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leading to a liver biopsy&#46;</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&#47;day&#44; methotrexate 10<span class="elsevierStyleHsp" style=""></span>mg&#47;week&#44; leflunomide 20<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; folic acid&#44; calcium and vitamin D&#44; presenting inactive RA with pancytopenia&#44; but no neutropenia or bleeding&#46;</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&#44; the first step in diagnostic reasoning should be to ask whether it is due to concomitant conditions&#44; treatment&#44; or if it is secondary to the underlying disease&#46;</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&#46;<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&#44; comorbidities&#44; advanced age&#44; leukopenia&#44; and therapy with corticosteroids and biologics&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The most common infections are the upper respiratory tract&#44; skin and soft tissue&#44; bones and joints&#46;<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 &#40;histoplasmosis&#44; tuberculosis&#44; leishmaniasis&#44; <span class="elsevierStyleItalic">Pneumocystis carinii</span>&#41; among patients with rheumatic diseases has increased&#44; especially since they share several clinical features such as fever&#44; fatigue&#44; chest pain&#44; pleural effusion&#44; diffuse pulmonary infiltrates&#44; pericarditis&#44; myalgia&#44; epistaxis&#44; joint pain&#44; arthritis&#44; erythema nodosum&#44; diffuse papules&#44; lesions in the oropharynx&#44; hepatosplenomegaly&#44; lymphadenopathy&#44; stroke&#44; seizures&#44; endocarditis&#44; anemia&#44; leukopenia&#44; thrombocytopenia&#44; elevated liver enzymes and bilirubin&#44; and uveitis&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Occasionally&#44; histoplasmosis is first manifested by extrapulmonary organ involvement&#46; These isolated lesions are usually considered manifestations of disseminated disease&#44; despite the lack of lung involvement&#46; This situation may mimic other diseases&#44; such as Felty&#39;s syndrome&#44; 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&#44;5</span></a> in an outpatient setting&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Therefore&#44; although our patient came from an endemic area &#40;the Argentine coast&#41; and histoplasmosis may mimic a flare of RA or an extra-articular manifestation of it &#40;Felty&#39;s syndrome&#58; fatigue&#44; joint pain&#44; arthritis&#44; pleural effusion&#44; hepatosplenomegaly&#44; pancytopenia and abnormal liver function&#41;&#44; serology&#44; blood&#44; bone marrow and liver cultures were negative for histoplasmosis and deep mycoses&#44; allowing us to rule out this diagnosis&#46;</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&#44; which could lead to polyclonal lymphocytic proliferation&#44; increasing the potential for malignant transformation&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> According to some reports&#44; the risk of cancer is two times higher in RA patients compared with the general population&#44; with the estimated risk in these patients for developing lymphoma<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> ranging from 1&#46;5 to 8&#46;7&#44; while the relative risk of developing non-Hodgkin&#39;s lymphoma in Felty&#39;s syndrome is closest to 13&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Anti-TNF drugs do not seem to increase the incidence of lymphoma&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Current disease in this case includes a series of hematological symptoms &#40;weight loss&#44; hepatosplenomegaly&#44; leukopenia&#44; anemia&#44; thrombocytopenia&#41; that made us suspect lymphoma&#46; However&#44; the absence of lymphadenopathy confirmed by a CT scan and negative results on bone marrow and liver biopsy allowed us to exclude them&#46;</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&#44; hepatomegaly&#44; cardiomyopathy&#44; neuropathy&#44; purpura and proteinuria&#44; is amyloidosis&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">It is characterized by the extracellular accumulation of amorphous&#44; eosinophilic hyaline material&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The diagnosis is established by Congo Red staining of rectal mucosa&#44; abdominal fat&#44; and tissues involved&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In this patient&#44; no such amorphous material was found in the liver tissue&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Felty&#39;s Syndrome</span><p id="par0075" class="elsevierStylePara elsevierViewall">It occurs in &#60;1&#37; of RA &#40;10&#8211;15 years since disease onset&#41; with positive RF and severe joint disease &#40;erosions&#44; dislocations&#41; contrasting with absent or moderate joint inflammation and accompanied by extra-articular manifestations &#40;weight loss&#44; brown pigmentation on the pretibial area&#44; ulcers on the lower limbs&#44; subcutaneous nodules&#44; lymphadenopathy&#44; and hepatosplenomegaly as well as Sj&#246;gren syndrome&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">60&#37;&#8211;70&#37; occurs in women 50&#8211;70 years of age&#44; and is characterized by the triad of RA&#44; persistent neutropenia &#40;&#60;2000&#47;mm<span class="elsevierStyleSup">3</span>&#41; and no other reason that explains it&#44; and splenomegaly&#44; with a strong association with HLA-DR4 &#40;nearly 95&#37; of cases&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;15</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The clinician should consider this diagnosis as likely given the time since disease onset &#40;15&#41; and the characteristics of the disease &#40;positive RF&#44; erosions&#41;&#44; and neutropenia and splenomegaly accompanied with weight loss&#44; pigmented lesions and leg ulcers&#46;</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&#44; also called pseudo-Felty&#39;s syndrome&#44; is a rare systemic complications &#40;&#60;0&#46;6&#37;&#41; of RA&#46; It is characterized by the presence of persistent neutropenia&#44; lymphocytosis and splenomegaly&#44; which in the absence of proper treatment can progress in 3&#37;&#8211;14&#37; of cases to large granular lymphocyte leukemia&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Approximately 30&#37;&#8211;40&#37; of patients with Felty&#39;s syndrome presents an expansion of large granular lymphocytes in peripheral blood &#40;lymphocytosis <span class="elsevierStyleHsp" style=""></span>&#62;0&#46;5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;l&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13&#44;16&#44;17</span></a> This accounts for 5&#37;&#8211;10&#37; of circulating mononuclear cells which morphologically are large &#40;15&#8211;18<span class="elsevierStyleHsp" style=""></span>&#956; in diameter&#41;&#44; round or have an indented nucleus and abundant cytoplasm with azurophilic granules &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> When associated with clonal invasion of the bone marrow&#44; spleen or liver&#44; it is called large granular lymphocyte leukemia&#46; This is a low-grade malignancy&#44; which is accompanied by neutropenia&#44; anemia&#44; thrombocytopenia and high susceptibility to infection&#46;<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&#44; along with clinical manifestations similar to Felty&#39;s syndrome&#44; but without lymphocytosis or large granular lymphocytes in the peripheral blood smear&#44; so this diagnosis was also discarded&#46;</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&#46; When a significant liver disease occurs&#44; it is usually due to autoimmune systemic involvement which also compromises the liver&#44; or coinfection with hepatotropic viruses such as Hepatitis B and C viruses&#44; or treatment-associated hepatotoxicity&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Hepatic nodular regenerative hyperplasia &#40;HNRH&#41; is a rare disorder first described in 1953 by Ranstrom as &#8220;miliary hepatocellular adenomatosis&#8221; and has many synonyms&#44; including non-cirrhotic portal hypertension&#44; diffuse nodular hyperplasia and nodular transformation of the liver&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Steiner Coind called it nodular regenerative hyperplasia&#44; the currently accepted term for this lesion&#44; characterized by secondary liver nodules&#44; hepatocyte hyperplasia with absent or low fibrosis and portal hypertension&#46; The prognosis is generally good&#44; unlike portal hypertension due to cirrhosis&#46; Both are easily confused&#44; so it is essential to perform a liver biopsy&#46;<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&#39;s syndrome&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Integrating this data with Doppler ultrasound of hepatic vessels&#44; which showed dilatation of the portal vein with signs of portal hypertension &#40;ascites and peripheral pancytopenia secondary to splenomegaly&#41;&#44; and having ruled out other causes of hepatosplenomegaly&#44; we assumed that the patient had HNRH as an autoimmune condition secondary to the underlying disease&#44; making a liver biopsy the necessary diagnostic test to confirm the diagnosis&#46;</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&#44; demonstrating the presence of parenchymal nodularity and hepatocyte regeneration with preserved portal tracts without evidence of significant fibrosis and negative Congo red staining &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</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 &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; with RA and Felty&#39;s syndrome the most frequent&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;23&#44;24</span></a> HNRH patients may be asymptomatic or present with recurrent abdominal pain&#44; systemic symptoms&#44; signs of hypersplenism &#40;splenomegaly or hematologic abnormalities&#41; and signs of portal hypertension &#40;such as ascites&#44; bleeding of esophageal varices&#44; or splenomegaly&#41;&#46; Laboratory tests show mild abnormal liver function tests in a nonspecific manner &#40;mainly elevated aspartate aminotransferase&#44; alanine aminotransferase&#44; GGT and alkaline phosphatase&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">68&#37; of patients have positive antinuclear antibodies and a similar percentage of patients are positive for RF&#46; With regard to the pathogenesis&#44; several hypotheses have been proposed&#58; &#40;a&#41; increase of portal blood flow due to an increase in splenic flow&#59; &#40;b&#41; primary vascular injury&#44; for example&#44; RA-associated vasculitis&#44; and &#40;c&#41; altered hepatic blood flow due to hepatic ischemia&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In 1998&#44; Perez Ruiz et al&#46; showed a possible role of antiphospholipid antibodies in its pathogenesis&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">On the other hand&#44; normal findings on needle biopsy do not exclude the diagnosis because&#44; although HNRH diffusely involves the liver&#44; it does so in patches and the degree of nodularity may vary from one part of the liver to another&#46; Treatment focuses on correcting the underlying cause &#40;autoimmune disease&#44; hematologic disorders&#44; drugs&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Although these patients have a relatively benign prognosis compared with cirrhotic portal hypertension&#44; a number of patients require splenectomy and referral to address complications such as pancytopenia and gastrointestinal bleeding secondary to esophageal varices&#46; Liver transplantation is rarely required and is reserved for patients with hepatic impairment&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In conclusion&#44; HNRH is a complication that can occur during the development of autoimmune diseases&#44; which should be considered in cases with hepatomegaly&#44; persistent abnormalities of liver function tests and&#47;or signs of portal hypertension&#46;</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&#46;</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&#46;</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&#47;or subjects referred to in the article&#46; This document is in the possession of the corresponding author&#46;</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&#46;</p></span></span>"
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          "identificador" => "xres528603"
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        1 => array:2 [
          "identificador" => "xpalclavsec548841"
          "titulo" => "Keywords"
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          "identificador" => "xres528604"
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          "identificador" => "xpalclavsec548842"
          "titulo" => "Palabras clave"
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          "identificador" => "sec0005"
          "titulo" => "Case Presentation"
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        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&#39;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"
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          "titulo" => "Final Result and Comment"
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          "titulo" => "Ethical Responsibilities"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Protection of people and animals"
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            1 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Data confidentiality"
            ]
            2 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Right to privacy and informed consent"
            ]
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          "identificador" => "sec0075"
          "titulo" => "Conflict of Interest"
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        9 => array:1 [
          "titulo" => "References"
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    "fechaRecibido" => "2014-03-27"
    "fechaAceptado" => "2014-09-27"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:3 [
            0 => "Hepatomegaly"
            1 => "Arthritis rheumatoid"
            2 => "Spleen enlargement"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
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            1 => "Artritis reumatoide"
            2 => "Esplenomegalia"
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    "resumen" => array:2 [
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        "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&#44; erosive&#44; and non-nodular rheumatoid arthritis of 15 years of evolution&#46; The patient had poor compliance with medical visits and treatment&#46; She came to the clinic with persistent pancytopenia and spleen and liver enlargement&#46; Liver and bone marrow biopsies were carried out and amyloidosis&#44; neoplasias and infections were ruled out&#46;</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&#46;</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 a&#241;os de edad con artritis reumatoide de 15 a&#241;os de evoluci&#243;n&#44; seropositiva &#8211;factor reumatoide positivo y anticuerpos antip&#233;ptido citrulinado positivos&#8211;&#44; erosiva&#44; no nodular&#44; con poca adherencia al tratamiento y controles m&#233;dicos&#44; que present&#243; un cuadro caracterizado por pancitopenia persistente y hepatoesplenomegalia&#46; La biopsia hep&#225;tica y de m&#233;dula &#243;sea descart&#243; tumores&#44; amiloidosis e infecciones&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se discute el diagn&#243;stico diferencial de pancitopenia y hepatoesplenomegalia en una paciente con artritis reumatoide de larga evoluci&#243;n&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Bedoya ME&#44; Ceccato F&#44; Paira S&#46; Hepatomegalia y esplenomegalia en una paciente con artritis reumatoide&#46; Reumatol Clin&#46; 2015&#59;11&#58;227&#8211;231&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">CT scan of the abdomen showing hepatomegaly and dilated portal and splenic veins&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Peripheral blood smear&#58; large granular lymphocytes&#46;</p>"
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        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Liver biopsy&#46; &#40;A&#41; Masson trichrome &#40;&#215;4&#41; where signs of hepatocyte regeneration without intervening sinusoids and no evidence of fibrosis was observed&#46; &#40;B&#41; Focus of intrahepatic cholestasis&#46; &#40;C and D&#41; Liver parenchyma with preserved portal space&#46;</p>"
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        "fuente" => "Taken from Rosenstein and Kramer<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and Shah et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>"
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          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">ANA&#44; antinuclear antibodies&#59; RF&#58; rheumatoid factor&#46;</p>"
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                  <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">&nbsp;\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&#39;s syndrome&nbsp;\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&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#37;&#8211;14&#37;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#37;&#8211;22&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#37;&#8211;14&#37;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&#47;low&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Absent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Present&nbsp;\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&#44; ANA &#40;positive&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Improvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exacerbation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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        "fuente" => "Taken from Malnick et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">RA&#58; rheumatoid arthritis&#59; PBC&#58; primary biliary cirrhosis&#59; CHF&#58; congestive heart failure&#59; SLE&#58; systemic lupus erythematosus&#59; PAN&#58; polyarteritis nodosa&#59; POEMS&#58; polyneuropathy&#44; organomegaly&#44; M protein&#44; organomegaly&#44; skin disorders&#59; ITP&#58; idiopathic thrombocytopenic purpura&#59; APS&#58; antiphospholipid syndrome&#59; TB&#58; tuberculosis&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ITP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Azathioprine&nbsp;\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&nbsp;\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&nbsp;\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&#39;s syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Polycythemia vera&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Busulfan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cardiac abnormalities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Metastasis&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Essential thrombocytosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Doxorubicin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PBC&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sickle cell&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cyclophosphamide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Celiac disease&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Macroglobulinemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chlorambucil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CHF&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Myeloid metaplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bleomycin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TBC&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lymphocytic Leukemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Conditions Associated With Nodular Hepatic Regenerative Hyperplasia&#46;</p>"
        ]
      ]
    ]
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      "titulo" => "References"
      "seccion" => array:1 [
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          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:26 [
            0 => array:3 [
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              "etiqueta" => "1"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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            3 => array:3 [
              "identificador" => "bib0020"
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                      "autores" => array:1 [
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                          "etal" => false
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                            1 => "J&#46;H&#46; Klippel"
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Clinicpathologic conference
Spleen and Liver Enlargement in a Patient With Rheumatoid Arthritis
Hepatomegalia y esplenomegalia en una paciente con artritis reumatoide
María Eugenia Bedoya
Corresponding author
eugebedoya11@gmail.com

Corresponding author.
, Federico Ceccato, Sergio Paira
Sección de Reumatología, Hospital J. M. Cullen, Santa Fe, Argentina
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comorbidities&#44; advanced age&#44; leukopenia&#44; and therapy with corticosteroids and biologics&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The most common infections are the upper respiratory tract&#44; skin and soft tissue&#44; bones and joints&#46;<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 &#40;histoplasmosis&#44; tuberculosis&#44; leishmaniasis&#44; <span class="elsevierStyleItalic">Pneumocystis carinii</span>&#41; among patients with rheumatic diseases has increased&#44; especially since they share several clinical features such as fever&#44; fatigue&#44; chest pain&#44; pleural effusion&#44; diffuse pulmonary infiltrates&#44; pericarditis&#44; myalgia&#44; epistaxis&#44; joint pain&#44; arthritis&#44; erythema nodosum&#44; diffuse papules&#44; lesions in the oropharynx&#44; hepatosplenomegaly&#44; lymphadenopathy&#44; stroke&#44; seizures&#44; endocarditis&#44; anemia&#44; leukopenia&#44; thrombocytopenia&#44; elevated liver enzymes and bilirubin&#44; and uveitis&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Occasionally&#44; histoplasmosis is first manifested by extrapulmonary organ involvement&#46; These isolated lesions are usually considered manifestations of disseminated disease&#44; despite the lack of lung involvement&#46; This situation may mimic other diseases&#44; such as Felty&#39;s syndrome&#44; 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&#44;5</span></a> in an outpatient setting&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Therefore&#44; although our patient came from an endemic area &#40;the Argentine coast&#41; and histoplasmosis may mimic a flare of RA or an extra-articular manifestation of it &#40;Felty&#39;s syndrome&#58; fatigue&#44; joint pain&#44; arthritis&#44; pleural effusion&#44; hepatosplenomegaly&#44; pancytopenia and abnormal liver function&#41;&#44; serology&#44; blood&#44; bone marrow and liver cultures were negative for histoplasmosis and deep mycoses&#44; allowing us to rule out this diagnosis&#46;</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&#44; which could lead to polyclonal lymphocytic proliferation&#44; increasing the potential for malignant transformation&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> According to some reports&#44; the risk of cancer is two times higher in RA patients compared with the general population&#44; with the estimated risk in these patients for developing lymphoma<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> ranging from 1&#46;5 to 8&#46;7&#44; while the relative risk of developing non-Hodgkin&#39;s lymphoma in Felty&#39;s syndrome is closest to 13&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Anti-TNF drugs do not seem to increase the incidence of lymphoma&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Current disease in this case includes a series of hematological symptoms &#40;weight loss&#44; hepatosplenomegaly&#44; leukopenia&#44; anemia&#44; thrombocytopenia&#41; that made us suspect lymphoma&#46; However&#44; the absence of lymphadenopathy confirmed by a CT scan and negative results on bone marrow and liver biopsy allowed us to exclude them&#46;</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&#44; hepatomegaly&#44; cardiomyopathy&#44; neuropathy&#44; purpura and proteinuria&#44; is amyloidosis&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">It is characterized by the extracellular accumulation of amorphous&#44; eosinophilic hyaline material&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The diagnosis is established by Congo Red staining of rectal mucosa&#44; abdominal fat&#44; and tissues involved&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In this patient&#44; no such amorphous material was found in the liver tissue&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Felty&#39;s Syndrome</span><p id="par0075" class="elsevierStylePara elsevierViewall">It occurs in &#60;1&#37; of RA &#40;10&#8211;15 years since disease onset&#41; with positive RF and severe joint disease &#40;erosions&#44; dislocations&#41; contrasting with absent or moderate joint inflammation and accompanied by extra-articular manifestations &#40;weight loss&#44; brown pigmentation on the pretibial area&#44; ulcers on the lower limbs&#44; subcutaneous nodules&#44; lymphadenopathy&#44; and hepatosplenomegaly as well as Sj&#246;gren syndrome&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">60&#37;&#8211;70&#37; occurs in women 50&#8211;70 years of age&#44; and is characterized by the triad of RA&#44; persistent neutropenia &#40;&#60;2000&#47;mm<span class="elsevierStyleSup">3</span>&#41; and no other reason that explains it&#44; and splenomegaly&#44; with a strong association with HLA-DR4 &#40;nearly 95&#37; of cases&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;15</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The clinician should consider this diagnosis as likely given the time since disease onset &#40;15&#41; and the characteristics of the disease &#40;positive RF&#44; erosions&#41;&#44; and neutropenia and splenomegaly accompanied with weight loss&#44; pigmented lesions and leg ulcers&#46;</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&#44; also called pseudo-Felty&#39;s syndrome&#44; is a rare systemic complications &#40;&#60;0&#46;6&#37;&#41; of RA&#46; It is characterized by the presence of persistent neutropenia&#44; lymphocytosis and splenomegaly&#44; which in the absence of proper treatment can progress in 3&#37;&#8211;14&#37; of cases to large granular lymphocyte leukemia&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Approximately 30&#37;&#8211;40&#37; of patients with Felty&#39;s syndrome presents an expansion of large granular lymphocytes in peripheral blood &#40;lymphocytosis <span class="elsevierStyleHsp" style=""></span>&#62;0&#46;5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;l&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13&#44;16&#44;17</span></a> This accounts for 5&#37;&#8211;10&#37; of circulating mononuclear cells which morphologically are large &#40;15&#8211;18<span class="elsevierStyleHsp" style=""></span>&#956; in diameter&#41;&#44; round or have an indented nucleus and abundant cytoplasm with azurophilic granules &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> When associated with clonal invasion of the bone marrow&#44; spleen or liver&#44; it is called large granular lymphocyte leukemia&#46; This is a low-grade malignancy&#44; which is accompanied by neutropenia&#44; anemia&#44; thrombocytopenia and high susceptibility to infection&#46;<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&#44; along with clinical manifestations similar to Felty&#39;s syndrome&#44; but without lymphocytosis or large granular lymphocytes in the peripheral blood smear&#44; so this diagnosis was also discarded&#46;</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&#46; When a significant liver disease occurs&#44; it is usually due to autoimmune systemic involvement which also compromises the liver&#44; or coinfection with hepatotropic viruses such as Hepatitis B and C viruses&#44; or treatment-associated hepatotoxicity&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Hepatic nodular regenerative hyperplasia &#40;HNRH&#41; is a rare disorder first described in 1953 by Ranstrom as &#8220;miliary hepatocellular adenomatosis&#8221; and has many synonyms&#44; including non-cirrhotic portal hypertension&#44; diffuse nodular hyperplasia and nodular transformation of the liver&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Steiner Coind called it nodular regenerative hyperplasia&#44; the currently accepted term for this lesion&#44; characterized by secondary liver nodules&#44; hepatocyte hyperplasia with absent or low fibrosis and portal hypertension&#46; The prognosis is generally good&#44; unlike portal hypertension due to cirrhosis&#46; Both are easily confused&#44; so it is essential to perform a liver biopsy&#46;<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&#39;s syndrome&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Integrating this data with Doppler ultrasound of hepatic vessels&#44; which showed dilatation of the portal vein with signs of portal hypertension &#40;ascites and peripheral pancytopenia secondary to splenomegaly&#41;&#44; and having ruled out other causes of hepatosplenomegaly&#44; we assumed that the patient had HNRH as an autoimmune condition secondary to the underlying disease&#44; making a liver biopsy the necessary diagnostic test to confirm the diagnosis&#46;</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&#44; demonstrating the presence of parenchymal nodularity and hepatocyte regeneration with preserved portal tracts without evidence of significant fibrosis and negative Congo red staining &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</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 &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; with RA and Felty&#39;s syndrome the most frequent&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;23&#44;24</span></a> HNRH patients may be asymptomatic or present with recurrent abdominal pain&#44; systemic symptoms&#44; signs of hypersplenism &#40;splenomegaly or hematologic abnormalities&#41; and signs of portal hypertension &#40;such as ascites&#44; bleeding of esophageal varices&#44; or splenomegaly&#41;&#46; Laboratory tests show mild abnormal liver function tests in a nonspecific manner &#40;mainly elevated aspartate aminotransferase&#44; alanine aminotransferase&#44; GGT and alkaline phosphatase&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">68&#37; of patients have positive antinuclear antibodies and a similar percentage of patients are positive for RF&#46; With regard to the pathogenesis&#44; several hypotheses have been proposed&#58; &#40;a&#41; increase of portal blood flow due to an increase in splenic flow&#59; &#40;b&#41; primary vascular injury&#44; for example&#44; RA-associated vasculitis&#44; and &#40;c&#41; altered hepatic blood flow due to hepatic ischemia&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In 1998&#44; Perez Ruiz et al&#46; showed a possible role of antiphospholipid antibodies in its pathogenesis&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">On the other hand&#44; normal findings on needle biopsy do not exclude the diagnosis because&#44; although HNRH diffusely involves the liver&#44; it does so in patches and the degree of nodularity may vary from one part of the liver to another&#46; Treatment focuses on correcting the underlying cause &#40;autoimmune disease&#44; hematologic disorders&#44; drugs&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Although these patients have a relatively benign prognosis compared with cirrhotic portal hypertension&#44; a number of patients require splenectomy and referral to address complications such as pancytopenia and gastrointestinal bleeding secondary to esophageal varices&#46; Liver transplantation is rarely required and is reserved for patients with hepatic impairment&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In conclusion&#44; HNRH is a complication that can occur during the development of autoimmune diseases&#44; which should be considered in cases with hepatomegaly&#44; persistent abnormalities of liver function tests and&#47;or signs of portal hypertension&#46;</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&#46;</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&#46;</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&#47;or subjects referred to in the article&#46; This document is in the possession of the corresponding author&#46;</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&#46;</p></span></span>"
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          "identificador" => "xres528603"
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        1 => array:2 [
          "identificador" => "xpalclavsec548841"
          "titulo" => "Keywords"
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          "identificador" => "xres528604"
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          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Case Presentation"
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        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"
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            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Amyloidosis"
            ]
            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Felty&#39;s Syndrome"
            ]
            4 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Pseudo-Felty Syndrome"
            ]
            5 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Hepatic Nodular Regenerative Hyperplasia"
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            6 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Clinical Diagnosis of the Presenter"
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        6 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Final Result and Comment"
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        7 => array:3 [
          "identificador" => "sec0055"
          "titulo" => "Ethical Responsibilities"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Protection of people and animals"
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            1 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Data confidentiality"
            ]
            2 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Right to privacy and informed consent"
            ]
          ]
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          "identificador" => "sec0075"
          "titulo" => "Conflict of Interest"
        ]
        9 => array:1 [
          "titulo" => "References"
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    "fechaRecibido" => "2014-03-27"
    "fechaAceptado" => "2014-09-27"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:3 [
            0 => "Hepatomegaly"
            1 => "Arthritis rheumatoid"
            2 => "Spleen enlargement"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
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            0 => "Hepatomegalia"
            1 => "Artritis reumatoide"
            2 => "Esplenomegalia"
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    "resumen" => array:2 [
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        "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&#44; erosive&#44; and non-nodular rheumatoid arthritis of 15 years of evolution&#46; The patient had poor compliance with medical visits and treatment&#46; She came to the clinic with persistent pancytopenia and spleen and liver enlargement&#46; Liver and bone marrow biopsies were carried out and amyloidosis&#44; neoplasias and infections were ruled out&#46;</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&#46;</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 a&#241;os de edad con artritis reumatoide de 15 a&#241;os de evoluci&#243;n&#44; seropositiva &#8211;factor reumatoide positivo y anticuerpos antip&#233;ptido citrulinado positivos&#8211;&#44; erosiva&#44; no nodular&#44; con poca adherencia al tratamiento y controles m&#233;dicos&#44; que present&#243; un cuadro caracterizado por pancitopenia persistente y hepatoesplenomegalia&#46; La biopsia hep&#225;tica y de m&#233;dula &#243;sea descart&#243; tumores&#44; amiloidosis e infecciones&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se discute el diagn&#243;stico diferencial de pancitopenia y hepatoesplenomegalia en una paciente con artritis reumatoide de larga evoluci&#243;n&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Bedoya ME&#44; Ceccato F&#44; Paira S&#46; Hepatomegalia y esplenomegalia en una paciente con artritis reumatoide&#46; Reumatol Clin&#46; 2015&#59;11&#58;227&#8211;231&#46;</p>"
      ]
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">CT scan of the abdomen showing hepatomegaly and dilated portal and splenic veins&#46;</p>"
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        "etiqueta" => "Fig&#46; 2"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Peripheral blood smear&#58; large granular lymphocytes&#46;</p>"
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        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Liver biopsy&#46; &#40;A&#41; Masson trichrome &#40;&#215;4&#41; where signs of hepatocyte regeneration without intervening sinusoids and no evidence of fibrosis was observed&#46; &#40;B&#41; Focus of intrahepatic cholestasis&#46; &#40;C and D&#41; Liver parenchyma with preserved portal space&#46;</p>"
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        "fuente" => "Taken from Rosenstein and Kramer<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and Shah et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>"
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          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">ANA&#44; antinuclear antibodies&#59; RF&#58; rheumatoid factor&#46;</p>"
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                  <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">&nbsp;\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&#39;s syndrome&nbsp;\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&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#37;&#8211;14&#37;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#37;&#8211;22&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#37;&#8211;14&#37;&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&#47;low&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Absent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Present&nbsp;\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&#44; ANA &#40;positive&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Improvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Exacerbation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "fuente" => "Taken from Malnick et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">RA&#58; rheumatoid arthritis&#59; PBC&#58; primary biliary cirrhosis&#59; CHF&#58; congestive heart failure&#59; SLE&#58; systemic lupus erythematosus&#59; PAN&#58; polyarteritis nodosa&#59; POEMS&#58; polyneuropathy&#44; organomegaly&#44; M protein&#44; organomegaly&#44; skin disorders&#59; ITP&#58; idiopathic thrombocytopenic purpura&#59; APS&#58; antiphospholipid syndrome&#59; TB&#58; tuberculosis&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \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&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Congenital absence of portal vein&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Busulfan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cardiac abnormalities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Metastasis&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Essential thrombocytosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Doxorubicin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PBC&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sickle cell&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cyclophosphamide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Celiac disease&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Macroglobulinemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chlorambucil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CHF&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Myeloid metaplasia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bleomycin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TBC&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lymphocytic Leukemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\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&nbsp;\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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Conditions Associated With Nodular Hepatic Regenerative Hyperplasia&#46;</p>"
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    ]
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
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          "bibliografiaReferencia" => array:26 [
            0 => array:3 [
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              "etiqueta" => "1"
              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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Idiomas
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