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and is more frequent in woman&#46; Sarcoidosis is a chronic granulomatous disease that may present with different clinical findings&#46; The pathognomonic histological finding of disease is the presence of non-caseating granulomas&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> These granulomas may form in almost any organ and system of the body&#46; Neurological involvement may occur in 5&#8211;10&#37; of patients&#46; Sarcoidosis may affect brain&#44; spinal cord&#44; and any part of the central or peripheral nervous system&#46; Neurosarcoidosis typically lead to cranial nerve involvement&#44; basilar meningitis&#44; myelopathy and diabetes insipidus as well as anterior hypothalamic disease symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Facial nerve paralysis is the most common cranial neuropathy&#46; Due to hypothalamic-pituitary involvement&#44; diabetes insipidus related symptoms like polydipsia and polyuria can occur&#46; Granulomatous inflammation and white matter abnormalities can also be seen in MRI&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> The relationship between hyponatremia and neurosarcoidosis was reported in some studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a> However&#44; the number of studies is very low&#46; Herein&#44; the relationship with hyponatremia in a patient with neurosarcoidosis was reported&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 64-year-old female patient&#44; is being followed with the diagnosis of neurosarcoidosis for nearly 30 years&#46; Patient presented with the complaints of arthralgia&#44; fatigue&#44; drowsiness and forgetfulness and was admitted to our rheumatology department&#46; She had hypertension in her medical history&#46; 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no mass image was seen in the pituitary MRI&#46; EMG of lower extremities was performed and it was consistent with polyneuropathy&#46; Endocrinology consultation was done&#59; in tests performed&#58; Cortisol&#58; 7&#46;74<span class="elsevierStyleHsp" style=""></span>g&#47;dL &#40;normal 6&#46;2&#8211;19&#46;4<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#41;&#44; ACTH&#58; 1&#46;68<span class="elsevierStyleHsp" style=""></span>pg&#47;ml &#40;normal 0&#8211;46<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#41;&#44; prolactin&#58; 14&#46;30<span class="elsevierStyleHsp" style=""></span>ng&#47;ml &#40;normal 4&#46;79&#8211;23&#46;3<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41;&#44; freeT4&#58; 1&#46;92<span class="elsevierStyleHsp" style=""></span>ng&#47;dI &#40;normal 0&#46;93&#8211;1&#46;71<span class="elsevierStyleHsp" style=""></span>ng&#47;dl&#41;&#44; freeT3&#58; 2&#46;57<span class="elsevierStyleHsp" style=""></span>pg&#47;dl &#40;normal 2&#8211;4&#46;4<span class="elsevierStyleHsp" style=""></span>pg&#47;dl&#41;&#44; TSH&#58; 1&#46;71<span class="elsevierStyleHsp" style=""></span>&#956;IU&#47;ml &#40;normal 0&#46;27&#8211;4&#46;2<span class="elsevierStyleHsp" style=""></span>&#956;IU&#47;n&#41;&#46; A pathology that could explain the hyponatremia was not detected in any research and it was thought to be associated with the underlying neurosarcoidosis&#46; Despite fluid and electrolyte therapy&#44; the serum Na did not increased&#46; Prednisone 40<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; was started&#46; One month later&#44; in control laboratory tests&#44; patient was clinically stable&#44; and had normal level of serum Na&#46; The patient&#39;s general condition is good and she is followed-up in the outpatient clinic&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Sarcoidosis is a chronic inflammatory disease with unknown etiology&#44; characterized by noncaseating granulomas and often shows multisystemic involvement&#46; Five to ten percent of patients have neurological involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Neurosarcoidosis may present with various neurological symptoms&#44; physical examination&#44; brain MRI&#44; laboratory and histological examination are required to reach a diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> In neurosarcoidosis&#44; severe hyponatremia may develop due to the hypopituitarism and secondary hypocorticolism&#46; In the literature&#44; neurosarcoidosis associated with hyponatremia has been rarely reported&#46; In a study on headache and mental status changes&#44; brain biopsy revealed the neurosarcoidosis&#44; characterized by noncaseating granulomas in the subependymal zone&#44; as the underlying cause of cerebral salt wasting syndrome and central nervous system &#40;CNS&#41; inflammation&#46; Sarcoidal granulomas can be seen in the meninges&#44; hypothalamus&#44; brain stem&#44; subependymal space&#44; choroid plexus&#44; peripheral nerves and also in the blood vessels that feed the nerves&#46; Hyponatremia due to CNS damage can occur&#46; The most common cause is syndrome of inappropriate anti-diuretic hormone&#40;ADH&#41; secretion&#46; The cause of persistent CNS inflammation in these patients was found to be neurosarcoidosis&#46; Neuropsychiatric symptoms have also occurred rarely&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> In another study&#44; sarcoidosis has been shown to cause the syndrome of inappropriate ADH secretion&#44; and hence the hyponatraemia&#46; After 1 year with the corticosteroid treatment&#44; decline in both the findings of syndrome of inappropriate ADH secretion and the systemic findings of sarcoidosis was observed&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> In a study investigating the relationship between sarcoidosis and pituitary mass&#44; a patient diagnosed with pulmonary and ophthalmic sarcoidosis was presented with fatigue and vomiting complaints&#46; Laboratory tests showed hyponatremia and the brain CT detected a suprasellar mass&#46; Since MRI illustrates the intrasellar and suprasellar mass and also the pituitary stalk thickening&#44; the clinical and radiological findings strongly support the hypothesis that the mass in the pituitary is due to the sarcoidosis&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> Unlike this case&#44; in our patient although the pituitary mass was not detected&#44; after other reasons of hyponatremia were excluded&#44; a response to corticosteroid therapy suggests that it may be associated with neurosarcoidosis&#46; The reason of hyponatremia in our case was thought to be neurosarcoidosis&#46; Indeed&#44; hyponatremia was improved after the corticosteroid therapy&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In conclusion&#44; we report a case with neurosarcoidosis presenting with hyponatremia&#46; Sarcoidosis is one of the diagnoses that should be kept in mind in patients presenting with electrolyte imbalance&#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="par0025" 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="par0030" 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="par0035" class="elsevierStylePara elsevierViewall">The authors must have obtained the informed consent of the patients and&#47;or subjects mentioned in the article&#46; The author for correspondence must be in possession of this document&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare 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">Sarcoidosis is an inflammatory disease with unknown cause characterized by non-caseating granuloma formations&#46; It may present with bilateral hilar lymphadenopathy&#44; skin lesions&#44; eye and musculoskeletal system involvement&#46; Hypercalcemia and hypercalciuria are important electrolyte imbalances resulting from sarcoidosis and sometimes they may cause nephrolitiasis and kidney failure&#46; Hyponatremia&#44; although being quite rare&#44; has been found in some patients with sarcoidosis&#46; Herein&#44; we have reported a patient with neurosarcoidosis who presented with hyponatremia and responded well to corticosteroid treatment&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La sarcoidosis es una enfermedad inflamatoria&#44; de causa desconocida&#44; que se caracteriza por la formaci&#243;n de granulomas no caseificantes&#46; Se puede presentar con linfadenopat&#237;a hiliar bilateral&#44; lesiones en la piel&#44; en los ojos&#44; y la implicaci&#243;n del sistema musculoesquel&#233;tico&#46; La hipercalcemia y la hipercalciuria son importantes desequilibrios electrol&#237;ticos resultantes de la sarcoidosis&#44; y algunas veces pueden causar nefrolitiasis e insuficiencia renal&#46; La hiponatremia&#44; a pesar de ser bastante rara&#44; se ha encontrado en algunos pacientes con sarcoidosis&#46; Aqu&#237;&#44; hemos informado de un paciente con neurosarcoidosis que se present&#243; con hiponatremia y respondi&#243; bien al tratamiento con glucocorticoides&#46;</p></span>"
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                          "etal" => false
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Case report
Hyponatremia as presentation in a patient with neurosarcoidosis
Hiponatremia como presentación en un paciente con neurosarcoidosis
Ekin Akyildiza, Murat Yalcina, Fidan Severb, Hüseyin Semiza, Senol Kobakc,
Corresponding author
senolkobak@gmail.com

Corresponding author.
a Sifa University, Faculty of Medicine, Department of Rheumatology, Turkey
b Sifa University, Faculty of Medicine, Department of Chest Diseases, Turkey
c Istinye University, Faculty of Medicine, LIV Hospital, Department of Rheumatology, Turkey
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and is more frequent in woman&#46; Sarcoidosis is a chronic granulomatous disease that may present with different clinical findings&#46; The pathognomonic histological finding of disease is the presence of non-caseating granulomas&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> These granulomas may form in almost any organ and system of the body&#46; Neurological involvement may occur in 5&#8211;10&#37; of patients&#46; Sarcoidosis may affect brain&#44; spinal cord&#44; and any part of the central or peripheral nervous system&#46; Neurosarcoidosis typically lead to cranial nerve involvement&#44; basilar meningitis&#44; myelopathy and diabetes insipidus as well as anterior hypothalamic disease symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Facial nerve paralysis is the most common cranial neuropathy&#46; Due to hypothalamic-pituitary involvement&#44; diabetes insipidus related symptoms like polydipsia and polyuria can occur&#46; Granulomatous inflammation and white matter abnormalities can also be seen in MRI&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> The relationship between hyponatremia and neurosarcoidosis was reported in some studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a> However&#44; the number of studies is very low&#46; Herein&#44; the relationship with hyponatremia in a patient with neurosarcoidosis was reported&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 64-year-old female patient&#44; is being followed with the diagnosis of neurosarcoidosis for nearly 30 years&#46; Patient presented with the complaints of arthralgia&#44; fatigue&#44; drowsiness and forgetfulness and was admitted to our rheumatology department&#46; She had hypertension in her medical history&#46; The physical examination revealed tenderness in the knee and ankle joints&#46; Other systemic examinations were found to be normal&#46; In the laboratory investigation&#44; serum Na&#58; 119<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;normal 135&#8211;140<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#44; serum ACE&#58; 102<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;normal &#60;45<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#44; serum calcium and serum hydroxyvitamin D levels were normal&#46; Liver&#44; kidney function tests and the urine analysis were normal&#46; Nephrology consultation and the research on etiology was conducted&#46; On thorax CT&#44; bilateral hilar lymphadenopathy was seen &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Due to the history of neurosarcoidosis&#44; cranial and pituitary MRI were ordered for a possible pituitary involvement&#46; In the brain MRI&#44; millimeter-sized chronic microangiopathic ischemic signal changes were observed in the periventricular deep white matter&#59; no mass image was seen in the pituitary MRI&#46; EMG of lower extremities was performed and it was consistent with polyneuropathy&#46; Endocrinology consultation was done&#59; in tests performed&#58; Cortisol&#58; 7&#46;74<span class="elsevierStyleHsp" style=""></span>g&#47;dL &#40;normal 6&#46;2&#8211;19&#46;4<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#41;&#44; ACTH&#58; 1&#46;68<span class="elsevierStyleHsp" style=""></span>pg&#47;ml &#40;normal 0&#8211;46<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#41;&#44; prolactin&#58; 14&#46;30<span class="elsevierStyleHsp" style=""></span>ng&#47;ml &#40;normal 4&#46;79&#8211;23&#46;3<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41;&#44; freeT4&#58; 1&#46;92<span class="elsevierStyleHsp" style=""></span>ng&#47;dI &#40;normal 0&#46;93&#8211;1&#46;71<span class="elsevierStyleHsp" style=""></span>ng&#47;dl&#41;&#44; freeT3&#58; 2&#46;57<span class="elsevierStyleHsp" style=""></span>pg&#47;dl &#40;normal 2&#8211;4&#46;4<span class="elsevierStyleHsp" style=""></span>pg&#47;dl&#41;&#44; TSH&#58; 1&#46;71<span class="elsevierStyleHsp" style=""></span>&#956;IU&#47;ml &#40;normal 0&#46;27&#8211;4&#46;2<span class="elsevierStyleHsp" style=""></span>&#956;IU&#47;n&#41;&#46; A pathology that could explain the hyponatremia was not detected in any research and it was thought to be associated with the underlying neurosarcoidosis&#46; Despite fluid and electrolyte therapy&#44; the serum Na did not increased&#46; Prednisone 40<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; was started&#46; One month later&#44; in control laboratory tests&#44; patient was clinically stable&#44; and had normal level of serum Na&#46; The patient&#39;s general condition is good and she is followed-up in the outpatient clinic&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Sarcoidosis is a chronic inflammatory disease with unknown etiology&#44; characterized by noncaseating granulomas and often shows multisystemic involvement&#46; Five to ten percent of patients have neurological involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Neurosarcoidosis may present with various neurological symptoms&#44; physical examination&#44; brain MRI&#44; laboratory and histological examination are required to reach a diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> In neurosarcoidosis&#44; severe hyponatremia may develop due to the hypopituitarism and secondary hypocorticolism&#46; In the literature&#44; neurosarcoidosis associated with hyponatremia has been rarely reported&#46; In a study on headache and mental status changes&#44; brain biopsy revealed the neurosarcoidosis&#44; characterized by noncaseating granulomas in the subependymal zone&#44; as the underlying cause of cerebral salt wasting syndrome and central nervous system &#40;CNS&#41; inflammation&#46; Sarcoidal granulomas can be seen in the meninges&#44; hypothalamus&#44; brain stem&#44; subependymal space&#44; choroid plexus&#44; peripheral nerves and also in the blood vessels that feed the nerves&#46; Hyponatremia due to CNS damage can occur&#46; The most common cause is syndrome of inappropriate anti-diuretic hormone&#40;ADH&#41; secretion&#46; The cause of persistent CNS inflammation in these patients was found to be neurosarcoidosis&#46; Neuropsychiatric symptoms have also occurred rarely&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> In another study&#44; sarcoidosis has been shown to cause the syndrome of inappropriate ADH secretion&#44; and hence the hyponatraemia&#46; After 1 year with the corticosteroid treatment&#44; decline in both the findings of syndrome of inappropriate ADH secretion and the systemic findings of sarcoidosis was observed&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> In a study investigating the relationship between sarcoidosis and pituitary mass&#44; a patient diagnosed with pulmonary and ophthalmic sarcoidosis was presented with fatigue and vomiting complaints&#46; Laboratory tests showed hyponatremia and the brain CT detected a suprasellar mass&#46; Since MRI illustrates the intrasellar and suprasellar mass and also the pituitary stalk thickening&#44; the clinical and radiological findings strongly support the hypothesis that the mass in the pituitary is due to the sarcoidosis&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> Unlike this case&#44; in our patient although the pituitary mass was not detected&#44; after other reasons of hyponatremia were excluded&#44; a response to corticosteroid therapy suggests that it may be associated with neurosarcoidosis&#46; The reason of hyponatremia in our case was thought to be neurosarcoidosis&#46; Indeed&#44; hyponatremia was improved after the corticosteroid therapy&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In conclusion&#44; we report a case with neurosarcoidosis presenting with hyponatremia&#46; Sarcoidosis is one of the diagnoses that should be kept in mind in patients presenting with electrolyte imbalance&#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="par0025" 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="par0030" 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="par0035" class="elsevierStylePara elsevierViewall">The authors must have obtained the informed consent of the patients and&#47;or subjects mentioned in the article&#46; The author for correspondence must be in possession of this document&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare 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">Sarcoidosis is an inflammatory disease with unknown cause characterized by non-caseating granuloma formations&#46; It may present with bilateral hilar lymphadenopathy&#44; skin lesions&#44; eye and musculoskeletal system involvement&#46; Hypercalcemia and hypercalciuria are important electrolyte imbalances resulting from sarcoidosis and sometimes they may cause nephrolitiasis and kidney failure&#46; Hyponatremia&#44; although being quite rare&#44; has been found in some patients with sarcoidosis&#46; Herein&#44; we have reported a patient with neurosarcoidosis who presented with hyponatremia and responded well to corticosteroid treatment&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La sarcoidosis es una enfermedad inflamatoria&#44; de causa desconocida&#44; que se caracteriza por la formaci&#243;n de granulomas no caseificantes&#46; Se puede presentar con linfadenopat&#237;a hiliar bilateral&#44; lesiones en la piel&#44; en los ojos&#44; y la implicaci&#243;n del sistema musculoesquel&#233;tico&#46; La hipercalcemia y la hipercalciuria son importantes desequilibrios electrol&#237;ticos resultantes de la sarcoidosis&#44; y algunas veces pueden causar nefrolitiasis e insuficiencia renal&#46; La hiponatremia&#44; a pesar de ser bastante rara&#44; se ha encontrado en algunos pacientes con sarcoidosis&#46; Aqu&#237;&#44; hemos informado de un paciente con neurosarcoidosis que se present&#243; con hiponatremia y respondi&#243; bien al tratamiento con glucocorticoides&#46;</p></span>"
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Article information
ISSN: 21735743
Original language: English
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Idiomas
Reumatología Clínica (English Edition)
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