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Mycosis fungoides-like lesions in a patient with diffuse cutaneous sporotrichosis
Lesiones que semejan una micosis fungoide en un paciente con esporotricosis cutánea difusa
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almacenadas procedentes de Colombia" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Patricia Escandón, Elizabeth Castañeda" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Patricia" "apellidos" => "Escandón" ] 1 => array:2 [ "nombre" => "Elizabeth" "apellidos" => "Castañeda" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130140614000825?idApp=UINPBA00004N" "url" => "/11301406/0000003200000003/v1_201507300100/S1130140614000825/v1_201507300100/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Note</span>" "titulo" => "Mycosis fungoides-like lesions in a patient with diffuse cutaneous sporotrichosis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "200" "paginaFinal" => "203" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Adriana Cotino Sánchez, Bertha Torres-Alvarez, Teodoro Gurrola Morales, Silvia Méndez Martínez, Mauricio Saucedo Gárate, Juan Pablo Castanedo-Cazares" "autores" => array:6 [ 0 => array:3 [ "nombre" => "Adriana" "apellidos" => "Cotino Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Bertha" "apellidos" => "Torres-Alvarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Teodoro" "apellidos" => "Gurrola Morales" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Silvia" "apellidos" => "Méndez Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Mauricio" "apellidos" => "Saucedo Gárate" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:4 [ "nombre" => "Juan Pablo" "apellidos" => "Castanedo-Cazares" "email" => array:1 [ 0 => "castanju@yahoo.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Pathology, Hospital General de Durango, Universidad Juárez del Estado de Durango, Durango, Mexico" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Dermatology, Hospital Central Dr. Ignacio Morones Prieto, Universidad Autónoma de San Luis Potosí, San Luis Potosí, Mexico" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lesiones que semejan una micosis fungoide en un paciente con esporotricosis cutánea difusa" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 848 "Ancho" => 1500 "Tamanyo" => 234628 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Clinical pictures of the patient after being treated with itraconazole. The improvement is evident, although hyper and hypopigmented areas with atrophic scars remained on the affected areas.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Sporotrichosis is a worldwide fungal infection caused by the inhalation or traumatic inoculation of spores of the dimorphic fungus <span class="elsevierStyleItalic">Sporothrix schenckii</span> complex.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,9,19</span></a> It is a polymorphic disease that has two clinical forms, localized and systemic (disseminated), although the most common presentation is a subacute or chronic subcutaneous process. Molecular studies have shown that the <span class="elsevierStyleItalic">S. schenckii</span> complex includes species that have not been completely characterized, such as <span class="elsevierStyleItalic">Sporothrix albican</span>s, <span class="elsevierStyleItalic">Sporothrix brasiliensis</span>, <span class="elsevierStyleItalic">Sporothrix globosa</span>, <span class="elsevierStyleItalic">Sporothrix luriei</span>, <span class="elsevierStyleItalic">Sporothrix mexicana</span>, and <span class="elsevierStyleItalic">S. schenckii</span>.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Sporotrichosis has a relatively high incidence in Latin American countries such as Mexico, where it is frequent in the central and occidental areas of the country.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,19</span></a> It is seen in both genders and at all ages, although it is more common among children and young adults in this part of the world.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6,19</span></a> It is considered an occupational infectious disease because miners, farmers, gardeners, and carpenters are frequently affected due to exposure to the natural habitat of this microorganism.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6,19</span></a> Indirect vectors such as rats, mice, cats, and squirrels have also been described.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We present the case of an alcoholic and iatrogenically immunosuppressed patient with disseminated cutaneous sporotrichosis with mycosis fungoides-like lesions.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 68-year-old male farmer from Durango, Mexico, presented to his local family physician with a 4-year history of asymptomatic scaly nodules and plaques on his face. These lesions were treated with topical antibiotics and steroids with transient and partial involution. Five months later, the nodules and plaques progressively increased in size evolving into tumors. Similar lesions appeared on the thorax, abdomen and limbs. Symptoms of malaise, intermittent fever, and a 10% loss of his usual weight were also present. The patient was reexamined by an internist who prescribed oral prednisone 50<span class="elsevierStyleHsp" style=""></span>mg/day, and topical mometasone 0.1% with a presumptive diagnosis of mycosis fungoides, supported by the clinical presentation and the histological study of a facial lesion. After three weeks of treatment, the patient exhibited clinical worsening with new nodular lesions, ulceration, and tumor enlargement. The patient was referred to a dermatology center.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient had a 20-year history of high blood pressure with irregular treatment, a 18 pack-year history of smoking, and 500<span class="elsevierStyleHsp" style=""></span>g of alcohol consumption per week. He did not remember any scratching, trauma, or skin puncture by thorns or organic material. Physical examination revealed asymptomatic multiple scaly nodules, tumors and ill-defined plaques 2 to 8-cm in diameter without tenderness, disseminated to the head, thorax and limbs, some with ulceration (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Painless bilateral cervical and clavicular adenopathy was found.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A complete blood cell count showed hemoglobin of 9.5<span class="elsevierStyleHsp" style=""></span>g/dl, and hematocrit of 29.5%. The white cell count was 17,769 neutrophils/mm<span class="elsevierStyleSup">3</span>, 2160 lymphocytes/mm<span class="elsevierStyleSup">3</span>, and 4080 eosinophils/mm<span class="elsevierStyleSup">3</span>. A buffy coat smear for Sézary cells, a chest X-ray and a thoracoabdominal CT scan were normal. Serology for HIV was negative.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Histologic examination of nodules on the right cheek and upper thorax revealed a suppurative granulomatous dermatitis. A biopsy specimen showed hyperkeratosis, acanthosis, and a diffuse infiltrate of granulocytes, lymphocytes, and plasma cells throughout the dermis. Periodic acid-Schiff (PAS) stain revealed the presence of yeast forms, 2–4<span class="elsevierStyleHsp" style=""></span>mm with enhancement of their walls (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Special stains for bacteria and acid-fast bacilli were negative. Tissue fungal culture on Sabouraud agar grew <span class="elsevierStyleItalic">Sporothrix schenckii</span>. Septate hyphae with conidia arranged in rosette-like clusters were observed after staining with lactophenol aniline blue (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The treatment was started with oral itraconazole, 200<span class="elsevierStyleHsp" style=""></span>mg/d which showed marked improvement over the first six weeks with normalization of white blood cells parameters, and complete remission after 4 months of treatment (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Sporotrichosis is a polymorphic disease with lymphocutaneous, fixed, and disseminated clinical variants.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,9,19</span></a> The most common lesions are fixed and lymphocutaneous. The typical course of disease begins days to weeks after inoculation with a nodule or ulcer at the site of entrance.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,9,19</span></a> Lesions enlarge slowly, and form satellite nodules progressing along regional lymphatics. Disseminated cutaneous sporotrichosis is characterized by more than three skin lesions in two different anatomical sites without extracutaneous involvement.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> This clinical presentation is rare, accounting for less than 2% of the cases, and is usually associated to immunosuppression, where the fungus acts as an opportunistic pathogen.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,9,19</span></a> Host immunity is hypoergic or anergic.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5,19</span></a> Risk factors include alcoholism, diabetes, AIDS, pregnancy, malnutrition, malignancy, and immunosuppressive therapy.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,19</span></a> In these settings, lesions are usually nodules, gums, and ulcers. Some disseminated variants have been associated to pyoverrucoid syndromes consisting of necrotic ulcers, erythematous nodules, and verrucous plaques with hematic crusts.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However, most cases are not easily recognized due to unusual histological and clinical manifestations for even years before the diagnosis.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> These atypical presentations may be related to the pathogenicity, virulence and infectivity of the <span class="elsevierStyleItalic">Sporothrix</span> strains, geographical factors, site of inoculation, and immunological status of the patient, among others.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,8</span></a> However, no differences between the pathogenicity and clinical setting among several species of <span class="elsevierStyleItalic">Sporothrix</span> complex have been proved.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Although the diagnosis of cutaneous sporotrichosis is basically clinical, it must be confirmed by culture. Few conditions are considered in the differential diagnosis and these include leishmaniasis, chromoblastomycosis, cutaneous tuberculosis, and chronic staphylococcal lymphangitis.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">There are worldwide reports from endemic countries concerning infrequent cutaneous presentations. Some include keratoacanthoma,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> sarcoidosis,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> arachnidism,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> chronic ulcer,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> cryptococcosis,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> mycetoma,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> moluscum,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> soft tissue tumor,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> leprosy,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> and pyoderma gangrenosum.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We could not find previous reports of disseminated sporotrichosis manifesting as nodules and tumors such as in mycosis fungoides. The similarity between these lesions and those observed in the tumoral stage of a cutaneous lymphoma may confuse the unskilled physician. However, the clinical history and histological features rule out this diagnosis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">It is assumed that the <span class="elsevierStyleItalic">Sporothrix</span> cell-wall polysaccharide fraction is responsible for its immunogenicity. After fungal antigens are processed and recognized, a TH1 response is elicited.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Interestingly, we found suppurative granulomas in these lesions, which are common among variants with preserved immunity, such as fixed and lymphangitic.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Therefore, we think that this clinical expression resembling mycosis fungoides-lesions could have been favored by an indeterminate inflammatory response. This is supported by the absence of the expected tuberculoid granuloma observed in disseminated variants, along with the chronic clinical setting, and the parasitic fungal yeasts observed in tissues.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Unfortunately, the sporotrichin test was unavailable.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Concerning treatment, a favorable outcome as that observed in this patient confirms the usefulness of itraconazole in sporotrichosis associated to immunosuppression and disseminated clinical forms.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,6</span></a> Although this case was complex, it clearly demonstrates that clinical expression is greatly determined by the immune response to the fungus. Therefore, careful attention to the individual's personal life such as this patient's occupation, his history of alcoholism and the fact that he lives in an endemic area, as well as a thoughtful interpretation of the skin biopsy and appropriate culture, should provide a correct diagnosis in similar cases.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:3 [ "identificador" => "xres536907" "titulo" => "Abstract" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Case report" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec557048" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres536906" "titulo" => "Resumen" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Caso clínico" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec557049" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-12-13" "fechaAceptado" => "2014-06-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec557048" "palabras" => array:4 [ 0 => "Sporotrichosis" 1 => "<span class="elsevierStyleItalic">Sporothrix schenckii</span>" 2 => "Itraconazole" 3 => "Mycosis fungoides" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec557049" "palabras" => array:4 [ 0 => "Esporotricosis" 1 => "<span class="elsevierStyleItalic">Sporothrix schenckii</span>" 2 => "Itraconazol" 3 => "Micosis fungoide" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sporotrichosis is a subacute or chronic mycosis acquired by traumatic inoculation or inhalation of fungal conidia. It is caused by the dimorphic fungus <span class="elsevierStyleItalic">Sporothrix</span>, which causes different clinical presentations, being the cutaneous and lymphocutaneous variants being the most frequent. The disseminated cutaneous form is a rare presentation occurring in a minority of cases in Mexico.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case report</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We report an atypical case of disseminated sporotrichosis in an alcoholic and iatrogenically immunosuppressed patient, whose clinical lesions resembled tumoral-stage mycosis fungoides. Histological examination and culture revealed the presence of <span class="elsevierStyleItalic">Sporothrix schenckii</span>.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The patient was treated with itraconazole 200<span class="elsevierStyleHsp" style=""></span>mg per day for 4 months with clinical resolution. To the best of our knowledge, this is the first report of this type of clinical manifestation.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Case report" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Antecedentes</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La esporotricosis es una micosis subaguda o crónica adquirida por inoculación traumática o inhalación de conidias fúngicas. Está causada por el hongo dimórfico <span class="elsevierStyleItalic">Sporothrix</span>, y puede presentar distintas manifestaciones clínicas, si bien las variantes linfocutánea y cutánea son las más frecuentes. La forma cutánea diseminada es una presentación infrecuente que se ha observado en una minoría de casos en México.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Caso clínico</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Informamos de un caso atípico de esporotricosis diseminada en un paciente alcohólico y con inmunosupresión iatrogénica, cuyas lesiones se asemejaban a una micosis fungoide en fase tumoral. La observación histológica y el cultivo demostraron la presencia de <span class="elsevierStyleItalic">Sporothrix schenckii</span>.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusiones</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El paciente fue tratado con 200<span class="elsevierStyleHsp" style=""></span>mg de itraconazol diarios durante 4 meses con resolución clínica. Este es el primer informe en relación con esta manifestación clínica.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Caso clínico" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 796 "Ancho" => 1501 "Tamanyo" => 249724 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Clinical images of the patient showing reddish-violaceous nodules and tumors with scales on face and scalp (left). Ill-defined violaceous plaques with ulcerations on the back (right).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 962 "Ancho" => 1500 "Tamanyo" => 359813 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Suppurative granuloma with central microabscesses composed of neutrophils surrounded by epithelioid cells, and a peripheral zone infiltrated by lymphoid and plasma cells (hematoxylin-eosin stain, 100×) (left). An oval body (4<span class="elsevierStyleHsp" style=""></span>μm in diameter) with a lighter center and darker stain at the periphery is seen, suggestive of <span class="elsevierStyleItalic">Sporothrix</span> yeast (PAS stain, 400×) (right).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1061 "Ancho" => 1500 "Tamanyo" => 234153 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Positive culture of <span class="elsevierStyleItalic">Sporothrix schenckii</span> on Sabouraud agar (left). Photomicrograph of the fungus stained with lactophenol cotton blue under light microscopy (400×). Its mycelial form is seen with typical conidiophores bearing conidia as a bouquet at the tip (right).</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 848 "Ancho" => 1500 "Tamanyo" => 234628 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Clinical pictures of the patient after being treated with itraconazole. 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| 2024 October | 71 | 8 | 79 |
| 2024 September | 83 | 10 | 93 |
| 2024 August | 60 | 4 | 64 |
| 2024 July | 70 | 9 | 79 |
| 2024 June | 105 | 8 | 113 |
| 2024 May | 122 | 8 | 130 |
| 2024 April | 87 | 11 | 98 |
| 2024 March | 100 | 8 | 108 |
| 2024 February | 115 | 12 | 127 |
| 2024 January | 129 | 15 | 144 |
| 2023 December | 123 | 7 | 130 |
| 2023 November | 186 | 4 | 190 |
| 2023 October | 144 | 8 | 152 |
| 2023 September | 83 | 4 | 87 |
| 2023 August | 55 | 5 | 60 |
| 2023 July | 78 | 7 | 85 |
| 2023 June | 79 | 7 | 86 |
| 2023 May | 150 | 5 | 155 |
| 2023 April | 123 | 6 | 129 |
| 2023 March | 112 | 17 | 129 |
| 2023 February | 103 | 15 | 118 |
| 2023 January | 110 | 14 | 124 |
| 2022 December | 88 | 25 | 113 |
| 2022 November | 94 | 13 | 107 |
| 2022 October | 67 | 18 | 85 |
| 2022 September | 61 | 15 | 76 |
| 2022 August | 81 | 28 | 109 |
| 2022 July | 77 | 14 | 91 |
| 2022 June | 60 | 15 | 75 |
| 2022 May | 65 | 16 | 81 |
| 2022 April | 70 | 12 | 82 |
| 2022 March | 98 | 18 | 116 |
| 2022 February | 110 | 14 | 124 |
| 2022 January | 155 | 15 | 170 |
| 2021 December | 94 | 14 | 108 |
| 2021 November | 83 | 12 | 95 |
| 2021 October | 121 | 14 | 135 |
| 2021 September | 102 | 16 | 118 |
| 2021 August | 89 | 12 | 101 |
| 2021 July | 72 | 8 | 80 |
| 2021 June | 120 | 12 | 132 |
| 2021 May | 153 | 14 | 167 |
| 2021 April | 242 | 42 | 284 |
| 2021 March | 157 | 20 | 177 |
| 2021 February | 125 | 7 | 132 |
| 2021 January | 108 | 20 | 128 |
| 2020 December | 95 | 16 | 111 |
| 2020 November | 83 | 21 | 104 |
| 2020 October | 72 | 9 | 81 |
| 2020 September | 60 | 71 | 131 |
| 2020 August | 71 | 78 | 149 |
| 2020 July | 65 | 31 | 96 |
| 2020 June | 58 | 23 | 81 |
| 2020 May | 68 | 22 | 90 |
| 2020 April | 58 | 12 | 70 |
| 2020 March | 84 | 26 | 110 |
| 2020 February | 66 | 21 | 87 |
| 2020 January | 77 | 13 | 90 |
| 2019 December | 90 | 18 | 108 |
| 2019 November | 43 | 21 | 64 |
| 2019 October | 45 | 9 | 54 |
| 2019 September | 81 | 15 | 96 |
| 2019 August | 39 | 0 | 39 |
| 2019 July | 59 | 13 | 72 |
| 2019 June | 112 | 27 | 139 |
| 2019 May | 229 | 21 | 250 |
| 2019 April | 117 | 26 | 143 |
| 2019 March | 25 | 11 | 36 |
| 2019 February | 68 | 5 | 73 |
| 2019 January | 38 | 6 | 44 |
| 2018 December | 75 | 4 | 79 |
| 2018 November | 47 | 9 | 56 |
| 2018 October | 59 | 28 | 87 |
| 2018 September | 80 | 8 | 88 |
| 2018 August | 68 | 4 | 72 |
| 2018 July | 45 | 3 | 48 |
| 2018 June | 41 | 8 | 49 |
| 2018 May | 70 | 1 | 71 |
| 2018 April | 51 | 1 | 52 |
| 2018 March | 48 | 4 | 52 |
| 2018 February | 35 | 1 | 36 |
| 2018 January | 28 | 3 | 31 |
| 2017 December | 22 | 5 | 27 |
| 2017 November | 38 | 9 | 47 |
| 2017 October | 18 | 2 | 20 |
| 2017 September | 23 | 10 | 33 |
| 2017 August | 26 | 5 | 31 |
| 2017 July | 26 | 7 | 33 |
| 2017 June | 27 | 6 | 33 |
| 2017 May | 50 | 3 | 53 |
| 2017 April | 36 | 5 | 41 |
| 2017 March | 144 | 27 | 171 |
| 2017 February | 69 | 0 | 69 |
| 2017 January | 60 | 10 | 70 |
| 2016 December | 70 | 7 | 77 |
| 2016 November | 108 | 6 | 114 |
| 2016 October | 89 | 13 | 102 |
| 2016 September | 49 | 4 | 53 |
| 2016 August | 51 | 2 | 53 |
| 2016 July | 49 | 4 | 53 |
| 2016 February | 1 | 0 | 1 |
| 2015 October | 3 | 2 | 5 |
| 2015 September | 0 | 1 | 1 |
| 2015 August | 1 | 1 | 2 |
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