Case Report
Facticial Panniculitis and Löfgren's Syndrome: A Case
Paniculitis facticia y síndrome de Löfgren inducidos por silicona: a propósito de un caso clínico
Read
12499
Timeswas read the article
2636
Total PDF
9863
Total HTML
Share statistics
array:24 [ "pii" => "S2173574312000603" "issn" => "21735743" "doi" => "10.1016/j.reumae.2012.04.008" "estado" => "S300" "fechaPublicacion" => "2012-11-01" "aid" => "432" "copyright" => "Elsevier España, S.L.. All rights reserved" "copyrightAnyo" => "2011" "documento" => "article" "crossmark" => 0 "subdocumento" => "sco" "cita" => "Reumatol Clin. 2012;8:368-71" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 6877 "formatos" => array:3 [ "EPUB" => 65 "HTML" => 6052 "PDF" => 760 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S1699258X12000642" "issn" => "1699258X" "doi" => "10.1016/j.reuma.2011.12.015" "estado" => "S300" "fechaPublicacion" => "2012-11-01" "aid" => "432" "copyright" => "Elsevier España, S.L." "documento" => "article" "crossmark" => 0 "subdocumento" => "sco" "cita" => "Reumatol Clin. 2012;8:368-71" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 11006 "formatos" => array:3 [ "EPUB" => 186 "HTML" => 8952 "PDF" => 1868 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Caso clínico</span>" "titulo" => "Paniculitis facticia y síndrome de Löfgren inducidos por silicona: a propósito de un caso clínico" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "368" "paginaFinal" => "371" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Facticial panniculitis and Löfgren′s syndrome: A case" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 926 "Ancho" => 950 "Tamanyo" => 124421 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">TC torácica. Adenopatías hiliares y mediastínicas (sarcoidosis grado 1).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Carolina Diez Morrondo, Natalia Palmou Fontana, José Manuel Lema Gontad, Noelia Álvarez Rivas, Mercedes Freire González, Jesús García Silva, Teresa Hermida Romero, Fausto Galdo" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Carolina" "apellidos" => "Diez Morrondo" ] 1 => array:2 [ "nombre" => "Natalia" "apellidos" => "Palmou Fontana" ] 2 => array:2 [ "nombre" => "José Manuel" "apellidos" => "Lema Gontad" ] 3 => array:2 [ "nombre" => "Noelia" "apellidos" => "Álvarez Rivas" ] 4 => array:2 [ "nombre" => "Mercedes" "apellidos" => "Freire González" ] 5 => array:2 [ "nombre" => "Jesús" "apellidos" => "García Silva" ] 6 => array:2 [ "nombre" => "Teresa" "apellidos" => "Hermida Romero" ] 7 => array:2 [ "nombre" => "Fausto" "apellidos" => "Galdo" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173574312000603" "doi" => "10.1016/j.reumae.2012.04.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574312000603?idApp=UINPBA00004M" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X12000642?idApp=UINPBA00004M" "url" => "/1699258X/0000000800000006/v1_201305061930/S1699258X12000642/v1_201305061930/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2173574312000585" "issn" => "21735743" "doi" => "10.1016/j.reumae.2012.04.007" "estado" => "S300" "fechaPublicacion" => "2012-11-01" "aid" => "430" "copyright" => "Elsevier España, S.L." "documento" => "article" "crossmark" => 0 "subdocumento" => "sco" "cita" => "Reumatol Clin. 2012;8:372-4" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 7520 "formatos" => array:3 [ "EPUB" => 52 "HTML" => 6602 "PDF" => 866 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Images in Clinical Rheumatology</span>" "titulo" => "The “Bone Within a Bone” Sign in Idiopathic Hypoparathyroidism" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "372" "paginaFinal" => "374" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El signo del «hueso dentro de hueso» en el hipoparatiroidismo idiopático" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1255 "Ancho" => 950 "Tamanyo" => 74133 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Lateral radiograph of lumbar spine showing similar findings to those of the thoracic spine (white arrows).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Walter Alberto Sifuentes Giraldo, Mónica Vázquez Díaz, Raquel Barrios Castellanos" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Walter Alberto" "apellidos" => "Sifuentes Giraldo" ] 1 => array:2 [ "nombre" => "Mónica" "apellidos" => "Vázquez Díaz" ] 2 => array:2 [ "nombre" => "Raquel" "apellidos" => "Barrios Castellanos" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1699258X12000629" "doi" => "10.1016/j.reuma.2011.12.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X12000629?idApp=UINPBA00004M" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574312000585?idApp=UINPBA00004M" "url" => "/21735743/0000000800000006/v1_201305061648/S2173574312000585/v1_201305061648/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2173574312000597" "issn" => "21735743" "doi" => "10.1016/j.reumae.2011.12.004" "estado" => "S300" "fechaPublicacion" => "2012-11-01" "aid" => "431" "copyright" => "Elsevier España, S.L." "documento" => "article" "crossmark" => 0 "subdocumento" => "sco" "cita" => "Reumatol Clin. 2012;8:365-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 5842 "formatos" => array:3 [ "EPUB" => 57 "HTML" => 4933 "PDF" => 852 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Large Granular Lymphocyte Leukemia as a Complication of Rheumatoid Arthritis" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "365" "paginaFinal" => "367" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Leucemia de linfocitos grandes granulares como complicación de artritis reumatoide" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 709 "Ancho" => 950 "Tamanyo" => 149831 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Lymphocytosis due to LGL.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Lois Iglesias, Walter Alberto Sifuentes Giraldo, Javier Bachiller Corral, Ana Saiz González, Elia Brito Brito, Antonio Zea Mendoza" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Ana" "apellidos" => "Lois Iglesias" ] 1 => array:2 [ "nombre" => "Walter Alberto" "apellidos" => "Sifuentes Giraldo" ] 2 => array:2 [ "nombre" => "Javier" "apellidos" => "Bachiller Corral" ] 3 => array:2 [ "nombre" => "Ana" "apellidos" => "Saiz González" ] 4 => array:2 [ "nombre" => "Elia" "apellidos" => "Brito Brito" ] 5 => array:2 [ "nombre" => "Antonio" "apellidos" => "Zea Mendoza" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1699258X12000630" "doi" => "10.1016/j.reuma.2011.12.014" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X12000630?idApp=UINPBA00004M" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574312000597?idApp=UINPBA00004M" "url" => "/21735743/0000000800000006/v1_201305061648/S2173574312000597/v1_201305061648/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Facticial Panniculitis and Löfgren's Syndrome: A Case" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "368" "paginaFinal" => "371" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Carolina Diez Morrondo, Natalia Palmou Fontana, José Manuel Lema Gontad, Noelia Álvarez Rivas, Mercedes Freire González, Jesús García Silva, Teresa Hermida Romero, Fausto Galdo" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Carolina" "apellidos" => "Diez Morrondo" "email" => array:1 [ 0 => "caroldiez81@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Natalia" "apellidos" => "Palmou Fontana" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "José Manuel" "apellidos" => "Lema Gontad" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Noelia" "apellidos" => "Álvarez Rivas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Mercedes" "apellidos" => "Freire González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Jesús" "apellidos" => "García Silva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 6 => array:3 [ "nombre" => "Teresa" "apellidos" => "Hermida Romero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 7 => array:3 [ "nombre" => "Fausto" "apellidos" => "Galdo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Reumatología, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Abente y Lago, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Paniculitis facticia y síndrome de Löfgren inducidos por silicona: a propósito de un caso clínico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 913 "Ancho" => 950 "Tamanyo" => 71663 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">X-ray: bilateral hilar lymphadenopathy.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Prostheses or silicone injections for cosmetic use to enhance or correct volume lead to tissue scarring. Although silicone has been considered an inert material, it is now known to produce local or systemic adverse reactions, with a latent period even lasting decades. Between local reactions it induces factitual panniculitis<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> due to foreign body or systemic reactions and some cases of connective tissue disease have been described.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In recent years several cases of sarcoidosis that occurred after injection of silicone for esthetic purposes in distant localizations<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–8</span></a> have been described in the literature. Most of these cases required the use of corticosteroids for symptom control, together with the removal of the silicone.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe a patient who, after the injection of liquid silicone, presented a local complication (factitious panniculitis) along with systemic complications (Löfgren syndrome).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case Report</span><p id="par0015" class="elsevierStylePara elsevierViewall">The patient is a 44-year-old woman without medical or surgical history of interest, a native of Colombia, a resident in Spain for 10 years. She had a history of liquid silicone injections in the buttocks 3 years earlier while in Colombia.</p><p id="par0020" class="elsevierStylePara elsevierViewall">She was by rheumatology due to joint pain in knees with posterior involvement of the ankles, elbows and wrists of one week of progression, along with a raised, erythematous, nonpruritic, painful skin lesions on both buttocks (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and fever (37.6<span class="elsevierStyleHsp" style=""></span>°C). The patient did not present general manifestations or morning stiffness, no manifestations suggestive of infection and denied foreign travel in recent months, as well as drug and alcohol consumption.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Physical examination found her hemodynamically stable, afebrile and in good overall condition. Musculoskeletal examination found a local temperature increase on both knees, with pain on flexion and extension, without erythema or effusion, along with swelling and increased local temperature in both ankles. The dermatological examination found erythematous papules, painful on palpation, indurated to the touch, on both buttocks.</p><p id="par0030" class="elsevierStylePara elsevierViewall">As additional evidence, a blood test showed normocytic and normochromic anemia with a hematocrit of 27.7% (nv 36–45) and hemoglobin of 9.4<span class="elsevierStyleHsp" style=""></span>g/dl (nv 12–16), together with a platelet count of 540,000 (nv 130–450). A search for iron deficiency showed (Fe: 18; vn 37–145) with normal ferritin, vitamin B12, folic acid and serum protein, and a peripheral blood smear which only highlighted a slight basophilia. The rest of the analytical studies only revealed subclinical hypothyroidism, with a slightly elevated TSH and normal thyroid hormones, for which we consulted the endocrinology department, which stated that the patient did not require replacement therapy. There was no leukocytosis or left shift, and renal and hepatic functions, ions and coagulation were normal. Acute phase reactants showed a sedimentation rate of 110<span class="elsevierStyleHsp" style=""></span>mmHg and C-reactive protein 28.8<span class="elsevierStyleHsp" style=""></span>mg/dl. Autoimmunity testing revealed rheumatoid factor of 24<span class="elsevierStyleHsp" style=""></span>U/l, antinuclear antibodies 1/80, with negative anti neutrophil cytoplasmic antibodies. The angiotensin converting enzyme (ACE) was within normal values (ECA: 38; vn 18–58). Requested blood cultures were negative, and urine sediment was normal. Requested serology for hepatitis, human immunodeficiency virus, rubella, cytomegalovirus, Epstein–Barr virus, Toxoplasma, Treponema pallidum, Borrelia, Mycoplasma and Chlamydia were negative.</p><p id="par0035" class="elsevierStylePara elsevierViewall">We performed a chest X-ray which displayed bilateral hilar lymphadenopathy (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). To rule out a possible TB we performed a Mantoux test that was negative and serial urine auramines, which were also negative. We performed a high-resolution CT of the chest, which was compatible with grade I sarcoidosis (bilateral hilar and mediastinal lymphadenopathy) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The transbronchial biopsy showed an inflammatory component in the bronchoalveolar lavage fluid and with a CD4/CD8 ratio of 5.26, with 80% of histiocytes, 15% lymphocytes and 5% neutrophils.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">During admission we also found palpable and painful erythematous nodular lesions on the tibial region of both lower limbs (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). After consulting with the dermatologist we performed a biopsy of the skin lesions of the buttocks and lower limbs. Pathology reported many histiocytes laden with lipid-containing cytoplasmic vacuoles affecting the septa and adipose tissue, which supported, given the clinical context, a diagnosis of factitious panniculitis due to silicone (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). In contrast, biopsy of the skin over the pretibial showed a mixed, septal panniculitis with granulomas without necrosis, compatible with erythema nodosum with no evidence of silicone material (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>). The Ziehl-Neelsen and PAS stains were negative. She was treated with NSAIDs (indomethacin 50<span class="elsevierStyleHsp" style=""></span>mg/8<span class="elsevierStyleHsp" style=""></span>h), with very good clinical response, remaining afebrile, with a decrease in swelling of the ankle and progressive disappearance of skin lesions.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Subsequently, visits to the departments of rheumatology, dermatology and respiratory medicine found the patient to be asymptomatic. No new outbreaks were seen even though she has not removed the silicone implants.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Sarcoidosis is a systemic granulomatous disease of unknown etiology that affects mainly young people, and whose most frequent clinical manifestations are bilateral hilar lymphadenopathy, pulmonary infiltrates and skin and eye lesions.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> It is characterized by the formation of noncaseating granulomas.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Löfgren in 1946 first described a syndrome characterized by the association of erythema nodosum and bilateral hilar lymphadenopathy. This syndrome is a form of acute or subacute sarcoidosis, usually benign in nature, often accompanied by polyarthritis/polyarticular joint pain and fever, and that is spontaneously resolved.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> It is usually associated with HLA-DRB1*03.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The pathogenesis of sarcoidosis is mediated by T cell dysfunction and hyperactivity of B cells, resulting from an abnormal immune response against a variety of specific environmental agents, which act as antigens and affect genetically predisposed individuals. Experiments with rats have shown that silicone is able to activate the humoral response and lead to delayed hypersensitivity and also exerts a direct effect on macrophages, causing the release of cytokines, with subsequent activation of lymphocytes.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Thus, it is believed that in a predisposed individual, silicone may act as the triggering antigen leading to the aberrant immune responses and many systemic manifestations.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> A wide variety of connective tissue diseases (systemic sclerosis, lupus erythematosus, rheumatoid arthritis) have been associated with silicone<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> implants. Specifically, several papers<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5–8</span></a> refer to the appearance of sarcoidosis or Löfgren syndrome in previously healthy people, as in our case, after undergoing various surgical procedures, mainly cosmetic, and silicone made implants in various body areas. Manifestations were particularly severe in some of these patients, with very marked constitutional symptoms characterized by fever, generalized joint pain, fatigue, intense lymphadenopathy and skin lesions, as well as moderate pleural effusion.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4,7,8</span></a> In all cases a chest radiograph and chest CT were performed, and a biopsy taken from the lymph nodes or skin lesions, showing noncaseating granulomas and ruling out TB by staining with Zhiel Nielsen. In most patients it was necessary, in addition to treatment with systemic corticosteroids, to remove the silicone implants, although one case was spared.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">On the other hand, silicone injections can cause foreign body reactions of the skin, which may extend to subcutaneous fat tissue, causing a factitial panniculitis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Lesions usually appear months or years after the injection as erythematous nodules or plaques, tender to palpation, even sometimes leading to ulcers and fatty necrosis.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Histology is characteristic and consists of a lobular panniculitis with giant multinucleated cells as a foreign body reaction. Material is frequently found within the vacuoles, which in this case consists of lipids or oil.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The presence of vacuoles of various sizes can produce the typical “Swiss cheese” appearance.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The etiological treatment (removal of the injected product) can be difficult, especially when it comes to liquid silicone. For symptomatic treatment local corticosteroids are used, systemically, mynocyclin<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and imiquimod 5%.</p><p id="par0075" class="elsevierStylePara elsevierViewall">An increase in the percentage of NK cells and neutrophils in bronchoalveolar lavage fluid is associated with a poor prognosis and the likelihood of increased requirement for steroids, contrary to what happened with our patient, which may have contributed to rapid improvement, even without steroids or removing the material.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0080" class="elsevierStylePara elsevierViewall">Silicone is a material frequently used in plastic surgery and, as noted, may produce undesirable reactions both locally and systemically. The highlight of the event here exposed is that the patient had, on the one hand, a local reaction in the form of factitious panniculitis (buttocks skin biopsy where we found large numbers of cytoplasmic vacuole-laden histiocytes filled with a lipid material compatible with silicone) and, second, Löfgren's syndrome with fever, arthralgias, hilar lymphadenopathy and skin lesions such as erythema nodosum (pretibial area skin biopsy showing a mixed septal panniculitis, without evidence of lipid droplets to suggest silicone implants). Unlike other cases reported in other scientific publications, it was not necessary at present to remove the silicone or use systemic corticosteroid, as the patient responded favorably to the use of NSAIDS.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Ethical disclosures</span><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Protection of human and animal subjects</span>. The authors declare that no experiments were performed on humans or animals for this investigation.</p><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Confidentiality of Data</span>. The authors declare that they have followed the protocols of their work centre on the publication of patient data and that all the patients included in the study have received sufficient information and have given their informed consent in writing to participate in that study.</p><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Right to privacy and informed consent</span>. The authors have obtained the informed consent of the patients and /or subjects mentioned in the article. The author for correspondence is in possession of this document.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres125953" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec113249" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres125954" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec113248" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case Report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Ethical disclosures" ] 9 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of Interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-09-14" "fechaAceptado" => "2011-12-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec113249" "palabras" => array:4 [ 0 => "Silicone" 1 => "Facticial panniculitis" 2 => "Löfgren's syndrome" 3 => "Non-steroidal-anti-inflammatory drugs" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec113248" "palabras" => array:4 [ 0 => "Silicona" 1 => "Paniculitis facticia" 2 => "Síndrome de Löfgren" 3 => "Antiinflamatorios no esteroideos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We herein report a patient who came to the hospital because of a polyarticular joint pain, fever and cutaneous lesions. She had silicone implants in her buttocks, a surgery performed 3 years before. We made a biopsy of the skin of the buttocks (facticial panniculitis due to silicone) and of the pretibial surface of the inferior extremities (erythema nodosum). A chest X-ray and a CT scan revealed bilateral hilar lymphadenopathy, and a transbronquial biopsy showed granulomatous inflammation. She had a good response to rest and anti-inflammatory drugs, so the removal of the silicone implants has not been necessary yet.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se presenta el caso clínico de una paciente que ingresó en nuestro servicio por clínica de poliartralgias, fiebre y lesiones cutáneas que afectaban a la región glútea y pretibial. Refería como antecedente la aplicación de inyecciones de silicona líquida en los glúteos con fines estéticos 3 años antes. Se realizó biopsia cutánea de las lesiones en la región glútea cuyo estudio anatomo-patológico fue compatible con paniculitis facticia por silicona así como de la región pretibial que fueron compatibles con eritema nodoso. La radiografía de tórax y el TAC torácico mostraron adenopatías hiliares bilaterales, y en la biopsia transbronquial se evidenció componente inflamatorio granulomatoso. La evolución fue satisfactoria con reposo y antiinflamatorios no esteroideos, por lo que no fue necesaria la extracción de la silicona.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Diez Morrondo C, et al. Paniculitis facticia y síndrome de Löfgren inducidos por silicona: a propósito de un caso clínico. Reumatol Clin. 2012;8:368–71.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1011 "Ancho" => 750 "Tamanyo" => 52774 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Erythematous, raised lesions on the buttocks (factitious panniculitis).</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" => 913 "Ancho" => 950 "Tamanyo" => 71663 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">X-ray: bilateral hilar lymphadenopathy.</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" => 922 "Ancho" => 948 "Tamanyo" => 125403 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Chest CT: hilar and mediastinal lymphadenopathy (grade 1 sarcoidosis).</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" => 833 "Ancho" => 900 "Tamanyo" => 80079 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Painful erythematous nodules on the legs (erythema nodosum).</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 710 "Ancho" => 950 "Tamanyo" => 194453 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Factitious panniculitis: histiocytes with intracytoplasmic lipid vacuoles.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Fig. 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 712 "Ancho" => 950 "Tamanyo" => 195023 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Erythema nodosum: granulomas in adipose tissue without necrosis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Factitial panniculitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "O. Sanmartín" 1 => "C. Requena" 2 => "L. Requena" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.det.2008.05.013" "Revista" => array:6 [ "tituloSerie" => "Dermatol Clin" "fecha" => "2008" "volumen" => "26" "paginaInicial" => "519" "paginaFinal" => "527" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18793986" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Silicone breast implants and the risk of connective tissue diseases and symptoms" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. Sanchez-Guerrero" 1 => "G.A. Colditz" 2 => "E.W. Karlson" 3 => "D.J. Hunter" 4 => "F.E. Speizer" 5 => "M.H. Liang" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJM199506223322502" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "1995" "volumen" => "332" "paginaInicial" => "1666" "paginaFinal" => "1670" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7760867" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lack of adverse effect of silicone implant on sarcoidosis of the breast" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R. Riefkohl" 1 => "T.L Roberts 3rd" 2 => "K.S McCarty Jr." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Plast Reconstr Surg" "fecha" => "1985" "volumen" => "76" "paginaInicial" => "296" "paginaFinal" => "298" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4023101" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Remission of sarcoidosis following removal of silicone gel breast implants" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S.S. Teuber" 1 => "L.P. Howell" 2 => "S.H. Yoshida" 3 => "M.E. Gershwin" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Int Arch Allergy Immunol" "fecha" => "1994" "volumen" => "105" "paginaInicial" => "404" "paginaFinal" => "407" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7981613" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0140673605663787" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sarcoidosis after adjustable silicone gastric banding—a report of two cases in Germany" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C. Stroh" 1 => "J. Bottger" 2 => "F. Meyer" 3 => "H. Lippert" 4 => "T. Manger" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1159/000235865" "Revista" => array:6 [ "tituloSerie" => "Obes Facts" "fecha" => "2009" "volumen" => "2" "paginaInicial" => "332" "paginaFinal" => "334" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20057201" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sarcoidosis (after cosmetic intervention)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K. Pónyai" 1 => "E. Ablonczy" 2 => "J. Hársing" 3 => "R. Gonzales" 4 => "A. Horváth" 5 => "S. Kárpáti" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Orv Hetil" "fecha" => "2005" "volumen" => "146" "paginaInicial" => "2113" "paginaFinal" => "2116" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16304804" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cutaneous and pulmonary sarcoidosis in a Hong Kong Chinese woman with silicone breast prostheses" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K.C. Chang" 1 => "K.T. Chan" 2 => "L.Y. Chong" 3 => "K.S. Lau" 4 => "C.M. Tam" 5 => "C.W. Lam" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Respirology" "fecha" => "2003" "volumen" => "8" "paginaInicial" => "379" "paginaFinal" => "382" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14528880" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Löfgren syndrome after silicone breast prosthesis implantation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. Barzó" 1 => "L. Tamási" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Orv Hetil" "fecha" => "1998" "volumen" => "139" "paginaInicial" => "2323" "paginaFinal" => "2326" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9789987" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Estudio de 94 casos de sarcoidosis con especial referencia al eritema nudoso" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Atanes" 1 => "J. Toro" 2 => "N. Gómez" 3 => "B. Aspe" 4 => "J. Graña" 5 => "J. Burson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Clin Esp" "fecha" => "1992" "volumen" => "191" "paginaInicial" => "65" "paginaFinal" => "70" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1502392" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Granulomatous facial reaction to injected cosmetic fillers—a presentation of five cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R. Poveda" 1 => "J.V. Bagán" 2 => "J. Murillo" 3 => "Y. Jiménez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Oral Patol Oral Cir Bucal" "fecha" => "2006" "volumen" => "11" "paginaInicial" => "1" "paginaFinal" => "5" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Silicone granuloma of the face treated with minocycline" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.J. Arin" 1 => "J. Bäte" 2 => "T. Krieg" 3 => "N. Hunzelmann" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2004.07.014" "Revista" => array:7 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2005" "volumen" => "52" "numero" => "2 Suppl. 1" "paginaInicial" => "53" "paginaFinal" => "56" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15692516" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000000800000006/v1_201305061648/S2173574312000603/v1_201305061648/en/main.assets" "Apartado" => array:4 [ "identificador" => "17376" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Case Report" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000000800000006/v1_201305061648/S2173574312000603/v1_201305061648/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574312000603?idApp=UINPBA00004M" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 14 | 25 |
| 2024 October | 63 | 58 | 121 |
| 2024 September | 75 | 61 | 136 |
| 2024 August | 82 | 49 | 131 |
| 2024 July | 40 | 55 | 95 |
| 2024 June | 67 | 52 | 119 |
| 2024 May | 64 | 42 | 106 |
| 2024 April | 63 | 19 | 82 |
| 2024 March | 66 | 44 | 110 |
| 2024 February | 63 | 33 | 96 |
| 2024 January | 45 | 26 | 71 |
| 2023 December | 44 | 28 | 72 |
| 2023 November | 47 | 44 | 91 |
| 2023 October | 89 | 30 | 119 |
| 2023 September | 77 | 40 | 117 |
| 2023 August | 51 | 14 | 65 |
| 2023 July | 49 | 24 | 73 |
| 2023 June | 61 | 28 | 89 |
| 2023 May | 52 | 23 | 75 |
| 2023 April | 57 | 14 | 71 |
| 2023 March | 66 | 32 | 98 |
| 2023 February | 49 | 27 | 76 |
| 2023 January | 45 | 19 | 64 |
| 2022 December | 72 | 29 | 101 |
| 2022 November | 80 | 32 | 112 |
| 2022 October | 100 | 37 | 137 |
| 2022 September | 51 | 37 | 88 |
| 2022 August | 64 | 40 | 104 |
| 2022 July | 67 | 43 | 110 |
| 2022 June | 64 | 34 | 98 |
| 2022 May | 67 | 38 | 105 |
| 2022 April | 78 | 49 | 127 |
| 2022 March | 80 | 50 | 130 |
| 2022 February | 90 | 42 | 132 |
| 2022 January | 100 | 35 | 135 |
| 2021 December | 63 | 35 | 98 |
| 2021 November | 53 | 33 | 86 |
| 2021 October | 91 | 57 | 148 |
| 2021 September | 81 | 40 | 121 |
| 2021 August | 49 | 52 | 101 |
| 2021 July | 59 | 35 | 94 |
| 2021 June | 77 | 30 | 107 |
| 2021 May | 69 | 37 | 106 |
| 2021 April | 226 | 73 | 299 |
| 2021 March | 109 | 24 | 133 |
| 2021 February | 65 | 26 | 91 |
| 2021 January | 79 | 21 | 100 |
| 2020 December | 57 | 29 | 86 |
| 2020 November | 103 | 16 | 119 |
| 2020 October | 77 | 9 | 86 |
| 2020 September | 60 | 25 | 85 |
| 2020 August | 60 | 23 | 83 |
| 2020 July | 65 | 20 | 85 |
| 2020 June | 41 | 17 | 58 |
| 2020 May | 31 | 18 | 49 |
| 2020 April | 33 | 10 | 43 |
| 2020 March | 24 | 4 | 28 |
| 2020 February | 1 | 0 | 1 |
| 2020 January | 4 | 0 | 4 |
| 2019 September | 7 | 0 | 7 |
| 2019 August | 2 | 0 | 2 |
| 2019 June | 2 | 0 | 2 |
| 2019 May | 1 | 0 | 1 |
| 2019 April | 1 | 0 | 1 |
| 2019 March | 2 | 0 | 2 |
| 2019 February | 1 | 0 | 1 |
| 2019 January | 3 | 0 | 3 |
| 2018 December | 15 | 0 | 15 |
| 2018 May | 9 | 0 | 9 |
| 2018 April | 80 | 7 | 87 |
| 2018 March | 113 | 6 | 119 |
| 2018 February | 59 | 3 | 62 |
| 2018 January | 65 | 9 | 74 |
| 2017 December | 78 | 4 | 82 |
| 2017 November | 82 | 9 | 91 |
| 2017 October | 65 | 6 | 71 |
| 2017 September | 80 | 8 | 88 |
| 2017 August | 79 | 10 | 89 |
| 2017 July | 92 | 9 | 101 |
| 2017 June | 97 | 13 | 110 |
| 2017 May | 133 | 18 | 151 |
| 2017 April | 77 | 10 | 87 |
| 2017 March | 116 | 9 | 125 |
| 2017 February | 152 | 12 | 164 |
| 2017 January | 70 | 6 | 76 |
| 2016 December | 134 | 26 | 160 |
| 2016 November | 115 | 20 | 135 |
| 2016 October | 168 | 18 | 186 |
| 2016 September | 249 | 22 | 271 |
| 2016 August | 248 | 17 | 265 |
| 2016 July | 110 | 18 | 128 |
| 2016 January | 1 | 0 | 1 |
| 2015 December | 1 | 0 | 1 |
| 2015 November | 1 | 0 | 1 |
| 2015 October | 0 | 29 | 29 |
| 2015 September | 5 | 0 | 5 |
| 2015 August | 4 | 0 | 4 |
| 2015 July | 79 | 5 | 84 |
| 2015 June | 119 | 12 | 131 |
| 2015 May | 128 | 30 | 158 |
| 2015 April | 104 | 14 | 118 |
| 2015 March | 138 | 9 | 147 |
| 2015 February | 146 | 9 | 155 |
| 2015 January | 125 | 15 | 140 |
| 2014 December | 105 | 20 | 125 |
| 2014 November | 98 | 11 | 109 |
| 2014 October | 112 | 21 | 133 |
| 2014 September | 91 | 10 | 101 |
| 2014 August | 85 | 14 | 99 |
| 2014 July | 103 | 17 | 120 |
| 2014 June | 130 | 19 | 149 |
| 2014 May | 126 | 34 | 160 |
| 2014 April | 121 | 13 | 134 |
| 2014 March | 138 | 21 | 159 |
| 2014 February | 110 | 8 | 118 |
| 2014 January | 116 | 13 | 129 |
| 2013 December | 92 | 7 | 99 |
| 2013 November | 82 | 8 | 90 |
| 2013 October | 118 | 14 | 132 |
| 2013 September | 90 | 11 | 101 |
| 2013 August | 84 | 17 | 101 |
| 2013 July | 89 | 11 | 100 |
| 2013 June | 78 | 11 | 89 |
| 2013 May | 117 | 14 | 131 |
| 2013 April | 108 | 11 | 119 |
| 2013 March | 115 | 19 | 134 |
| 2013 February | 99 | 14 | 113 |
| 2013 January | 133 | 17 | 150 |
| 2012 December | 128 | 20 | 148 |
| 2012 November | 23 | 2 | 25 |
Show all
