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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Nephrogenic systemic fibrosis &#40;NSF&#41; is a rare fibrosing disorder was first described in renally impaired patients as a scleromyxedema-like disorder in 2000 by Cowper et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> It is characterized by progressive diffuse fibrotic changes of the skin bilaterally and symmetrically on the extremities&#44; and occasionally on the trunk&#46; Ninety-five percent of NSF cases are associated with exposure to gadolinium-based contrast agents in renal dialysis patients&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Calciphylaxis is seen generally in patients with kidney failure and presents with livedo racemosa&#44; indurated plaques&#44; hemorrhagic bullae&#44; skin ulcers&#44; and necrosis located mostly on abdomen&#44; breasts&#44; buttocks and extremities&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Association of these two rare entities was published in three cases in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe the case of a 44-year-old female with bilateral painful&#44; erythematous swellings and thickening of abdominal skin for three weeks&#46; She had suffered from hypertension&#44; diabetes&#44; asthma&#44; and hypothyroidism for 10 years and end-stage renal disease &#40;ESRD&#41; for 5 years&#46; She was a hemodialysis patient for one week&#46; She had been using doxazosin and furosemide for hypertension&#44; subcutaneous insulin for diabetes&#44; inhaler steroid for asthma&#44; levothyroxine for hypothyroidism&#44; antacid and calcium containing antiphosphate for ESRD&#44; and subcutaneous erythropoietin for anemia for years&#46; She was obese with mass index &#40;BMI&#41; 51<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#46; She had no history of magnetic resonance imaging &#40;MRI&#41;&#46; On dermatologic examination&#44; violaceous and painful plaque-like subcutaneous nodules surrounded by livedo reticularis-like patches were observed on the legs&#44; and some of them progressed to necrotic features&#46; She also had infraumblical sclerotic subcutaneous nodules and peau d&#8217;orange appearence &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a&#8211;c&#41;&#46; Histopathologic examination of crural lesions revealed dermal and subcutaneous arteriolar calcification and narrowing of the vascular lumen in subcutaneous tissue&#46; Histopathologic examination of umblical lesion showed a dense spindle cell proliferation&#44; focal sclerosis&#44; thick collagen bundles in the dermis&#44; significant fibrous thickening of the septa in subcutaneous tissue and subcutaneous arteriolar calcification&#46; On immunohistochemical analysis CD34 and Factor 13 positivity were seen&#44; but CD68 was negative &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>a&#8211;d&#41;&#46; The histopathological examination and clinical findings were compatible with calciphylaxis on the extremites&#44; and NSF and calciphylaxis on the trunk&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Laboratory tests were as follows&#59; hemoglobin&#58; 10&#46;0<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; erythrocyte sedimentation rate &#40;ESR&#41;&#58; 79<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#44; creatinin 5&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#44; parathormone &#40;PTH&#41;&#58; 564<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#44; phosphor &#40;P&#41;&#58; 7&#46;3<span class="elsevierStyleHsp" style=""></span>mEq&#47;L and Calcium &#40;Ca&#41;&#58; 7&#46;8<span class="elsevierStyleHsp" style=""></span>mEq&#47;L&#46; Vasculitis was ruled out with laboratory findings &#40;complement factors &#40;C3&#44; C4&#41;&#44; rheumatoid factor &#40;RF&#41;&#44; antineutrophilic cytoplasmic antibodies &#40;ANCAs&#41;&#44; anticardiolipin antibodies&#44; cryoglobulin&#44; cryofibrinogen&#41;&#44; except mild antinuclear antibody positivity &#40;ANA&#58; 1&#47;160 with cytoplasmic pattern&#41;&#46; Serum protein electrophoresis was normal&#46; Pulmonary X-rays and echocardiography were normal&#46; Computerized tomography &#40;CT&#41; and scintigraphy could not be performed because of the high BMI&#46; She had no systemic involvement for NSF&#46; Plain X-rays of the extremities showed vascular calcification&#44; but doppler ultrasonography was normal&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient received hemodialysis treatment with a low calcium dialysate and discontinue a calcium-containing antiphosphate medication&#46; For wound management wet dressing and topical antibiotics were used and morphine-like medications were used for analgesia&#46; Since hypocalcemia was a possibility&#44; sevelamer was not appropriate for the patient&#46; Cinacalcet and sodium thiosulfate were not availible&#46; Hyperbaric oxygen therapy was contraindicated due to asthma&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">NSF and calciphylaxis are rare diseases typically seen in chronic renal failure&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> In literature 95&#37; of NSF cases were associated with exposure to gadolinium-based contrast agents&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> In our case there was no history of MRI prior to skin lesions&#44; but she had been using erythropoietin &#40;EPO&#41; for some years&#46; There were several cases in literature of NSF without gadolinium contrast exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> However it&#39;s mentioned that EPO may be associated with NSF&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> The typical clinical feature of NSF is diffuse fibrotic skin changes&#44; but Deng et al&#46; documented a case of NSF localized on one antecubital region because of infusion of EPO&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> The lesions of our case were seen in infraumblical region with localized sclerotic subcutaneous nodules and peau d&#8217;orange appearance without systemic involvement&#44; but this area was not correlated with the insulin or EPO exposure sites&#46; Risk factors for the disease are female gender&#44; diabetes mellitus&#44; obesity&#44; malnutrition&#44; using of warfarin&#44; calcium-containing antiphosphate medication and Vitamin D&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> The risk factors for our case are obesity&#44; female gender&#44; diabetes mellitus and calcium-containing antiphosphate medication&#46; Halasz et al&#46; mentioned recently that the diagnosis of calciphylaxis may be done by radiologic techniques such as direct radiography&#44; mammography or CT prior to receiving histopathological results&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> Radiography of the extremities in our case showed linear vascular calcification&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Coexistence of these two rare entities- NSF and calciphylaxis- was published in three cases in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;5</span></a> Edsall et al&#46; documented a report of two cases who were clinically typical of NSF with evident vascular calcification on skin biopsy like calciphylaxis&#44; but had no clinical features of calciphylaxis&#46; They mentioned NSF may be a predisposing factor for calciphylaxis in early stages&#44; or calcification may play a role in the pathophysiology of NSF&#46; They also thought fibrosis and calcification in kidney failure may be the result of increased activity of transforming growth factor-b&#47;Smad signaling cascades&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> Lewis et al&#46; reported a case of NSF and calciphylaxis with pseudoxanthoma elasticum-like changes in the same localization&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> In our case the infraumblical-localized lesion of our patient revealed the diagnosis of NSF with vascular calcification-like calciphylaxis&#46; By describing this case we want to emphasize that&#44; although microscopic calcification has been reported in the skin biopsies of NSF&#44; coexistence of the calciphylaxis and nephrogenic systemic fibrosis with different localizations may be seen&#46; To the best of our knowledge this is the first case of coexistence of the calciphylaxis and nephrogenic systemic fibrosis with different localizations in a hemodialysis patient&#46; This situation may be explained with consociate etiological origin&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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Letter to the Editor
The first case of coexistence of calciphylaxis and nephrogenic systemic fibrosis with different localizations in a hemodialysis patient
El primer caso de coexistencia de calcifilaxis y fibrosis sistémica nefrogénica con diferentes localizaciones en un paciente en hemodiálisis
Muge Gore Karaalia,
Autor para correspondencia
mugegore@hotmail.com

Corresponding author.
, Vefa Aslı Turgut Erdemirb, Cem Leblebicic, Ozan Erdema, Asude Kara Polata, Mehmet Salih Gurelb
a Department of Dermatology, Istanbul Training and Research Hospital, Istanbul, Turkey
b Department of Dermatology, Medeniyet University, Faculty of Medicine, Istanbul, Turkey
c Department of Pathology, Istanbul Training and Research Hospital, Istanbul, Turkey
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        "titulo" => "El primer caso de coexistencia de calcifilaxis y fibrosis sist&#233;mica nefrog&#233;nica con diferentes localizaciones en un paciente en hemodi&#225;lisis"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Dermatologic examination&#46; &#40;a&#44; b&#41; Violaceous&#44; plaque-like subcutaneous nodules surrounded by livedo reticularis-like patches and necrotic ulcerations on legs&#46; &#40;c&#41; Sclerotic subcutaneous nodules and peau d&#8217;orange appearance on infraumblical region&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Nephrogenic systemic fibrosis &#40;NSF&#41; is a rare fibrosing disorder was first described in renally impaired patients as a scleromyxedema-like disorder in 2000 by Cowper et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> It is characterized by progressive diffuse fibrotic changes of the skin bilaterally and symmetrically on the extremities&#44; and occasionally on the trunk&#46; Ninety-five percent of NSF cases are associated with exposure to gadolinium-based contrast agents in renal dialysis patients&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Calciphylaxis is seen generally in patients with kidney failure and presents with livedo racemosa&#44; indurated plaques&#44; hemorrhagic bullae&#44; skin ulcers&#44; and necrosis located mostly on abdomen&#44; breasts&#44; buttocks and extremities&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Association of these two rare entities was published in three cases in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe the case of a 44-year-old female with bilateral painful&#44; erythematous swellings and thickening of abdominal skin for three weeks&#46; She had suffered from hypertension&#44; diabetes&#44; asthma&#44; and hypothyroidism for 10 years and end-stage renal disease &#40;ESRD&#41; for 5 years&#46; She was a hemodialysis patient for one week&#46; She had been using doxazosin and furosemide for hypertension&#44; subcutaneous insulin for diabetes&#44; inhaler steroid for asthma&#44; levothyroxine for hypothyroidism&#44; antacid and calcium containing antiphosphate for ESRD&#44; and subcutaneous erythropoietin for anemia for years&#46; She was obese with mass index &#40;BMI&#41; 51<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#46; She had no history of magnetic resonance imaging &#40;MRI&#41;&#46; On dermatologic examination&#44; violaceous and painful plaque-like subcutaneous nodules surrounded by livedo reticularis-like patches were observed on the legs&#44; and some of them progressed to necrotic features&#46; She also had infraumblical sclerotic subcutaneous nodules and peau d&#8217;orange appearence &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a&#8211;c&#41;&#46; Histopathologic examination of crural lesions revealed dermal and subcutaneous arteriolar calcification and narrowing of the vascular lumen in subcutaneous tissue&#46; Histopathologic examination of umblical lesion showed a dense spindle cell proliferation&#44; focal sclerosis&#44; thick collagen bundles in the dermis&#44; significant fibrous thickening of the septa in subcutaneous tissue and subcutaneous arteriolar calcification&#46; On immunohistochemical analysis CD34 and Factor 13 positivity were seen&#44; but CD68 was negative &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>a&#8211;d&#41;&#46; The histopathological examination and clinical findings were compatible with calciphylaxis on the extremites&#44; and NSF and calciphylaxis on the trunk&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Laboratory tests were as follows&#59; hemoglobin&#58; 10&#46;0<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; erythrocyte sedimentation rate &#40;ESR&#41;&#58; 79<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#44; creatinin 5&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#44; parathormone &#40;PTH&#41;&#58; 564<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#44; phosphor &#40;P&#41;&#58; 7&#46;3<span class="elsevierStyleHsp" style=""></span>mEq&#47;L and Calcium &#40;Ca&#41;&#58; 7&#46;8<span class="elsevierStyleHsp" style=""></span>mEq&#47;L&#46; Vasculitis was ruled out with laboratory findings &#40;complement factors &#40;C3&#44; C4&#41;&#44; rheumatoid factor &#40;RF&#41;&#44; antineutrophilic cytoplasmic antibodies &#40;ANCAs&#41;&#44; anticardiolipin antibodies&#44; cryoglobulin&#44; cryofibrinogen&#41;&#44; except mild antinuclear antibody positivity &#40;ANA&#58; 1&#47;160 with cytoplasmic pattern&#41;&#46; Serum protein electrophoresis was normal&#46; Pulmonary X-rays and echocardiography were normal&#46; Computerized tomography &#40;CT&#41; and scintigraphy could not be performed because of the high BMI&#46; She had no systemic involvement for NSF&#46; Plain X-rays of the extremities showed vascular calcification&#44; but doppler ultrasonography was normal&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient received hemodialysis treatment with a low calcium dialysate and discontinue a calcium-containing antiphosphate medication&#46; For wound management wet dressing and topical antibiotics were used and morphine-like medications were used for analgesia&#46; Since hypocalcemia was a possibility&#44; sevelamer was not appropriate for the patient&#46; Cinacalcet and sodium thiosulfate were not availible&#46; Hyperbaric oxygen therapy was contraindicated due to asthma&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">NSF and calciphylaxis are rare diseases typically seen in chronic renal failure&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> In literature 95&#37; of NSF cases were associated with exposure to gadolinium-based contrast agents&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> In our case there was no history of MRI prior to skin lesions&#44; but she had been using erythropoietin &#40;EPO&#41; for some years&#46; There were several cases in literature of NSF without gadolinium contrast exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> However it&#39;s mentioned that EPO may be associated with NSF&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> The typical clinical feature of NSF is diffuse fibrotic skin changes&#44; but Deng et al&#46; documented a case of NSF localized on one antecubital region because of infusion of EPO&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> The lesions of our case were seen in infraumblical region with localized sclerotic subcutaneous nodules and peau d&#8217;orange appearance without systemic involvement&#44; but this area was not correlated with the insulin or EPO exposure sites&#46; Risk factors for the disease are female gender&#44; diabetes mellitus&#44; obesity&#44; malnutrition&#44; using of warfarin&#44; calcium-containing antiphosphate medication and Vitamin D&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> The risk factors for our case are obesity&#44; female gender&#44; diabetes mellitus and calcium-containing antiphosphate medication&#46; Halasz et al&#46; mentioned recently that the diagnosis of calciphylaxis may be done by radiologic techniques such as direct radiography&#44; mammography or CT prior to receiving histopathological results&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> Radiography of the extremities in our case showed linear vascular calcification&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Coexistence of these two rare entities- NSF and calciphylaxis- was published in three cases in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;5</span></a> Edsall et al&#46; documented a report of two cases who were clinically typical of NSF with evident vascular calcification on skin biopsy like calciphylaxis&#44; but had no clinical features of calciphylaxis&#46; They mentioned NSF may be a predisposing factor for calciphylaxis in early stages&#44; or calcification may play a role in the pathophysiology of NSF&#46; They also thought fibrosis and calcification in kidney failure may be the result of increased activity of transforming growth factor-b&#47;Smad signaling cascades&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> Lewis et al&#46; reported a case of NSF and calciphylaxis with pseudoxanthoma elasticum-like changes in the same localization&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> In our case the infraumblical-localized lesion of our patient revealed the diagnosis of NSF with vascular calcification-like calciphylaxis&#46; By describing this case we want to emphasize that&#44; although microscopic calcification has been reported in the skin biopsies of NSF&#44; coexistence of the calciphylaxis and nephrogenic systemic fibrosis with different localizations may be seen&#46; To the best of our knowledge this is the first case of coexistence of the calciphylaxis and nephrogenic systemic fibrosis with different localizations in a hemodialysis patient&#46; This situation may be explained with consociate etiological origin&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histopathological examinations&#46; &#40;a&#41; Lesions on legs&#58; Dermal and subcutaneous arteriolar calcification and narrowing of the vascular lumen in subcutaneous tissue &#40;HE stain&#59; original magnification &#215;200&#41;&#46; &#40;b&#44; c&#41; Lesions on infraumblical region&#58; Spindle cell proliferation&#44; focal sclerosis&#44; thick collagen bundles in dermis&#44; fibrous thickening of the septum in subcutaneous tissue and subcutaneous arteriolar calcification &#40;HE stain&#59; original magnification &#215;40 and &#215;200 respectively&#41;&#46; &#40;d&#41; CD34 positivity&#46;</p>"
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Información del artículo
ISSN: 02116995
Idioma original: Inglés
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