Eccema dishidrótico tras el tratamiento con inmunoglobulinas intravenosas | Piel. Formación continuada en dermatología

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Inicialmente utilizadas en inmunodeficiencias, en la actualidad se usan en una amplia variedad de enfermedades neurológicas, dermatológicas y autoinmunes<a class="elsevierStyleCrossRefs" href="#bib0145">1–4</a>. Las reacciones adversas cutáneas secundarias a su uso son poco frecuentes y generalmente no comprometen la vida del paciente, sin embargo, es importante hacer un buen reconocimiento de las mismas.Pacientes y revisión sistemática de la literaturaSe recogen 3 pacientes remitidos desde el servicio de neurología de nuestro centro por lesiones cutáneas compatibles clínicamente con eccema dishidrótico tras el uso de inmunoglobulinas intravenosas (<a class="elsevierStyleCrossRef" href="#fig0005">fig. 1</a>), que fueron confirmadas mediante el estudio histológico (<a class="elsevierStyleCrossRef" href="#fig0010">fig. 2</a>). A partir de estos casos se realizó una búsqueda bibliográfica en la base de datos Pubmed mediante los términos dyshidrotic eczema intravenous inmunoglobulin, pompholyx intravenous inmunoglobulin, eczema intravenous inmunoglobulin y cutaneous adverse effects intravenous inmunoglobulins, seleccionando aquellos artículos en inglés o castellano y que describieran lesiones eccematosas o dishidróticas tras el uso de inmunoglobulinas intravenosas. De cada uno de los artículos seleccionados se extrajo la siguiente información: edad y sexo de los pacientes, motivo de indicación de inmunoglobulinas intravenosas, dosis, número de dosis y marca comercial de la inmunoglobulina, número de dosis recibidas y días desde la última dosis de inmunoglobulina hasta la aparición de lesiones cutáneas, antecedentes de ciclos previos de tratamiento con inmunoglobulinas intravenosas, tipo de lesiones cutáneas y su localización y el tratamiento que se estableció para las lesiones cutáneas.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>En la revisión de la literatura (<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>)<a class="elsevierStyleCrossRefs" href="#bib0150">2–26</a> se recogen 63 pacientes (60 casos publicados y los 3 casos descritos en nuestro centro), 60 adultos con edades comprendidas entre los 20 y 78 años y 3 niños de 5, 7 y 10 años. Las enfermedades neurológicas fueron el principal motivo de indicar inmunoglobulinas intravenosas (88,9%), seguido de las dermatológicas (6,3%). En este segundo grupo se indicó el tratamiento con inmunoglobulinas intravenosas a 2 pacientes con síndrome de Stevens-Johnson y a 2 con urticaria crónica. La pauta de inmunoglobulinas intravenosas más utilizada fueron 5 dosis de 0,4g/kg/día (47,6%), y estos ciclos de 5 dosis se podían repetir a lo largo de varios meses. En la mayoría de los pacientes el número de dosis que recibieron antes de la aparición de lesiones cutáneas dishidróticas y/o eccematosas fue menor o igual a 5 dosis (52 pacientes, 82,5%) con una latencia en días desde la última dosis de inmunoglobulinas intravenosas en casi 2/3 de pacientes menor o igual a 7 días (46 pacientes, 73%).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>La localización más frecuente de las lesiones dishidróticas y/o eccematosas fue en las manos (33,3%) seguido de las manos y los pies (30,2%). En 10 pacientes (15,9%) la presentación inicial fueron lesiones generalizadas o eritrodermia, mientras que en 6 pacientes (9,5%) las lesiones comenzaron de forma localizada con posterior generalización. Hasta en un 38,1% de los casos (24 pacientes) no se describió el tratamiento recibido para las lesiones cutáneas secundarias, mientras que el tratamiento pautado más frecuente fueron los corticoides tópicos (21 pacientes, 33,3%).DiscusiónA pesar de que cada vez está más extendido el uso de las inmunoglobulinas intravenosas, sobre todo en aquellas enfermedades en las que se sospecha de mecanismos autoinmunitarios en su fisiopatología, su mecanismo de acción no está del todo aclarado. Se postula que actúan bloqueando los receptores Fc de los macrófagos, inhibiendo los linfocitos T y B, neutralizando autoanticuerpos y otras citocinas inflamatorias<a class="elsevierStyleCrossRef" href="#bib0275">27</a>. La incidencia de reacciones adversas de las inmunoglobulinas intravenosas varía significativamente entre un estudio y otro, oscilando entre un 1% a un 81%. Las reacciones adversas durante la infusión suelen ser cuadros pseudogripales (cefalea, fiebre, mialgias…) y menos frecuentemente aparecen cuadros anafilácticos, que pueden ser prevenidos en parte si se descarta un déficit de IgA. Los efectos secundarios a largo plazo incluyen los fenómenos tromboembólicos, el fallo renal agudo y las lesiones cutáneas. Se considera en general una terapia segura, sobre todo si se evita su uso en pacientes de alto riesgo (como son el antecedente de troboembolismo o insuficiencia renal previa), si se administra de forma lenta y si se hidrata correctamente al paciente<a class="elsevierStyleCrossRef" href="#bib0280">28</a>.Las lesiones cutáneas suelen aparecer entre los 4 y 12 días tras el inicio del tratamiento, datos que son consistentes con los obtenidos en esta revisión bibliográfica. Suele tener un curso agudo con aparición de lesiones dishidróticas o de aspecto eccematoso, sobre todo en las manos y en la cara, aunque hay descritas formas generalizadas que no suelen acompañarse de clínica sistémica. Estos datos son similares a los descritos en nuestra revisión, siendo la localización más frecuente en las manos, seguida de manos y pies. Se desconoce el mecanismo por el que ocurre, aunque se sospecha como principal responsable un componente de la IgG, ya que se han observado este tipo de reacciones con diferentes marcas comerciales que contienen diferentes excipientes<a class="elsevierStyleCrossRefs" href="#bib0150">2–26</a>. Dado que las lesiones cutáneas suelen ser leves y mejoran con tratamientos convencionales, no es necesaria la suspensión del tratamiento siempre y cuando suponga un beneficio para la enfermedad de base<a class="elsevierStyleCrossRef" href="#bib0145">1</a>. Además, parece que no supone un mayor riesgo de desarrollar una dermatitis atópica ni otro tipo de dermatitis eccematosa en el futuro, aunque las lesiones cutáneas pueden recidivar tras siguientes dosis de inmunoglobulinas intravenosas<a class="elsevierStyleCrossRef" href="#bib0150">2</a>. En las recurrencias las lesiones cutáneas pueden aparecer con una latencia menor, ser más extensas y prolongarse más en el tiempo<a class="elsevierStyleCrossRefs" href="#bib0150">2,3</a>. Esto sugiere la participación de la memoria inmunológica y probablemente un mecanismo de hipersensibilidad en el que las inmunoglobulinas actuarían como superantígenos de ciertos linfocitos B, lo que desencadenaría su activación<a class="elsevierStyleCrossRef" href="#bib0275">27</a>. El diagnóstico generalmente es clínico, aunque en ocasiones puede ser necesario recurrir a un estudio histológico de las lesiones cutáneas, o serológico, para descartar infecciones virales como posibles causantes como son el parvovirus, el micoplasma, el virus de Epstein-Barr y el citomegalovirus.En resumen, se presentan 3 casos de eccema dishidrótico tras el uso de inmunoglobulinas intravenosas y se realiza una revisión bibliográfica que recoge 63 pacientes. Se trata de una reacción adversa poco frecuente, que generalmente no condiciona la suspensión del tratamiento, pero que es necesario su reconocimiento para recomendar un tratamiento adecuado.Responsabilidades éticasProtección de personas y animalesLos autores declaran que para esta investigación no se han realizado experimentos en seres humanos ni en animales.Confidencialidad de los datosLos autores declaran que han seguido los protocolos de su centro de trabajo sobre la publicación de datos de pacientes.Derecho a la privacidad y consentimiento informadoLos autores declaran que en este artículo no aparecen datos de pacientes.Conflicto de interesesLos autores declaran no tener ningún conflicto de intereses." 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entry_with_role_rowhead " align="left" valign="top">Hombres \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23 (36,5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mujeres \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (17,5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No reportado \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29 (46) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Indicación</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neurológicas \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56 (88,9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hematológicas (púrpura trombocitopénica idiopática) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1,6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oftalmológicas (retinocoroidopatía en perdigonada) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1,6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vasculitis (enfermedad de Kawasaki) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1,6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dermatológicas \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (6,3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Síndrome de Stevens-Johnson \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (3,2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urticaria crónica \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (3,2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Dosis (n.° de dosis previstas×dosis diaria)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5×0,4/kg/día \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 (47,6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4×0,4/kg/día \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1,6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3×0,4/kg/día \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1,6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0,4/kg/día \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (3,2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3×1g/kg/día \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1,6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2×1g/kg/día \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (25,4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1×1g/kg/día \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1,6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1×2g/kg/día \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (4,8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6×30mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1,6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5×40mg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1,6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5×400mg/kg/día \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1,6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4×0,5g/kg/día \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1,6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No reportado \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (6,3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Número de dosis de inmunoglobulinas antes de la aparición de las lesiones cutáneas</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">≤5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52 (82,5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6-10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (3,2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No reportado \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (14,3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Latencia en días desde la última dosis de inmunoglobulinas hasta la aparición de las lesiones cutáneas</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">≤7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">46 (73) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">>7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 (9,5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No reportado \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (17,5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Antecedentes de infusiones previas de inmunoglobulinas</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 (11,1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43 (68,3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No reportado \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 (20,6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Localización de las lesiones dishidróticas±eccematosas</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Manos \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 (33,3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Manos+pies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19 (30,2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Manos+otras localizaciones (cara, tronco o extremidades) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (12,7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Otras localizaciones (tronco, extremidades) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1,6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Inicio generalizado o eritrodermia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (15,9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Inicialmente localizado con evolución a eritrodermia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 (9,5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No reportado \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (6,3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Tratamiento de las lesiones cutáneas</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Corticoides tópicos \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 (33,3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Corticoides sistémicos \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 (9,5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Corticoides tópicos+sistémicos \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (1,6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ninguno \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (17,5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No reportado \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 (38,1) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1708655.png" ] ] ] ] "descripcion" => array:1 [ "es" => "Reacciones cutáneas en pacientes tratados con imunoglobulinas intravenosas. 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La piel en el contexto de la medicina y sus especialidades

Eccema dishidrótico tras el tratamiento con inmunoglobulinas intravenosas

Pompholyx after intravenous immunoglobulin therapy

Hirune Cembrero-Saraleguia,

Autor para correspondencia

hirunecembrero@gmail.com

Autor para correspondencia.

, Marta Martínez Garcíaa, Carlos Alberto Cemillán Fernándezb

a Servicio de Dermatología, Hospital Universitario Severo Ochoa, Leganés, Madrid, España

b Servicio de Neurología, Hospital Universitario Severo Ochoa, Leganés, Madrid, España

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">El uso de inmunoglobulinas intravenosas en la pr&#225;ctica cl&#237;nica se ha extendido en los &#250;ltimos a&#241;os&#46; Inicialmente utilizadas en inmunodeficiencias&#44; en la actualidad se usan en una amplia variedad de enfermedades neurol&#243;gicas&#44; dermatol&#243;gicas y autoinmunes<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1&#8211;4</span></a>&#46; Las reacciones adversas cut&#225;neas secundarias a su uso son poco frecuentes y generalmente no comprometen la vida del paciente&#44; sin embargo&#44; es importante hacer un buen reconocimiento de las mismas&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Pacientes y revisi&#243;n sistem&#225;tica de la literatura</span><p id="par0010" class="elsevierStylePara elsevierViewall">Se recogen 3 pacientes remitidos desde el servicio de neurolog&#237;a de nuestro centro por lesiones cut&#225;neas compatibles cl&#237;nicamente con eccema dishidr&#243;tico tras el uso de inmunoglobulinas intravenosas &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#44; que fueron confirmadas mediante el estudio histol&#243;gico &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46; A partir de estos casos se realiz&#243; una b&#250;squeda bibliogr&#225;fica en la base de datos Pubmed mediante los t&#233;rminos <span class="elsevierStyleItalic">dyshidrotic eczema intravenous inmunoglobulin</span>&#44; <span class="elsevierStyleItalic">pompholyx intravenous inmunoglobulin</span>&#44; <span class="elsevierStyleItalic">eczema intravenous inmunoglobulin</span> y <span class="elsevierStyleItalic">cutaneous adverse effects intravenous inmunoglobulins</span>&#44; seleccionando aquellos art&#237;culos en ingl&#233;s o castellano y que describieran lesiones eccematosas o dishidr&#243;ticas tras el uso de inmunoglobulinas intravenosas&#46; De cada uno de los art&#237;culos seleccionados se extrajo la siguiente informaci&#243;n&#58; edad y sexo de los pacientes&#44; motivo de indicaci&#243;n de inmunoglobulinas intravenosas&#44; dosis&#44; n&#250;mero de dosis y marca comercial de la inmunoglobulina&#44; n&#250;mero de dosis recibidas y d&#237;as desde la &#250;ltima dosis de inmunoglobulina hasta la aparici&#243;n de lesiones cut&#225;neas&#44; antecedentes de ciclos previos de tratamiento con inmunoglobulinas intravenosas&#44; tipo de lesiones cut&#225;neas y su localizaci&#243;n y el tratamiento que se estableci&#243; para las lesiones cut&#225;neas&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">En la revisi&#243;n de la literatura &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">2&#8211;26</span></a> se recogen 63 pacientes &#40;60 casos publicados y los 3 casos descritos en nuestro centro&#41;&#44; 60 adultos con edades comprendidas entre los 20 y 78 a&#241;os y 3 ni&#241;os de 5&#44; 7 y 10 a&#241;os&#46; Las enfermedades neurol&#243;gicas fueron el principal motivo de indicar inmunoglobulinas intravenosas &#40;88&#44;9&#37;&#41;&#44; seguido de las dermatol&#243;gicas &#40;6&#44;3&#37;&#41;&#46; En este segundo grupo se indic&#243; el tratamiento con inmunoglobulinas intravenosas a 2 pacientes con s&#237;ndrome de Stevens-Johnson y a 2 con urticaria cr&#243;nica&#46; La pauta de inmunoglobulinas intravenosas m&#225;s utilizada fueron 5 dosis de 0&#44;4<span class="elsevierStyleHsp" style=""></span>g&#47;kg&#47;d&#237;a &#40;47&#44;6&#37;&#41;&#44; y estos ciclos de 5 dosis se pod&#237;an repetir a lo largo de varios meses&#46; En la mayor&#237;a de los pacientes el n&#250;mero de dosis que recibieron antes de la aparici&#243;n de lesiones cut&#225;neas dishidr&#243;ticas y&#47;o eccematosas fue menor o igual a 5 dosis &#40;52 pacientes&#44; 82&#44;5&#37;&#41; con una latencia en d&#237;as desde la &#250;ltima dosis de inmunoglobulinas intravenosas en casi 2&#47;3 de pacientes menor o igual a 7 d&#237;as &#40;46 pacientes&#44; 73&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">La localizaci&#243;n m&#225;s frecuente de las lesiones dishidr&#243;ticas y&#47;o eccematosas fue en las manos &#40;33&#44;3&#37;&#41; seguido de las manos y los pies &#40;30&#44;2&#37;&#41;&#46; En 10 pacientes &#40;15&#44;9&#37;&#41; la presentaci&#243;n inicial fueron lesiones generalizadas o eritrodermia&#44; mientras que en 6 pacientes &#40;9&#44;5&#37;&#41; las lesiones comenzaron de forma localizada con posterior generalizaci&#243;n&#46; Hasta en un 38&#44;1&#37; de los casos &#40;24 pacientes&#41; no se describi&#243; el tratamiento recibido para las lesiones cut&#225;neas secundarias&#44; mientras que el tratamiento pautado m&#225;s frecuente fueron los corticoides t&#243;picos &#40;21 pacientes&#44; 33&#44;3&#37;&#41;&#46;</p></span></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discusi&#243;n</span><p id="par0025" class="elsevierStylePara elsevierViewall">A pesar de que cada vez est&#225; m&#225;s extendido el uso de las inmunoglobulinas intravenosas&#44; sobre todo en aquellas enfermedades en las que se sospecha de mecanismos autoinmunitarios en su fisiopatolog&#237;a&#44; su mecanismo de acci&#243;n no est&#225; del todo aclarado&#46; Se postula que act&#250;an bloqueando los receptores Fc de los macr&#243;fagos&#44; inhibiendo los linfocitos T y B&#44; neutralizando autoanticuerpos y otras citocinas inflamatorias<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">27</span></a>&#46; La incidencia de reacciones adversas de las inmunoglobulinas intravenosas var&#237;a significativamente entre un estudio y otro&#44; oscilando entre un 1&#37; a un 81&#37;&#46; Las reacciones adversas durante la infusi&#243;n suelen ser cuadros pseudogripales &#40;cefalea&#44; fiebre&#44; mialgias&#8230;&#41; y menos frecuentemente aparecen cuadros anafil&#225;cticos&#44; que pueden ser prevenidos en parte si se descarta un d&#233;ficit de IgA&#46; Los efectos secundarios a largo plazo incluyen los fen&#243;menos tromboemb&#243;licos&#44; el fallo renal agudo y las lesiones cut&#225;neas&#46; Se considera en general una terapia segura&#44; sobre todo si se evita su uso en pacientes de alto riesgo &#40;como son el antecedente de troboembolismo o insuficiencia renal previa&#41;&#44; si se administra de forma lenta y si se hidrata correctamente al paciente<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">28</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Las lesiones cut&#225;neas suelen aparecer entre los 4 y 12 d&#237;as tras el inicio del tratamiento&#44; datos que son consistentes con los obtenidos en esta revisi&#243;n bibliogr&#225;fica&#46; Suele tener un curso agudo con aparici&#243;n de lesiones dishidr&#243;ticas o de aspecto eccematoso&#44; sobre todo en las manos y en la cara&#44; aunque hay descritas formas generalizadas que no suelen acompa&#241;arse de cl&#237;nica sist&#233;mica&#46; Estos datos son similares a los descritos en nuestra revisi&#243;n&#44; siendo la localizaci&#243;n m&#225;s frecuente en las manos&#44; seguida de manos y pies&#46; Se desconoce el mecanismo por el que ocurre&#44; aunque se sospecha como principal responsable un componente de la IgG&#44; ya que se han observado este tipo de reacciones con diferentes marcas comerciales que contienen diferentes excipientes<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">2&#8211;26</span></a>&#46; Dado que las lesiones cut&#225;neas suelen ser leves y mejoran con tratamientos convencionales&#44; no es necesaria la suspensi&#243;n del tratamiento siempre y cuando suponga un beneficio para la enfermedad de base<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">1</span></a>&#46; Adem&#225;s&#44; parece que no supone un mayor riesgo de desarrollar una dermatitis at&#243;pica ni otro tipo de dermatitis eccematosa en el futuro&#44; aunque las lesiones cut&#225;neas pueden recidivar tras siguientes dosis de inmunoglobulinas intravenosas<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">2</span></a>&#46; En las recurrencias las lesiones cut&#225;neas pueden aparecer con una latencia menor&#44; ser m&#225;s extensas y prolongarse m&#225;s en el tiempo<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">2&#44;3</span></a>&#46; Esto sugiere la participaci&#243;n de la memoria inmunol&#243;gica y probablemente un mecanismo de hipersensibilidad en el que las inmunoglobulinas actuar&#237;an como superant&#237;genos de ciertos linfocitos B&#44; lo que desencadenar&#237;a su activaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">27</span></a>&#46; El diagn&#243;stico generalmente es cl&#237;nico&#44; aunque en ocasiones puede ser necesario recurrir a un estudio histol&#243;gico de las lesiones cut&#225;neas&#44; o serol&#243;gico&#44; para descartar infecciones virales como posibles causantes como son el parvovirus&#44; el micoplasma&#44; el virus de Epstein-Barr y el citomegalovirus&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">En resumen&#44; 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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">No reportado</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29 &#40;46&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Indicaci&#243;n</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Neurol&#243;gicas</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56 &#40;88&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Hematol&#243;gicas &#40;p&#250;rpura trombocitop&#233;nica idiop&#225;tica&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Oftalmol&#243;gicas &#40;retinocoroidopat&#237;a en perdigonada&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Vasculitis &#40;enfermedad de Kawasaki&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Dermatol&#243;gicas</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;6&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>S&#237;ndrome de Stevens-Johnson&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;3&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Urticaria cr&#243;nica&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;3&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Dosis &#40;n&#46;&#176; de dosis previstas</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">&#215;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">dosis diaria&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">5</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">&#215;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">0&#44;4&#47;kg&#47;d&#237;a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30 &#40;47&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">4</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">&#215;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">0&#44;4&#47;kg&#47;d&#237;a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">3</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">&#215;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">0&#44;4&#47;kg&#47;d&#237;a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">0&#44;4&#47;kg&#47;d&#237;a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;3&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">3</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">&#215;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">g&#47;kg&#47;d&#237;a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">2</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">&#215;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">g&#47;kg&#47;d&#237;a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 &#40;25&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">&#215;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">g&#47;kg&#47;d&#237;a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">&#215;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">2</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">g&#47;kg&#47;d&#237;a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;4&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">6</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">&#215;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">30</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mg</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">5</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">&#215;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">40</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mg</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">5</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">&#215;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">400</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mg&#47;kg&#47;d&#237;a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">4</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">&#215;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">0&#44;5</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">g&#47;kg&#47;d&#237;a</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">No reportado</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;6&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">N&#250;mero de dosis de inmunoglobulinas antes de la aparici&#243;n de las lesiones cut&#225;neas</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8804;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">5</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52 &#40;82&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">6-10</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;3&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">No reportado</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;14&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Latencia en d&#237;as desde la &#250;ltima dosis de inmunoglobulinas hasta la aparici&#243;n de las lesiones cut&#225;neas</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#8804;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">7</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46 &#40;73&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#62;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">7</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 &#40;9&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">No reportado</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11 &#40;17&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Antecedentes de infusiones previas de inmunoglobulinas</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">S&#237;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;11&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">No</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43 &#40;68&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">No reportado</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13 &#40;20&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Localizaci&#243;n de las lesiones dishidr&#243;ticas</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">eccematosas</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Manos</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21 &#40;33&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Manos</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#43;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">pies</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19 &#40;30&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Manos</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#43;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">otras localizaciones &#40;cara&#44; tronco o extremidades&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;12&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Otras localizaciones &#40;tronco&#44; extremidades&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;1&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Inicio generalizado o eritrodermia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;15&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Inicialmente localizado con evoluci&#243;n a eritrodermia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 &#40;9&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">No reportado</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;6&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
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          "es" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Reacciones cut&#225;neas en pacientes tratados con imunoglobulinas intravenosas&#46; Datos obtenidos de la revisi&#243;n de la literatura incluyendo los 3 pacientes de nuestra serie</p>"
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                          "etal" => false
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Información del artículo

ISSN: 02139251
Idioma original: Español

DOI:10.1016/j.piel.2017.07.003

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