtypes and distinct characteristics may occur.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6</span></a> The patient in the present case can be classified as having localized papular LM of the mild papular mucinosis subtype.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Diagnostic criteria include papular rash, mucin deposition, and variable degree of fibroblast proliferation on histopathological examination, as well as the absence of gammopathy, thyroid disease, or systemic involvement.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Histopathology shows mucin deposition, predominantly in the middle and upper dermis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The differential diagnosis of LM includes granuloma annulare, lichen amyloidosus, lichenoid eruptions, lichen planus, and eruptive collagenoma.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">There are no well-defined treatments reported in the literature, and the recommended approach is clinical observation alone.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> In general, the prognosis is good, even without specific treatment, and in rare cases, spontaneous resolution may occur.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,8</span></a> To date, there is no description of the evolution of localized conditions to scleromyxedema. Topical corticosteroids and calcineurin inhibitors are used to relieve symptoms.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Financial support</span><p id="par0060" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Authors’ contributions</span><p id="par0065" class="elsevierStylePara elsevierViewall">Nathalia Hoffmann Guarda: Design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Renan Rangel Bonamigo: Approval of the final version of the manuscript; design and planning of the study; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Renata Heck: Approval of the final version of the manuscript; design and planning of the study; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "What’s your diagnosis?" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Financial support" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Authors’ contributions" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-08-22" "fechaAceptado" => "2021-10-25" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Sanitary Dermatology Outpatient Clinic, Secretaria de Saúde do Estado do Rio Grande do Sul, Porto Alegre, RS, Brasil.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1045 "Ancho" => 1675 "Tamanyo" => 186374 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythematous, confluent plaques with an infiltrated appearance, in the gluteal region, bilaterally.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1317 "Ancho" => 1675 "Tamanyo" => 186757 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Erythematous plaque with a papular center on the left abdominal region.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1113 "Ancho" => 1675 "Tamanyo" => 235232 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Erythematous, whitish papules on the upper back and posterior cervical regions.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1080 "Ancho" => 3341 "Tamanyo" => 624496 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">(A)</span> Mucin deposits in the upper and middle dermis, with no associated fibroblastic proliferation; absence of amyloid (Hematoxylin & eosin, ×40). (B) Special staining highlights mucin deposition in the dermis (Alcian Blue ×40).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Updated classification of papular mucinosis, lichen myxedematosus, and scleromyxedema" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "F. Rongioletti" 1 => "A. 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