Cryptococcal cellulitis in an immunocompetent host
Identifieur interne : 006B46 ( Istex/Corpus ); précédent : 006B45; suivant : 006B47Cryptococcal cellulitis in an immunocompetent host
Auteurs : Bego A Sanchez-Albisua ; Jose Luis Rodriguez-Peralto ; Guillermo Romero ; Javier Alonso ; Francisco Vanaclocha ; Luis IglesiasSource :
- Journal of the American Academy of Dermatology [ 0190-9622 ] ; 1997.
Abstract
J Am Acad Dermatol 1997;36:109-12.
Url:
DOI: 10.1016/S0190-9622(97)70340-2
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ISTEX:E51E25B3B63D7CD3501D9E6AC019F7C5EADC4A79Le document en format XML
<record><TEI wicri:istexFullTextTei="biblStruct"><teiHeader><fileDesc><titleStmt><title xml:lang="en">Cryptococcal cellulitis in an immunocompetent host</title><author><name sortKey="Sanchez Albisua, Bego A" sort="Sanchez Albisua, Bego A" uniqKey="Sanchez Albisua B" first="Bego A" last="Sanchez-Albisua">Bego A Sanchez-Albisua</name><affiliation><mods:affiliation>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</mods:affiliation></affiliation></author><author><name sortKey="Rodriguez Peralto, Jose Luis" sort="Rodriguez Peralto, Jose Luis" uniqKey="Rodriguez Peralto J" first="Jose Luis" last="Rodriguez-Peralto">Jose Luis Rodriguez-Peralto</name><affiliation><mods:affiliation>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</mods:affiliation></affiliation></author><author><name sortKey="Romero, Guillermo" sort="Romero, Guillermo" uniqKey="Romero G" first="Guillermo" last="Romero">Guillermo Romero</name><affiliation><mods:affiliation>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</mods:affiliation></affiliation></author><author><name sortKey="Alonso, Javier" sort="Alonso, Javier" uniqKey="Alonso J" first="Javier" last="Alonso">Javier Alonso</name><affiliation><mods:affiliation>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</mods:affiliation></affiliation></author><author><name sortKey="Vanaclocha, Francisco" sort="Vanaclocha, Francisco" uniqKey="Vanaclocha F" first="Francisco" last="Vanaclocha">Francisco Vanaclocha</name><affiliation><mods:affiliation>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</mods:affiliation></affiliation></author><author><name sortKey="Iglesias, Luis" sort="Iglesias, Luis" uniqKey="Iglesias L" first="Luis" last="Iglesias">Luis Iglesias</name><affiliation><mods:affiliation>Madrid, SpainFrom the 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of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</mods:affiliation></affiliation></author><author><name sortKey="Rodriguez Peralto, Jose Luis" sort="Rodriguez Peralto, Jose Luis" uniqKey="Rodriguez Peralto J" first="Jose Luis" last="Rodriguez-Peralto">Jose Luis Rodriguez-Peralto</name><affiliation><mods:affiliation>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</mods:affiliation></affiliation></author><author><name sortKey="Romero, Guillermo" sort="Romero, Guillermo" uniqKey="Romero G" first="Guillermo" last="Romero">Guillermo Romero</name><affiliation><mods:affiliation>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</mods:affiliation></affiliation></author><author><name sortKey="Alonso, Javier" sort="Alonso, Javier" uniqKey="Alonso J" first="Javier" last="Alonso">Javier Alonso</name><affiliation><mods:affiliation>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</mods:affiliation></affiliation></author><author><name sortKey="Vanaclocha, Francisco" sort="Vanaclocha, Francisco" uniqKey="Vanaclocha F" first="Francisco" last="Vanaclocha">Francisco Vanaclocha</name><affiliation><mods:affiliation>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</mods:affiliation></affiliation></author><author><name sortKey="Iglesias, Luis" sort="Iglesias, Luis" uniqKey="Iglesias L" first="Luis" last="Iglesias">Luis Iglesias</name><affiliation><mods:affiliation>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</mods:affiliation></affiliation></author></analytic><monogr></monogr><series><title level="j">Journal of the American Academy of Dermatology</title><title level="j" type="abbrev">YMJD</title><idno type="ISSN">0190-9622</idno><imprint><publisher>ELSEVIER</publisher><date type="published" when="1997">1997</date><biblScope 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specimen</json:string><json:string>cryptococcal cellulitis</json:string><json:string>american academy</json:string><json:string>bulla</json:string><json:string>clin</json:string><json:string>acad dermatol</json:string><json:string>carcinoma</json:string><json:string>case report</json:string><json:string>brief communications</json:string><json:string>hemorrhagic bullae</json:string><json:string>dermatology january</json:string><json:string>oral prednisone</json:string><json:string>edematous plaque</json:string><json:string>immunosuppressed patients</json:string><json:string>inflamed border</json:string><json:string>transplant recipients</json:string><json:string>severe lymphopenia</json:string><json:string>dermatology volume</json:string><json:string>topical nitrogen mustard</json:string><json:string>direct immunofluorescence</json:string><json:string>mechlorethamine ointment</json:string><json:string>renal</json:string><json:string>plaque</json:string><json:string>biopsy</json:string><json:string>transplant</json:string></teeft></keywords><author><json:item><name>Begoña Sanchez-Albisua MDa</name><affiliations><json:string>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</json:string></affiliations></json:item><json:item><name>Jose Luis Rodriguez-Peralto MDb</name><affiliations><json:string>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</json:string></affiliations></json:item><json:item><name>Guillermo Romero MDa</name><affiliations><json:string>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</json:string></affiliations></json:item><json:item><name>Javier Alonso MDa</name><affiliations><json:string>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, 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Luis</forename><surname>Rodriguez-Peralto</surname></persName><roleName type="degree">MDb</roleName><affiliation>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</affiliation></author><author xml:id="author-0002"><persName><forename type="first">Guillermo</forename><surname>Romero</surname></persName><roleName type="degree">MDa</roleName><affiliation>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</affiliation></author><author xml:id="author-0003"><persName><forename type="first">Javier</forename><surname>Alonso</surname></persName><roleName type="degree">MDa</roleName><affiliation>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</affiliation></author><author xml:id="author-0004"><persName><forename type="first">Francisco</forename><surname>Vanaclocha</surname></persName><roleName type="degree">MDa</roleName><affiliation>Madrid, SpainFrom the 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NDATA="IMAGE" name="gr2"></istex:entity></istex:docType><istex:document><article docsubtype="fla" xml:lang="en"><item-info><jid>YMJD</jid><aid>74891</aid><ce:pii>S0190-9622(97)70340-2</ce:pii><ce:doi>10.1016/S0190-9622(97)70340-2</ce:doi><ce:copyright type="other" year="1997">American Academy of Dermatology, Inc</ce:copyright></item-info><head><ce:article-footnote><ce:label>☆</ce:label><ce:note-para>Reprint requests: Begoña Sanchez-Albisua, Department of Dermatology, Hospital 12 de Octubre, Ctra. de Andalucia, KM 5,4, 28041 Madrid, Spain.</ce:note-para></ce:article-footnote><ce:article-footnote><ce:label>☆☆</ce:label><ce:note-para>0190-9622/97/$5.00 + 0 <ce:bold>16/54/74891</ce:bold></ce:note-para></ce:article-footnote><ce:title>Cryptococcal cellulitis in an immunocompetent host</ce:title><ce:author-group><ce:author><ce:given-name>Begoña</ce:given-name><ce:surname>Sanchez-Albisua</ce:surname><ce:degrees>MD<ce:sup>a</ce:sup></ce:degrees></ce:author><ce:author><ce:given-name>Jose Luis</ce:given-name><ce:surname>Rodriguez-Peralto</ce:surname><ce:degrees>MD<ce:sup>b</ce:sup></ce:degrees></ce:author><ce:author><ce:given-name>Guillermo</ce:given-name><ce:surname>Romero</ce:surname><ce:degrees>MD<ce:sup>a</ce:sup></ce:degrees></ce:author><ce:author><ce:given-name>Javier</ce:given-name><ce:surname>Alonso</ce:surname><ce:degrees>MD<ce:sup>a</ce:sup></ce:degrees></ce:author><ce:author><ce:given-name>Francisco</ce:given-name><ce:surname>Vanaclocha</ce:surname><ce:degrees>MD<ce:sup>a</ce:sup></ce:degrees></ce:author><ce:author><ce:given-name>Luis</ce:given-name><ce:surname>Iglesias</ce:surname><ce:degrees>MD<ce:sup>a</ce:sup></ce:degrees></ce:author><ce:affiliation><ce:textfn>Madrid, Spain</ce:textfn></ce:affiliation><ce:affiliation><ce:textfn>From the Departments of Dermatology<ce:sup>a</ce:sup> and Pathology,<ce:sup>b</ce:sup> Hospital 12 de Octubre, Madrid</ce:textfn></ce:affiliation></ce:author-group><ce:abstract><ce:section-title>Abstract</ce:section-title><ce:abstract-sec><ce:simple-para>J Am Acad Dermatol 1997;36:109-12.</ce:simple-para></ce:abstract-sec></ce:abstract></head><body><ce:sections><ce:para>Isolated cutaneous cryptococcosis is rare, but susceptibility is greatly increased by immunosuppression. <ce:cross-ref refid="bib1"><ce:sup>1</ce:sup></ce:cross-ref> Cutaneous lesions vary greatly in morphology and include cellulitis, which has only been described in immunosuppressed patients. <ce:cross-refs refid="bib2 bib3 bib4 bib5 bib6 bib7 bib8 bib9 bib10 bib11 bib12 bib13 bib14 bib15 bib16 bib17 bib18 bib19 bib20 bib21 bib22"><ce:sup>2-22</ce:sup></ce:cross-refs> We report a case of cutaneous cryptococcal cellulitis in an apparently immunocompetent patient.</ce:para><ce:section><ce:section-title>CASE REPORT</ce:section-title><ce:para>A 76-year-old pigeon-owner and housewife had a 2-week history of fever, malaise, and a tender plaque on her right leg. Examination revealed a well-demarcated, erythematous, edematous plaque with large, tense, hemorrhagic bullae on the anterior and posterior aspects of her right leg (<ce:cross-ref refid="fig1">Fig. 1 , <ce:italic>A</ce:italic></ce:cross-ref> ).
<ce:display><ce:figure id="fig1"><ce:label>Fig. 1</ce:label><ce:caption><ce:simple-para><ce:bold>A,</ce:bold> Edematous plaque with large, tense, hemorrhagic bullae on medial leg. <ce:bold>B,</ce:bold> After debridement. Note irregular, necrotic plaque with inflamed border and granulating base.</ce:simple-para></ce:caption> <ce:link locator="gr1"></ce:link></ce:figure></ce:display>After debridement, an irregular, necrotic, violaceous plaque with inflamed border remained (<ce:cross-ref refid="fig1">Fig. 1 , <ce:italic>B</ce:italic></ce:cross-ref> ). Local lymphadenopathy was absent.</ce:para><ce:para>A biopsy specimen showed marked dermal edema, multilocular epidermal bullae, a dense perivascular infiltrate composed of neutrophils and lymphocytes, and a profuse extravasation of erythrocytes. Subcutaneous tissue contained a large necrotic granulomatous area with abundant debris, lymphocytes, histiocytes, and epithelioid cells. The center contained multiple budding forms with a periodic acid–Schiff–positive (PAS) and Alcian blue–positive capsule. Skin culture was negative for bacteria, and positive for <ce:italic>Cryptococcus neoformans</ce:italic> .</ce:para><ce:para>After being questioned again, the patient remembered a "cold" with a productive cough 4 months earlier that lasted about 2 months and cleared spontaneously.</ce:para><ce:para>Laboratory studies revealed a normal blood cell count except for mild leukocytosis (11,000/mm <ce:sup>3</ce:sup> ) with a normal differential count. The results of chest and tibial roentgenography were normal. Culture and latex agglutination tests of blood, urine, and cerebrospinal fluid were negative. Immunoglobulins, CD4 and CD8 cell counts, and response to mitogens were normal. HIV serology was negative.</ce:para><ce:para>She was treated with itraconazole, 400 mg/day, for 1 month and then 200 mg/day for 4 months. From the first week of treatment she remained afebrile and healing began. On the tenth day of treatment a biopsy specimen revealed absence of <ce:italic>Cryptococcus</ce:italic> . After 2 months of treatment the lesion was completely healed, but 1 month later some papule-nodules with pus developed around the scar.</ce:para><ce:para>The biopsy specimen showed a deep dermal and subcutaneous lymphohistioplasmocytoid infiltrate with multinucleated cells arranged in a granulomatous pattern with central necrosis involving the papillary and reticular dermis. Histochemical stains (PAS and silver-methenamine) revealed the presence of cryptococcus (<ce:cross-ref refid="fig2">Fig. 2</ce:cross-ref> ).
<ce:display><ce:figure id="fig2"><ce:label>Fig. 2</ce:label><ce:caption><ce:simple-para>Photomicrograph of biopsy specimen shows numerous yeasts with aneosinophilic capsule. (Periodic acid–Schiff stain; original magnification ×250.)</ce:simple-para></ce:caption> <ce:link locator="gr2"></ce:link></ce:figure></ce:display>Laboratory investigations did not reveal extracutaneous disease or immunosuppression.</ce:para><ce:para>After discontinuation of itraconazole, the patient received oral fluconazole 50 mg/day for 6 months with minimal improvement. She was then treated with fluconazole 400 mg/day for the next 3 months with complete clinical healing. When this dose was reduced to 200 mg/day for 2 months, new papule-nodules occurred in the scar. A biopsy specimen was positive for <ce:italic>Cryptococcus</ce:italic> . She then received a 1-month cycle of amphotericin B (10 to 30 mg/day) and 5-flucytosine. Clinical remission was achieved 2 months later and persisted 14 months later.</ce:para></ce:section><ce:section><ce:section-title>DISCUSSION</ce:section-title><ce:para>Cryptococcosis is caused by <ce:italic>C. neoformans</ce:italic> . It exists as a saprophyte in nature and is particularly abundant in soils enriched with pigeon droppings. Our patient was in close contact with pigeons, but pigeon breeders do not have an increased rate of infection. <ce:cross-ref refid="bib23"><ce:sup>23</ce:sup></ce:cross-ref></ce:para><ce:para>Cell-mediated immunity is critical in host defense and susceptibility to dissemination. Although in more than half the patients no apparent predisposing factor can be identified, selective impairment of the lymphocyte response to cryptococci has been found in most patients studied. <ce:cross-ref refid="bib3"><ce:sup>3</ce:sup></ce:cross-ref> These findings may help explain the increased incidence of cryptococcosis in immunosuppressed patients, especially those receiving corticosteroids, in those with a lymphoreticular malignancy, in transplant recipients, and in those patients with AIDS. <ce:cross-ref refid="bib23"><ce:sup>23</ce:sup></ce:cross-ref> Our patient was repeatedly investigated for immunosuppression with negative results.</ce:para><ce:para>The existence of primary cutaneous cryptococcosis is controversial. In the opinion of most investigators, a solitary skin lesion is actually secondary to an asymptomatic lung disease. <ce:cross-refs refid="bib1 bib23"><ce:sup>1,23</ce:sup></ce:cross-refs> In our patient the portal of entry is unclear and a lung infection that spontaneously cleared cannot be excluded.</ce:para><ce:para>In our review of the literature we have found 33 cases of cryptococcal cellulitis. Only eight had no evidence of extracutaneous involvement. Most occurred in severely immunosuppressed patients taking prednisone with or without other immunosuppressive drugs. It has been associated with systemic lupus erythematosus, <ce:cross-refs refid="bib2 bib3"><ce:sup>2,3</ce:sup></ce:cross-refs> chronic lymphocytic leukemia, <ce:cross-ref refid="bib2"><ce:sup>2</ce:sup></ce:cross-ref> myeloma, <ce:cross-refs refid="bib2 bib4"><ce:sup>2,4</ce:sup></ce:cross-refs> chronic active hepatitis, <ce:cross-ref refid="bib5"><ce:sup>5</ce:sup></ce:cross-ref> cervical medullary tumor, <ce:cross-ref refid="bib6"><ce:sup>6</ce:sup></ce:cross-ref> congenital lymphedema with severe lymphopenia and hypoalbuminemia, <ce:cross-ref refid="bib7"><ce:sup>7</ce:sup></ce:cross-ref> intestinal lymphangiectasia with severe lymphopenia and hypoalbuminemia, <ce:cross-ref refid="bib8"><ce:sup>8</ce:sup></ce:cross-ref> liver transplantation, <ce:cross-ref refid="bib9"><ce:sup>9</ce:sup></ce:cross-ref> inflammatory bowel disease, <ce:cross-refs refid="bib3 bib10"><ce:sup>3,10</ce:sup></ce:cross-refs> and especially with kidney transplantation. <ce:cross-refs refid="bib3 bib8 bib11 bib12 bib13 bib14 bib15 bib16 bib17 bib18 bib19 bib20"><ce:sup>3,8,11-20</ce:sup></ce:cross-refs> Two cases occurred in debilitated but not severely immunocompromised patients. <ce:cross-refs refid="bib21 bib22"><ce:sup>21,22</ce:sup></ce:cross-refs> To our knowledge, the clinical presentation in our patient has never been reported before in a previously healthy patient.</ce:para><ce:para>Disseminated cryptococcosis is almost uniformly fatal if untreated. With appropriate antifungal treatment, the mortality rate is reduced to 10% to 20%. <ce:cross-ref refid="bib8"><ce:sup>8</ce:sup></ce:cross-ref> In systemic infections intravenous amphotericin B with or without oral flucytosine is the mainstay of therapy. Given the potential toxicities of amphotericin B, treatment with itraconazole and fluconazole has been evaluated with encouraging results in both systemic <ce:cross-refs refid="bib24 bib25"><ce:sup>24,25</ce:sup></ce:cross-refs> and cutaneous <ce:cross-refs refid="bib26 bib27"><ce:sup>26,27</ce:sup></ce:cross-refs> disease. Cryptococcal cellulitis was treated with amphotericin B with or without 5-flucytosine in all but two of the previously reported cases of cryptococcal cellulitis. Most cleared or the patients died of other causes. Fluconazole was used in two patients: a kidney transplant recipient with disseminated disease for whom amphotericin B was considered to be contraindicated <ce:cross-ref refid="bib18"><ce:sup>18</ce:sup></ce:cross-ref> and a case of cutaneous localized cryptococcosis in a debilitated but not immunosuppressed patient. <ce:cross-ref refid="bib21"><ce:sup>21</ce:sup></ce:cross-ref> Both cases cleared. In our patient the results of treatment with itraconazole and fluconazole were not satisfactory. Therefore treatment was changed to amphotericin B and 5-flucytosine. 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Dermatol</sb:maintitle></sb:title><sb:volume-nr>128</sb:volume-nr></sb:series><sb:date>1992</sb:date></sb:issue><sb:pages><sb:first-page>1045</sb:first-page><sb:last-page>1046</sb:last-page></sb:pages></sb:host></sb:reference></ce:bib-reference></ce:bibliography-sec></ce:bibliography></tail></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>Cryptococcal cellulitis in an immunocompetent host</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>Cryptococcal cellulitis in an immunocompetent host</title></titleInfo><name type="personal"><namePart type="given">Begoña</namePart><namePart type="family">Sanchez-Albisua</namePart><namePart type="termsOfAddress">MDa</namePart><affiliation>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Jose Luis</namePart><namePart type="family">Rodriguez-Peralto</namePart><namePart type="termsOfAddress">MDb</namePart><affiliation>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Guillermo</namePart><namePart type="family">Romero</namePart><namePart type="termsOfAddress">MDa</namePart><affiliation>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Javier</namePart><namePart type="family">Alonso</namePart><namePart type="termsOfAddress">MDa</namePart><affiliation>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Francisco</namePart><namePart type="family">Vanaclocha</namePart><namePart type="termsOfAddress">MDa</namePart><affiliation>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Luis</namePart><namePart type="family">Iglesias</namePart><namePart type="termsOfAddress">MDa</namePart><affiliation>Madrid, SpainFrom the Departments of Dermatologya and Pathology,b Hospital 12 de Octubre, Madrid</affiliation><role><roleTerm type="text">author</roleTerm></role></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="Full-length article"></genre><originInfo><publisher>ELSEVIER</publisher><dateIssued encoding="w3cdtf">1997</dateIssued><copyrightDate encoding="w3cdtf">1997</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><physicalDescription><internetMediaType>text/html</internetMediaType></physicalDescription><abstract lang="en">J Am Acad Dermatol 1997;36:109-12.</abstract><note>Reprint requests: Begoña Sanchez-Albisua, Department of Dermatology, Hospital 12 de Octubre, Ctra. de Andalucia, KM 5,4, 28041 Madrid, Spain.</note><note>0190-9622/97/$5.00 + 0 16/54/74891</note><relatedItem type="host"><titleInfo><title>Journal of the American Academy of Dermatology</title></titleInfo><titleInfo type="abbreviated"><title>YMJD</title></titleInfo><genre type="journal">journal</genre><originInfo><dateIssued encoding="w3cdtf">199701</dateIssued></originInfo><identifier type="ISSN">0190-9622</identifier><identifier type="PII">S0190-9622(05)X7229-2</identifier><part><date>199701</date><detail type="volume"><number>36</number><caption>vol.</caption></detail><detail type="issue"><number>1</number><caption>no.</caption></detail><extent unit="issue pages"><start>1</start><end>145</end></extent><extent unit="pages"><start>109</start><end>112</end></extent></part></relatedItem><identifier type="istex">E51E25B3B63D7CD3501D9E6AC019F7C5EADC4A79</identifier><identifier type="DOI">10.1016/S0190-9622(97)70340-2</identifier><identifier type="PII">S0190-9622(97)70340-2</identifier><accessCondition type="use and reproduction" contentType="copyright">©1997 American Academy of Dermatology, Inc</accessCondition><recordInfo><recordContentSource>ELSEVIER</recordContentSource><recordOrigin>American Academy of Dermatology, Inc, ©1997</recordOrigin></recordInfo></mods></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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