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and consists of bilateral&#44; symmetrical discoloration of the hands and feet&#59; it is a benign and self-limiting process that does not require treatment&#46; Only in rare cases is acrocyanosis in children caused by Raynaud&#39;s phenomenon and&#44; when this occurs&#44; it needs immediate medical attention in order to prevent complications&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Report</span><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a boy aged 4 years and 10 months who was brought to his health center after having had episodes of cold&#44; pallor and pain in both feet&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The family history included a 43-year-old father who had undergone removal of a benign gallbladder polyp&#44; a healthy 42-year-old mother&#44; 4 healthy older siblings&#44; and paternal grandparents diagnosed with type 2 diabetes mellitus&#46; The patient had been born in an vaginal delivery&#44; after a normal&#44; monitored pregnancy&#46; His ponderal index at birth was in the 75th&#8211;90th percentile&#46; He had no known allergies&#46; At the age of 2 months&#44; he had been hospitalized for acute otitis media&#46; He was up to date with the immunization schedule of his Spanish autonomous community&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient had been brought to his health center after having experienced several episodes of pallor and a sensation of cold&#44; followed by flushing&#44; in both feet up to his ankles&#44; which was accompanied by intense pain lasting approximately 30<span class="elsevierStyleHsp" style=""></span>min&#46; The episodes were not related to abrupt changes in temperature&#44; and the signs disappeared progressively with massage and local warming &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Physical examination during that visit revealed no evidence of discoloration&#44; nor were any anomalies found on palpation of symmetrical distal pulses&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">As these clinical signs led us to suspect Raynaud&#39;s phenomenon&#44; we referred the patient to pediatric rheumatology&#44; where blood tests&#44; including liver and kidney function&#44; and microbiological and autoantibody studies were found to be normal&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the vascular surgery unit&#44; he underwent a Doppler ultrasound study of digital forward flow&#44; which was normal&#46; On qualitative capillaroscopy&#44; there was no evidence of dilation&#44; tortuosity or branching&#44; and capillary function was normal&#59; quantitative assessment of capillaries by capillaroscopy was also normal&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Given that the results of all the studies were normal&#44; the patient was discharged from the hospital&#46; At the present time&#44; the episodes are more sporadic&#46; They continue to subside with massage and local warming&#44; and have no impact on the child&#39;s daily activities&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">The diagnosis in the case described in this article was Raynaud&#39;s phenomenon&#44; based on the clinical course&#44; the results of supplemental tests and the exclusion of other causes&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Raynaud&#39;s phenomenon is caused by vasospasm of the small arteries and arterioles of the fingers and toes&#46; It is triggered by a number of stimuli&#44; including exposure to cold or emotional stress&#46; It can be symmetrical or involve an extremity on only one side&#46; It is attributed mainly to hyperactivity of the sympathetic nervous system&#44; together with an imbalance between vasodilator and vasoconstrictor substances&#46; A number of studies have reported that the cutaneous nerve endings of patients diagnosed with Raynaud&#39;s phenomenon show an inadequate release of a potent vasodilator&#44; the calcitonin-gene related peptide&#46; This primary disorder may become more pronounced when associated with other factors&#44; such as cold or emotional stress&#44; which would trigger a cascade of compounds involved in vasoconstriction&#44; such as catecholamines&#44; endothelin-1&#44; and 5-hydroxytryptamine&#46; These mediators could be the ultimate cause of the endothelial damage seen in more severe cases&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Some studies have suggested that high blood levels of homocysteine may be associated with Raynaud&#39;s phenomenon because of its role&#44; as an atherosclerotic factor&#44; in reducing vasodilation&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Raynaud&#39;s phenomenon appears to have a strong familial component&#44; which has led to the undertaking of genetic studies that have not yet been concluded&#46; 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including autoantibody positivity and anomalies observed in capillaroscopy&#44; which reveals giant capillaries with irregular architecture and&#44; in some cases&#44; an avascular area&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8211;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Primary Raynaud&#39;s phenomenon &#40;previously referred to as Raynaud&#39;s disease&#41;&#58; It presents in the absence of other diseases and the course is usually benign&#46; The findings on capillaroscopy are normal and tests for antinuclear antibodies &#40;ANA&#41; are negative&#44; features that differentiate it from secondary Raynaud&#39;s phenomenon&#46;</p></li></ul></p><p id="par0080" class="elsevierStylePara elsevierViewall">Raynaud&#39;s phenomenon is extremely rare in children&#59; the first report of this disease in children was in 1967&#44; almost exactly 100 years after the initial description&#44; in 1862&#46; In general&#44; according to published series&#44; girls are more predisposed to develop Raynaud&#39;s phenomenon and the onset occurs during the changes observed around menarche&#44; due to the influence of hormones&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The largest cohort studied&#44; published in 2003&#44; involving 123 children with Raynaud&#39;s phenomenon&#44; demonstrated that there is marked heterogeneity in terms of patient age&#44; disease presentation and symptoms&#59; for example&#44; exposure to cold was the major trigger in the majority of the cases &#40;roughly 70&#37;&#41; but&#44; in 10&#37;&#44; no trigger was identified&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Primary Raynaud&#39;s phenomenon had a bimodal presentation&#44; affecting young children and adolescents&#44; and a considerable number of children&#44; the majority under 2 years of age&#44; were initially diagnosed as having acrocyanosis&#46; The clues that should lead us to suspect Raynaud&#39;s phenomenon&#44; rather than acrocyanosis&#44; include the presence of atypical features&#44; like a duration of more than 72<span class="elsevierStyleHsp" style=""></span>h and&#47;or unilateral cyanosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Management of this disease is generally supportive and is based on an accurate diagnosis&#46; Mild forms can be controlled by hygienic measures&#44; such as the avoidance of exposure to cold or stressful situations&#44; with no need for drug therapy&#46; Moderate to severe cases require vasodilator therapy&#44; such as systemic or topical calcium channel blockers&#46; In very severe cases&#44; intravenous infusion of prostacyclin&#44; endothelin-1 receptor antagonists&#44; inhibitors of phosphodiesterase-5&#44; antiplatelet agents and antithrombotic therapy are being used with variable results&#46; Surgery is reserved for extreme cases in which there is no response to the different drug therapies&#44; and consists of digital sympathectomy&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In recent years&#44; new treatments are being investigated&#44; including selective alpha-2c adrenergic receptor blockers&#44; protein kinase inhibitors and calcitonin gene-related peptide&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In patients with secondary Raynaud&#39;s phenomenon&#44; specific treatment of the underlying disease is critical for controlling the episodes&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Our patient appears to have primary Raynaud&#39;s phenomenon in its mildest form&#44; as indicated by the clinical findings and the results of the tests performed&#46; As we mentioned above&#44; the treatment is supportive and consists in avoiding exposure to intense cold and situations of major stress&#46; We think it is important to point out these cases&#44; as this disease is rare in children and difficult to diagnose because the duration of the episodes is usually limited and&#44; most of them are not evaluated by a physician&#46; Thus&#44; we wish to stress how important it is that the family take photographs during an episode&#44; and we encourage professionals to consider Raynaud&#39;s phenomenon when dealing with similar cases&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical Disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of Interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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Case Report
Raynaud's Phenomenon in Children
Fenómeno de Raynaud en pediatría
Elena Ortega Vicente
Corresponding author
elenaovicente@gmail.com

Corresponding author.
, Mercedes Garrido Redondo
Medical specialist, Pediatrics,, CS Tórtola, Valladolid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Raynaud&#39;s phenomenon was first described in an adult in 1862&#46; It is classically defined as a series of changes in the color of the fingers and&#47;or toes which occur in three distinct phases&#58; first a phase of pallor &#40;white&#41;&#44; followed by a cyanotic phase &#40;blue&#41; and&#44; finally&#44; hyperemia &#40;red&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Not all the patients experience these three phases&#59; in most cases&#44; there is a single phase in which the color of the skin of the fingers or toes changes to a typically bluish color known as acrocyanosis&#44; a circumstance that makes diagnosis more difficult&#46; In contrast to Raynaud&#39;s phenomenon&#44; acrocyanosis is a relatively common finding in infants and small children&#44; and consists of bilateral&#44; symmetrical discoloration of the hands and feet&#59; it is a benign and self-limiting process that does not require treatment&#46; Only in rare cases is acrocyanosis in children caused by Raynaud&#39;s phenomenon and&#44; when this occurs&#44; it needs immediate medical attention in order to prevent complications&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Report</span><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a boy aged 4 years and 10 months who was brought to his health center after having had episodes of cold&#44; pallor and pain in both feet&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The family history included a 43-year-old father who had undergone removal of a benign gallbladder polyp&#44; a healthy 42-year-old mother&#44; 4 healthy older siblings&#44; and paternal grandparents diagnosed with type 2 diabetes mellitus&#46; The patient had been born in an vaginal delivery&#44; after a normal&#44; monitored pregnancy&#46; His ponderal index at birth was in the 75th&#8211;90th percentile&#46; He had no known allergies&#46; At the age of 2 months&#44; he had been hospitalized for acute otitis media&#46; He was up to date with the immunization schedule of his Spanish autonomous community&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient had been brought to his health center after having experienced several episodes of pallor and a sensation of cold&#44; followed by flushing&#44; in both feet up to his ankles&#44; which was accompanied by intense pain lasting approximately 30<span class="elsevierStyleHsp" style=""></span>min&#46; The episodes were not related to abrupt changes in temperature&#44; and the signs disappeared progressively with massage and local warming &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Physical examination during that visit revealed no evidence of discoloration&#44; nor were any anomalies found on palpation of symmetrical distal pulses&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">As these clinical signs led us to suspect Raynaud&#39;s phenomenon&#44; we referred the patient to pediatric rheumatology&#44; where blood tests&#44; including liver and kidney function&#44; and microbiological and autoantibody studies were found to be normal&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the vascular surgery unit&#44; he underwent a Doppler ultrasound study of digital forward flow&#44; which was normal&#46; On qualitative capillaroscopy&#44; there was no evidence of dilation&#44; tortuosity or branching&#44; and capillary function was normal&#59; quantitative assessment of capillaries by capillaroscopy was also normal&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Given that the results of all the studies were normal&#44; the patient was discharged from the hospital&#46; At the present time&#44; the episodes are more sporadic&#46; They continue to subside with massage and local warming&#44; and have no impact on the child&#39;s daily activities&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">The diagnosis in the case described in this article was Raynaud&#39;s phenomenon&#44; based on the clinical course&#44; the results of supplemental tests and the exclusion of other causes&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Raynaud&#39;s phenomenon is caused by vasospasm of the small arteries and arterioles of the fingers and toes&#46; It is triggered by a number of stimuli&#44; including exposure to cold or emotional stress&#46; It can be symmetrical or involve an extremity on only one side&#46; It is attributed mainly to hyperactivity of the sympathetic nervous system&#44; together with an imbalance between vasodilator and vasoconstrictor substances&#46; A number of studies have reported that the cutaneous nerve endings of patients diagnosed with Raynaud&#39;s phenomenon show an inadequate release of a potent vasodilator&#44; the calcitonin-gene related peptide&#46; This primary disorder may become more pronounced when associated with other factors&#44; such as cold or emotional stress&#44; which would trigger a cascade of compounds involved in vasoconstriction&#44; such as catecholamines&#44; endothelin-1&#44; and 5-hydroxytryptamine&#46; These mediators could be the ultimate cause of the endothelial damage seen in more severe cases&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Some studies have suggested that high blood levels of homocysteine may be associated with Raynaud&#39;s phenomenon because of its role&#44; as an atherosclerotic factor&#44; in reducing vasodilation&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Raynaud&#39;s phenomenon appears to have a strong familial component&#44; which has led to the undertaking of genetic studies that have not yet been concluded&#46; It is classified as&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8211;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Secondary Raynaud&#39;s phenomenon&#58; Normally&#44; there is a well-defined primary disease&#44; such as a connective tissue disease &#40;systemic lupus erythematosus&#44; polyarteritis nodosa or scleroderma&#41;&#44; repeated trauma &#40;work involving vibratory tools&#41;&#44; drugs &#40;interferon &#945;&#44; bleomycin&#41;&#44; infections&#44; metabolic diseases &#40;cryoglobulinemia&#44; atherosclerosis&#41;&#44; exposure to chemical agents &#40;tobacco&#44; plastics&#41;&#44; CREST &#40;calcinosis&#44; Raynaud&#39;s phenomenon&#44; esophageal dysmotility&#44; sclerodactyly and telangiectasia&#41;&#44; etc&#46; It is associated with a high morbidity rate&#44; and can even produce gangrene in the fingers or toes&#46; It requires chronic treatment and the results of ancillary tests usually show alterations&#44; including autoantibody positivity and anomalies observed in capillaroscopy&#44; which reveals giant capillaries with irregular architecture and&#44; in some cases&#44; an avascular area&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8211;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Primary Raynaud&#39;s phenomenon &#40;previously referred to as Raynaud&#39;s disease&#41;&#58; It presents in the absence of other diseases and the course is usually benign&#46; The findings on capillaroscopy are normal and tests for antinuclear antibodies &#40;ANA&#41; are negative&#44; features that differentiate it from secondary Raynaud&#39;s phenomenon&#46;</p></li></ul></p><p id="par0080" class="elsevierStylePara elsevierViewall">Raynaud&#39;s phenomenon is extremely rare in children&#59; the first report of this disease in children was in 1967&#44; almost exactly 100 years after the initial description&#44; in 1862&#46; In general&#44; according to published series&#44; girls are more predisposed to develop Raynaud&#39;s phenomenon and the onset occurs during the changes observed around menarche&#44; due to the influence of hormones&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The largest cohort studied&#44; published in 2003&#44; involving 123 children with Raynaud&#39;s phenomenon&#44; demonstrated that there is marked heterogeneity in terms of patient age&#44; disease presentation and symptoms&#59; for example&#44; exposure to cold was the major trigger in the majority of the cases &#40;roughly 70&#37;&#41; but&#44; in 10&#37;&#44; no trigger was identified&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Primary Raynaud&#39;s phenomenon had a bimodal presentation&#44; affecting young children and adolescents&#44; and a considerable number of children&#44; the majority under 2 years of age&#44; were initially diagnosed as having acrocyanosis&#46; The clues that should lead us to suspect Raynaud&#39;s phenomenon&#44; rather than acrocyanosis&#44; include the presence of atypical features&#44; like a duration of more than 72<span class="elsevierStyleHsp" style=""></span>h and&#47;or unilateral cyanosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Management of this disease is generally supportive and is based on an accurate diagnosis&#46; Mild forms can be controlled by hygienic measures&#44; such as the avoidance of exposure to cold or stressful situations&#44; with no need for drug therapy&#46; Moderate to severe cases require vasodilator therapy&#44; such as systemic or topical calcium channel blockers&#46; In very severe cases&#44; intravenous infusion of prostacyclin&#44; endothelin-1 receptor antagonists&#44; inhibitors of phosphodiesterase-5&#44; antiplatelet agents and antithrombotic therapy are being used with variable results&#46; Surgery is reserved for extreme cases in which there is no response to the different drug therapies&#44; and consists of digital sympathectomy&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In recent years&#44; new treatments are being investigated&#44; including selective alpha-2c adrenergic receptor blockers&#44; protein kinase inhibitors and calcitonin gene-related peptide&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In patients with secondary Raynaud&#39;s phenomenon&#44; specific treatment of the underlying disease is critical for controlling the episodes&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Our patient appears to have primary Raynaud&#39;s phenomenon in its mildest form&#44; as indicated by the clinical findings and the results of the tests performed&#46; As we mentioned above&#44; the treatment is supportive and consists in avoiding exposure to intense cold and situations of major stress&#46; We think it is important to point out these cases&#44; as this disease is rare in children and difficult to diagnose because the duration of the episodes is usually limited and&#44; most of them are not evaluated by a physician&#46; Thus&#44; we wish to stress how important it is that the family take photographs during an episode&#44; and we encourage professionals to consider Raynaud&#39;s phenomenon when dealing with similar cases&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical Disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of Interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Raynaud&#39;s phenomenon is caused by spasm of the small arteries and arterioles of the fingers&#46; It is triggered by various stimuli including exposure to cold or a stressful event&#46; It may be symmetrical or wrap one end&#46; The appearance of this entity in children is rare&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We report the case of a 4 year old male consultation health center by episodes of coldness&#44; pallor and pain in both feet&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El fen&#243;meno de Raynaud est&#225; causado por vasoespasmo de las peque&#241;as arterias y arteriolas de los dedos&#46; Se desencadena por diversos est&#237;mulos&#44; entre ellos la exposici&#243;n al fr&#237;o o un evento estresante&#46; Puede ser sim&#233;trico o envolver una sola extremidad&#46; La aparici&#243;n de esta entidad en ni&#241;os es muy infrecuente&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de un var&#243;n de 4 a&#241;os que consulta en su centro de salud por episodios de frialdad&#44; palidez y dolor en ambos pies&#46;</p></span>"
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Article information
ISSN: 21735743
Original language: English
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