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outer ear &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41; and neck and back &#40;with acne&#41;&#46; We found no other signs or lymphadenopathy&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Diagnosis&#47;disease Course</span><p id="par0010" class="elsevierStylePara elsevierViewall">Laboratory findings&#58; leukocytosis 13&#44;000 &#40;normal&#58; 10&#44;020&#41;&#59; platelets 68&#44;000&#59; C-reactive protein &#40;CRP&#41; 14&#46;7 &#40;&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#59; and erythrocyte sedimentation rate 20<span class="elsevierStyleHsp" style=""></span>mm&#47;1st hour&#46; Moreover&#44; antinuclear antibodies&#44; anti-DNA antibodies&#44; antineutrophil cytoplasmic antibodies&#44; anti-extractable nuclear antigen antibodies&#44; angiotensin-converting enzyme&#44; rheumatoid factor&#44; anti-cyclic citrullinated peptide antibodies&#44; immunoglobulins&#44; complement and TSH&#47;free T4 were normal&#46; Mantoux and serology &#40;hepatitis B and C viruses&#44; human immunodeficiency virus&#44; syphilis&#41; and cultures were negative &#40;blood culture&#44; urine culture&#44; exudates from pharynx&#44; urethra and pustules&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#8211;4</span></a> Neck and abdominal ultrasound and chest and shoulder radiographs provided no useful evidence&#46; Biopsy of the skin lesions&#58; compatible with palmoplantar pustulosis&#46; Bone scintigraphy&#58; increased symmetrical uptake in sternoclavicular &#8220;bull&#39;s head&#8221;&#44; compatible with synovitis&#44; acne&#44; pustulosis&#44; hyperostosis and osteitis &#40;SAPHO&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; Treatment was begun with nonsteroidal anti-inflammatory drugs&#44; systemic &#40;16<span class="elsevierStyleHsp" style=""></span>mg oral methylprednisolone&#41; and topical &#40;betamethasone-gentamycin ointment&#41; corticosteroids&#46; The fever&#44; joint involvement and skin lesions remitted &#40;scaling&#59; <a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#44; and the analytical findings were normalized &#40;previous CRP&#44; leukocytosis and thrombocytopenia&#41;&#46; Once corticosteroid therapy had been reduced&#44; methotrexate was begun with a rapid dose escalation&#44; and the response was positive and tolerance was good&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3&#44;5&#44;6</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">The SAPHO syndrome is an uncommon disorder of unknown etiology&#44; that affects young men and women in a similar distribution&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a> Most authors classify it under the spondyloarthritides&#44; although it could be a reactive arthropathy secondary to an infection by an agent with a low virulence&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;4&#44;7&#44;8</span></a> On occasion&#44; it may prove difficult to diagnose because it overlaps with other infectious conditions that present with fever and skin lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a> The presence of edema in neck and chest&#44; acne and oligoarthritis&#44; in the absence of bacteriological isolation&#44; leads us to suspect an autoimmune etiology&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> The skin biopsy and scintigraphic data subsequently confirmed our presumed diagnosis&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Ethical Disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Protection of human and animal subjects</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association &#40;Declaration of Helsinki&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Confidentiality of data</span><p id="par0025" 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="sect0035">Right to privacy and informed consent</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; 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Images in Clinical Rheumatology
Fever, Palmoplantar Pustules and Oligoarthritis in a Young Woman
Fiebre, lesiones vesículo-ampollosas y oligoartritis en una paciente joven
Francisco Gallo Puelles
Corresponding author
fgallopuelles@hotmail.com

Corresponding author.
, Manuel José Moreno Ramos, María José Diaz Navarro, Manuel Castaño Sánchez
Servicio de Reumatología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Report</span><p id="par0005" class="elsevierStylePara elsevierViewall">The patient was a 41-year-old woman&#44; with no other remarkable findings of interest&#46; She presented with a 3-week history of fever&#44; arthralgia&#44; swollen neck and pustular lesions on her hands&#44; accompanied by pain&#46; Over the last few days&#44; she reported parasternal swelling that also affected right shoulder&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Physical exploration revealed erythema and edema in neck&#44; glenohumeral and right sternoclavicular arthritis&#44; and diffuse dorsopalmar pustular lesions on her hands &#40;up to 2<span class="elsevierStyleHsp" style=""></span>mm&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1&#8211;3</a>&#41;&#44; outer ear &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41; and neck and back &#40;with acne&#41;&#46; We found no other signs or lymphadenopathy&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Diagnosis&#47;disease Course</span><p id="par0010" class="elsevierStylePara elsevierViewall">Laboratory findings&#58; leukocytosis 13&#44;000 &#40;normal&#58; 10&#44;020&#41;&#59; platelets 68&#44;000&#59; C-reactive protein &#40;CRP&#41; 14&#46;7 &#40;&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#59; and erythrocyte sedimentation rate 20<span class="elsevierStyleHsp" style=""></span>mm&#47;1st hour&#46; Moreover&#44; antinuclear antibodies&#44; anti-DNA antibodies&#44; antineutrophil cytoplasmic antibodies&#44; anti-extractable nuclear antigen antibodies&#44; angiotensin-converting enzyme&#44; rheumatoid factor&#44; anti-cyclic citrullinated peptide antibodies&#44; immunoglobulins&#44; complement and TSH&#47;free T4 were normal&#46; Mantoux and serology &#40;hepatitis B and C viruses&#44; human immunodeficiency virus&#44; syphilis&#41; and cultures were negative &#40;blood culture&#44; urine culture&#44; exudates from pharynx&#44; urethra and pustules&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#8211;4</span></a> Neck and abdominal ultrasound and chest and shoulder radiographs provided no useful evidence&#46; Biopsy of the skin lesions&#58; compatible with palmoplantar pustulosis&#46; Bone scintigraphy&#58; increased symmetrical uptake in sternoclavicular &#8220;bull&#39;s head&#8221;&#44; compatible with synovitis&#44; acne&#44; pustulosis&#44; hyperostosis and osteitis &#40;SAPHO&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; Treatment was begun with nonsteroidal anti-inflammatory drugs&#44; systemic &#40;16<span class="elsevierStyleHsp" style=""></span>mg oral methylprednisolone&#41; and topical &#40;betamethasone-gentamycin ointment&#41; corticosteroids&#46; The fever&#44; joint involvement and skin lesions remitted &#40;scaling&#59; <a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;&#44; and the analytical findings were normalized &#40;previous CRP&#44; leukocytosis and thrombocytopenia&#41;&#46; Once corticosteroid therapy had been reduced&#44; methotrexate was begun with a rapid dose escalation&#44; and the response was positive and tolerance was good&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3&#44;5&#44;6</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">The SAPHO syndrome is an uncommon disorder of unknown etiology&#44; that affects young men and women in a similar distribution&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a> Most authors classify it under the spondyloarthritides&#44; although it could be a reactive arthropathy secondary to an infection by an agent with a low virulence&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;4&#44;7&#44;8</span></a> On occasion&#44; it may prove difficult to diagnose because it overlaps with other infectious conditions that present with fever and skin lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a> The presence of edema in neck and chest&#44; acne and oligoarthritis&#44; in the absence of bacteriological isolation&#44; leads us to suspect an autoimmune etiology&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> The skin biopsy and scintigraphic data subsequently confirmed our presumed diagnosis&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Ethical Disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Protection of human and animal subjects</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association &#40;Declaration of Helsinki&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Confidentiality of data</span><p id="par0025" 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="sect0035">Right to privacy and informed consent</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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                          "etal" => false
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                            2 => "M&#46; Ishiga"
                            3 => "M&#46; Kishimoto"
                            4 => "S&#46; Yagi"
                            5 => "N&#46; Okimoto"
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ISSN: 21735743
Original language: English
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