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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Frida Kahlo is an icon among 20th-century women in the arts&#46; Interest &#8211; and even devotion &#8211; about her works&#44; remain more than 50 years after her death&#46; Younger generations know about her and usually have a position on her paintings&#44; whether they like them or not&#46; Frida has been the subject of several biographic and iconographic books and some popular motion pictures&#46; She is the center of many web sites and is represented in numerous examples of popular arts and crafts&#44; particularly in her natal Mexico&#46; Her personality has become a symbol embraced by activists of feminism and sexual liberation&#44; persons with a disability&#44; and Mexican culture&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">1&#8211;7</span></a> She is also probably the painter with more medical papers centered on her health&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The purpose of this paper is to review some historical pieces of evidence to explain the cause of some of her medical problems&#44; namely&#44; primary antiphospholipid syndrome&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">Frida Kahlo was born in Mexico City in 1907&#44; the 3rd of 4 daughters&#46; Her father had a history of epilepsy&#44; and her mother suffered fits that had apparently psychological basis&#46; Her sister Adriana suffered three spontaneous abortions&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">1&#8211;3&#44;6</span></a> Frida had a severe condition diagnosed as Polio at the age of 6&#44; which&#44; after a prolonged evolution&#44; requiring bed rest for nine months&#44; left moderate atrophy and weakness in her right leg as well as some discrepancy in length with the left side&#46; Eventually&#44; her recovery allowed her to run and dance&#46; She used dressing tricks to hide the slight difference among her legs&#44; but still had some pelvic imbalance and probably some degree of scoliosis &#40;diagnosed later in her life&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6&#44;8&#8211;10</span></a> On September 17&#44; 1925&#44; at the age of 18&#44; the bus she was traveling in collided with a streetcar&#46; This accident caused her several fractures in vertebrae&#44; clavicle&#44; pelvis&#44; and right leg and foot&#59; luxation of the left elbow and a penetrating wound caused by a metal handrail which entered on the left side of the pelvis and emerged through the left side of her vulva&#46; She developed peritonitis requiring surgery and had cystitis after prolonged catheterization&#46; After she recovered from these problems&#44; persistent back pain led to the diagnosis of vertebral fractures&#44; starting the use of several different types of plaster and metal corsets for prolonged periods for the rest of her life&#46; By 1931&#44; X-ray studies of the spine showed the existence of spina bifida and scoliosis&#44; besides of the traumatic lesions&#46; After that&#44; she had multiple spine surgeries in diverse hospitals&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6&#44;8&#8211;12</span></a> An X-Ray film of 1954 &#8211; the year of her death &#8211; shows a metal bar fixed by screws from 3rd to 5th lumbar vertebrae&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Since 1931 she suffered persistent and severe pain in the right leg and foot&#44; with remarkable thinning of that limb&#46; She required for the rest of her life&#44; the use of diverse narcotic analgesics&#44; which she combined with alcohol in varying forms and quantities&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6</span></a> A small ulcer appeared on the right foot&#44; as it persisted and increased its size&#44; leading to several surgeries on that foot&#44; including amputation of phalanxes and sesamoid bones and a sympathectomy&#46; Finally&#44; as gangrene complicates the case&#44; her right leg was amputated until the knee in 1953&#46; It should be noted that Frida was a heavy smoker&#44; a risk factor for both&#44; chronic ulcers and gangrene&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Several of her biographers refer to multiple miscarriages&#44; including two therapeutic abortions&#58; one in 1929 &#40;attempting to prevent complications from her damaged pelvis&#41; and one in 1934&#46; At least two spontaneous abortions occurred&#46; One in 1932&#44; after four months of pregnancy&#44; while in Detroit&#44; and another in 1937&#46; The other miscarriages have not been defined clearly as to when and where they occurred&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6&#44;13&#44;14</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In 1931&#44; she had a positive Wassermann&#39;s test when she was studied in San Francisco by Dr&#46; Leo Eloesser&#44; a Surgeon at San Francisco&#44; who became his life-long friend and main medical advisor&#46; The positive Wassermann test led to treatment with Neosalvarsan and later to therapies with blood transfusions and bismuth&#44; considering that syphilis could explain some of her problems&#46; The laboratory reaction was negative in several other times&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6&#44;15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">From this time&#44; she had long periods of severe limitation due to fatigue and pain&#44; mainly in her neck&#44; back&#44; and right leg&#44; accompanied with weight loss and depression&#46; She could not continue giving her painting lessons&#46; After one of her spine surgeries&#44; while lying on her bed or limited to a wheelchair&#44; she painted many of her works&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6&#44;8&#8211;12</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In 1954&#44; after attending a political manifestation&#44; against her doctors&#8217; advice&#44; she fell ill with pneumonia and died on July 13&#44; that year&#46; Her death certificate &#40;signed by her Psychiatrist&#44; Dr&#46; Ram&#243;n Parres&#41; refers to &#8220;pulmonary embolism&#8221; as the cause of her death&#44;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6</span></a> although no autopsy was performed&#46; Some of her biographers mention the possibility that a narcotic overdose&#44; either voluntary or not&#44; could have influenced her outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Like many episodes of her life&#44; Frida illustrated some of her clinical features in her works&#46; The painting&#44; known as &#8220;What I saw in the water&#8221; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#59; oil on canvas&#44; 1938&#59; 91<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>70&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#46; Daniel Filipacchi&#39;s collection&#44; Paris&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">4</span></a> shows a bleeding sore by her deformed&#44; right first toe&#46; A drawing known as &#8220;Self-portrait&#44; sitting&#8221; &#40;pencil on paper&#44; 1931&#59; 29<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>20&#46;4<span class="elsevierStyleHsp" style=""></span>cm&#46; Teresa Proenza&#39;s Collection&#44; Mexico City&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">4</span></a> show her sitting with a bandaged left foot that shows a dark stain&#46; A similar painting&#44; &#8220;Remembrance of the open wound&#44;&#8221; is little known as a fire destroyed the owner&#39;s house&#46; This painting shows her with a bleeding wound in her left thigh&#44; apparently invented as there is not an account of such lesion&#44; but it also shows a bandaged and bleeding left foot again&#46; It is known only from a photograph owned by Raquel Tibol&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">6</span></a> After that&#44; her diary&#44; which she started in 1946&#59; includes a drawing of a severed right leg and foot &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#59; watercolor and ink on a paper page&#44; 1953&#59; Frida Kahlo&#39;s Museum&#44; Mexico City&#41; with the famous legend &#8220;Feet&#44; what do I need them for if I have wings to fly&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">4</span></a> Another drawing from the same Diary &#40;watercolor and ink on a paper page&#44; 1954&#59; Frida Kahlo&#39;s Museum&#44; Mexico City&#41; shows Frida with a wooden leg&#44; again on the left side&#46; Chronic ulcer&#44; disabling pain&#44; and gangrene occurred on the right lower limb&#46; The reason to depict an affected left side is not known&#46; Is it intentionally misleading&#63; Is it a mistake&#63; It seems unlikely as it happens in at least three works&#46; Regarding the abortions&#44; two works dated in 1932 describe one of them&#46; The lithography is known as &#8220;Frida and the abortion &#40;lithography on paper&#44; 2nd copy&#44; 32<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>23&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#59; Dolores Olmedo Collection&#44; Mexico City&#41;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">4</span></a> and a painting titled &#8220;Henry Ford Hospital&#44;&#8221; or &#8220;The flying bed&#8221; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#44; oil on metal sheet&#44; 30&#46;5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>38<span class="elsevierStyleHsp" style=""></span>cm&#59; Dolores Olmedo Collection&#44; Mexico City&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">4</span></a> Both works show her naked&#44; with tears in her eyes&#44; bleeding genitals and communicating lines to a fetus and other elements&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">This summary of clinical features found in Frida Kahlo&#39;s biographic accounts and paintings would lead most contemporary Rheumatologists to investigate the possibility of primary antiphospholipid syndrome&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the findings in Frida&#39;s history and compares some of those features with currently accepted Criteria for the Classification of Antiphospholipid Syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">13</span></a> Knowledge on its epidemiology&#44; pathogenesis&#44; diagnosis&#44; and management has progressed notably&#44; and as a result&#44; vascular and obstetric outcomes of this condition have improved&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">14</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Several medical papers have explored possible explanations for her chronic pain&#44; both in the right lower limb and generalized&#44; as well as disability&#46; They include the sequelae of trauma and vertebral fractures&#44; with nerve root compromise&#44; but some authors point to the relative importance of spina bifida<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">8&#44;10</span></a>&#59; complex regional pain syndrome<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">8&#44;10&#44;15</span></a> and even to post-polio syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">8&#44;10&#44;15&#8211;17</span></a> Compelling pieces of evidence point to post-traumatic fibromyalgia&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">18</span></a> and some authors refer to lead poisoning&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">19</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The chronic lesion&#44; described as a &#8220;trophic ulcer&#8221; on the right foot&#44; has been seen as a complication of severe trauma in a limb with neurological deficiencies from polio&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6&#44;8&#44;10</span></a> Also&#44; Post-Polio syndrome has been invoked&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">15&#8211;17</span></a> There is a possibility of osteomyelitis complicating her surgeries on that foot&#46; However&#44; as the lesion progressed&#44; it was accompanied by signs of vascular insufficiency and finally gangrene&#46; Therefore&#44; previous explanations seem inadequate&#44; and these findings suggest vascular thrombosis&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Frida&#39;s abortion &#40;at four months of her second pregnancy&#41;&#44; as well as the &#8220;multiple miscarriages&#8221; and the therapeutic abortions&#44; have been explained as complications of her accident causing uterine damage or pelvic abnormalities&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6&#44;20&#44;21</span></a> Attempts to explain her inability to carry a pregnancy to term&#44; include an exploratory laparotomy performed in 1934 after an abortion&#44; which found &#8220;ovarian infantilism&#8221;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6</span></a> and recent reviews of her case mention the possibility of Asherman&#39;s syndrome &#40;endometrial scarring&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">22</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Wassermann&#39;s test was performed looking for syphilis&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6</span></a> It was the usual test in those days&#46; Frida had at least one positive test&#46; Our present interest in this finding lies in the fact that it was a primitive way to find antibodies to cardiolipin&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">23</span></a> The coagulation inhibitor named &#8220;the lupus anticoagulant&#8221; was known since 1952<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">24</span></a>&#59; however&#44; the concept of Antiphospholipid Syndrome arose only in 1983&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">25</span></a> Such a notion was far from being known by Frida&#39;s Doctors&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Several papers published in medical journals have centered on Frida Kahlo&#39;s life&#44; works&#44; and clinical history&#46; A non-exhaustive search in PubMed and PMC on March 26&#44; 2020&#44; yielded 40 papers&#44; including Frida Kahlo as the main or secondary object of the publication&#46; Her name was mentioned in many more papers discussing pain&#44; art&#44; and related issues&#46; Besides of the titles already mentioned here&#44; some papers discuss the role of herself depicting her pain and her medical interventions<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">26&#8211;32</span></a>&#59; the perspective of her case as seen by rheumatologists<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">33&#44;34</span></a>&#59; the sublimation of her suffering&#44; pain&#44; and loss&#44; describing possible psychiatric explanations&#46;<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">35&#8211;42</span></a> Even her homoeroticism has been discussed&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">43</span></a> Two papers deal with the relationship with her physicians&#46;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">44&#44;45</span></a> Some articles describe specific paintings&#46;<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">46&#8211;49</span></a> Others report on museum exhibitions on Frida Kahlo<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">50&#8211;52</span></a> and her importance as a relevant character in educational interventions for health professionals&#46;<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">53&#44;54</span></a> None of these papers mention the possibility of antiphospholipid syndrome&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0080" class="elsevierStylePara elsevierViewall">Historical accounts of pregnancy morbidity&#44; vascular thrombosis&#44; and at least one mention of a positive test for antibodies to cardiolipin support the possibility of an antiphospholipid syndrome explaining some of the medical problems of Frida Kahlo&#46; Her works depict several clues to understand her pain and the diversity of medical issues&#46; Observing her pictures frequently leads to an emotional reaction and to admiration of her ability to overcome adversity&#46; After all&#44; citing Courtney et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleItalic">it is how she chose to live life&#44; not her death&#44; for which she is remembered&#46;</span></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Authorship</span><p id="par0085" class="elsevierStylePara elsevierViewall">JMT and MCAC originated the conception and design of the study&#46; All of the authors participated in gathering&#44; analyzing and interpretation of data&#59; critical review of its intellectual content and definitive approval of the final text</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Source of financing</span><p id="par0090" class="elsevierStylePara elsevierViewall">This investigation has not obtained any help from public agencies&#59; commercial entities or non-profit organizations&#46; Only authors&#8217; own resources&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Frida Kahlo&#39;s medical history shows sequelae of polio&#44; a severe traumatic event that caused multiple fractures and a penetrating pelvic injury&#44; as well as a history of countless surgeries&#46; In her biographical accounts and her works&#44; chronic disabling pain always appears for long periods&#46; Besides&#44; a chronic foot ulcer&#44; gangrene that required amputation of the right leg&#44; a history of abortions&#44; and a positive Wasserman reaction suggest that the artist could have suffered from antiphospholipid antibody syndrome &#40;APS&#41;&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La historia cl&#237;nica de Frida Kahlo muestra secuelas de polio&#44; un evento traum&#225;tico grave que caus&#243; m&#250;ltiples fracturas y una lesi&#243;n penetrante de pelvis&#44; as&#237; como historia de incontables cirug&#237;as&#46; En sus recuentos biogr&#225;ficos y en sus obras&#44; siempre aparece dolor cr&#243;nico incapacitante por largos periodos&#46; Adem&#225;s&#44; una &#250;lcera cr&#243;nica del pie&#44; gangrena que requiri&#243; la amputaci&#243;n de la pierna derecha&#44; la historia de abortos y una reacci&#243;n de Wasserman positiva sugieren que la artista podr&#237;a haber padecido s&#237;ndrome antifosfolip&#237;dico &#40;SAF&#41;&#46;</p></span>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Revised classification criteria for antiphospholipid syndrome<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">13</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Features in Frida Kahlo biography<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6&#44;8&#8211;14</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Vascular thrombosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Chronic ulcer in right footGangrene and amputation of right legDeath by pulmonary embolism&#63;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Pregnancy morbidity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Her second pregnancy ended spontaneously at 4 months&#46;&#8220;Several miscarriages&#8221;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Laboratory criteria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Possible positivity of anticardiolipin antibodies&#44; demonstrated by a positive Wassermann Test&nbsp;\t\t\t\t\t\t\n
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                        0 => array:2 [
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Frida&#58; a biography of Frida Kahlo"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "H&#46; Herrera"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "1983"
                        "editorial" => "Harper and Row"
                        "editorialLocalizacion" => "New York"
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                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
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                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "1992"
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                        "editorialLocalizacion" => "Cologne"
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              ]
            ]
            4 => array:3 [
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                0 => array:2 [
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                      "titulo" => "Devouring Frida&#58; the art history and popular celebrity of Frida Kahlo"
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                          "autores" => array:1 [
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                        "fecha" => "2005"
                        "editorial" => "Random House Mondadori&#44; SA de CV"
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                      "Libro" => array:3 [
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Vol. 18. Núm. 2.
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Vol. 18. Núm. 2.
Páginas 65-68 (febrero 2022)
Special Article
Could Frida Kahlo have had antiphospholipid syndrome?
¿Pudo Frida Kahlo padecer síndrome antifosfolípidico?
Jorge Morales Torresa,b,
Autor para correspondencia
jorgitomorales@prodigy.net.mx

Corresponding author.
, Francisco Javier Acevesc, Mary Carmen Amigo Castañedad, Claudia Berenice Hernández Cuevasb
a Hospital Aranda de la Parra, León, GTO, Mexico
b Morales Vargas Centro de Investigación, León, GTO, Mexico
c Unidad de Artritis y Reumatismo, Guadalajara, JAL, Mexico
d Centro Médico ABC, Ciudad de México, Mexico

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Special Article
Could Frida Kahlo have had antiphospholipid syndrome?
¿Pudo Frida Kahlo padecer síndrome antifosfolípidico?
Jorge Morales Torresa,b,
Autor para correspondencia
jorgitomorales@prodigy.net.mx

Corresponding author.
, Francisco Javier Acevesc, Mary Carmen Amigo Castañedad, Claudia Berenice Hernández Cuevasb
a Hospital Aranda de la Parra, León, GTO, Mexico
b Morales Vargas Centro de Investigación, León, GTO, Mexico
c Unidad de Artritis y Reumatismo, Guadalajara, JAL, Mexico
d Centro Médico ABC, Ciudad de México, Mexico
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Frida Kahlo is an icon among 20th-century women in the arts&#46; Interest &#8211; and even devotion &#8211; about her works&#44; remain more than 50 years after her death&#46; Younger generations know about her and usually have a position on her paintings&#44; whether they like them or not&#46; Frida has been the subject of several biographic and iconographic books and some popular motion pictures&#46; She is the center of many web sites and is represented in numerous examples of popular arts and crafts&#44; particularly in her natal Mexico&#46; Her personality has become a symbol embraced by activists of feminism and sexual liberation&#44; persons with a disability&#44; and Mexican culture&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">1&#8211;7</span></a> She is also probably the painter with more medical papers centered on her health&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The purpose of this paper is to review some historical pieces of evidence to explain the cause of some of her medical problems&#44; namely&#44; primary antiphospholipid syndrome&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">Frida Kahlo was born in Mexico City in 1907&#44; the 3rd of 4 daughters&#46; Her father had a history of epilepsy&#44; and her mother suffered fits that had apparently psychological basis&#46; Her sister Adriana suffered three spontaneous abortions&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">1&#8211;3&#44;6</span></a> Frida had a severe condition diagnosed as Polio at the age of 6&#44; which&#44; after a prolonged evolution&#44; requiring bed rest for nine months&#44; left moderate atrophy and weakness in her right leg as well as some discrepancy in length with the left side&#46; Eventually&#44; her recovery allowed her to run and dance&#46; She used dressing tricks to hide the slight difference among her legs&#44; but still had some pelvic imbalance and probably some degree of scoliosis &#40;diagnosed later in her life&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6&#44;8&#8211;10</span></a> On September 17&#44; 1925&#44; at the age of 18&#44; the bus she was traveling in collided with a streetcar&#46; This accident caused her several fractures in vertebrae&#44; clavicle&#44; pelvis&#44; and right leg and foot&#59; luxation of the left elbow and a penetrating wound caused by a metal handrail which entered on the left side of the pelvis and emerged through the left side of her vulva&#46; She developed peritonitis requiring surgery and had cystitis after prolonged catheterization&#46; After she recovered from these problems&#44; persistent back pain led to the diagnosis of vertebral fractures&#44; starting the use of several different types of plaster and metal corsets for prolonged periods for the rest of her life&#46; By 1931&#44; X-ray studies of the spine showed the existence of spina bifida and scoliosis&#44; besides of the traumatic lesions&#46; After that&#44; she had multiple spine surgeries in diverse hospitals&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6&#44;8&#8211;12</span></a> An X-Ray film of 1954 &#8211; the year of her death &#8211; shows a metal bar fixed by screws from 3rd to 5th lumbar vertebrae&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Since 1931 she suffered persistent and severe pain in the right leg and foot&#44; with remarkable thinning of that limb&#46; She required for the rest of her life&#44; the use of diverse narcotic analgesics&#44; which she combined with alcohol in varying forms and quantities&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6</span></a> A small ulcer appeared on the right foot&#44; as it persisted and increased its size&#44; leading to several surgeries on that foot&#44; including amputation of phalanxes and sesamoid bones and a sympathectomy&#46; Finally&#44; as gangrene complicates the case&#44; her right leg was amputated until the knee in 1953&#46; It should be noted that Frida was a heavy smoker&#44; a risk factor for both&#44; chronic ulcers and gangrene&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Several of her biographers refer to multiple miscarriages&#44; including two therapeutic abortions&#58; one in 1929 &#40;attempting to prevent complications from her damaged pelvis&#41; and one in 1934&#46; At least two spontaneous abortions occurred&#46; One in 1932&#44; after four months of pregnancy&#44; while in Detroit&#44; and another in 1937&#46; The other miscarriages have not been defined clearly as to when and where they occurred&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6&#44;13&#44;14</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In 1931&#44; she had a positive Wassermann&#39;s test when she was studied in San Francisco by Dr&#46; Leo Eloesser&#44; a Surgeon at San Francisco&#44; who became his life-long friend and main medical advisor&#46; The positive Wassermann test led to treatment with Neosalvarsan and later to therapies with blood transfusions and bismuth&#44; considering that syphilis could explain some of her problems&#46; The laboratory reaction was negative in several other times&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6&#44;15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">From this time&#44; she had long periods of severe limitation due to fatigue and pain&#44; mainly in her neck&#44; back&#44; and right leg&#44; accompanied with weight loss and depression&#46; She could not continue giving her painting lessons&#46; After one of her spine surgeries&#44; while lying on her bed or limited to a wheelchair&#44; she painted many of her works&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6&#44;8&#8211;12</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In 1954&#44; after attending a political manifestation&#44; against her doctors&#8217; advice&#44; she fell ill with pneumonia and died on July 13&#44; that year&#46; Her death certificate &#40;signed by her Psychiatrist&#44; Dr&#46; Ram&#243;n Parres&#41; refers to &#8220;pulmonary embolism&#8221; as the cause of her death&#44;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6</span></a> although no autopsy was performed&#46; Some of her biographers mention the possibility that a narcotic overdose&#44; either voluntary or not&#44; could have influenced her outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Like many episodes of her life&#44; Frida illustrated some of her clinical features in her works&#46; The painting&#44; known as &#8220;What I saw in the water&#8221; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#59; oil on canvas&#44; 1938&#59; 91<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>70&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#46; Daniel Filipacchi&#39;s collection&#44; Paris&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">4</span></a> shows a bleeding sore by her deformed&#44; right first toe&#46; A drawing known as &#8220;Self-portrait&#44; sitting&#8221; &#40;pencil on paper&#44; 1931&#59; 29<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>20&#46;4<span class="elsevierStyleHsp" style=""></span>cm&#46; Teresa Proenza&#39;s Collection&#44; Mexico City&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">4</span></a> show her sitting with a bandaged left foot that shows a dark stain&#46; A similar painting&#44; &#8220;Remembrance of the open wound&#44;&#8221; is little known as a fire destroyed the owner&#39;s house&#46; This painting shows her with a bleeding wound in her left thigh&#44; apparently invented as there is not an account of such lesion&#44; but it also shows a bandaged and bleeding left foot again&#46; It is known only from a photograph owned by Raquel Tibol&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">6</span></a> After that&#44; her diary&#44; which she started in 1946&#59; includes a drawing of a severed right leg and foot &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#59; watercolor and ink on a paper page&#44; 1953&#59; Frida Kahlo&#39;s Museum&#44; Mexico City&#41; with the famous legend &#8220;Feet&#44; what do I need them for if I have wings to fly&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">4</span></a> Another drawing from the same Diary &#40;watercolor and ink on a paper page&#44; 1954&#59; Frida Kahlo&#39;s Museum&#44; Mexico City&#41; shows Frida with a wooden leg&#44; again on the left side&#46; Chronic ulcer&#44; disabling pain&#44; and gangrene occurred on the right lower limb&#46; The reason to depict an affected left side is not known&#46; Is it intentionally misleading&#63; Is it a mistake&#63; It seems unlikely as it happens in at least three works&#46; Regarding the abortions&#44; two works dated in 1932 describe one of them&#46; The lithography is known as &#8220;Frida and the abortion &#40;lithography on paper&#44; 2nd copy&#44; 32<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>23&#46;5<span class="elsevierStyleHsp" style=""></span>cm&#59; Dolores Olmedo Collection&#44; Mexico City&#41;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">4</span></a> and a painting titled &#8220;Henry Ford Hospital&#44;&#8221; or &#8220;The flying bed&#8221; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#44; oil on metal sheet&#44; 30&#46;5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>38<span class="elsevierStyleHsp" style=""></span>cm&#59; Dolores Olmedo Collection&#44; Mexico City&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">4</span></a> Both works show her naked&#44; with tears in her eyes&#44; bleeding genitals and communicating lines to a fetus and other elements&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">This summary of clinical features found in Frida Kahlo&#39;s biographic accounts and paintings would lead most contemporary Rheumatologists to investigate the possibility of primary antiphospholipid syndrome&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the findings in Frida&#39;s history and compares some of those features with currently accepted Criteria for the Classification of Antiphospholipid Syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">13</span></a> Knowledge on its epidemiology&#44; pathogenesis&#44; diagnosis&#44; and management has progressed notably&#44; and as a result&#44; vascular and obstetric outcomes of this condition have improved&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">14</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Several medical papers have explored possible explanations for her chronic pain&#44; both in the right lower limb and generalized&#44; as well as disability&#46; They include the sequelae of trauma and vertebral fractures&#44; with nerve root compromise&#44; but some authors point to the relative importance of spina bifida<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">8&#44;10</span></a>&#59; complex regional pain syndrome<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">8&#44;10&#44;15</span></a> and even to post-polio syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">8&#44;10&#44;15&#8211;17</span></a> Compelling pieces of evidence point to post-traumatic fibromyalgia&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">18</span></a> and some authors refer to lead poisoning&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">19</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The chronic lesion&#44; described as a &#8220;trophic ulcer&#8221; on the right foot&#44; has been seen as a complication of severe trauma in a limb with neurological deficiencies from polio&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6&#44;8&#44;10</span></a> Also&#44; Post-Polio syndrome has been invoked&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">15&#8211;17</span></a> There is a possibility of osteomyelitis complicating her surgeries on that foot&#46; However&#44; as the lesion progressed&#44; it was accompanied by signs of vascular insufficiency and finally gangrene&#46; Therefore&#44; previous explanations seem inadequate&#44; and these findings suggest vascular thrombosis&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Frida&#39;s abortion &#40;at four months of her second pregnancy&#41;&#44; as well as the &#8220;multiple miscarriages&#8221; and the therapeutic abortions&#44; have been explained as complications of her accident causing uterine damage or pelvic abnormalities&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6&#44;20&#44;21</span></a> Attempts to explain her inability to carry a pregnancy to term&#44; include an exploratory laparotomy performed in 1934 after an abortion&#44; which found &#8220;ovarian infantilism&#8221;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6</span></a> and recent reviews of her case mention the possibility of Asherman&#39;s syndrome &#40;endometrial scarring&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">22</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Wassermann&#39;s test was performed looking for syphilis&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">3&#44;6</span></a> It was the usual test in those days&#46; Frida had at least one positive test&#46; Our present interest in this finding lies in the fact that it was a primitive way to find antibodies to cardiolipin&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">23</span></a> The coagulation inhibitor named &#8220;the lupus anticoagulant&#8221; was known since 1952<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">24</span></a>&#59; however&#44; the concept of Antiphospholipid Syndrome arose only in 1983&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">25</span></a> Such a notion was far from being known by Frida&#39;s Doctors&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Several papers published in medical journals have centered on Frida Kahlo&#39;s life&#44; works&#44; and clinical history&#46; A non-exhaustive search in PubMed and PMC on March 26&#44; 2020&#44; yielded 40 papers&#44; including Frida Kahlo as the main or secondary object of the publication&#46; Her name was mentioned in many more papers discussing pain&#44; art&#44; and related issues&#46; Besides of the titles already mentioned here&#44; some papers discuss the role of herself depicting her pain and her medical interventions<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">26&#8211;32</span></a>&#59; the perspective of her case as seen by rheumatologists<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">33&#44;34</span></a>&#59; the sublimation of her suffering&#44; pain&#44; and loss&#44; describing possible psychiatric explanations&#46;<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">35&#8211;42</span></a> Even her homoeroticism has been discussed&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">43</span></a> Two papers deal with the relationship with her physicians&#46;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">44&#44;45</span></a> Some articles describe specific paintings&#46;<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">46&#8211;49</span></a> Others report on museum exhibitions on Frida Kahlo<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">50&#8211;52</span></a> and her importance as a relevant character in educational interventions for health professionals&#46;<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">53&#44;54</span></a> None of these papers mention the possibility of antiphospholipid syndrome&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0080" class="elsevierStylePara elsevierViewall">Historical accounts of pregnancy morbidity&#44; vascular thrombosis&#44; and at least one mention of a positive test for antibodies to cardiolipin support the possibility of an antiphospholipid syndrome explaining some of the medical problems of Frida Kahlo&#46; Her works depict several clues to understand her pain and the diversity of medical issues&#46; Observing her pictures frequently leads to an emotional reaction and to admiration of her ability to overcome adversity&#46; After all&#44; citing Courtney et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleItalic">it is how she chose to live life&#44; not her death&#44; for which she is remembered&#46;</span></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Authorship</span><p id="par0085" class="elsevierStylePara elsevierViewall">JMT and MCAC originated the conception and design of the study&#46; All of the authors participated in gathering&#44; analyzing and interpretation of data&#59; critical review of its intellectual content and definitive approval of the final text</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Source of financing</span><p id="par0090" class="elsevierStylePara elsevierViewall">This investigation has not obtained any help from public agencies&#59; commercial entities or non-profit organizations&#46; Only authors&#8217; own resources&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Frida Kahlo&#39;s medical history shows sequelae of polio&#44; a severe traumatic event that caused multiple fractures and a penetrating pelvic injury&#44; as well as a history of countless surgeries&#46; In her biographical accounts and her works&#44; chronic disabling pain always appears for long periods&#46; Besides&#44; a chronic foot ulcer&#44; gangrene that required amputation of the right leg&#44; a history of abortions&#44; and a positive Wasserman reaction suggest that the artist could have suffered from antiphospholipid antibody syndrome &#40;APS&#41;&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La historia cl&#237;nica de Frida Kahlo muestra secuelas de polio&#44; un evento traum&#225;tico grave que caus&#243; m&#250;ltiples fracturas y una lesi&#243;n penetrante de pelvis&#44; as&#237; como historia de incontables cirug&#237;as&#46; En sus recuentos biogr&#225;ficos y en sus obras&#44; siempre aparece dolor cr&#243;nico incapacitante por largos periodos&#46; Adem&#225;s&#44; una &#250;lcera cr&#243;nica del pie&#44; gangrena que requiri&#243; la amputaci&#243;n de la pierna derecha&#44; la historia de abortos y una reacci&#243;n de Wasserman positiva sugieren que la artista podr&#237;a haber padecido s&#237;ndrome antifosfolip&#237;dico &#40;SAF&#41;&#46;</p></span>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Revised classification criteria for antiphospholipid syndrome<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">13</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Vascular thrombosis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Chronic ulcer in right footGangrene and amputation of right legDeath by pulmonary embolism&#63;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Her second pregnancy ended spontaneously at 4 months&#46;&#8220;Several miscarriages&#8221;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Laboratory criteria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Possible positivity of anticardiolipin antibodies&#44; demonstrated by a positive Wassermann Test&nbsp;\t\t\t\t\t\t\n
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