Letter to the Editor
Development of Pylomatrixoma After the Subcutaneous Injection of Methotrexate for the Treatment of Juvenile Idiopathic Arthritis
Desarrollo de pilomatrixoma tras la inyección subcutánea de metotrexato en el tratamiento de la artritis idiopática juvenil
Elvira Afonso Péreza, Carlos Garcia Porruab,
, Iria Margarita Castiñeiras Matoc, Fernando Bal Nievesd
Corresponding author
a Medicina Familiar y Comunitaria, Centro de Salud de Guitiriz, Lugo, Spain
b Sección de Reumatología, Hospital Universitario Lucus Augusti, Lugo, Spain
c Sección de Dermatología, Hospital Universitario Lucus Augusti, Lugo, Spain
d Servicio de Anatomía Patológica, Hospital Universitario Lucus Augusti, Lugo, Spain
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Idiopathic Arthritis" "tieneTextoCompleto" => true "saludo" => "To the Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "380" "paginaFinal" => "381" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Elvira Afonso Pérez, Carlos Garcia Porrua, Iria Margarita Castiñeiras Mato, Fernando Bal Nieves" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Elvira" "apellidos" => "Afonso Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "Carlos" "apellidos" => "Garcia Porrua" "email" => array:1 [ 0 => "carlos.garcia.porrua@sergas.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "Iria Margarita" "apellidos" => "Castiñeiras Mato" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Fernando" "apellidos" => "Bal Nieves" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Medicina Familiar y Comunitaria, Centro de Salud de Guitiriz, Lugo, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Sección de Reumatología, Hospital Universitario Lucus Augusti, Lugo, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Sección de Dermatología, Hospital Universitario Lucus Augusti, Lugo, Spain" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario Lucus Augusti, Lugo, Spain" "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Desarrollo de pilomatrixoma tras la inyección subcutánea de metotrexato en el tratamiento de la artritis idiopática juvenil" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1385 "Ancho" => 950 "Tamanyo" => 334224 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) A well-defined, non-encapsulated tumor of the hair matrix. Cell proliferation in the lobes distinguished aspect formed by basaloid cells, keratinization and dystrophic calcifications (hematoxylin–eosin). (B) Under more detail we observed basophilic epithelioid cell proliferation suffering abrupt keratinization and presence of eosinophilic bodies called ghost cells (hematoxylin–eosin).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pilomatrixoma (PM), pilomatricoma or calcifying Malherbe's epithelioma are benign skin tumors derived from the hair follicles. They usually occur in children and adolescents as a single tumor in the upper body and their etiology is unknown. In this regard, it has been described in association with multiple trauma and disease, with no clear causal relationship.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We report the first case of a child diagnosed with juvenile idiopathic arthritis (JIA) who developed a PM in the puncture site of subcutaneous methotrexate administration and we review the literature in this regard.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient, a girl, was diagnosed in 2007 with JIA at 3 years of age due to the presence of idiopathic chronic monoarthritis and with her father presenting Psoriasis. She had been treated with local infiltration of corticosteroids on 2 occasions and then, due to the persistence of disease activity, was prescribed weekly subcutaneous methotrexate in 2008. Currently, the patient is 7 years old and is on weekly subcutaneous methotrexate (15<span class="elsevierStyleHsp" style=""></span>mg/0.3<span class="elsevierStyleHsp" style=""></span>ml), being clinically asymptomatic and performing a normal life. After the last administration of subcutaneous methotrexate she presented a nodular cystic lesion. The lesion was treated with local cold, without improvement. Subsequently, it increased in size and consistency, becoming harder and painful upon palpation. On examination she had a hard, subcutaneous injury and uneven surface on the lateral aspect of the left arm, about 2<span class="elsevierStyleHsp" style=""></span>cm in diameter, painful on palpation, not adhered to deep planes and covered with purplish skin. We conducted a consultation with Dermatology upon the suspicion of a foreign body reaction versus PM, who decided to excise the tumor and send it for pathologic examination. Pathology confirmed the diagnosis of PM (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The PM is a well-circumscribed benign tumor located in the lower dermis and which extends into the subcutaneous tissue. It consists of irregular islands of epithelial cells, a basophilic stain located in the periphery with scant cytoplasm and hyperchromatic nuclei and other eosinophilic bodies called “ghost or shadow cells” whose nucleus does not stain. The stroma shows a foreign body reaction with giant cells, foci of calcification and ossification.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In 2005 there was one case of PM in relation to BCG vaccination.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Subsequently, Malpathak et al. described the formation of a giant PM after intramuscular injection. In this case, the authors postulated that local trauma and hematoma development could lead to suppression of apoptosis and thus the formation of the PM.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Our case shows a clear temporal relationship with the subcutaneous injection of methotrexate, a fact not mentioned in the literature. The trauma caused by puncturing the skin or injecting fluid could act as a trigger factor favoring the development of PM. The increased use of different subcutaneous therapies in JIA should alert physicians treating these patients for the development of PM.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Afonso Pérez E, et al. Desarrollo de pilomatrixoma tras la inyección subcutánea de metotrexato en el tratamiento de la artritis idiopática juvenil. Reumatol Clin. 2012. <span class="elsevierStyleInterRef" href="doi:10.1016/j.reuma.2012.05.009">http://dx.doi.org/10.1016/j.reuma.2012.05.009</span></p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1385 "Ancho" => 950 "Tamanyo" => 334224 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) A well-defined, non-encapsulated tumor of the hair matrix. Cell proliferation in the lobes distinguished aspect formed by basaloid cells, keratinization and dystrophic calcifications (hematoxylin–eosin). (B) Under more detail we observed basophilic epithelioid cell proliferation suffering abrupt keratinization and presence of eosinophilic bodies called ghost cells (hematoxylin–eosin).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pilomatricoma: a review of six pediatric cases with nine lesions" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "N. Turhan-Haktanir" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Turkish Journal of Pediatrics" "fecha" => "2009" "volumen" => "51" "paginaInicial" => "44" "paginaFinal" => "48" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19378890" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pilomatricomas múltiples. Presentación de un caso" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A.G. Andrés Andrés" 1 => "M. Silveira Cancela" 2 => "F. Valdés Tascón" 3 => "P. Lago Mandado" 4 => "A. Abadí Abadí" 5 => "M. Rodicio García" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Acta Pediatrica Espanola" "fecha" => "2010" "volumen" => "68" "paginaInicial" => "146" "paginaFinal" => "148" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pilomatricoma arising al a BCG vaccination site" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Aquilina" 1 => "P. Gatt" 2 => "N.J. Boffa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2230.2005.02016.x" "Revista" => array:6 [ "tituloSerie" => "Clinical and Experimental Dermatology" "fecha" => "2006" "volumen" => "31" "paginaInicial" => "296" "paginaFinal" => "297" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16487123" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Giant pilomatricoma following an intramuscular injection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "V.D. Malpathak" 1 => "V.P. Zawar" 2 => "A.A. Chuh" 3 => "P.S. Ghadi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Journal of Dermatological Case Reports" "fecha" => "2008" "volumen" => "29" "paginaInicial" => "11" "paginaFinal" => "13" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000000800000006/v1_201305061648/S2173574312001530/v1_201305061648/en/main.assets" "Apartado" => array:4 [ "identificador" => "8400" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000000800000006/v1_201305061648/S2173574312001530/v1_201305061648/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574312001530?idApp=UINPBA00004M" ]
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| 2013 June | 35 | 8 | 43 |
| 2013 May | 46 | 13 | 59 |
| 2013 April | 50 | 11 | 61 |
| 2013 March | 50 | 13 | 63 |
| 2013 February | 38 | 11 | 49 |
| 2013 January | 55 | 28 | 83 |
| 2012 December | 50 | 17 | 67 |
| 2012 November | 10 | 1 | 11 |
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