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M. Cullen, Santa Fe, Argentina" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hepatomegalia y esplenomegalia en una paciente con artritis reumatoide" ] ] "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" => 1014 "Ancho" => 996 "Tamanyo" => 98324 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Peripheral blood smear: large granular lymphocytes.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Case Presentation</span><p id="par0005" class="elsevierStylePara elsevierViewall">The patient is a 51-year-old female diagnosed with rheumatoid arthritis (RA) who met the criteria of the American College of Rheumatology 1987, with disease onset 15 years prior, seropositive (rheumatoid factor [RF] and anti-peptide antibodies citrullinated), erosive disease, non-nodular, who had a family history of lymphoma. She denied substance abuse and toxic tobacco or alcohol use. This patient had been under treatment with leflunomide (6 years), methotrexate (3 years) and hydroxychloroquine (1 year) without response, for which she received 2 months of treatment with etanercept, which was suspended due to a skin reaction. She later received adalimumab during 5 months in 2010, lost to follow-up.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In September 2012 she complained of fatigue, loss of 8<span class="elsevierStyleHsp" style=""></span>kg of weight in 4 months, grade III dyspnea and abdominal distention for 10 days. On physical examination the patient had no fever (37<span class="elsevierStyleHsp" style=""></span>°C), was normotensive (blood pressure 110/80<span class="elsevierStyleHsp" style=""></span>mmHg), presented tachycardia (110<span class="elsevierStyleHsp" style=""></span>bpm), tachypnea (28<span class="elsevierStyleHsp" style=""></span>cycles/min), thin skin and pale mucous membranes with multiple bruises. The remainder of the examination showed the presence of a pulmonary systolic multifocal murmur 2/6, bibasal hypoventilation and dullness, globular abdomen with hepatomegaly and splenomegaly, ascites and collateral circulation, and a painful ulcer, 5<span class="elsevierStyleHsp" style=""></span>cm in diameter on the trochanter of the right hip, and purpura on the legs below the knees. There was hypotrophy of interosseous muscles, ulnar deviation, swan neck deformity and arthritis of the metacarpophalangeal joints of the third right and fourth bilateral fingers. The clinimetry showed HAQ: 2375 and DAS28: 7.29 (ESR: 142<span class="elsevierStyleHsp" style=""></span>mm in the first hour, 3 swollen joints, 12 tender joints, patient assessment of activity: 100<span class="elsevierStyleHsp" style=""></span>mm).</p><p id="par0015" class="elsevierStylePara elsevierViewall">Laboratory data showed: hematocrit 25%, hemoglobin 7.6<span class="elsevierStyleHsp" style=""></span>g/dl, WBC 1900<span class="elsevierStyleHsp" style=""></span>cells/ml, neutrophils 1140<span class="elsevierStyleHsp" style=""></span>cells/ml, platelets 82 000<span class="elsevierStyleHsp" style=""></span>cells/ml, CRP 17.4<span class="elsevierStyleHsp" style=""></span>mg/l, erythrocyte sedimentation rate 142<span class="elsevierStyleHsp" style=""></span>mm in the first hour, increased alkaline phosphatase (997<span class="elsevierStyleHsp" style=""></span>U/l), RF (latex: 1/1280), anti-citrullinated peptide antibodies (53.7<span class="elsevierStyleHsp" style=""></span>U/ml) and anti-nuclear antibodies (Hep2): 1/2560. Renal function, alanine aminotransferase (13<span class="elsevierStyleHsp" style=""></span>U/l), aspartate aminotransferase (19<span class="elsevierStyleHsp" style=""></span>U/l), anticardiolipin antibodies, lupus anticoagulant, anti-DNA (<span class="elsevierStyleItalic">Crithidia</span>), C3 and C4, and serology for histoplasmosis, HBV and HCV were normal.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Cultures of blood, urine, stool and bone marrow were negative for common bacteria, typical and atypical mycobacteria and fungi. Thoracentesis reported an uncomplicated exudate. Computed tomography with contrast (oral and IV) of the head, neck and pelvis were normal; the scan showed the presence of a bibasal pleural effusion, and the abdomen (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) showed homogeneous hepatomegaly (230<span class="elsevierStyleHsp" style=""></span>mm of longitudinal diameter) and splenomegaly (200<span class="elsevierStyleHsp" style=""></span>mm of longitudinal diameter). Hepatic vessels on an eco Doppler ultrasound showed dilation of the portal vein (14<span class="elsevierStyleHsp" style=""></span>mm in diameter) with no evidence of thrombosis. Upper gastrointestinal fiberoptic endoscopy ruled out the presence of esophageal varices.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The peripheral blood smear showed leukopenia and thrombocytopenia, so a bone marrow biopsy was performed, finding hypercellularity with megakaryocytes, myeloid hyperplasia and isolated clusters of mature lymphocytes. The patient began treatment with methylprednisolone 50<span class="elsevierStyleHsp" style=""></span>mg/day orally for 1 month, with subsequent gradual decline, methotrexate 15<span class="elsevierStyleHsp" style=""></span>mg/week, calcium, vitamin D and folic acid. However, despite the immunosuppressive therapy, pancytopenia persisted (hematocrit 28.4%, hemoglobin 9.2<span class="elsevierStyleHsp" style=""></span>g/dl, WBC 3200<span class="elsevierStyleHsp" style=""></span>cells/ml, platelets 44 000<span class="elsevierStyleHsp" style=""></span>cells/ml) and the patient showed worsened liver function (alanine aminotransferase: 62<span class="elsevierStyleHsp" style=""></span>U/l; aspartate aminotransferase: 47<span class="elsevierStyleHsp" style=""></span>U/l), leading to a liver biopsy.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Based on the results it was decided to treat the patient with prednisone 10<span class="elsevierStyleHsp" style=""></span>mg/day, methotrexate 10<span class="elsevierStyleHsp" style=""></span>mg/week, leflunomide 20<span class="elsevierStyleHsp" style=""></span>mg/day, folic acid, calcium and vitamin D, presenting inactive RA with pancytopenia, but no neutropenia or bleeding.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Differential Diagnosis</span><p id="par0035" class="elsevierStylePara elsevierViewall">Faced with a patient diagnosed with longstanding RA who develops persistent pancytopenia and hepatosplenomegaly, the first step in diagnostic reasoning should be to ask whether it is due to concomitant conditions, treatment, or if it is secondary to the underlying disease.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Infections</span><p id="par0040" class="elsevierStylePara elsevierViewall">Patients with RA have an increased risk of infection.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The major risk factors for their development is the presence of extra-articular manifestations, comorbidities, advanced age, leukopenia, and therapy with corticosteroids and biologics, among others.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The most common infections are the upper respiratory tract, skin and soft tissue, bones and joints.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Concern about the risk of severe opportunistic infections (histoplasmosis, tuberculosis, leishmaniasis, <span class="elsevierStyleItalic">Pneumocystis carinii</span>) among patients with rheumatic diseases has increased, especially since they share several clinical features such as fever, fatigue, chest pain, pleural effusion, diffuse pulmonary infiltrates, pericarditis, myalgia, epistaxis, joint pain, arthritis, erythema nodosum, diffuse papules, lesions in the oropharynx, hepatosplenomegaly, lymphadenopathy, stroke, seizures, endocarditis, anemia, leukopenia, thrombocytopenia, elevated liver enzymes and bilirubin, and uveitis.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Occasionally, histoplasmosis is first manifested by extrapulmonary organ involvement. These isolated lesions are usually considered manifestations of disseminated disease, despite the lack of lung involvement. This situation may mimic other diseases, such as Felty's syndrome, and it is important to suspect it as an unusual manifestation of the disease when it occurs<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> in an outpatient setting.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Therefore, although our patient came from an endemic area (the Argentine coast) and histoplasmosis may mimic a flare of RA or an extra-articular manifestation of it (Felty's syndrome: fatigue, joint pain, arthritis, pleural effusion, hepatosplenomegaly, pancytopenia and abnormal liver function), serology, blood, bone marrow and liver cultures were negative for histoplasmosis and deep mycoses, allowing us to rule out this diagnosis.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Neoplasms</span><p id="par0060" class="elsevierStylePara elsevierViewall">RA is characterized by persistent immune stimulation, which could lead to polyclonal lymphocytic proliferation, increasing the potential for malignant transformation.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> According to some reports, the risk of cancer is two times higher in RA patients compared with the general population, with the estimated risk in these patients for developing lymphoma<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> ranging from 1.5 to 8.7, while the relative risk of developing non-Hodgkin's lymphoma in Felty's syndrome is closest to 13.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Anti-TNF drugs do not seem to increase the incidence of lymphoma.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Current disease in this case includes a series of hematological symptoms (weight loss, hepatosplenomegaly, leukopenia, anemia, thrombocytopenia) that made us suspect lymphoma. However, the absence of lymphadenopathy confirmed by a CT scan and negative results on bone marrow and liver biopsy allowed us to exclude them.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Amyloidosis</span><p id="par0065" class="elsevierStylePara elsevierViewall">Another rare disease with a poor prognosis associated with longstanding RA patients who present with systemic symptoms, hepatomegaly, cardiomyopathy, neuropathy, purpura and proteinuria, is amyloidosis.</p><p id="par0070" class="elsevierStylePara elsevierViewall">It is characterized by the extracellular accumulation of amorphous, eosinophilic hyaline material.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The diagnosis is established by Congo Red staining of rectal mucosa, abdominal fat, and tissues involved.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In this patient, no such amorphous material was found in the liver tissue.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Felty's Syndrome</span><p id="par0075" class="elsevierStylePara elsevierViewall">It occurs in <1% of RA (10–15 years since disease onset) with positive RF and severe joint disease (erosions, dislocations) contrasting with absent or moderate joint inflammation and accompanied by extra-articular manifestations (weight loss, brown pigmentation on the pretibial area, ulcers on the lower limbs, subcutaneous nodules, lymphadenopathy, and hepatosplenomegaly as well as Sjögren syndrome).</p><p id="par0080" class="elsevierStylePara elsevierViewall">60%–70% occurs in women 50–70 years of age, and is characterized by the triad of RA, persistent neutropenia (<2000/mm<span class="elsevierStyleSup">3</span>) and no other reason that explains it, and splenomegaly, with a strong association with HLA-DR4 (nearly 95% of cases).<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12–15</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The clinician should consider this diagnosis as likely given the time since disease onset (15) and the characteristics of the disease (positive RF, erosions), and neutropenia and splenomegaly accompanied with weight loss, pigmented lesions and leg ulcers.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Pseudo-Felty Syndrome</span><p id="par0090" class="elsevierStylePara elsevierViewall">The proliferation of large granular lymphocytes, also called pseudo-Felty's syndrome, is a rare systemic complications (<0.6%) of RA. It is characterized by the presence of persistent neutropenia, lymphocytosis and splenomegaly, which in the absence of proper treatment can progress in 3%–14% of cases to large granular lymphocyte leukemia.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Approximately 30%–40% of patients with Felty's syndrome presents an expansion of large granular lymphocytes in peripheral blood (lymphocytosis <span class="elsevierStyleHsp" style=""></span>>0.5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/l) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13,16,17</span></a> This accounts for 5%–10% of circulating mononuclear cells which morphologically are large (15–18<span class="elsevierStyleHsp" style=""></span>μ in diameter), round or have an indented nucleus and abundant cytoplasm with azurophilic granules (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> When associated with clonal invasion of the bone marrow, spleen or liver, it is called large granular lymphocyte leukemia. This is a low-grade malignancy, which is accompanied by neutropenia, anemia, thrombocytopenia and high susceptibility to infection.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The patient in this case had long-standing RA with severe joint damage and serious sequelae, along with clinical manifestations similar to Felty's syndrome, but without lymphocytosis or large granular lymphocytes in the peripheral blood smear, so this diagnosis was also discarded.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Hepatic Nodular Regenerative Hyperplasia</span><p id="par0100" class="elsevierStylePara elsevierViewall">The presence of significant liver disease in patients with RA is rare. When a significant liver disease occurs, it is usually due to autoimmune systemic involvement which also compromises the liver, or coinfection with hepatotropic viruses such as Hepatitis B and C viruses, or treatment-associated hepatotoxicity.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Hepatic nodular regenerative hyperplasia (HNRH) is a rare disorder first described in 1953 by Ranstrom as “miliary hepatocellular adenomatosis” and has many synonyms, including non-cirrhotic portal hypertension, diffuse nodular hyperplasia and nodular transformation of the liver.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Steiner Coind called it nodular regenerative hyperplasia, the currently accepted term for this lesion, characterized by secondary liver nodules, hepatocyte hyperplasia with absent or low fibrosis and portal hypertension. The prognosis is generally good, unlike portal hypertension due to cirrhosis. Both are easily confused, so it is essential to perform a liver biopsy.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Clinical Diagnosis of the Presenter</span><p id="par0110" class="elsevierStylePara elsevierViewall">Our patient had the clinical features of RA associated with Felty's syndrome.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Integrating this data with Doppler ultrasound of hepatic vessels, which showed dilatation of the portal vein with signs of portal hypertension (ascites and peripheral pancytopenia secondary to splenomegaly), and having ruled out other causes of hepatosplenomegaly, we assumed that the patient had HNRH as an autoimmune condition secondary to the underlying disease, making a liver biopsy the necessary diagnostic test to confirm the diagnosis.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Final Result and Comment</span><p id="par0120" class="elsevierStylePara elsevierViewall">The liver biopsy was a diagnostic test, demonstrating the presence of parenchymal nodularity and hepatocyte regeneration with preserved portal tracts without evidence of significant fibrosis and negative Congo red staining (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Nodular regenerative hyperplasia is a rare condition that affects both sexes and is usually found in association with many diseases (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), with RA and Felty's syndrome the most frequent.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21,23,24</span></a> HNRH patients may be asymptomatic or present with recurrent abdominal pain, systemic symptoms, signs of hypersplenism (splenomegaly or hematologic abnormalities) and signs of portal hypertension (such as ascites, bleeding of esophageal varices, or splenomegaly). Laboratory tests show mild abnormal liver function tests in a nonspecific manner (mainly elevated aspartate aminotransferase, alanine aminotransferase, GGT and alkaline phosphatase).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">68% of patients have positive antinuclear antibodies and a similar percentage of patients are positive for RF. With regard to the pathogenesis, several hypotheses have been proposed: (a) increase of portal blood flow due to an increase in splenic flow; (b) primary vascular injury, for example, RA-associated vasculitis, and (c) altered hepatic blood flow due to hepatic ischemia.</p><p id="par0135" class="elsevierStylePara elsevierViewall">In 1998, Perez Ruiz et al. showed a possible role of antiphospholipid antibodies in its pathogenesis.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">On the other hand, normal findings on needle biopsy do not exclude the diagnosis because, although HNRH diffusely involves the liver, it does so in patches and the degree of nodularity may vary from one part of the liver to another. Treatment focuses on correcting the underlying cause (autoimmune disease, hematologic disorders, drugs).</p><p id="par0145" class="elsevierStylePara elsevierViewall">Although these patients have a relatively benign prognosis compared with cirrhotic portal hypertension, a number of patients require splenectomy and referral to address complications such as pancytopenia and gastrointestinal bleeding secondary to esophageal varices. Liver transplantation is rarely required and is reserved for patients with hepatic impairment.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,26</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In conclusion, HNRH is a complication that can occur during the development of autoimmune diseases, which should be considered in cases with hepatomegaly, persistent abnormalities of liver function tests and/or signs of portal hypertension.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Ethical Responsibilities</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Protection of people and animals</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare this research did not perform experiments on humans or animals.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data confidentiality</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors state that no patient data appear in this article.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Right to privacy and informed consent</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors have obtained the informed consent of patients and/or subjects referred to in the article. This document is in the possession of the corresponding author.</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of Interest</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to state.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres528603" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec548841" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres528604" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec548842" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case Presentation" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Differential Diagnosis" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Infections" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Neoplasms" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Amyloidosis" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Felty's Syndrome" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Pseudo-Felty Syndrome" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Hepatic Nodular Regenerative Hyperplasia" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Clinical Diagnosis of the Presenter" ] ] ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Final Result and Comment" ] 7 => array:3 [ "identificador" => "sec0055" "titulo" => "Ethical Responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Data confidentiality" ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflict of Interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-03-27" "fechaAceptado" => "2014-09-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec548841" "palabras" => array:3 [ 0 => "Hepatomegaly" 1 => "Arthritis rheumatoid" 2 => "Spleen enlargement" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec548842" "palabras" => array:3 [ 0 => "Hepatomegalia" 1 => "Artritis reumatoide" 2 => "Esplenomegalia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We describe the case of a 51-year-old woman with a seropositive, erosive, and non-nodular rheumatoid arthritis of 15 years of evolution. The patient had poor compliance with medical visits and treatment. She came to the clinic with persistent pancytopenia and spleen and liver enlargement. Liver and bone marrow biopsies were carried out and amyloidosis, neoplasias and infections were ruled out.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We discuss the differential diagnosis of pancytopenia and spleen and liver enlargement in a long-standing rheumatoid arthritis patient.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se describe a una paciente de 51 años de edad con artritis reumatoide de 15 años de evolución, seropositiva –factor reumatoide positivo y anticuerpos antipéptido citrulinado positivos–, erosiva, no nodular, con poca adherencia al tratamiento y controles médicos, que presentó un cuadro caracterizado por pancitopenia persistente y hepatoesplenomegalia. La biopsia hepática y de médula ósea descartó tumores, amiloidosis e infecciones.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se discute el diagnóstico diferencial de pancitopenia y hepatoesplenomegalia en una paciente con artritis reumatoide de larga evolución.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Bedoya ME, Ceccato F, Paira S. Hepatomegalia y esplenomegalia en una paciente con artritis reumatoide. Reumatol Clin. 2015;11:227–231.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 834 "Ancho" => 996 "Tamanyo" => 92891 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">CT scan of the abdomen showing hepatomegaly and dilated portal and splenic veins.</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" => 1014 "Ancho" => 996 "Tamanyo" => 98324 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Peripheral blood smear: large granular lymphocytes.</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" => 1365 "Ancho" => 1792 "Tamanyo" => 683614 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Liver biopsy. (A) Masson trichrome (×4) where signs of hepatocyte regeneration without intervening sinusoids and no evidence of fibrosis was observed. (B) Focus of intrahepatic cholestasis. (C and D) Liver parenchyma with preserved portal space.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Taken from Rosenstein and Kramer<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and Shah et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>" "tabla" => array:2 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">ANA, antinuclear antibodies; RF: rheumatoid factor.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Felty's syndrome \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pseudo-Felty syndrome \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Extra-articular manifestations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Common \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Common \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Erosive arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Common \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Common \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Recurrent infections \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Common \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Common \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Splenomegaly \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Common \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Common \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Leukemia progression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rare \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3%–14% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Spontaneous remission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0%–22% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0%–14% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">WBC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal/low \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Lymphocytosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Absent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Present \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">RF, ANA (positive) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Common \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Common \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Response to splenectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Improvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Exacerbation \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab851794.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Clinical and Laboratory Differences Between Felty's Syndrome and Pseudo-Felty.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Taken from Malnick et al.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>" "tabla" => array:2 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">RA: rheumatoid arthritis; PBC: primary biliary cirrhosis; CHF: congestive heart failure; SLE: systemic lupus erythematosus; PAN: polyarteritis nodosa; POEMS: polyneuropathy, organomegaly, M protein, organomegaly, skin disorders; ITP: idiopathic thrombocytopenic purpura; APS: antiphospholipid syndrome; TB: tuberculosis.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Rheumatic \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Hematologic \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pharmacological \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Congenital \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Other \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">RA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ITP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Azathioprine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Congenital absence of portal vein \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Toxic oil syndrome \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Felty's syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Polycythemia vera \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Busulfan \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cardiac abnormalities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Metastasis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">SLE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Essential thrombocytosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Doxorubicin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PBC \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">PAN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sickle cell \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cyclophosphamide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Celiac disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Systemic sclerosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Macroglobulinemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Chlorambucil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CHF \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">APS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Myeloid metaplasia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bleomycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TBC \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">CREST syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lymphocytic Leukemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">POEMS Syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hodgkin and non-Hodgkin lymphoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab851795.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Conditions Associated 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Year/Month | Html | Total | |
---|---|---|---|
2024 November | 18 | 22 | 40 |
2024 October | 166 | 50 | 216 |
2024 September | 152 | 33 | 185 |
2024 August | 168 | 47 | 215 |
2024 July | 171 | 54 | 225 |
2024 June | 172 | 86 | 258 |
2024 May | 210 | 54 | 264 |
2024 April | 163 | 22 | 185 |
2024 March | 157 | 45 | 202 |
2024 February | 161 | 49 | 210 |
2024 January | 140 | 24 | 164 |
2023 December | 124 | 27 | 151 |
2023 November | 146 | 29 | 175 |
2023 October | 209 | 35 | 244 |
2023 September | 188 | 49 | 237 |
2023 August | 143 | 15 | 158 |
2023 July | 130 | 41 | 171 |
2023 June | 134 | 31 | 165 |
2023 May | 145 | 26 | 171 |
2023 April | 124 | 6 | 130 |
2023 March | 200 | 31 | 231 |
2023 February | 192 | 34 | 226 |
2023 January | 177 | 27 | 204 |
2022 December | 215 | 42 | 257 |
2022 November | 221 | 35 | 256 |
2022 October | 235 | 30 | 265 |
2022 September | 205 | 45 | 250 |
2022 August | 199 | 50 | 249 |
2022 July | 184 | 52 | 236 |
2022 June | 202 | 40 | 242 |
2022 May | 233 | 39 | 272 |
2022 April | 236 | 56 | 292 |
2022 March | 268 | 54 | 322 |
2022 February | 314 | 36 | 350 |
2022 January | 314 | 44 | 358 |
2021 December | 263 | 46 | 309 |
2021 November | 227 | 56 | 283 |
2021 October | 256 | 66 | 322 |
2021 September | 217 | 56 | 273 |
2021 August | 211 | 64 | 275 |
2021 July | 206 | 42 | 248 |
2021 June | 273 | 54 | 327 |
2021 May | 306 | 58 | 364 |
2021 April | 704 | 131 | 835 |
2021 March | 409 | 39 | 448 |
2021 February | 262 | 32 | 294 |
2021 January | 254 | 41 | 295 |
2020 December | 246 | 48 | 294 |
2020 November | 283 | 47 | 330 |
2020 October | 153 | 55 | 208 |
2020 September | 220 | 56 | 276 |
2020 August | 185 | 42 | 227 |
2020 July | 139 | 30 | 169 |
2020 June | 150 | 42 | 192 |
2020 May | 148 | 23 | 171 |
2020 April | 89 | 13 | 102 |
2020 March | 24 | 5 | 29 |
2018 December | 2 | 0 | 2 |
2018 May | 19 | 1 | 20 |
2018 April | 342 | 7 | 349 |
2018 March | 274 | 7 | 281 |
2018 February | 197 | 8 | 205 |
2018 January | 216 | 8 | 224 |
2017 December | 203 | 9 | 212 |
2017 November | 225 | 13 | 238 |
2017 October | 219 | 8 | 227 |
2017 September | 170 | 10 | 180 |
2017 August | 210 | 20 | 230 |
2017 July | 229 | 17 | 246 |
2017 June | 272 | 26 | 298 |
2017 May | 347 | 8 | 355 |
2017 April | 325 | 16 | 341 |
2017 March | 397 | 16 | 413 |
2017 February | 532 | 18 | 550 |
2017 January | 254 | 9 | 263 |
2016 December | 249 | 13 | 262 |
2016 November | 274 | 9 | 283 |
2016 October | 269 | 10 | 279 |
2016 September | 345 | 3 | 348 |
2016 August | 285 | 6 | 291 |
2016 July | 123 | 8 | 131 |
2015 December | 2 | 0 | 2 |
2015 November | 1 | 19 | 20 |
2015 October | 3 | 25 | 28 |
2015 September | 3 | 0 | 3 |
2015 August | 6 | 55 | 61 |
2015 July | 47 | 29 | 76 |