Letter - Tropical/Infectious and parasitic dermatology
Mutilating localized cutaneous leishmaniasis caused by Leishmania guyanensis
Dina Fabrício da Silvaa,
, Sidharta Quercia Gadelhaa, Andréa de Souza Cavalcantea, Rosilene Viana de Andradea, Jorge Augusto de Oliveira Guerrab, Alcidarta dos Reis Gadelhac
Autor para correspondência
a Department of Dermatology, Fundação de Dermatologia Tropical Heitor Vieira Dourado, Manaus, AM, Brazil
b Department of Leishmaniasis, Fundação de Dermatologia Tropical Heitor Vieira Dourado, Manaus, AM, Brazil
c Department of Dermatopathology, Fundação de Dermatologia Tropical Heitor Vieira Dourado, Manaus, AM, Brazil
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(A) Septate, brownish hyphae (“Borelli spiders”). Direct microscopy, KOH 20% + DMSO, ×40. (B) Colony micromorphology showing brownish, septate hyphae, from which conidiophores with elongated conidia at their extremities arise, giving the appearance of a gnarled staff. <span class="elsevierStyleItalic">Rhinocladiella</span> spp., lactophenol, ×40.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jessica Lana Conceição e Silva Baka, Gabriela Giraldelli, Andrea Reis Bernardes-Engemann, Carlos Baptista Barcaui, Rosane Orofino-Costa" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Jessica Lana Conceição e Silva" "apellidos" => "Baka" ] 1 => array:2 [ "nombre" => "Gabriela" "apellidos" => "Giraldelli" ] 2 => array:2 [ "nombre" => "Andrea Reis" "apellidos" => "Bernardes-Engemann" ] 3 => array:2 [ "nombre" => "Carlos Baptista" "apellidos" => "Barcaui" ] 4 => array:2 [ "nombre" => "Rosane" "apellidos" => "Orofino-Costa" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S2666275223000322" "doi" => "10.1016/j.abdp.2023.02.005" "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/S2666275223000322?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059623000077?idApp=UINPBA00008Z" "url" => "/03650596/0000009800000003/v3_202305121633/S0365059623000077/v3_202305121633/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0365059623000132" "issn" => "03650596" "doi" => "10.1016/j.abd.2022.04.012" "estado" => "S300" "fechaPublicacion" => "2023-05-01" "aid" => "712" "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 - Dermatopathology</span>" "titulo" => "Invasive extramammary Paget's disease with lymph node metastases and high-grade B-cell lymphoma" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "414" "paginaFinal" => "418" ] ] "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" => 891 "Ancho" => 2508 "Tamanyo" => 519953 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Clinical findings. A subcutaneous mass in the right inguinal area is observed. (A) Atypical cells with a pale cytoplasm proliferated rapidly, and the findings are similar to those of previous invasive Paget’s disease (Hematoxylin & eosin, ×400).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Misato Ueda, Makoto Omori, Ayumi Sakai" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Misato" "apellidos" => "Ueda" ] 1 => array:2 [ "nombre" => "Makoto" "apellidos" => "Omori" ] 2 => array:2 [ "nombre" => "Ayumi" "apellidos" => "Sakai" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S2666275223000383" "doi" => "10.1016/j.abdp.2023.02.011" "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/S2666275223000383?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059623000132?idApp=UINPBA00008Z" "url" => "/03650596/0000009800000003/v3_202305121633/S0365059623000132/v3_202305121633/en/main.assets" ] "en" => array:17 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter - Tropical/Infectious and parasitic dermatology</span>" "titulo" => "Mutilating localized cutaneous leishmaniasis caused by <span class="elsevierStyleItalic">Leishmania guyanensis</span>" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "419" "paginaFinal" => "421" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Dina Fabrício da Silva, Sidharta Quercia Gadelha, Andréa de Souza Cavalcante, Rosilene Viana de Andrade, Jorge Augusto de Oliveira Guerra, Alcidarta dos Reis Gadelha" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Dina Fabrício da" "apellidos" => "Silva" "email" => array:1 [ 0 => "dina.fabricio@hotmail.com" ] "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" => "Sidharta Quercia" "apellidos" => "Gadelha" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Andréa de Souza" "apellidos" => "Cavalcante" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Rosilene Viana de" "apellidos" => "Andrade" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Jorge Augusto de Oliveira" "apellidos" => "Guerra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "Alcidarta dos Reis" "apellidos" => "Gadelha" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Dermatology, Fundação de Dermatologia Tropical Heitor Vieira Dourado, Manaus, AM, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Leishmaniasis, Fundação de Dermatologia Tropical Heitor Vieira Dourado, Manaus, AM, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Dermatopathology, Fundação de Dermatologia Tropical Heitor Vieira Dourado, Manaus, AM, Brazil" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "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" => 1211 "Ancho" => 1675 "Tamanyo" => 449995 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0070" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histopathological examination. Hematoxylin & eosin, ×1000. Granulomatous inflammation consisting of plasmocytes, lymphocytes, histiocytes, epithelioid cells, and the presence of rare amastigotes (arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">American tegumentary leishmaniasis (ATL) is an infectious disease caused by protozoa of the genus <span class="elsevierStyleItalic">Leishmania</span> transmitted by the bite of a female sandfly of the genus <span class="elsevierStyleItalic">Lutzomyia</span>.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In Brazil, it is found in all states, with Amazonas and Pará accounting for 58% of reported cases between 2007 and 2017.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The three main species responsible for ATL in Brazil are <span class="elsevierStyleItalic">L.(V.) braziliensis</span>, <span class="elsevierStyleItalic">L.(V.) guyanensis</span>, and <span class="elsevierStyleItalic">L.(L.) amazonensis</span>.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Epidemiological data and polymerase chain reaction (PCR) analysis may be essential for the diagnosis of unusual clinical forms, and/or in the absence of amastigotes in smears and histological sections.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">This case report describes a 49-year-old male patient, a farmer, without comorbidities, from Maués, state of Amazonas, Brazil. He sought medical care at a Dermatology service complaining of a condition which had started three years before, with a papule on the proximal phalanx of the third finger, progressing to an ulcer that extended to the dorsum of the right hand. Considering the clinical picture, nine direct tests were performed to search for amastigotes, all with negative results. Different types of treatments with antibiotics and corticoids were prescribed without improvement, and with worsening and progression of the lesions for the last six months. On examination, an ulcer was observed on the dorsum of the right hand, covered by yellowish crusts, with clear and erythematous borders, which extended to the phalanges, resulting in anatomical deformity of the third finger. There were also nodules following an ascending lymphatic path, in the right forearm, some of which showed painless ulceration, with raised erythematous borders, measuring approximately 2<span class="elsevierStyleHsp" style=""></span>cm (<a class="elsevierStyleCrossRef" href="#fig0005">Figs. 1</a>A and <a class="elsevierStyleCrossRef" href="#fig0005">1</a> B). Histopathological examination of biopsies from the lesion located on the dorsum of the hand and from a nodule on the forearm revealed the presence of granulomatous inflammatory infiltrate consisting of histiocytes, epithelioid cells, giant cells, several plasmocytes, lymphocytes, and the presence of rare amastigotes (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The PCR sequencing, carried out with the aid of primers described by Graça et al.,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> on the biopsy fragment identified the species <span class="elsevierStyleItalic">Leishmania guyanensis</span>. The bacteriological culture of the fragment from the dorsum of the hand was positive for the Gram-negative bacillus <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>. The radiological examination showed bone sequestration and destruction of the cortex of the distal and middle phalanges of the third finger, suggestive of chronic osteomyelitis (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The combined treatment consisting of meglumine antimoniate 1200<span class="elsevierStyleHsp" style=""></span>mg of Sb<span class="elsevierStyleSup">+5</span>/day intravenously for 30 days and cefepime, according to the sensitivity identified in the antibiogram, at a dose of 1<span class="elsevierStyleHsp" style=""></span>g 2×/day for 10 days, resulted in significant improvement in the skin lesions (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The patient is currently undergoing multidisciplinary follow-up with the orthopedics service for surgical treatment of the osteomyelitis after regression of the skin ulcer.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">ATL can be classified into localized cutaneous, disseminated, diffuse, and mucocutaneous leishmaniasis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The typical lesion of localized cutaneous leishmaniasis is initially a papule that progresses to an ulcer with a raised, infiltrated border and a granular background, which may be accompanied by regional lymphadenopathy and/or nodular lymphangitis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However, the clinical forms of pleomorphic and atypical aspects can hinder and delay the diagnosis and, consequently, adequate treatment.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Among the atypical forms of ATL, the verrucous, lupoid, eczematous, zosteriform, tumor, acneiform, and sporotrichoid forms have been reported.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> Pazok Hossein et al. described cases similar to the one described in the present case report as lupoid variants of ATL in patients from Afghanistan and Turkey, respectively.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The diagnosis should be based on epidemiology, lesion characteristics, direct examination, and culture. In atypical cases, histopathological examination and PCR are fundamental tools.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Direct examination is the most frequently used method for diagnosis because it is simple, inexpensive and easy to perform. However, the probability of finding the parasite is inversely proportional to the time of evolution of the skin lesions, being rare after one year.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">On histopathology, intense granulomatous inflammatory infiltrate is observed, and histiocytes, epithelioid and giant cells, lymphocytes, plasma cells, some eosinophils, and depending on the time of evolution, macrophages containing amastigotes can be seen.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">PCR, a method based on parasite DNA amplification, has a sensitivity and specificity of 100% in the typical forms and a sensitivity of 94% in atypical presentations.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5</span></a> In this case, PCR compatible with <span class="elsevierStyleItalic">Leishmania guyanensis</span> was crucial for the correct diagnosis and starting treatment.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The rare bone involvement reported in cases of ATL and proven infection by <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>, as well as the radiological alterations suggestive of persistent chronic osteomyelitis in the radiological control, suggest that the bone lesions observed in the present case were caused by contiguity from the secondary infection.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However, histopathological examination and culture of the bone lesion are necessary.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Despite its wide distribution in Brazil, atypical presentations of ATL can make the diagnosis difficult. Therefore, the relevance of epidemiology and PCR in atypical lesions is highlighted, as well as the importance of an early diagnosis, so that sequelae or mutilations can be prevented.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Financial support</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Authors' contributions</span><p id="par0060" class="elsevierStylePara elsevierViewall">Dina Fabrício da Silva: Approval of the final version of the manuscript; drafting and editing of the manuscript; collection, analysis, and interpretation of data; intellectual participation in the propaedeutic and/or therapeutic conduct of the case; critical review of the literature; critical review of the manuscript.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Sidharta Quercia Gadelha: Approval of the final version of the manuscript; drafting and editing of the manuscript; collection, analysis, and interpretation of data; intellectual participation in the propaedeutic and/or therapeutic conduct of the case; critical review of the literature; critical review of the manuscript.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Andréa de Souza Cavalcante: Approval of the final version of the manuscript; design and planning of the study; intellectual participation in the propaedeutic and/or therapeutic conduct of the case; critical review of the literature; critical review of the manuscript.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Rosilene Viana de Andrade: Approval of the final version of the manuscript; design and planning of the study; participation in the writing of the histopathological report; critical review of the literature; critical review of the manuscript.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Jorge Augusto de Oliveira Guerra: Approval of the final version of the manuscript; design and planning of the study; intellectual participation in the propaedeutic and/or therapeutic conduct of the case; critical review of the literature; critical review of the manuscript.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Alcidarta dos Reis Gadelha: Approval of the final version of the manuscript; design and planning of the study; intellectual participation in the propaedeutic and/or therapeutic conduct of the case; 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="par0090" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 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" => "2022-01-19" "fechaAceptado" => "2022-04-10" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Fundação de Dermatologia Tropical Heitor Vieira Dourado, Manaus, AM, Brazil.</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" => 1479 "Ancho" => 1675 "Tamanyo" => 368553 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0065" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Ulcer on the dorsum of the right hand covered by yellowish crusts, with clear erythematous borders extending to the phalanges with anatomical deformity of the third finger. (B) Ulcerated nodules following an ascending lymphatic path in the right forearm.</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" => 1211 "Ancho" => 1675 "Tamanyo" => 449995 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0070" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histopathological examination. Hematoxylin & eosin, ×1000. Granulomatous inflammation consisting of plasmocytes, lymphocytes, histiocytes, epithelioid cells, and the presence of rare amastigotes (arrow).</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" => 1589 "Ancho" => 1508 "Tamanyo" => 316513 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0075" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Right-hand x-ray. Presence of bone sequestration, and destruction of the cortex of the distal and middle phalanges of the third finger, suggestive of chronic osteomyelitis.</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" => 1120 "Ancho" => 1675 "Tamanyo" => 172424 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0080" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Significant improvement and regression of the crusted ulcer after treatment with meglumine antimoniate for 30 days.</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:1 [ "referenciaCompleta" => "bvsms.saude.gov [Internet]. 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