Estadísticas

 array:23 [
  "pii" => "S1699258X23000980"
  "issn" => "1699258X"
  "doi" => "10.1016/j.reuma.2023.03.002"
  "estado" => "S300"
  "fechaPublicacion" => "2023-08-01"
  "aid" => "1683"
  "copyrightAnyo" => "2023"
  "documento" => "simple-article"
  "crossmark" => 1
  "subdocumento" => "crp"
  "cita" => "Reumatol Clin. 2023;19:404-6"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:1 [
    "total" => 0
  ]
  "Traduccion" => array:1 [
    "en" => array:18 [
      "pii" => "S2173574323001053"
      "issn" => "21735743"
      "doi" => "10.1016/j.reumae.2023.05.005"
      "estado" => "S300"
      "fechaPublicacion" => "2023-08-01"
      "aid" => "1683"
      "documento" => "simple-article"
      "crossmark" => 1
      "subdocumento" => "crp"
      "cita" => "Reumatol Clin. 2023;19:404-6"
      "abierto" => array:3 [
        "ES" => false
        "ES2" => false
        "LATM" => false
      ]
      "gratuito" => false
      "lecturas" => array:1 [
        "total" => 0
      ]
      "en" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>"
        "titulo" => "Systemic lupus erythematosus mimicking leprosy&#58; A challenge to early diagnosis"
        "tienePdf" => "en"
        "tieneTextoCompleto" => "en"
        "tieneResumen" => array:2 [
          0 => "en"
          1 => "es"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "404"
            "paginaFinal" => "406"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "es" => array:1 [
            "titulo" => "Lupus eritematoso sist&#233;mico que remeda lepra&#58; reto para el diagn&#243;stico temprano"
          ]
        ]
        "contieneResumen" => array:2 [
          "en" => true
          "es" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "en" => true
        ]
        "contienePdf" => array:1 [
          "en" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0005"
            "etiqueta" => "Fig&#46; 1"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr1.jpeg"
                "Alto" => 1493
                "Ancho" => 2508
                "Tamanyo" => 404875
              ]
            ]
            "descripcion" => array:1 [
              "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Histological section of the lateral foot &#40;scar area&#41; revealing small vessel vasculitis associated with areas of scarring fibrosis and dystrophic calcification&#46; There are no alcohol-acid-resistant bacilli&#46; Compatible with erythema nodosum leprosum with scar areas&#46; &#40;B&#41; Histological section of the scalp region revealing mild hyperkeratosis&#44; epidermal atrophy&#44; ballooning of basal keratinocytes and discrete perivascular lymphohistiocytic infiltrate&#46; Compatible with lupus erythematosus&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Patrick Nunes Brito, Danielle Pereira Barros, Brenda Nunes Brito, Rayza Brito Silva, Marcus Emilio Costa Maciel, Monica Camilo Nunes de Sousa"
            "autores" => array:6 [
              0 => array:2 [
                "nombre" => "Patrick"
                "apellidos" => "Nunes Brito"
              ]
              1 => array:2 [
                "nombre" => "Danielle"
                "apellidos" => "Pereira Barros"
              ]
              2 => array:2 [
                "nombre" => "Brenda"
                "apellidos" => "Nunes Brito"
              ]
              3 => array:2 [
                "nombre" => "Rayza"
                "apellidos" => "Brito Silva"
              ]
              4 => array:2 [
                "nombre" => "Marcus Emilio"
                "apellidos" => "Costa Maciel"
              ]
              5 => array:2 [
                "nombre" => "Monica"
                "apellidos" => "Camilo Nunes de Sousa"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "en"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S1699258X23000980"
          "doi" => "10.1016/j.reuma.2023.03.002"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X23000980?idApp=UINPBA00004M"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574323001053?idApp=UINPBA00004M"
      "url" => "/21735743/0000001900000007/v1_202309042019/S2173574323001053/v1_202309042019/en/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S1699258X22002753"
    "issn" => "1699258X"
    "doi" => "10.1016/j.reuma.2022.10.005"
    "estado" => "S300"
    "fechaPublicacion" => "2023-08-01"
    "aid" => "1660"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and Sociedad Espa&#241;ola de Reumatolog&#237;a y Colegio Mexicano de Reumatolog&#237;a"
    "documento" => "simple-article"
    "crossmark" => 1
    "subdocumento" => "cor"
    "cita" => "Reumatol Clin. 2023;19:407-8"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:1 [
      "total" => 0
    ]
    "es" => array:10 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Carta al Editor</span>"
      "titulo" => "&#191;Se comporta la enfermedad pulmonar difusa igual en todas las enfermedades reum&#225;ticas&#63; Revisi&#243;n de la literatura"
      "tienePdf" => "es"
      "tieneTextoCompleto" => "es"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "407"
          "paginaFinal" => "408"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "en" => array:1 [
          "titulo" => "Does interstitial lung disease behave in the same way in all rheumatic diseases&#63; A review of the literature"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "es" => true
      ]
      "contienePdf" => array:1 [
        "es" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Diego Dur&#225;n Barata, Andrea P&#233;rez Figuera, Winnifer Brice&#241;o Franquiz, Beatriz Pintado Cort"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "Diego"
              "apellidos" => "Dur&#225;n Barata"
            ]
            1 => array:2 [
              "nombre" => "Andrea"
              "apellidos" => "P&#233;rez Figuera"
            ]
            2 => array:2 [
              "nombre" => "Winnifer"
              "apellidos" => "Brice&#241;o Franquiz"
            ]
            3 => array:2 [
              "nombre" => "Beatriz"
              "apellidos" => "Pintado Cort"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "es"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S2173574323000850"
        "doi" => "10.1016/j.reumae.2022.10.005"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574323000850?idApp=UINPBA00004M"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X22002753?idApp=UINPBA00004M"
    "url" => "/1699258X/0000001900000007/v1_202307241059/S1699258X22002753/v1_202307241059/es/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S1699258X22002303"
    "issn" => "1699258X"
    "doi" => "10.1016/j.reuma.2022.09.006"
    "estado" => "S300"
    "fechaPublicacion" => "2023-08-01"
    "aid" => "1654"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and Sociedad Espa&#241;ola de Reumatolog&#237;a y Colegio Mexicano de Reumatolog&#237;a"
    "documento" => "simple-article"
    "crossmark" => 1
    "subdocumento" => "crp"
    "cita" => "Reumatol Clin. 2023;19:402-3"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:12 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>"
      "titulo" => "Severe and life-threatening onset of systemic lupus erythematosus"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "402"
          "paginaFinal" => "403"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Una presentaci&#243;n grave y potencialmente fatal de lupus eritematoso sist&#233;mico"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Ana Martins, Sofia Pimenta, Daniela Oliveira, Frederico Martins, Beatriz Sam&#245;es, L&#250;cia Costa"
          "autores" => array:6 [
            0 => array:2 [
              "nombre" => "Ana"
              "apellidos" => "Martins"
            ]
            1 => array:2 [
              "nombre" => "Sofia"
              "apellidos" => "Pimenta"
            ]
            2 => array:2 [
              "nombre" => "Daniela"
              "apellidos" => "Oliveira"
            ]
            3 => array:2 [
              "nombre" => "Frederico"
              "apellidos" => "Martins"
            ]
            4 => array:2 [
              "nombre" => "Beatriz"
              "apellidos" => "Sam&#245;es"
            ]
            5 => array:2 [
              "nombre" => "L&#250;cia"
              "apellidos" => "Costa"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S2173574323000679"
        "doi" => "10.1016/j.reumae.2022.09.003"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574323000679?idApp=UINPBA00004M"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X22002303?idApp=UINPBA00004M"
    "url" => "/1699258X/0000001900000007/v1_202307241059/S1699258X22002303/v1_202307241059/en/main.assets"
  ]
  "en" => array:19 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>"
    "titulo" => "Systemic lupus erythematosus mimicking leprosy&#58; A challenge to early diagnosis"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "404"
        "paginaFinal" => "406"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Patrick Nunes Brito, Danielle Pereira Barros, Brenda Nunes Brito, Rayza Brito Silva, Marcus Emilio Costa Maciel, Monica Camilo Nunes de Sousa"
        "autores" => array:6 [
          0 => array:4 [
            "nombre" => "Patrick"
            "apellidos" => "Nunes Brito"
            "email" => array:1 [
              0 => "patrick091979@hotmail.com"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "Danielle"
            "apellidos" => "Pereira Barros"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Brenda"
            "apellidos" => "Nunes Brito"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "Rayza"
            "apellidos" => "Brito Silva"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "Marcus Emilio"
            "apellidos" => "Costa Maciel"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          5 => array:3 [
            "nombre" => "Monica"
            "apellidos" => "Camilo Nunes de Sousa"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:3 [
          0 => array:3 [
            "entidad" => "HDT-UFT &#8211; Hospital de Doen&#231;as Tropicais&#44; Brazil"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Centro Universit&#225;rio do Maranh&#227;o Imperatriz&#44; Brazil"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Universidade Federal do Tocantins &#8211; UFNT&#44; Brazil"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Lupus eritematoso sist&#233;mico que remeda lepra&#58; reto para el diagn&#243;stico temprano"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1493
            "Ancho" => 2508
            "Tamanyo" => 404875
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Histological section of the lateral foot &#40;scar area&#41; revealing small vessel vasculitis associated with areas of scarring fibrosis and dystrophic calcification&#46; There are no alcohol-acid-resistant bacilli&#46; Compatible with erythema nodosum leprosum with scar areas&#46; &#40;B&#41; Histological section of the scalp region revealing mild hyperkeratosis&#44; epidermal atrophy&#44; ballooning of basal keratinocytes and discrete perivascular lymphohistiocytic infiltrate&#46; Compatible with lupus erythematosus&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Systemic lupus erythematosus &#40;SLE&#41; is a rare&#44; chronic inflammatory disease of connective tissue&#44; of an autoimmune nature and whose pathogenesis is heterogeneous&#44; generally characterized by the deposition of immune complexes and production of autoantibodies&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> The clinical presentation of SLE is variable and can affect any organ&#44; singly or cumulatively&#44; at any age&#46; As its clinical status is variable and sometimes nonspecific&#44; the diagnosis can be delayed and patients are often treated for conditions other than SLE&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2&#44;3</span></a> In the literature there are already descriptions of several cases of SLE that mimic leprosy and vice versa&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">4&#8211;10</span></a> although it is still difficult to establish the prevalence of these conditions given that patients can spend a lot of time treating diseases with incorrect diagnosis&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical observation</span><p id="par0010" class="elsevierStylePara elsevierViewall">Patient&#44; male&#44; 33 years old&#44; admitted in hospital due to adverse reaction to treatment for multibacillary leprosy &#40;dapsone&#41; after less than 1 month of use and presence of difficult-to-heal ulcers in lower limbs for 2 years&#44; even with previous antibiotic therapy&#46; Diagnosis of multibacillary leprosy through February&#47;2022 biopsy&#44; consistent with erythema nodosum leprosum with scar areas and negative AFB test&#46; Previous pathology reported treatment for tertiary syphilis 3 years ago&#44; without other comorbidities&#46; On admission&#44; evaluated by a dermatologist&#44; who questioned the initial diagnosis&#44; however&#44; he advised the use of empirical intravenous antibiotic therapy&#44; suspension of treatment for leprosy&#44; request markers for SLE and activity of rheumatologic disease&#44; in addition to the evaluation of rheumatology for a possible diagnosis of lupus&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the rheumatological evaluation&#44; he had the criteria of non-scarring alopecia&#44; discoid lupus&#44; photosensitivity&#44; hemolytic anemia&#44; leukopenia and pericardial effusion on echocardiography&#46; As for the results of the rheumatological markers&#44; they demonstrated&#44; through indirect immunofluorescence&#44; an ANA fine speckled nuclear pattern &#40;AC-4&#41; greater than 1&#47;640 and ANTI-dsDNA 1&#47;10&#59; through the enzyme-immunoassay method&#44; an Anti-SSA of 49&#46;7<span class="elsevierStyleHsp" style=""></span>U &#40;positive&#41;&#44; anticardiolipin IGG of 34&#46;3 GPL &#40;positive&#41; and anticardiolipin IGM of 145&#46;5 MPL &#40;positive&#41;&#59; the lupus anticoagulant&#44; through the coagulometric method&#44; was also positive with 1&#46;22&#59; and through turbidimetry&#44; a reduction in serum complement proteins C3 and C4 was also evidenced&#44; with 35<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and &#60;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; respectively&#46; Thus scoring 28 points by the EULAR&#47;ACR-2019 criteria&#46; Clinical and laboratory diagnosis established for lupus&#44; as well as the result of a new biopsy &#40;scalp&#41; compatible with lupus erythematosus &#40;comparative between first and second biopsy in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The SELENA-SLEDAI criteria were used to initiate immunosuppressive therapy&#44; which considered vasculitis in the lower limbs &#40;ulcers without healing for 2 years&#41;&#44; 24-h proteinuria greater than 0&#46;5<span class="elsevierStyleHsp" style=""></span>g&#44; alopecia&#44; hypocomplementemia&#44; leukopenia&#44; fever&#44; scoring 19 and characterizing severe disease activity&#46; Opted for pulse therapy 3&#58;1 for 6 months&#44; with 3 days of methylprednisolone followed by 1 day of cyclophosphamide&#46; Patient was later discharged with prescription of hydroxychloroquine&#44; prednisone&#44; folic acid&#44; acetylsalicylic acid&#44; vitamin and mineral supplementation and follow-up with rheumatology&#44; infectiology and ophthalmology&#46; After 1 month&#44; the patient returned for evaluation with a rheumatologist and presented with improvement of the vasculitis lesions&#44; although still without complete healing and maintained normal renal function values&#46; However&#44; he maintained the same values of proteinuria in the follow-up after one month&#58; proteinuria<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;24<span class="elsevierStyleHsp" style=""></span>h&#46; After 1 month&#44; the patient was referred to another reference unit for his own interest&#44; as this other unit was closer to where he lived&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Some forms of leprosy&#44; such as lepromatous and borderline leprosy&#44; may present with serological alterations and clinical alterations that are also consistent with other rheumatic pathologies&#44; mainly rheumatoid arthritis and SLE&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">8&#8211;10</span></a> Among the most common serological abnormalities we have rheumatoid factor &#40;which may even be present in population without disease&#41;&#44; ANA&#44; anti-DNA and anticardiolipin antibody&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6&#44;7</span></a> Clinical changes involve erythema nodosum and vasculitis&#44; skin changes that are very common in leprosy and which should be considered by health professionals&#44; especially in regions where this disease is endemic&#46; Other similar clinical manifestations between the two conditions can also occur such as livedo reticularis&#44; malar rash&#44; skin thickening&#44; Raynaud&#39;s phenomenon&#44; oral ulcers and even glomerulonephritis&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">8&#8211;11</span></a> There are several goals when developing a treatment plan for the patient with SLE&#58; reducing disease activity &#40;induction of remission&#41;&#44; preventing exacerbations&#44; treating them when they occur&#44; and decreasing damage to organs and systems&#44; as well as complications of the disease&#46; disease and treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3&#44;11</span></a> Among the drugs available today&#44; corticosteroids and immunosuppressants are generally used&#44; which protect the organs from the inflammatory aggression caused by disorders in the immune system and induce remission of the disease&#44; but do not prevent or reverse the initial failure of the system&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">12&#8211;14</span></a> Just as the diagnostic criteria allowed greater sensitivity to detect those affected by SLE&#44; some criteria were also developed to identify disease activity&#44; such as the SLEDAI &#40;Systemic Lupus Erythematosus Disease Activity Index&#41;&#44; widely used and reproducible in Brazil&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">15&#44;16</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Although less frequent in men&#44; the diagnostic hypothesis of SLE should always be considered in patients with a chronic history of conditions without clinical improvement even after undergoing various therapies&#46; The case presented reveals that&#44; even showing typical changes for the disease with photosensitivity&#44; non-scarring alopecia and discoid lupus for more than 2 years&#44; the diagnosis of the disease was initially wrong&#44; requiring even a biopsy&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Information</span><p id="par0030" class="elsevierStylePara elsevierViewall">Consent was obtained for experimentation with human subjects&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare they have no conflict of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:11 [
        0 => array:3 [
          "identificador" => "xres1937907"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec1670000"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres1937908"
          "titulo" => "Resumen"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec1670001"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Clinical observation"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Discussion"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Conclusion"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Information"
        ]
        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Conflict of interest"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2022-10-22"
    "fechaAceptado" => "2023-03-09"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1670000"
          "palabras" => array:5 [
            0 => "Lupus"
            1 => "Cutaneous lupus"
            2 => "Leprosy"
            3 => "Syphilis"
            4 => "EULAR-ACR-2019"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1670001"
          "palabras" => array:5 [
            0 => "Lupus"
            1 => "Lupus cut&#225;neo"
            2 => "Lepra"
            3 => "S&#237;filis"
            4 => "EULAR-ACR-2019"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We describe a case of a male patient with systemic lupus erythematosus &#40;SLE&#41; and lupus nephritis&#46; A patient who was initially diagnosed with multibacillary leprosy&#44; an infectious disease&#44; with clinical symptoms for two years&#46; However&#44; after hospitalization and investigation&#44; his diagnosis was revoked and replaced with SLE&#46; The aim of this study is to emphasize the importance of knowing the most important and significant clinical changes in SLE and thus allowing an accurate diagnosis&#44; preventing disease progression with target organ involvement&#44; and allowing better clinical management&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Describimos el caso de un var&#243;n con lupus eritematoso sist&#233;mico y nefritis l&#250;pica&#46; Se trata de un paciente con diagn&#243;stico inicial de lepra multibacilar&#44; una enfermedad infecciosa con s&#237;ntomas cl&#237;nicos desde hac&#237;a 2 a&#241;os&#46; Sin embargo&#44; tras su hospitalizaci&#243;n e investigaci&#243;n&#44; se revoc&#243; dicho diagn&#243;stico&#44; sustituy&#233;ndose por lupus eritematoso sist&#233;mico&#46; El objetivo de este estudio es resaltar la importancia de conocer los cambios cl&#237;nicos m&#225;s importantes y significativos del lupus eritematoso sist&#233;mico&#44; permitiendo as&#237; su diagn&#243;stico preciso y previniendo la progresi&#243;n de la enfermedad con compromiso de &#243;rganos diana&#44; as&#237; como un mejor manejo cl&#237;nico&#46;</p></span>"
      ]
    ]
    "multimedia" => array:1 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1493
            "Ancho" => 2508
            "Tamanyo" => 404875
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Histological section of the lateral foot &#40;scar area&#41; revealing small vessel vasculitis associated with areas of scarring fibrosis and dystrophic calcification&#46; There are no alcohol-acid-resistant bacilli&#46; Compatible with erythema nodosum leprosum with scar areas&#46; &#40;B&#41; Histological section of the scalp region revealing mild hyperkeratosis&#44; epidermal atrophy&#44; ballooning of basal keratinocytes and discrete perivascular lymphohistiocytic infiltrate&#46; Compatible with lupus erythematosus&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:16 [
            0 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Avalia&#231;&#227;o dos sintomas&#44; complica&#231;&#245;es&#44; tratamento e efeitos colaterais medicamentosos sobre a qualidade de vida de portadores de L&#250;pus Eritematoso Sist&#234;mico &#40;LES&#41;&#58; revis&#227;o de literatura"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "H&#46;C&#46; Sampaio J&#250;nior"
                            1 => "H&#46;C&#46; Lopes"
                            2 => "L&#46;S&#46;V&#46; Rocha"
                            3 => "M&#46;O&#46;B&#46; Cavalcante"
                            4 => "A&#46;L&#46; Carvalho J&#250;nior"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Br J Health Rev"
                        "fecha" => "2020"
                        "volumen" => "3"
                        "paginaInicial" => "10303"
                        "paginaFinal" => "10318"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Medidas de avalia&#231;&#227;o em l&#250;pus eritematoso sist&#234;mico"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "E&#46; Freire"
                            1 => "L&#46;M&#46; Souto"
                            2 => "R&#46;M&#46; Ciconelli"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rev Br Reumatol"
                        "fecha" => "2011"
                        "volumen" => "51"
                        "paginaInicial" => "75"
                        "paginaFinal" => "80"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiology of systemic l&#250;pus erythematosus&#58; a comparation of world wide disease burden"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "N&#46; Danchenko"
                            1 => "J&#46;A&#46; Satia"
                            2 => "M&#46;S&#46; Aanthony"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1191/0961203306lu2305xx"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lupus"
                        "fecha" => "2006"
                        "volumen" => "15"
                        "paginaInicial" => "308"
                        "paginaFinal" => "318"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16761508"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Coexistent leprosy and systemic lupus erythematosus"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "D&#46;I&#46; Posner"
                            1 => "M&#46;A&#46; Ghill"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Cutis"
                        "fecha" => "1987"
                        "volumen" => "39"
                        "paginaInicial" => "136"
                        "paginaFinal" => "138"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3829720"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "L&#250;pus eritematoso sist&#234;mico associado &#224; mol&#233;stia de hansen&#58; relato de tr&#234;s casos"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "R&#46;C&#46; Ferro"
                            1 => "S&#46;R&#46;M&#46; Fernandes"
                            2 => "L&#46;T&#46;L&#46; Costallat"
                            3 => "A&#46;M&#46; Samara"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rev Bras Reumatol"
                        "fecha" => "1991"
                        "volumen" => "31"
                        "paginaInicial" => "31"
                        "paginaFinal" => "35"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anticorpos anticardiolipina em pacientes com mal de hansen"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46;C&#46;D&#46; Repka"
                            1 => "T&#46;L&#46; Skare"
                            2 => "G&#46; Salles J&#250;nior"
                            3 => "G&#46;M&#46; Paul"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rev Bras Reumatol"
                        "fecha" => "2001"
                        "volumen" => "41"
                        "paginaInicial" => "1"
                        "paginaFinal" => "6"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Vasculite na hansen&#237;ase mimetizando doen&#231;as reum&#225;ticas"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "S&#46;L&#46;E&#46; Ribeiro"
                            1 => "E&#46;L&#46; Guedes"
                            2 => "H&#46;L&#46;A&#46; Pereira"
                            3 => "L&#46;S&#46; Souza"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rev Bras Reumatol"
                        "fecha" => "2007"
                        "volumen" => "47"
                        "paginaInicial" => "140"
                        "paginaFinal" => "144"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Manifesta&#231;&#245;es reum&#225;ticas da hansen&#237;ase"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "H&#46;L&#46;A&#46; Pereira"
                            1 => "S&#46;L&#46;E&#46; Ribeiro"
                            2 => "E&#46;I&#46; Sato"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Acta Reumatol Port"
                        "fecha" => "2008"
                        "volumen" => "33"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lepromatous leprosy presenting with polyarthritis&#44; myositis and immune complexes glomerunonephritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46;M&#46;I&#46; Iveson"
                            1 => "A&#46;C&#46; McDougall"
                            2 => "A&#46;J&#46; Leathem"
                            3 => "H&#46;J&#46; Harris"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/bmj.3.5984.619"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br Med J"
                        "fecha" => "1975"
                        "volumen" => "3"
                        "paginaInicial" => "619"
                        "paginaFinal" => "621"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/126102"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Manifesta&#231;&#245;es reum&#225;ticas na hansen&#237;ase dificuldades no diagn&#243;stico precoce"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46; Freire"
                            1 => "H&#46;E&#46; Carneiro"
                            2 => "R&#46;B&#46; Teodoro"
                            3 => "H&#46;A&#46; Cecin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Rev Bras Reumatol"
                        "fecha" => "1998"
                        "paginaInicial" => "210"
                        "paginaFinal" => "214"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Reumatolog&#237;a&#58; diagn&#243;stico e tratamento"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46;A&#46;P&#46; Carvalho"
                            1 => "C&#46; Lanna"
                            2 => "M&#46; Bertolo"
                            3 => "G&#46; Ferreira"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Grupo Gen-Guanabara Koogan"
                        "fecha" => "2014"
                        "paginaInicial" => "378"
                        "paginaFinal" => "410"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Controlled trial with chloroquine diphosphate in systemic lupus erythematosus"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "I&#46;M&#46; Meinao"
                            1 => "E&#46;I&#46; Sato"
                            2 => "L&#46;E&#46; Andrade"
                            3 => "M&#46;B&#46; Ferraz"
                            4 => "E&#46; Atra"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1177/096120339600500313"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lupus"
                        "fecha" => "1996"
                        "volumen" => "5"
                        "paginaInicial" => "237"
                        "paginaFinal" => "241"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8803897"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Hydroxychloroquine short ages among patients with systemic l&#250;pus erythematosus during the COVID-19 pandemic&#58; experience of the Systemic Lupus International Collaborating Clinics"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Mendel"
                            1 => "S&#46; Bernatsy"
                            2 => "A&#46; Askane"
                            3 => "S&#46;C&#46; Bae"
                            4 => "A&#46;E&#46; Clarke"
                            5 => "N&#46; Costedoata-Chalumeau"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/annrheumdis-2020-219628"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Rheum Dis"
                        "fecha" => "2021"
                        "volumen" => "80"
                        "paginaInicial" => "1"
                        "paginaFinal" => "2"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33318041"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The relevance of antimalarial therapy with regard to thrombosis&#44; hypercholesterolemia and cytokines in SLE"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "D&#46;J&#46; Wallace"
                            1 => "M&#46; Linker-Israeli"
                            2 => "A&#46;L&#46; Metzger"
                            3 => "V&#46;J&#46; Stecher"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Lupus"
                        "fecha" => "1993"
                        "volumen" => "2"
                        "numero" => "Suppl&#46; 1"
                        "paginaInicial" => "S13"
                        "paginaFinal" => "S15"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cross cultural validation and reliability of three disease activity indices in systemic lupus erythematosus"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46;D&#46; Gladman"
                            1 => "C&#46;H&#46; Goldsmith"
                            2 => "M&#46;B&#46; Urowitz"
                            3 => "P&#46; Bacon"
                            4 => "C&#46; Bombardier"
                            5 => "D&#46; Isenberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Rheumatol"
                        "fecha" => "1992"
                        "volumen" => "19"
                        "paginaInicial" => "608"
                        "paginaFinal" => "611"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1593583"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Estudo da reprodutibilidade e validade do &#237;ndice de atividade do lupus eritematoso sist&#234;mico"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "E&#46;I&#46; Sato"
                            1 => "M&#46;B&#46; Ferraz"
                            2 => "V&#46;P&#46;M&#46; Lourenzi"
                            3 => "J&#46; Natour"
                            4 => "F&#46; Ikedo"
                            5 => "E&#46; Atra"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Ver Bras Reumatol"
                        "fecha" => "1991"
                        "volumen" => "31"
                        "paginaInicial" => "133"
                        "paginaFinal" => "136"
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/1699258X/0000001900000007/v1_202307241059/S1699258X23000980/v1_202307241059/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "33643"
    "tipo" => "SECCION"
    "es" => array:2 [
      "titulo" => "Casos cl&#237;nicos"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "es"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/1699258X/0000001900000007/v1_202307241059/S1699258X23000980/v1_202307241059/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X23000980?idApp=UINPBA00004M"
]