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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">RDD is a benign proliferation of histiocytes&#44; also known as Sinus histiocytosis with massive lymphadenopathy&#44; commonly present in young adults&#46; Is rare as isolated cutaneous presentation and appears with hyperpigmented or erythematous papules&#44; nodules or plaques&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Affects lymph nodes as well as extra-nodal areas as a systemic disease with fever&#44; leukocytosis&#44; elevated erythrocyte sedimentation rate &#40;ESR&#41;&#44; and polyclonal hypergammaglobulinemia&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 62-year-old Hispanic female developed a small lesion on her right forearm on December 2014&#46; The lesion increased in size significantly over a three weeks period becoming a large soft tissue mass and she developed multiple red spots at the site of the mass &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a and b&#41;&#46; In February 2015&#44; an MRI showed a T1 Fat suppression hypointense and T2 hyperintense lesion with a discrete mass and enhancement in post gadolinium coronal views with edema&#44; ulceration along the superficial fascia&#46; A gray scale and power Doppler &#40;PD&#41; ultrasound &#40;US&#41; a month later&#44; showed increased soft tissues thickness with enlargement of the fat pad and septa&#44; with slight PD signal in the periphery &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>c and d&#41;&#46; A high definition US guided-biopsy was performed showing a nonspecific polymorphic inflammation with plentiful macrophages&#46; Gram&#44; Gomori Methenamine Silver &#40;GMS&#41; and Acid-Fast Bacilli &#40;AFB&#41; stains&#44; were all negative&#46; Other immunostains and immunophenotyping &#40;haematoxlin eosin&#41; studies described to date were non-diagnostic &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>a&#8211;e&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Work up revealed only ANA 1&#58;640 with no evidence of an underlying inflammatory process or autoimmune disease&#44; such as antiphospholipid syndrome and IgG4 associated sclerosis&#46; A surgical excision of right forearm 7<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>cm tumor showed multinodular lesion with thick histiocyte and fibroblasts rich septa&#46; Each nodule contained extended sheets of large&#44; foamy and epithelioid histiocytes&#44; many containing lymphocytes and some plasma cells in the cytoplasm&#44; a phenomenon known as emperipolesis&#46; Foam cell with palely eosinophilic bubbly cytoplasm abundantly granular with open vesicular nuclei with prominent nucleoli were also observed &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>e&#8211;i&#41;&#46; Based on the presence of the Protein S-100 and other histologic findings the diagnosis of Rosai&#8211;Dorfman disease &#40;RDD&#41; was made&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">RDD is a benign proliferation of histiocytes&#44; which affects lymph nodes as well as extra-nodal areas&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2</span></a> Sometimes it presents as systemic disease with massive cervical lymphadenopathy with fever&#44; leukocytosis&#44; elevated erythrocyte sedimentation rate &#40;ESR&#41;&#44; and polyclonal hypergammaglobulinemia&#44; affecting any age group&#44; but it has a predilection for young adults &#40;mean age 20&#46;6 years&#41;&#59; cutaneous form is more common in Asians&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The hallmark of RDD is emperipolesis&#44; defined as the presence of an intact cell within the cytoplasm of another cell&#46; Emperipolesis is unlike phagocytosis&#44; in which the engulfed cells are killed by the lysosomal enzymes of the macrophage&#46; Presence of plasma cells is frequently dense in cutaneous RDD&#46; Thus&#44; some experts consider that a tight relationship exists between RDD disease and IgG4-related sclerosing diseases&#46; The differential diagnosis includes a wide range of heterogeneous diseases such as inflammatory pseudotumor&#44; malignant histiocytosis and lymphoma&#44; hemophagocytic syndrome associated with T-cell lymphoma and&#47;or viral infection&#44; Langerhans cell histiocytosis&#44; Reticulohistiocytoma cutis&#44; Eruptive xanthoma&#44; generalized eruptive histiocytoma&#44; Juvenile xanthogranuloma&#44; inflammatory malignant fibrous histiocytoma&#44; Lepromatous leprosy&#44; Hodgkin&#39;s lymphoma&#46; The most distinguishing feature for RD compared to those entities is the presence of Emperipolesis and of protein S-100&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The outcome is described in three different stages&#58; <span class="elsevierStyleItalic">growing</span> &#40;half to one year&#41;&#44; <span class="elsevierStyleItalic">full-blown</span> &#40;12 and 24 months&#41;&#44; when the polymorphous infiltrating cells and RD cells gradually decrease&#46; Some fibrosis and foam cells may appear in the late <span class="elsevierStyleItalic">regressing</span> phase where lesions are nodule or plaques imparting a yellowish hue&#44; and scar-like tissue&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#8211;7</span></a> A recent review has proposed a new classification of histiocytoses according to histology&#44; phenotype&#44; molecular alterations&#44; clinics and imaging characteristics&#44; including&#58; &#40;a&#41; Langerhans-related&#44; &#40;b&#41; cutaneous and mucocutaneous&#44; &#40;c&#41; malignant histiocytoses&#44; &#40;d&#41; Rosai&#8211;Dorfman disease&#44; &#40;e&#41; hemophagocytic lymphohistiocytosis and macrophage activation syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Follow up visit at month 3 after surgical scission and oral steroids revealed full vanishing of the tumor and complete recovery&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0035" class="elsevierStylePara elsevierViewall">RDD is not well recognized and sometimes misdiagnosed as inflammatory pseudotumor&#46; Histological diagnosis is critically necessary&#44; nonetheless our case supports the potential role for ultrasonography in Rheumatology outpatient clinics&#46; Empiric treatment including systemic or intralesional steroids&#44; chemotherapy&#44; radiation therapy and thalidomide have been tried&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;9</span></a> Interestingly RDD&#44; can resolve spontaneously&#44; over a long period of time&#44; two years or longer&#44; especially this cutaneous form&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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Case report
Rosai–Dorfman disease: Ultrasonography and histopathology study of a soft tissue mass in the forearm
Enfermedad de Rosai-Dorfman: estudio por ultrasonografía e histológico de una masa de partes blandas en el antebrazo
Fadi Badlissia, German Albert Pihanb, Hèctor Corominasa,c,
Autor para correspondencia
a Division of Rheumatology and Lupus Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
b Hematopathology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
c Unitat territorial de Reumatologia, Hospital Universitari de Sant Pau & Hospital Dos de Maig, Universitat Autónoma de Barcelona (UAB), Barcelona, 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">RDD is a benign proliferation of histiocytes&#44; also known as Sinus histiocytosis with massive lymphadenopathy&#44; commonly present in young adults&#46; Is rare as isolated cutaneous presentation and appears with hyperpigmented or erythematous papules&#44; nodules or plaques&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Affects lymph nodes as well as extra-nodal areas as a systemic disease with fever&#44; leukocytosis&#44; elevated erythrocyte sedimentation rate &#40;ESR&#41;&#44; and polyclonal hypergammaglobulinemia&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 62-year-old Hispanic female developed a small lesion on her right forearm on December 2014&#46; The lesion increased in size significantly over a three weeks period becoming a large soft tissue mass and she developed multiple red spots at the site of the mass &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a and b&#41;&#46; In February 2015&#44; an MRI showed a T1 Fat suppression hypointense and T2 hyperintense lesion with a discrete mass and enhancement in post gadolinium coronal views with edema&#44; ulceration along the superficial fascia&#46; A gray scale and power Doppler &#40;PD&#41; ultrasound &#40;US&#41; a month later&#44; showed increased soft tissues thickness with enlargement of the fat pad and septa&#44; with slight PD signal in the periphery &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>c and d&#41;&#46; A high definition US guided-biopsy was performed showing a nonspecific polymorphic inflammation with plentiful macrophages&#46; Gram&#44; Gomori Methenamine Silver &#40;GMS&#41; and Acid-Fast Bacilli &#40;AFB&#41; stains&#44; were all negative&#46; Other immunostains and immunophenotyping &#40;haematoxlin eosin&#41; studies described to date were non-diagnostic &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>a&#8211;e&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Work up revealed only ANA 1&#58;640 with no evidence of an underlying inflammatory process or autoimmune disease&#44; such as antiphospholipid syndrome and IgG4 associated sclerosis&#46; A surgical excision of right forearm 7<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>cm tumor showed multinodular lesion with thick histiocyte and fibroblasts rich septa&#46; Each nodule contained extended sheets of large&#44; foamy and epithelioid histiocytes&#44; many containing lymphocytes and some plasma cells in the cytoplasm&#44; a phenomenon known as emperipolesis&#46; Foam cell with palely eosinophilic bubbly cytoplasm abundantly granular with open vesicular nuclei with prominent nucleoli were also observed &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>e&#8211;i&#41;&#46; Based on the presence of the Protein S-100 and other histologic findings the diagnosis of Rosai&#8211;Dorfman disease &#40;RDD&#41; was made&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">RDD is a benign proliferation of histiocytes&#44; which affects lymph nodes as well as extra-nodal areas&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2</span></a> Sometimes it presents as systemic disease with massive cervical lymphadenopathy with fever&#44; leukocytosis&#44; elevated erythrocyte sedimentation rate &#40;ESR&#41;&#44; and polyclonal hypergammaglobulinemia&#44; affecting any age group&#44; but it has a predilection for young adults &#40;mean age 20&#46;6 years&#41;&#59; cutaneous form is more common in Asians&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The hallmark of RDD is emperipolesis&#44; defined as the presence of an intact cell within the cytoplasm of another cell&#46; Emperipolesis is unlike phagocytosis&#44; in which the engulfed cells are killed by the lysosomal enzymes of the macrophage&#46; Presence of plasma cells is frequently dense in cutaneous RDD&#46; Thus&#44; some experts consider that a tight relationship exists between RDD disease and IgG4-related sclerosing diseases&#46; The differential diagnosis includes a wide range of heterogeneous diseases such as inflammatory pseudotumor&#44; malignant histiocytosis and lymphoma&#44; hemophagocytic syndrome associated with T-cell lymphoma and&#47;or viral infection&#44; Langerhans cell histiocytosis&#44; Reticulohistiocytoma cutis&#44; Eruptive xanthoma&#44; generalized eruptive histiocytoma&#44; Juvenile xanthogranuloma&#44; inflammatory malignant fibrous histiocytoma&#44; Lepromatous leprosy&#44; Hodgkin&#39;s lymphoma&#46; The most distinguishing feature for RD compared to those entities is the presence of Emperipolesis and of protein S-100&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The outcome is described in three different stages&#58; <span class="elsevierStyleItalic">growing</span> &#40;half to one year&#41;&#44; <span class="elsevierStyleItalic">full-blown</span> &#40;12 and 24 months&#41;&#44; when the polymorphous infiltrating cells and RD cells gradually decrease&#46; Some fibrosis and foam cells may appear in the late <span class="elsevierStyleItalic">regressing</span> phase where lesions are nodule or plaques imparting a yellowish hue&#44; and scar-like tissue&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#8211;7</span></a> A recent review has proposed a new classification of histiocytoses according to histology&#44; phenotype&#44; molecular alterations&#44; clinics and imaging characteristics&#44; including&#58; &#40;a&#41; Langerhans-related&#44; &#40;b&#41; cutaneous and mucocutaneous&#44; &#40;c&#41; malignant histiocytoses&#44; &#40;d&#41; Rosai&#8211;Dorfman disease&#44; &#40;e&#41; hemophagocytic lymphohistiocytosis and macrophage activation syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Follow up visit at month 3 after surgical scission and oral steroids revealed full vanishing of the tumor and complete recovery&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0035" class="elsevierStylePara elsevierViewall">RDD is not well recognized and sometimes misdiagnosed as inflammatory pseudotumor&#46; Histological diagnosis is critically necessary&#44; nonetheless our case supports the potential role for ultrasonography in Rheumatology outpatient clinics&#46; Empiric treatment including systemic or intralesional steroids&#44; chemotherapy&#44; radiation therapy and thalidomide have been tried&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;9</span></a> Interestingly RDD&#44; can resolve spontaneously&#44; over a long period of time&#44; two years or longer&#44; especially this cutaneous form&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;a&#44; b&#44; c&#44; d&#41; H&#38;E stain low power&#58; infiltration of the dermis or subcutaneous tissue with associated sclerosis&#58; histiocytes&#44; lymphocytes and fibrosis is in the background&#46; Admixed with these large histiocytes there are lymphocytes&#44; plasma cells&#44; neutrophils and eosinophils&#46; &#40;e&#44; f&#44; g&#44; h&#41; High power of the H&#38;E sections&#58; histiocytes containing lymphocytes and plasma cells within a slightly eosinophilic cytoplasm&#44; foam cell with bubbly palely eosinophilic cytoplasm abundantly granular with open vesicular nuclei with prominent nucleoli&#46; &#40;i&#41; S100 stain highlights the macrophages and histiocytes seen on the H&#38;E stain&#46; Lymphocytes&#44; and stained histiocyte containing other cells &#40;emperipolesis&#41; known also as the Rosai&#8211;Dorfman &#40;RD&#41; cell&#46;</p>"
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