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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Introdu&#231;&#227;o</span><p id="par0005" class="elsevierStylePara elsevierViewall">A sarcoidose &#233; uma doen&#231;a multissist&#234;mica de causa desconhecida&#44; caracterizada pela presen&#231;a de inflama&#231;&#227;o granulomatosa n&#227;o infecciosa em v&#225;rios &#243;rg&#227;os&#46; Estudos mostram que suscetibilidade gen&#233;tica e fatores ambientais contribuem para o desenvolvimento de uma resposta imune exacerbada&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">1</span></a> O curso cl&#237;nico varia e&#44; na metade dos casos&#44; a doen&#231;a se resolve espontaneamente dentro de dois a cinco anos&#46; Ap&#243;s cinco anos&#44; a remiss&#227;o &#233; muito menos prov&#225;vel&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">2</span></a> Os pulm&#245;es e os linfonodos tor&#225;cicos s&#227;o os &#243;rg&#227;os mais comumente afetados &#40;90&#37; dos casos&#41;&#44; mas a doen&#231;a pode acometer quase todos os &#243;rg&#227;os&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">O envolvimento cut&#226;neo &#233; comum&#44; com incid&#234;ncia relatada entre 9&#37; a 37&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">2&#44;4&#8211;7</span></a> As manifesta&#231;&#245;es cut&#226;neas podem ser classificadas em duas categorias&#58; les&#245;es espec&#237;ficas&#44; em que h&#225; evid&#234;ncia histopatol&#243;gica de granulomas sarco&#237;deos t&#237;picos&#44; e les&#245;es n&#227;o espec&#237;ficas&#44; que se desenvolvem como resultado de um padr&#227;o global de rea&#231;&#227;o inflamat&#243;ria&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">2&#44;4&#8211;9</span></a> O eritema nodoso &#233; a les&#227;o cut&#226;nea n&#227;o espec&#237;fica mais comum&#44; ocorre em formas agudas de sarcoidose&#44; indicando&#44; em geral&#44; boa prognose&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> As les&#245;es espec&#237;ficas s&#227;o cr&#244;nicas&#44; assintom&#225;ticas e requerem tratamento&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">2&#44;4&#8211;9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">M&#225;culas&#44; p&#225;pulas e placas&#44; l&#250;pus p&#233;rnio&#44; n&#243;dulos superficiais e n&#243;dulos subcut&#226;neos &#40;conhecidos como n&#243;dulos de Darier&#8208;Roussy&#41; constituem as les&#245;es espec&#237;ficas mais comuns&#46; Manifesta&#231;&#245;es menos comuns incluem les&#245;es hipopigmentadas&#44; o angiolupoide e formas psoriasiformes&#44; eritrod&#233;rmicas&#44; ulcerativas&#44; ictiosiformes&#44; verrucosas ou liquenoides&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">2&#44;4&#8211;9</span></a> Aparecimento de les&#245;es sobre cicatrizes antigas&#44; que se tornam inflamadas&#44; ou em tatuagens&#44; &#233; observado&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Quando h&#225; suspeita cl&#237;nica&#44; &#233; importante uma bi&#243;psia de pele para estabelecer evid&#234;ncias histopatol&#243;gicas de sarcoidose e excluir outras causas de doen&#231;a granulomatosa&#44; por meio da demonstra&#231;&#227;o de microrganismos no tecido em culturas&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> A histopatologia revela granulomas n&#227;o necrotizantes compostos de histi&#243;citos mononucleares&#44; caracteristicamente com pequeno n&#250;mero de linf&#243;citos circundantes&#44; al&#233;m de c&#233;lulas gigantes de Langhans&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">4</span></a> Caracteristicamente&#44; a intradermorrea&#231;&#227;o &#224; tuberculina &#233; negativa&#46; Uma vez confirmada sarcoidose cut&#226;nea&#44; a avalia&#231;&#227;o de poss&#237;vel comprometimento sist&#234;mico &#233; obrigat&#243;ria&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">2&#44;11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">A terapia geralmente &#233; direcionada ao &#243;rg&#227;o mais gravemente afetado&#44; o que frequentemente leva &#224; melhora das les&#245;es cut&#226;neas&#46; Para pacientes com sarcoidose cut&#226;nea isolada ou com doen&#231;a cut&#226;nea grave&#44; recomenda&#8208;se uma abordagem gradual com terapias locais&#44; imunomoduladores e imunossupressores sist&#234;micos&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">A sarcoidose &#233; considerada infrequente no Brasil&#59; suas caracter&#237;sticas n&#227;o s&#227;o analisadas em detalhe desde 1976&#44; quando foi feita uma revis&#227;o de 40 casos&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">13</span></a> O objetivo deste estudo foi caracterizar os aspectos cl&#237;nicos e epidemiol&#243;gicos da sarcoidose cut&#226;nea em um hospital terci&#225;rio de S&#227;o Paulo&#44; Brasil&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="par0035" class="elsevierStylePara elsevierViewall">Ap&#243;s aprova&#231;&#227;o do comit&#234; de &#233;tica institucional&#44; foi feito um estudo retrospectivo que analisou os prontu&#225;rios m&#233;dicos de 72 casos diagnosticados como sarcoidose cut&#226;nea no Departamento de Dermatologia da Universidade de S&#227;o Paulo&#44; Brasil&#44; de maio de 1994 a mar&#231;o de 2018&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">O diagn&#243;stico de sarcoidose cut&#226;nea foi baseado em quadro cl&#237;nico compat&#237;vel&#44; evid&#234;ncia histopatol&#243;gica de granulomas sarco&#237;deos na bi&#243;psia de pele e exclus&#227;o de outras doen&#231;as granulomatosas por meio de colora&#231;&#245;es especiais para microrganismos e culturas&#46; Todos os pacientes foram submetidos &#224; avalia&#231;&#227;o dos &#243;rg&#227;os internos&#44; inclusive hist&#243;ria com revis&#227;o completa dos sistemas&#44; exame f&#237;sico&#44; radiografia de t&#243;rax &#40;estadiamento radiogr&#225;fico para sarcoidose pulmonar &#63; RSPS&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">2&#44;11</span></a> testes de fun&#231;&#227;o pulmonar&#44; avalia&#231;&#227;o oftalmol&#243;gica&#44; perfil hematol&#243;gico e bioqu&#237;mico&#44; eletrocardiograma e teste tubercul&#237;nico&#46; Outras investiga&#231;&#245;es haviam sido feitas conforme necess&#225;rio&#44; de acordo com o quadro cl&#237;nico individual&#46; Foram exclu&#237;dos do estudo os casos cujos prontu&#225;rios m&#233;dicos n&#227;o estavam dispon&#237;veis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Os dados cl&#237;nicos foram revisados retrospectivamente para obten&#231;&#227;o das vari&#225;veis g&#234;nero&#44; idade ao diagn&#243;stico&#44; etnia&#44; morfologia e distribui&#231;&#227;o de les&#245;es cut&#226;neas&#44; envolvimento extracut&#226;neo&#44; manifesta&#231;&#227;o inicial e tratamento estabelecido&#46; Depois disso&#44; dados estat&#237;sticos descritivos foram usados para sintetizar as informa&#231;&#245;es&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="par0050" class="elsevierStylePara elsevierViewall">Dos 74 pacientes selecionados inicialmente com diagn&#243;stico confirmado de sarcoidose cut&#226;nea&#44; dois&#44; dos quais n&#227;o havia informa&#231;&#227;o cl&#237;nica suficiente&#44; foram exclu&#237;dos&#46; As caracter&#237;sticas cl&#237;nicas dos 72 casos restantes est&#227;o resumidas na <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#46; A raz&#227;o entre homens e mulheres foi de aproximadamente 1&#58;2&#44;8 &#8211; 19 homens &#40;26&#37;&#41; e 53 mulheres &#40;74&#37;&#41;&#46; A mediana de idade no momento do diagn&#243;stico foi de 49&#44;6 anos &#40;de 28 a 69&#41;&#46; A maioria dos pacientes era de etnia branca &#40;61&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">As les&#245;es cut&#226;neas espec&#237;ficas observadas inclu&#237;ram placas em 32 casos &#40;44&#37;&#41;&#44; seguidas por p&#225;pulas em 30 &#40;42&#37;&#41;&#44; n&#243;dulos subcut&#226;neos em 11 &#40;15&#37;&#41;&#44; l&#250;pus p&#233;rnio em oito &#40;11&#37;&#41;&#44; angiolupoide em quatro &#40;6&#37;&#41;&#44; les&#245;es hipopigmentadas em dois &#40;3&#37;&#41;&#44; les&#245;es psoriasiformes em um &#40;1&#37;&#41; e les&#245;es liquenoides em um &#40;1&#37;&#41;&#46; Cicatriz e sarcoidose associada &#224; tatuagem foram observadas em um &#40;1&#37;&#41; e dois &#40;3&#37;&#41; pacientes&#44; respectivamente &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Vinte pacientes &#40;28&#37;&#41; apresentavam mais de um tipo de les&#227;o dermatol&#243;gica&#46; Oito pacientes tiveram les&#245;es em outras localiza&#231;&#245;es&#44; como unhas &#40;tr&#234;s&#41;&#44; cavidade bucal &#40;dois&#41;&#44; couro cabeludo &#40;alopecia cicatricial espec&#237;fica&#41; &#40;dois&#41; e genit&#225;lia &#40;um&#41;&#46; Cabe&#231;a e pesco&#231;o foram os locais mais acometidos&#44; com les&#245;es em 50 pacientes &#40;69&#37;&#41;&#46; Quarenta e quatro pacientes &#40;61&#37;&#41; apresentaram comprometimento facial&#46; As les&#245;es afetaram apenas a face em 16 pacientes &#40;22&#37;&#41; e 21 &#40;29&#37;&#41; tiveram les&#245;es no nariz&#46; Les&#245;es estavam presentes nas extremidades superiores em 38 pacientes &#40;53&#37;&#41;&#44; extremidades inferiores em 26 &#40;36&#37;&#41; e tronco em 25 &#40;35&#37;&#41;&#46; Cinquenta e seis pacientes &#40;40&#37;&#41; demonstraram les&#245;es em dois ou mais locais&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Comprometimento sist&#234;mico espec&#237;fico foi detectado em 58 pacientes &#40;81&#37;&#41; e as les&#245;es cut&#226;neas foram a primeira manifesta&#231;&#227;o em 43 &#40;74&#37;&#41; desses &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#41;&#46; O diagn&#243;stico de sarcoidose extracut&#226;nea ocorreu antes da doen&#231;a cut&#226;nea em 15 casos &#40;26&#37;&#41;&#46; Sarcoidose pulmonar foi a manifesta&#231;&#227;o sist&#234;mica mais frequente&#44; acometeu 56 pacientes &#40;97&#37; dos pacientes com comprometimento sist&#234;mico&#41;&#46; De acordo com o RSPS&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">1</span></a> 25 pacientes apresentavam sarcoidose pulmonar est&#225;gio I &#40;linfadenopatia isolada&#41;&#44; 21 est&#225;gio II &#40;infiltra&#231;&#227;o pulmonar com linfadenopatia&#41;&#44; dois est&#225;gio III &#40;infiltra&#231;&#227;o pulmonar sem linfadenopatia&#41; e oito est&#225;gio IV &#40;fibrose pulmonar&#41;&#46; Outros &#243;rg&#227;os comumente envolvidos foram os rins em oito pacientes &#40;14&#37;&#41;&#44; linfonodos extrator&#225;cicos em oito &#40;14&#37;&#41; e olhos em sete &#40;12&#37;&#41;&#46; Dos pacientes com doen&#231;a renal&#44; cinco apresentavam apenas hipercalci&#250;ria assintom&#225;tica e tr&#234;s apresentavam nefrolit&#237;ase&#46; As manifesta&#231;&#245;es oculares mais comuns foram uve&#237;te e hipertrofia da gl&#226;ndula lacrimal em cinco e dois pacientes&#44; respectivamente&#46; Dois pacientes &#40;3&#37;&#41; apresentaram sarcoidose card&#237;aca&#46; A doen&#231;a afetou o f&#237;gado&#44; o ba&#231;o&#44; o p&#226;ncreas&#44; o trato gastrintestinal&#44; o trato respirat&#243;rio superior&#44; os m&#250;sculos&#44; os ossos e as articula&#231;&#245;es&#44; separadamente&#44; em casos isolados&#46; A sarcoidose permaneceu confinada &#224; pele&#44; durante o seguimento&#44; em 14 pacientes &#40;19&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Cinquenta e dois pacientes &#40;72&#37;&#41; necessitaram de terapia sist&#234;mica e 12 &#40;17&#37;&#41; receberam apenas terapia local &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a>&#41;&#46; Tr&#234;s pacientes perderam o acompanhamento cl&#237;nico ap&#243;s o diagn&#243;stico&#44; um teve remiss&#227;o espont&#226;nea e quatro ainda n&#227;o haviam iniciado o tratamento quando do levantamento&#46; Dos pacientes que foram tratados apenas com terapia local&#44; uso t&#243;pico de corticosteroides foi feito em 10&#44; corticosteroide intralesional em cinco e inibidor t&#243;pico de calcineurina &#40;tacrolimo&#41; em tr&#234;s&#46; Em metade desses casos&#44; uma associa&#231;&#227;o de terapias locais foi necess&#225;ria&#46; Os corticosteroides por via oral constitu&#237;ram a medica&#231;&#227;o sist&#234;mica mais usada em 48 pacientes &#40;92&#37;&#41;&#44; seguido por antimal&#225;ricos em 28 &#40;54&#37;&#41;&#44; metotrexato em 18 &#40;35&#37;&#41;&#44; azatioprina em quatro &#40;8&#37;&#41; e leflunomida em dois &#40;4&#37;&#41;&#44; antibi&#243;ticos da classe das tetraciclinas em dois &#40;4&#37;&#41;&#44; talidomida em um &#40;2&#37;&#41; e infliximabe em um &#40;2&#37;&#41;&#46; Dezessete pacientes &#40;33&#37;&#41; receberam corticosteroides orais como monoterapia&#46; O n&#250;mero m&#233;dio de medicamentos sist&#234;micos usados em cada paciente durante o per&#237;odo de acompanhamento foi de 1&#44;98&#46; A terapia sist&#234;mica foi direcionada para les&#245;es cut&#226;neas e&#44; portanto&#44; gerenciada exclusivamente pelo dermatologista em 24 pacientes &#40;46&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discuss&#227;o</span><p id="par0070" class="elsevierStylePara elsevierViewall">Embora a preval&#234;ncia de sarcoidose no Brasil ainda n&#227;o tenha sido estabelecida&#44; estima&#8208;se que seja menor do que 10 casos&#47;100&#46;000 habitantes&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">14</span></a> Dermatologistas brasileiros mais antigos alegavam que a sarcoidose cut&#226;nea era extremamente rara no Brasil&#46; Em geral&#44; considerava&#8208;se que &#8220;um caso de sarcoidose cut&#226;nea &#233; possivelmente um caso mal diagnosticado de hansen&#237;ase ou tuberculose&#8221;&#46; Parece que a incid&#234;ncia da doen&#231;a tem aumentado gradualmente nas &#250;ltimas d&#233;cadas&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">2</span></a> Os n&#250;meros em rela&#231;&#227;o ao sexo e &#224; m&#233;dia de idade ao diagn&#243;stico na presente s&#233;rie coincidem com as estat&#237;sticas de outros pa&#237;ses&#46; No entanto&#44; a maioria de nossos pacientes era branca &#40;61&#37;&#41;&#44; ao contr&#225;rio da maior preval&#234;ncia cl&#225;ssica em negros&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">2&#44;4&#44;15</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Les&#245;es cut&#226;neas levaram &#224; detec&#231;&#227;o de sarcoidose extracut&#226;nea em 74&#37; dos pacientes&#44; valor corroborado por outros estudos&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">De acordo com v&#225;rias s&#233;ries anteriormente publicadas&#44; as les&#245;es espec&#237;ficas mais comuns da sarcoidose s&#227;o as p&#225;pulas&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">18&#8211;20</span></a> No entanto&#44; a sarcoidose do tipo placa foi a apresenta&#231;&#227;o mais frequente em nosso estudo &#40;44&#37;&#41;&#44; seguida pelas p&#225;pulas &#40;42&#37;&#41;&#46; Essa propor&#231;&#227;o tamb&#233;m foi encontrada em s&#233;ries recentes do L&#237;bano e em Taiwan&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">21&#44;22</span></a> Placas podem surgir de novo ou a partir de uma conflu&#234;ncia de p&#225;pulas&#46; Quando comparadas &#224;s p&#225;pulas&#44; as placas tendem a ter uma infiltra&#231;&#227;o mais profunda e s&#227;o mais propensas a deixar cicatrizes permanents ao se resolver&#46; A presen&#231;a de placas tem sido associada a um curso cr&#244;nico da doen&#231;a&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">18&#8211;20</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">N&#243;dulos subcut&#226;neos espec&#237;ficos &#40;n&#227;o eritema nodoso&#41; foram observados em 15&#37; dos pacientes&#44; frequ&#234;ncia maior do que a encontrada em outros estudos&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">8&#44;18&#44;20</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">O l&#250;pus p&#233;rnio&#44; les&#227;o muito caracter&#237;stica da sarcoidose cut&#226;nea&#44; geralmente segue um curso cr&#244;nico e frequentemente coexiste com sarcoidose do trato respirat&#243;rio superior&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">7</span></a> Em nossa casu&#237;stica&#44; oito pacientes apresentaram l&#250;pus p&#233;rnio&#44; todos com doen&#231;a sist&#234;mica associada&#44; muitas vezes grave e com envolvimento de muitos &#243;rg&#227;os&#46; Apenas um paciente apresentou comprometimento do trato respirat&#243;rio superior&#46; Cicatrizes e sarcoidose associada &#224; tatuagem foram diagnosticadas em um e em dois pacientes&#44; respectivamente&#46; Essas les&#245;es podem ser diagnosticadas erroneamente como cicatrizes hipertr&#243;ficas ou queloides&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">7</span></a> Em alguns pacientes foram detectadas les&#245;es espec&#237;ficas menos frequentes&#44; como sarcoidose angiolupoide&#44; hipopigmentada&#44; psoriasiforme e liquenoide&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Acometimento facial esteve presente em 61&#37; dos pacientes&#59; uma propor&#231;&#227;o semelhante tem sido relatada por outros estudos&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">22&#44;23</span></a> Em 40&#37; dos casos&#44; as les&#245;es acometiam duas ou mais localiza&#231;&#245;es&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Nosso procedimento inicial de rotina para o diagn&#243;stico de sarcoidose incluiu histopatologia e cultura da pele &#40;com feitura de colora&#231;&#245;es espec&#237;ficas para microrganismos&#41;&#44; radiografia de t&#243;rax ou tomografia e um teste cut&#226;neo negativo para tuberculina&#46; Esse protocolo foi suficiente para diagnosticar sarcoidose sist&#234;mica na maioria dos pacientes&#46; Ap&#243;s o diagn&#243;stico&#44; a avalia&#231;&#227;o b&#225;sica incluiu avalia&#231;&#227;o oftalmol&#243;gica&#44; perfil hematol&#243;gico e bioqu&#237;mico &#40;n&#237;vel s&#233;rico e urin&#225;rio de c&#225;lcio&#44; fun&#231;&#227;o hep&#225;tica e renal&#41;&#44; eletrocardiograma e testes de fun&#231;&#227;o pulmonar&#46; Testes adicionais foram solicitados conforme a necessidade&#46; Os n&#237;veis s&#233;ricos de enzima conversora de angiotensina n&#227;o s&#227;o medidos em nosso servi&#231;o&#46; Apenas 60&#37; dos pacientes com sarcoidose apresentam n&#237;veis aumentados dessa enzima&#44; os quais n&#227;o s&#227;o espec&#237;ficos para a doen&#231;a&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">7</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Caso a sarcoidose sist&#234;mica n&#227;o seja diagnosticada em um paciente com granulomas sarco&#237;dicos cut&#226;neos&#44; deve ser feito acompanhamento em longo prazo&#46; Em nossa s&#233;rie&#44; a sarcoidose sist&#234;mica foi detectada em 81&#37; dos pacientes&#59; em quase todos&#44; p&#244;de ser demonstrada logo ap&#243;s e como consequ&#234;ncia do diagn&#243;stico de doen&#231;a cut&#226;nea&#46; A sarcoidose pulmonar foi a manifesta&#231;&#227;o sist&#234;mica mais comum&#44; afetou 97&#37; dos nossos casos&#46; A linfadenopatia foi o achado radiol&#243;gico mais frequente &#40;82&#37;&#41;&#44; seguido de infiltra&#231;&#227;o pulmonar &#40;41&#37;&#41; e fibrose &#40;14&#37;&#41;&#46; Outros &#243;rg&#227;os comumente envolvidos foram os rins &#40;14&#37;&#41;&#44; linfonodos extrator&#225;cicos &#40;14&#37;&#41; e olhos &#40;12&#37;&#41;&#46; Com exce&#231;&#227;o do envolvimento renal&#44; que esteve presente em maior propor&#231;&#227;o em nosso estudo&#44; outros acometimentos de &#243;rg&#227;os foram encontrados em taxas semelhantes &#224;s descritas anteriormente&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">1</span></a> Uma frequ&#234;ncia maior de manifesta&#231;&#245;es renais pode ser relacionada a um poss&#237;vel subdiagn&#243;stico de hipercalci&#250;ria assintom&#225;tica em pacientes estudados em outras publica&#231;&#245;es&#46; Isso enfatiza a necessidade de dosar n&#227;o apenas o n&#237;vel s&#233;rico de c&#225;lcio&#44; mas tamb&#233;m o c&#225;lcio urin&#225;rio&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Quatorze pacientes apresentaram apenas manifesta&#231;&#245;es cut&#226;neas&#46; &#201; controverso na literatura se esses pacientes apresentar&#227;o envolvimento sist&#234;mico adicional ou se sua doen&#231;a ficar&#225; restrita &#224; pele&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Corticosteroides t&#243;picos e intralesionais foram as terapias locais mais usadas em nossos pacientes&#46; Essas drogas s&#227;o consideradas terapia de primeira linha para sarcoidose cut&#226;nea com doen&#231;a limitada ou leve&#44; ou ent&#227;o como adjuvante para ajudar a controlar o dist&#250;rbio cut&#226;neo quando a doen&#231;a extracut&#226;nea est&#225; sob controle adequado&#46; Inibidores t&#243;picos de calcineurina&#44; que t&#234;m baixo perfil geral de efeitos colaterais e s&#227;o indicados para doen&#231;as de pele limitadas&#44; tamb&#233;m podem ser usados&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">12&#44;24</span></a> Dos 12 pacientes &#40;17&#37;&#41; tratados apenas com terapia local&#44; cinco apresentaram les&#245;es cut&#226;neas isoladas e sete doen&#231;a pulmonar leve&#44; n&#227;o necessitaram de tratamento sist&#234;mico&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Para pacientes com doen&#231;a grave ou que n&#227;o respondem &#224; terapia t&#243;pica&#44; os corticosteroides orais s&#227;o terapia sist&#234;mica de primeira linha&#46; Em caso de reca&#237;da ou se os sinais persistirem&#44; agentes poupadores de esteroides devem ser institu&#237;dos isoladamente&#44; ou com baixas doses de corticosteroide associado&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">12&#44;25</span></a> Em nossa s&#233;rie&#44; os corticosteroides foram os medicamentos mais usados &#40;92&#37;&#41;&#44; em alguns casos como monoterapia &#40;33&#37;&#41;&#46; Antimal&#225;ricos &#40;54&#37;&#41; e metotrexato &#40;35&#37;&#41; tamb&#233;m foram usados&#46; Outras medica&#231;&#245;es poupadoras de corticoides inclu&#237;ram azatioprina &#40;quatro pacientes&#41;&#44; leflunomida &#40;tr&#234;s&#41;&#44; antibi&#243;ticos da classe das tetraciclinas &#40;tr&#234;s&#41; e talidomida &#40;um&#41;&#46; O infliximabe tem sido usado recentemente para a sarcoidose recalcitrante&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">25</span></a> Esse medicamento foi prescrito para um paciente que apresentava l&#250;pus p&#233;rnio&#44; com doen&#231;a sist&#234;mica e cut&#226;nea grave&#44; ap&#243;s falha terap&#234;utica com outros esquemas combinados&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">O n&#250;mero m&#233;dio de medicamentos sist&#234;micos usados em cada paciente durante o per&#237;odo de acompanhamento foi de 1&#44;98&#44; confirmou que a maioria dos pacientes precisou receber de uma a duas medica&#231;&#245;es diferentes para alcan&#231;ar o controle da doen&#231;a&#46; A terapia sist&#234;mica foi direcionada para les&#245;es cut&#226;neas em 24 pacientes &#40;46&#37;&#41; e&#44; portanto&#44; gerenciada exclusivamente pelo dermatologista nesses casos&#46; Esses pacientes apresentavam apenas comprometimento cut&#226;neo &#40;sete&#41; ou tinham comprometimento pulmonar leve&#44; n&#227;o considerado merecedor de tratamento pelos internistas &#40;17&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclus&#227;o</span><p id="par0135" class="elsevierStylePara elsevierViewall">Os achados cl&#237;nicos e epidemiol&#243;gicos do presente estudo foram&#44; em sua maioria&#44; semelhantes aos publicados na literatura&#46; Suas limita&#231;&#245;es incluem o desenho retrospectivo e&#44; em alguns casos&#44; a falta de dados detalhados nos prontu&#225;rios dos pacientes&#46; Comparando&#8208;se com dados da literatura&#44; observou&#8208;se uma incid&#234;ncia aumentada de comprometimento renal &#40;hipercalci&#250;ria&#41;&#46; Apesar do pequeno tamanho da amostra&#44; representa a maior s&#233;rie brasileira sobre o assunto&#44; sugerindo que a sarcoidose possa n&#227;o ser t&#227;o infrequente no Brasil&#46; Embora existam muitas doen&#231;as infecciosas granulomatosas end&#234;micas em nosso pa&#237;s&#44; a sarcoidose certamente se destaca como um diagn&#243;stico importante a ser considerado&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Suporte financeiro</span><p id="par0170" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Contribui&#231;&#227;o dos autores</span><p id="par0140" class="elsevierStylePara elsevierViewall">Mariana Fernandes Torquato&#58; An&#225;lise estat&#237;stica&#59; concep&#231;&#227;o e planejamento do estudo&#59; elabora&#231;&#227;o e reda&#231;&#227;o do manuscrito&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; revis&#227;o cr&#237;tica da literatura&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Marcella Karen Souza da Costa&#58; An&#225;lise estat&#237;stica&#59; concep&#231;&#227;o e planejamento do estudo&#59; elabora&#231;&#227;o e reda&#231;&#227;o do manuscrito&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; revis&#227;o cr&#237;tica da literatura&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Marcello Menta Simonsen Nico&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; participa&#231;&#227;o intelectual em conduta proped&#234;utica e&#47;ou terap&#234;utica de casos estudados&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflitos de interesse</span><p id="par0160" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Fundamentos</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A sarcoidose &#233; uma doen&#231;a multissist&#234;mica de causa desconhecida&#44; caracterizada pela presen&#231;a de inflama&#231;&#227;o granulomatosa n&#227;o infecciosa em diversos &#243;rg&#227;os&#46; O envolvimento cut&#226;neo &#233; comum&#44; com incid&#234;ncia relatada entre 9&#37; e 37&#37; dos pacientes&#46; Estudos sobre sarcoidose cut&#226;nea no Brasil s&#227;o escassos&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Descrever aspectos cl&#237;nico&#8208;epidemiol&#243;gicos dos pacientes com sarcoidose cut&#226;nea diagnosticada no Departamento de Dermatologia da Universidade de S&#227;o Paulo&#44; de maio de 1994 a mar&#231;o de 2018&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Os aspectos cl&#237;nicos de pacientes com sarcoidose cut&#226;nea confirmada foram revisados retrospectivamente e classificados de acordo com g&#234;nero&#44; etnia&#44; idade ao diagn&#243;stico&#44; tipo de manifesta&#231;&#227;o cut&#226;nea&#44; envolvimento sist&#234;mico e tratamento efetuado&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A sarcoidose cut&#226;nea foi diagnosticada em 72 pacientes&#44; predominou no sexo feminino &#40;74&#37;&#41;&#44; idade m&#233;dia ao diagn&#243;stico de 49&#44;6 anos&#44; com maioria de etnia branca &#40;61&#37;&#41;&#46; P&#225;pulas e placas foram as les&#245;es mais comuns&#46; Doen&#231;a sist&#234;mica foi detectada em 81&#37; dos pacientes&#44; afetando principalmente pulm&#245;es e linfonodos tor&#225;cicos &#40;97&#37;&#41;&#46; Tipicamente&#44; as les&#245;es cut&#226;neas foram a primeira manifesta&#231;&#227;o &#40;74&#37;&#41;&#46; Terapia sist&#234;mica foi necess&#225;ria em 72&#37;&#44; com seguimento cl&#237;nico feito por dermatologistas em grande parte dos casos&#46; Os glicocorticoides orais foram os medicamentos sist&#234;micos mais usados &#40;92&#37;&#41;&#44; com m&#233;dia de 1&#44;98 medicamento sist&#234;mico por paciente&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Limita&#231;&#245;es do estudo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Dados insuficientes nos prontu&#225;rios m&#233;dicos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclus&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Esta s&#233;rie destaca o papel do dermatologista no reconhecimento e diagn&#243;stico da sarcoidose cut&#226;nea&#44; na avalia&#231;&#227;o do acometimento sist&#234;mico e seu tratamento&#46; A sarcoidose cut&#226;nea j&#225; foi considerada extremamente infrequente no Brasil em compara&#231;&#227;o com doen&#231;as granulomatosas infecciosas&#59; no entanto&#44; a presente casu&#237;stica parece sugerir que a enfermidade n&#227;o &#233; t&#227;o rara em nosso meio&#46;</p></span>"
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>P&#225;pulas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Subcut&#226;nea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>L&#250;pus p&#233;rnio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Angiolupoide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hipopigmentada&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Associada &#224; tatuagem&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cicatrizes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Psoriasiforme&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Liquenoide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8805; 2 tipos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Localiza&#231;&#245;es especiais</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Unha&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cavidade oral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alopecia cicatricial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Genital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Distribui&#231;&#227;o</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cabe&#231;a e pesco&#231;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Face&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Somente Face&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Nariz&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Membros superiores&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Membros inferiores&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tronco&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  """
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">97&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">43&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Est&#225;gio 2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">36&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Est&#225;gio 3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Est&#225;gio 4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Linfadenopatia extrator&#225;cica&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ocular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Card&#237;aco&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hep&#225;tico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Espl&#234;nico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Trato gastrintestinal&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Muscular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Trato respirat&#243;rio superior&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Articular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#211;sseo&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Manifesta&#231;&#227;o inicial</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cut&#226;nea&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Extracut&#226;nea&nbsp;\t\t\t\t\t\t\n
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