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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Bruton&#39;s tyrosine kinase &#40;BTK&#41; is essential for the development and maturation of B-lymphocytes&#46; These cells do not mature in individuals with mutations in this enzyme&#44; and they have X-linked agammaglobulinemia&#44; the most common type of congenital agammaglobulinemia&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">BTK is also expressed in tumor cells&#44; and its inhibition is gaining increasing importance in the treatment of B-lineage neoplasms&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> BTK participates in the activation of these cells&#44; being important for the survival of malignant B cells and&#44; therefore&#44; its inhibition decreases their proliferation and survival&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Ibrutinib is a potent irreversible BTK inhibitor and was the first inhibitor of this enzyme approved by the FDA for the treatment of the following diseases in adults&#58; 1&#41; Chronic graft-versus-host disease&#44; after the failure of one or more systemic therapy lines&#59; 2&#41; Chronic lymphocytic leukemia&#47;small cell lymphocytic lymphoma &#40;CLL&#47;SCLL&#41;&#59; 3&#41; CLL&#47;SCLL in adults with 17p deletion&#59; 4&#41; Mantle-cell lymphoma in adults who have received at least one prior therapy&#59; 5&#41; Relapsed&#47;refractory marginal zone lymphoma&#44; in adults who require systemic therapy and have received at least one prior anti-CD20-based therapy&#59; and 6&#41; In Waldenstr&#246;m&#39;s macroglobulinemia&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The described side effects are fatigue&#44; diarrhea&#44; peripheral edema&#44; cardiac arrhythmia &#40;atrial fibrillation&#41;&#44; bleeding&#44; and infections &#40;respiratory tract&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Ibrutinib can have cutaneous adverse effects&#44; with a peak incidence in the first year of treatment&#46; The most common manifestations are skin rash&#44; petechiae and ecchymosis&#46; Also&#44; urticaria&#44; herpes simplex and herpes zoster reactivation&#44; panniculitis&#44; and Stevens-Johnson syndrome may occur&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Despite the specificity for BTK&#44; some skin effects are similar to those produced by EGF &#40;epidermal growth factor&#41; inhibitors&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> such as the described acneiform rash&#44; changes in hair&#47;eyelashes&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and longitudinal grooves on nails&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A 72-year-old patient who had received ibrutinib for six months to treat mantle lymphoma unresponsive to conventional therapy was assessed&#46; The patient reported a slight alteration in his hair&#44; with a change in its curling &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Some hair shafts were cut and examined <span class="elsevierStyleItalic">in natura</span> with scanning electron microscopy&#46; At medium magnification&#44; discreet longitudinal channels were observed in the hair shafts &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A and B&#41;&#44; which are not seen in normal hair &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#41;&#46; At high magnification&#44; these channels were very evident &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The authors did not find any reports in the literature of an examination of hairs shafts with scanning electron microscopy showing alterations caused by ibrutinib&#46; There are some reports with EGF inhibitors&#44; in which channels were also described in the hair shafts&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> in this case with greater clinical consequences&#44; making the hair frizzy and the eyelashes elongated &#40;trichomegaly&#41; and without curvature&#46; The channels seen in these drug-induced cases are similar to those seen in families with uncombable hair&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and in a syndromic type of pili canaliculi associated with a central nervous system degeneration called giant axonal neuropathy&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The findings of this patient demonstrate&#44; on ultrastructural examination&#44; a similarity between the alterations of EGF and BTK inhibitors&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">BTK inhibition is an expanding concept in the treatment of hematologic malignancies&#44; with 22 drugs under development&#44; and the emergence of drugs with less systemic and cutaneous toxicity is possible in the near future&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;12</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#39; contributions</span><p id="par0060" class="elsevierStylePara elsevierViewall">Hiram Larangeira de Almeida Jr&#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><p id="par0065" class="elsevierStylePara elsevierViewall">Debora Sarzi Sartori&#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; 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><p id="par0070" class="elsevierStylePara elsevierViewall">Douglas Malkoun&#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; 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><p id="par0075" class="elsevierStylePara elsevierViewall">Carlos Eduardo Pouey Cunha&#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; 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="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Letter - Research
Scanning electron microscopy of ibrutinib-induced hair shaft changes
Hiram Larangeira de Almeida Jr.a,b,
Autor para correspondência
hiramalmeidajr@hotmail.com

Corresponding author.
, Debora Sarzi Sartorib, Douglas Malkouna, Carlos Eduardo Pouey Cunhaa
a Department of Dermatology, Universidade Federal de Pelotas, Pelotas, RS, Brazil
b Graduate Program in Health and Behavior, Universidade Católica de Pelotas, Pelotas, RS, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Bruton&#39;s tyrosine kinase &#40;BTK&#41; is essential for the development and maturation of B-lymphocytes&#46; These cells do not mature in individuals with mutations in this enzyme&#44; and they have X-linked agammaglobulinemia&#44; the most common type of congenital agammaglobulinemia&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">BTK is also expressed in tumor cells&#44; and its inhibition is gaining increasing importance in the treatment of B-lineage neoplasms&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> BTK participates in the activation of these cells&#44; being important for the survival of malignant B cells and&#44; therefore&#44; its inhibition decreases their proliferation and survival&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Ibrutinib is a potent irreversible BTK inhibitor and was the first inhibitor of this enzyme approved by the FDA for the treatment of the following diseases in adults&#58; 1&#41; Chronic graft-versus-host disease&#44; after the failure of one or more systemic therapy lines&#59; 2&#41; Chronic lymphocytic leukemia&#47;small cell lymphocytic lymphoma &#40;CLL&#47;SCLL&#41;&#59; 3&#41; CLL&#47;SCLL in adults with 17p deletion&#59; 4&#41; Mantle-cell lymphoma in adults who have received at least one prior therapy&#59; 5&#41; Relapsed&#47;refractory marginal zone lymphoma&#44; in adults who require systemic therapy and have received at least one prior anti-CD20-based therapy&#59; and 6&#41; In Waldenstr&#246;m&#39;s macroglobulinemia&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The described side effects are fatigue&#44; diarrhea&#44; peripheral edema&#44; cardiac arrhythmia &#40;atrial fibrillation&#41;&#44; bleeding&#44; and infections &#40;respiratory tract&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Ibrutinib can have cutaneous adverse effects&#44; with a peak incidence in the first year of treatment&#46; The most common manifestations are skin rash&#44; petechiae and ecchymosis&#46; Also&#44; urticaria&#44; herpes simplex and herpes zoster reactivation&#44; panniculitis&#44; and Stevens-Johnson syndrome may occur&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Despite the specificity for BTK&#44; some skin effects are similar to those produced by EGF &#40;epidermal growth factor&#41; inhibitors&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> such as the described acneiform rash&#44; changes in hair&#47;eyelashes&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and longitudinal grooves on nails&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A 72-year-old patient who had received ibrutinib for six months to treat mantle lymphoma unresponsive to conventional therapy was assessed&#46; The patient reported a slight alteration in his hair&#44; with a change in its curling &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Some hair shafts were cut and examined <span class="elsevierStyleItalic">in natura</span> with scanning electron microscopy&#46; At medium magnification&#44; discreet longitudinal channels were observed in the hair shafts &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A and B&#41;&#44; which are not seen in normal hair &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>C&#41;&#46; At high magnification&#44; these channels were very evident &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">The authors did not find any reports in the literature of an examination of hairs shafts with scanning electron microscopy showing alterations caused by ibrutinib&#46; There are some reports with EGF inhibitors&#44; in which channels were also described in the hair shafts&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> in this case with greater clinical consequences&#44; making the hair frizzy and the eyelashes elongated &#40;trichomegaly&#41; and without curvature&#46; The channels seen in these drug-induced cases are similar to those seen in families with uncombable hair&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and in a syndromic type of pili canaliculi associated with a central nervous system degeneration called giant axonal neuropathy&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The findings of this patient demonstrate&#44; on ultrastructural examination&#44; a similarity between the alterations of EGF and BTK inhibitors&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">BTK inhibition is an expanding concept in the treatment of hematologic malignancies&#44; with 22 drugs under development&#44; and the emergence of drugs with less systemic and cutaneous toxicity is possible in the near future&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;12</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#39; contributions</span><p id="par0060" class="elsevierStylePara elsevierViewall">Hiram Larangeira de Almeida Jr&#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><p id="par0065" class="elsevierStylePara elsevierViewall">Debora Sarzi Sartori&#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; 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><p id="par0070" class="elsevierStylePara elsevierViewall">Douglas Malkoun&#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; 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><p id="par0075" class="elsevierStylePara elsevierViewall">Carlos Eduardo Pouey Cunha&#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; 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="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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