Diagnosis at first sight
Bleeding tumour with rapid onset in an immunosuppressed patient
Tumoración sangrante de rápida aparición en paciente inmunodeprimido
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B) Tinción PAS, donde pueden verse las características conidias muriformes en cadenas (centro imagen).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Alejandro Lapeña Casado, Antonio Beltrán Rosel, Victoria Lezcano Biosca, Mariano Ara Martín" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Alejandro" "apellidos" => "Lapeña Casado" ] 1 => array:2 [ "nombre" => "Antonio" "apellidos" => "Beltrán Rosel" ] 2 => array:2 [ "nombre" => "Victoria" "apellidos" => "Lezcano Biosca" ] 3 => array:2 [ "nombre" => "Mariano" "apellidos" => "Ara Martín" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2529993X21000290" "doi" => "10.1016/j.eimce.2021.02.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X21000290?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X20302767?idApp=UINPBA00004N" "url" => "/0213005X/0000003900000004/v1_202104030817/S0213005X20302767/v1_202104030817/es/main.assets" ] ] "itemSiguiente" => array:18 [ "pii" => "S2529993X21000654" "issn" => "2529993X" "doi" => "10.1016/j.eimce.2020.07.006" "estado" => "S300" "fechaPublicacion" => "2021-04-01" "aid" => "2279" "copyright" => "Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Enferm Infecc Microbiol Clin. 2021;39:204-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Diagnosis at first sight</span>" "titulo" => "Diabetic ketoacidosis presenting as… neck pain?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "204" "paginaFinal" => "205" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cetoacidosis diabética precipitada por… ¿dolor de cuello?" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 810 "Ancho" => 1300 "Tamanyo" => 120266 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Initial neck ultrasonography (USG) showing a complex lesion in the right thyroid lobe measuring approximately 5.4<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3.1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3.2<span class="elsevierStyleHsp" style=""></span>cm with peripheral vascularity.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Carlos A. 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detection of antibiotic resistance mechanisms.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Marina Oviaño, Belén Rodríguez-Sánchez" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Marina" "apellidos" => "Oviaño" ] 1 => array:2 [ "nombre" => "Belén" "apellidos" => "Rodríguez-Sánchez" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X21000563?idApp=UINPBA00004N" "url" => "/2529993X/0000003900000004/v1_202104030716/S2529993X21000563/v1_202104030716/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Diagnosis at first sight</span>" "titulo" => "Bleeding tumour with rapid onset in an immunosuppressed patient" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "201" "paginaFinal" => "203" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Alejandro Lapeña Casado, Antonio Beltrán Rosel, Victoria Lezcano Biosca, Mariano Ara Martín" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Alejandro" "apellidos" => "Lapeña Casado" "email" => array:1 [ 0 => "alapeca93@gmail.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" => "Antonio" "apellidos" => "Beltrán Rosel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Victoria" "apellidos" => "Lezcano Biosca" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Mariano" "apellidos" => "Ara Martín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología y Venereología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Microbiología y Parasitología, Hospital Clínico Lozano Blesa, Zaragoza, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tumoración sangrante de rápida aparición en paciente inmunodeprimido" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2189 "Ancho" => 1500 "Tamanyo" => 840059 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0065" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Grocott's stain, where both conidia (rounded structures) and septate hyphae 7–10 microns thick with acute angled bifurcations can be seen. (B) PAS staining, where the characteristic muriform chains of conidia can be seen (centre image).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">We present the case of a 78-year-old man with no known drug allergies, with a history of hypertension and prostate cancer with stage IVB bone metastases on symptomatic treatment with dexamethasone. He consulted for a skin lesion on his left arm which had appeared one month previously and progressively grown, with spontaneous bleeding, and another three on his lower limbs which had appeared in the previous two weeks; he stated that four months earlier he had a superficial graze on his left arm after scraping it on the branch of a cherry tree. He had no fever or other systemic symptoms. Physical examination (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A–C) revealed an erosive/bleeding violaceous tumour on the back of the patient's left forearm measuring 3.5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>cm in diameter, with a superficial blackish scab, but no specific dermoscopic criteria for a primary skin tumour. He also had three similar but smaller lesions on his lower limbs.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">After complete surgical removal of the forearm skin lesion, subsequent histological study (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A and B) revealed an inflammatory infiltrate in the papillary and reticular dermis composed of histiocytes and multinucleated giant cells with abscessing foci. Grocott and PAS stains (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A and B) revealed abundant septate hyphae and chains of conidia.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Progress</span><p id="par0015" class="elsevierStylePara elsevierViewall">The definitive diagnosis was arrived at by culture of a new biopsy. Colonies of a brownish-green filamentous fungus grew in Sabouraud agar after 2–3 days. Lactophenol blue staining showed the chains of muriform conidia characteristic of the genus <span class="elsevierStyleItalic">Alternaria</span>. The strain was sent to the reference laboratory and, by sequencing the 18S rRNA small ribosomal subunit, the species was identified as <span class="elsevierStyleItalic">Alternaria alternata</span>.</p><p id="par0020" class="elsevierStylePara elsevierViewall">As the patient was terminally ill and refused further tests such as chest CT and long-standing intravenous or oral antifungal treatment, local cryotherapy was carried out, with subsequent application of a topical antifungal to the smaller lesions on his legs, which controlled progression of the lesions and reduced their size. The patient died a few weeks later of his underlying disease.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Comments</span><p id="par0025" class="elsevierStylePara elsevierViewall">Cutaneous alternariosis is a rare opportunistic fungal infection that comes under the grouping of phaeohyphomycosis (filamentous fungi capable of synthesising melanin). <span class="elsevierStyleItalic">Alternaria</span> spp. are frequently isolated on the ground, in vegetation or in the air. It rarely causes dermatological infection, as it requires a break in the skin barrier on exposed body surfaces, combined with severe immunosuppression, to cause skin disease in the middle and deep dermis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Although cases have also been described in healthy individuals, most occur in the context of transplants (especially solid organ), blood cancers and/or pharmacological immunosuppression. Only three cases have been reported to date in which solid tumours acted as a predisposing or contributing factor to the state of immunosuppression.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a> The clinical presentation varies, from erythematous macules to violaceous papules, to nodules with a tendency to ulceration.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> They can simulate other conditions such as primary skin tumours or, as in our case, metastasis. However, the typical biopsy finding of granulomatous inflammation and septate hyphae refocused the case; the culture finally confirmed the diagnosis. As there have been no randomised clinical trials, there is no standardised treatment.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The most effective therapy consists of reversing the state of immunosuppression, and if they are resectable, surgical excision is recommended. To avoid recurrence, antifungal treatment with itraconazole, voriconazole, posaconazole or amphotericin B is usually added, all of which have shown susceptibility <span class="elsevierStyleItalic">in vitro</span>, although there is no consensus on duration or dose. Alternative and/or adjuvant treatments have been described, such as photodynamic therapy, cryotherapy or local hyperthermia, but in each case results are mixed and poorly contrasted.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">This work has been funded by the <span class="elsevierStyleGrantSponsor" id="gs0000">Autonomous Government of Aragon</span> (Grupo de Investigación Agua y Salud Ambiental [Water and Environmental Health Research Group], B43_20R), <span class="elsevierStyleGrantSponsor" id="gs0005">Feder 2014–2020 “Building Europe from Aragon”</span> and <span class="elsevierStyleGrantSponsor" id="gs0010">Universidad de Zaragoza</span> (UZ2018-BIO-01).</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Progress" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Comments" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Funding" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "⋆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Lapeña Casado A, Beltrán Rosel A, Lezcano Biosca V, Ara Martín M. Tumoración sangrante de rápida aparición en paciente inmunodeprimido. Enferm Infecc Microbiol Clin. 2021;39:201–203.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2193 "Ancho" => 2500 "Tamanyo" => 499800 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0055" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Polymorphic skin lesions. (A) Back of left forearm: a poorly defined, stony tumour plaque with a blackish crusty surface, 3.5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>cm in diameter, with peri-lesional ecchymotic plaques. (B) Front of the right leg with two rounded plaques 1.5<span class="elsevierStyleHsp" style=""></span>cm in diameter. (C) The left knee has a plaque with a diameter of 2.5<span class="elsevierStyleHsp" style=""></span>cm with irregular, raised borders and a friable, bleeding centre.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1543 "Ancho" => 1500 "Tamanyo" => 646327 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0060" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Skin biopsy of left elbow lesion, haematoxylin-eosin (H&E). (A) Panoramic view: pseudoepitheliomatous squamous hyperplasia with abundant inflammatory infiltrate. (B) At higher magnification, the inflammatory component is heterogeneous with abundant histiocytes/macrophages, and in a minor proportion a mixture of lymphocytes and neutrophils, in addition to proliferation of vessels. Refringent and laminar structures identified in macrophage cytoplasm (arrows).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2189 "Ancho" => 1500 "Tamanyo" => 840059 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0065" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Grocott's stain, where both conidia (rounded structures) and septate hyphae 7–10 microns thick with acute angled bifurcations can be seen. (B) PAS staining, where the characteristic muriform chains of conidia can be seen (centre image).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Relapse of cutaneous Alternaria infectoria in a renal transplant recipient after 2 years" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Ara" 1 => "C. Aspiroz" 2 => "P. Zaballos" 3 => "V. Alcalde" 4 => "R. Alvarez" 5 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 8 | 2 | 10 |
| 2024 September | 16 | 4 | 20 |
| 2024 August | 17 | 4 | 21 |
| 2024 July | 8 | 3 | 11 |
| 2024 June | 12 | 2 | 14 |
| 2024 May | 9 | 4 | 13 |
| 2024 April | 11 | 2 | 13 |
| 2024 March | 25 | 3 | 28 |
| 2024 February | 47 | 4 | 51 |
| 2024 January | 9 | 1 | 10 |
| 2023 December | 13 | 3 | 16 |
| 2023 November | 18 | 2 | 20 |
| 2023 October | 27 | 3 | 30 |
| 2023 September | 21 | 0 | 21 |
| 2023 August | 7 | 5 | 12 |
| 2023 July | 9 | 3 | 12 |
| 2023 June | 7 | 0 | 7 |
| 2023 May | 22 | 0 | 22 |
| 2023 April | 27 | 1 | 28 |
| 2023 March | 15 | 3 | 18 |
| 2023 February | 15 | 6 | 21 |
| 2023 January | 8 | 11 | 19 |
| 2022 December | 19 | 3 | 22 |
| 2022 November | 37 | 9 | 46 |
| 2022 October | 57 | 8 | 65 |
| 2022 September | 49 | 6 | 55 |
| 2022 August | 9 | 8 | 17 |
| 2022 July | 10 | 8 | 18 |
| 2022 June | 14 | 11 | 25 |
| 2022 May | 35 | 4 | 39 |
| 2022 April | 11 | 7 | 18 |
| 2022 March | 16 | 11 | 27 |
| 2022 February | 56 | 6 | 62 |
| 2022 January | 37 | 6 | 43 |
| 2021 December | 42 | 9 | 51 |
| 2021 November | 21 | 7 | 28 |
| 2021 October | 12 | 7 | 19 |
| 2021 September | 2 | 0 | 2 |
| 2021 April | 32 | 0 | 32 |
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