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B) Anatomía patológica de la muestra en la que se objetiva amiloide rojo Congo, sin teñir los alveolos pulmonares, y con tinción intensa roja el depósito de amiloide, así como en la imagen inferior a la derecha, birrefringencia verde manzana bajo luz polarizada.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sara González Castro, Ana Jaureguizar Oriol, Juan Rigual Bobillo" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Sara" "apellidos" => "González Castro" ] 1 => array:2 [ "nombre" => "Ana" "apellidos" => "Jaureguizar Oriol" ] 2 => array:2 [ "nombre" => "Juan" "apellidos" => "Rigual Bobillo" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020623002668" "doi" => "10.1016/j.medcle.2023.03.015" "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/S2387020623002668?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775323001598?idApp=UINPBA00004N" "url" => "/00257753/0000016100000002/v1_202307131046/S0025775323001598/v1_202307131046/es/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Epstein–Barr virus associated smooth-muscle tumor" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "90" "paginaFinal" => "91" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Anna Aguilar, Tulio Mateo Silva, Arnau Monforte" "autores" => array:3 [ 0 => array:3 [ "nombre" => "Anna" "apellidos" => "Aguilar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Tulio Mateo" "apellidos" => "Silva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:4 [ "nombre" => "Arnau" "apellidos" => "Monforte" "email" => array:1 [ 0 => "arnau.monforte@vallhebron.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Internal Medicine, Hospital Universitari Vall d’Hebron, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Pathology, Hospital Universitari Vall d’Hebron, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Infectious Diseases, Hospital Universitari Vall d’Hebron, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tumor de músculo liso asociado al virus de Epstein-Barr" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 497 "Ancho" => 1005 "Tamanyo" => 178604 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Hematoxylin and eosin of the tumor composed of intersecting fascicles of mildly atypical spindled cells with wide eosinophilic cytoplasm and elongated nuclei, suggesting a smooth-muscle origin. (B) Tumoral nuclei with positive in situ hybridization for EBV-encoded small RNA (EBER) stain in almost every smooth-muscle cell.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 30-year-old man attended the emergency room presenting a ten-day course of progressive paresthesia from toes to pelvis, inability to walk and urinate in the last 48<span class="elsevierStyleHsp" style=""></span>h. He was born in Pakistan and he was diagnosed with HIV infection in the past. He presented a disseminated <span class="elsevierStyleItalic">Mycobacterium avium complex</span> (MAC) infection which was treated, but he abandoned both antimycobacterial and antirretroviral treatment (ART), until two weeks before the present episode. He was asymptomatic with 30 CD4 T-lymphocyte cells/mm<span class="elsevierStyleSup">3</span> and three million of HIV RNA copies/ml, and he restarted ART.</p><p id="par0010" class="elsevierStylePara elsevierViewall">At the time of admission the physical examination revealed a urinary retention, a motor balance of 3 out of 5 in both legs and hypoesthesia up to T8 level. Urgent magnetic resonance imaging was performed under the suspicion of spinal cord compression (AIS D), showing two epidural lesions, one of them with severe compressive effect over the spinal cord at T6-T7 level, and the other one at T4 level. Intravenous steroids bolus at an initial dose of 500<span class="elsevierStyleHsp" style=""></span>mg of methylprednisolone per day were started under a suspected neoplastic etiology.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the following 24<span class="elsevierStyleHsp" style=""></span>h the patient showed improvement in leg strength, however, the symptoms worsened after 48<span class="elsevierStyleHsp" style=""></span>h with decrease in motor balance to 1 over 5 (AIS C) and progression of sensory impairment up to T6. The patient was taken for urgent decompressive surgery with a bilateral T7 laminectomy and T4 left-hemilaminectomy, visualizing a granulomatous tissue with low level of vascularization. The patient presented a very good postoperative course and started rehabilitation. The pathologist informed a moderately cellular proliferation composed of medium-sized elongated nuclei with fine granular chromatin and round nuclei with granular chromatin, and eosinophilic-pale elongated cytoplasm. There was diffuse EBV-encoded small RNA (EBER) expression, which was conclusive of a smooth-muscle tumor associated with EBV (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The result was discussed with Oncology and Radiotherapy in committee, precluding the need for a systemic treatment other than immune recovery.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Smooth-muscle tumor (SMT) associated with Epstein–Barr virus (EBV) was firstly reported in 1995 in young PWH. Demonstration of EBV infection by in situ hybridization within smooth-muscle tumor cells remains critical for the final diagnosis.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Its pathogenesis is unknown, but some hypotheses may suggest EBV infection of mesenchymal cells. There the EBV may have an oncogenic role, as has been described in B lymphocytes (lymphoma) and epithelial cells (nasopharyngeal carcinoma). The multicentricity of these tumors appears to be related to various EBV infectious events rather than a malignant dissemination of the tumor. Therefore they are considered non-malignant and they have better prognosis than other aggressive mesenchymal tumors.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Surgery could be necessary to control compressive symptoms, but the recovery of immunity is the most effective measure to control viral replication and tumor growth, even without additional systemic treatment.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">This case shows an emergency due to this non-malignant tumor, which is surprising regarding the rapid onset of the symptoms. In advanced HIV infection, CD4 T-lymphocytes decrease which can drive to opportunistic infections and replication of some potentially oncogenic viruses. However, after the reintroduction of ART a rapid decrease in HIV-RNA and increase in CD4 T-lymphocytes count could produce an inflammatory cascade known as inmune reconstitution inflammatory syndrome (IRIS) in locations where there is an infection. Such presentation has been described in many mycobacterial, fungal and viral infections in advanced inmunosupresion, including human herpesvirus-8 (HHV-8) and EBV. Therefore, the EBV involvement in this tumor could explain its rapid occurrence after the reintroduction of ART due to an associated IRIS.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The differential diagnosis was challenging. A thoracic epidural lesion in advanced HIV infection suggested an infectious or a malignant cause of a spinal cord compression. The absence of vertebral involvement was inconsistent with tuberculosis but the patient had already been diagnosed in the past with a disseminated MAC infection, which was not completely treated. Disseminated neoplastic disease is a common cause of thoracic spinal cord compression, being lymphoproliferative disorders well described in advanced HIV infection, mainly related to EBV infection. In this case, a surgical biopsy revealed the diagnosis, and the patient presented a favorable clinical outcome.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion, SMT should be suspected in a severely immunocompromised host in association with EBV replication, as it could potentially be cured by restoration of the immunity.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0040" class="elsevierStylePara elsevierViewall">Written informed consent was obtained from the patient for publication of this case and accompanying images.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">This work has not received any funding.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interests</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare they have no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interests" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 497 "Ancho" => 1005 "Tamanyo" => 178604 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Hematoxylin and eosin of the tumor composed of intersecting fascicles of mildly atypical spindled cells with wide eosinophilic cytoplasm and elongated nuclei, suggesting a smooth-muscle origin. (B) Tumoral nuclei with positive in situ hybridization for EBV-encoded small RNA (EBER) stain in almost every smooth-muscle cell.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Association of Epstein–Barr virus with leiomyosarcomas in young people with AIDS" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K.L. McClain" 1 => "C.T. Leach" 2 => "H.B. Jenson" 3 => "V.V. Joshi" 4 => "B.H. Pollock" 5 => "R.T. 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Nelson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/path.4449" "Revista" => array:6 [ "tituloSerie" => "J Pathol" "fecha" => "2015" "volumen" => "235" "paginaInicial" => "229" "paginaFinal" => "241" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25251832" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00257753/0000016100000002/v1_202307131046/S002577532300180X/v1_202307131046/en/main.assets" "Apartado" => array:4 [ "identificador" => "66430" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas al Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00257753/0000016100000002/v1_202307131046/S002577532300180X/v1_202307131046/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S002577532300180X?idApp=UINPBA00004N" ]
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