Case Report
Adjuvant Induced Autoimmune/Inflammatory Syndrome Presenting as Joint and Lung Manifestations
Síndrome autoinmune/inflamatorio inducido por adyuvante que debuta con manifestaciones pulmonares y articulares
Guillermo Flores Padilla, Benjamín Mora Mendoza, Axel Pedraza Montenegro
Corresponding author
Servicio de Medicina Interna, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, Mexico City, Mexico
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There is a lack of consistency in the assessment because very different results are obtained for the same variables (discrepancy).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "José Aso Escario, José Vicente Martínez Quiñones, Alberto Aso Vizán, Ricardo Arregui Calvo, Marta Bernal Lafuente, Andrés Alcázar Crevillén" "autores" => array:6 [ 0 => array:2 [ "nombre" => "José" "apellidos" => "Aso Escario" ] 1 => array:2 [ "nombre" => "José Vicente" "apellidos" => "Martínez Quiñones" ] 2 => array:2 [ "nombre" => "Alberto" "apellidos" => "Aso Vizán" ] 3 => array:2 [ "nombre" => "Ricardo" "apellidos" => "Arregui Calvo" ] 4 => array:2 [ "nombre" => "Marta" "apellidos" => "Bernal Lafuente" ] 5 => array:2 [ "nombre" => "Andrés" "apellidos" => "Alcázar Crevillén" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1699258X14000795" "doi" => "10.1016/j.reuma.2014.03.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X14000795?idApp=UINPBA00004M" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217357431400118X?idApp=UINPBA00004M" "url" => "/21735743/0000001000000006/v1_201410180251/S217357431400118X/v1_201410180251/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Adjuvant Induced Autoimmune/Inflammatory Syndrome Presenting as Joint and Lung Manifestations" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "406" "paginaFinal" => "408" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Guillermo Flores Padilla, Benjamín Mora Mendoza, Axel Pedraza Montenegro" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Guillermo" "apellidos" => "Flores Padilla" ] 1 => array:2 [ "nombre" => "Benjamín" "apellidos" => "Mora Mendoza" ] 2 => array:4 [ "nombre" => "Axel" "apellidos" => "Pedraza Montenegro" "email" => array:1 [ 0 => "axel09_p@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Interna, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, Mexico City, Mexico" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome autoinmune/inflamatorio inducido por adyuvante que debuta con manifestaciones pulmonares y articulares" ] ] "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" => 1316 "Ancho" => 1498 "Tamanyo" => 265346 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Skin biopsy of gluteal region with foreign body granuloma with calcifications, vascular proliferation, necrosis and areas of sclerosis. (B) Superficial skin necrosis, gluteal region, right side view. (C) Plain chest CT-AR, panlobular emphysema. (D) Lower limb CT, with confluent hyperdense nodular lesions in both buttocks that spread to the thigh and posterior leg region suggesting calcifications.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The autoimmune/inflammatory syndrome induced by an adjuvant is a condition characterized by the presence of various manifestations and/or non-specific symptoms, which can represent different rheumatological entities.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Patients frequently have a history of applying a foreign substance to their body that can act as an adjuvant, such as unspecified materials for esthetic purposes.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Four conditions have been associated with this syndrome: siliconosis, Gulf War syndrome, post-vaccination syndrome and macrophagic myofasciitis<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> phenomenon; these entities have recently been encompassed in the autoimmune/inflammatory syndromes induced by adjuvants.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> In our country there are several case series, which report this condition after the application of oily substances in their majority, of unspecified type and for esthetic purposes.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Observation</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 59-year-old housewife comes to the clinic due to pain in the lumbar region that precludes adequate gait. Family history of relevance was a daughter with rheumatoid arthritis and a sister who died of scleroderma complications. She denied smoking and uses alcohol occasionally. COMBE denied. Hypertension was diagnosed a year prior and treated with enalapril 10<span class="elsevierStyleHsp" style=""></span>mg PO every 12<span class="elsevierStyleHsp" style=""></span>h. She had a dislocated right elbow 9 months ago, with thoracolumbar trauma, treated conservatively. She denied allergy and transfusions. She refers an unspecified chemical injection in buttocks 11 years ago for esthetic purposes, subsequent degeneration of the region with formation of superficial necrosis and calcification, as well as deformation and hardening.</p><p id="par0020" class="elsevierStylePara elsevierViewall">She had polyarticular joint pain bilaterally and symmetrical, with increased volume and local temperature, lower limb edema and pain of the cervical spine for 18 months. She also presented lower airway disease and rhinitis, suggestive of infection. At the beginning we thought the patient presented granulomatosis with polyangiitis (Wegener), so we began treatment with prednisone at doses of 25<span class="elsevierStyleHsp" style=""></span>mg per day for about 6 months, and later was treated through homeopathy with “natural cortisol’, with partial remission.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Her current problem began 2 months ago with thoracolumbar pain, treated with non-steroidal anti-inflammatory drugs and centrally acting with partial remission. 7 days prior she had increased pain radiating to the right lower limb, accompanied by paresthesias and decreased strength on the same side due to persistent pain and decided to come to our unit.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was conscious, oriented in time, place and person, with the presence of skin disease on the face with purplish malar erythema, subcutaneous nodular induration and telangiectasia, episcleritis of the left eye, skin hyperpigmentation and <span class="elsevierStyleSmallCaps">V</span> lesions suggestive of venous angiomas, and bilateral painless mobile submandibular lymphadenopathy of less than 1<span class="elsevierStyleHsp" style=""></span>cm. She had rhythmic heart sounds, breath sounds presented symmetrical bilateral, interscapulovertebral, subcrepitant, and infrascapular rales. Her abdomen was soft, not painful and peristalsis was present. The right gluteal area lateral surface presented an area of necrosis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Upper extremities presented disseminated ecchymosis and periungual punctate lesions, suggestive of necrosis; carpus and metacarpals were not painful or swollen, but there was pain on the proximal interphalangeal joints with 2 symmetrical painful but not swollen joints, mild ulnar deviation of the fingers that corrected when placed on a hard surface, with limited range of motion in the shoulders. Intact lower extremities without edema, muscle stretch reflexes +/++++, muscle strength 4/5 bilaterally; tarsal, metatarsal and interphalangeal joints were normal.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The plain chest high-resolution tomography (CT-HR) showed panlobular emphysema (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Simple CT of the lower limbs demonstrated confluent hyperdense nodular lesions in both buttocks which spread to the thigh and posterior leg (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> MRI of lumbar spine, herniated disc L4-L5). Densitometry was compatible with osteoporosis. Laboratory tests, C-reactive [PCR] erythrocyte sedimentation rate [ESR] and protein were slightly elevated, and autoimmune markers such as elevated rheumatoid factor and anti-cyclic citrullinated peptide antibodies (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), suggested the presence of active autoimmune disease. Her thyroid profile had a biochemical pattern of subclinical hyperthyroidism (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">It was initially considered that the patient had granulomatosis with polyangiitis (Wegener), due to the condition of the lower and upper respiratory tract; however, we concluded that there was no evidence of pulmonary vasculitis, but only a chronic condition, and no renal disease. Otorhinolaryngology considered that changes in nasal mucosa were not compatible with vasculitis. It was considered that the condition was dermal photosensitivity of the neck and face, as well as dermal and muscular reaction due to the application of adjuvant both in the face and buttocks.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The patient presented markers of inflammation (acute phase reactants, ESR and CRP) and autoimmunity (rheumatoid factor and anti-cyclic citrullinated peptide antibodies)<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The presence of rheumatoid factor, polyarticular joint pain and anti-cyclic citrullinated peptide antibodies suggested rheumatoid arthritis, and considering the start of manifestations in years after the implementation of the adjuvant, we considered it as part of the autoimmune/inflammatory syndrome induced by adjuvant. Partial attenuation induced by the use of glucocorticoids was seen, but she was still a candidate for surgical treatment due to the extension and migration of the calcifications.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Skin biopsy of the gluteal region reported granulomatous foreign body reaction with calcifications, vascular proliferation, necrosis and areas of sclerosis<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0045" class="elsevierStylePara elsevierViewall">The patient presented an autoimmune/inflammatory syndrome induced by an adjuvant, fulfilling the criteria suggested for this entity<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,4</span></a> (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), such as the presence of rheumatoid arthritis with onset after the application of the adjuvant and clinical manifestations such as arthritis and ischemia, autoimmune markers (rheumatoid factor and anti-cyclic citrullinated peptide antibodies), a history of the application of a foreign substance (probably oil) which acts as an adjuvant itself and the histological demonstration of granulomatous inflammation and foreign body reaction in the relevant affected areas. None of the reported cases have shown lung disease as the first manifestation in the series of this syndrome,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> although, as described in this case, it may occur in rheumatoid arthritis, although the initial debut as presented here, associated with autoimmune/inflammatory syndrome induced by adjuvant, had not been described before. It is noteworthy that the criteria proposed in previous publications for this syndrome requires acceptance by the relevant international organizations for adequate definition of the disease.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical Responsibilities</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of people and animals</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that this research has not performed experiments on humans or animals.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Data privacy</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace on the publication of data from patients and all patients included in the study have received sufficient information and gave written informed consent to participate in the study.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Right to privacy and informed consent</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors state that patient data does not appear in this article.</p></span></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres376333" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec355394" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres376334" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec355395" "titulo" => "Palabras clave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "Introduction" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical Observation" ] ] ] 5 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of Interest" ] 8 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical Responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Data privacy" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-03-04" "fechaAceptado" => "2014-01-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec355394" "palabras" => array:3 [ 0 => "Autoimmune" 1 => "Adjuvants" 2 => "Granulomatosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec355395" "palabras" => array:3 [ 0 => "Autoinmune" 1 => "Adyuvante" 2 => "Granulomatosis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A 59-year-old female with a history of injection of an oily material in the buttocks 11 years ago. She developed symmetric additive polyarthritis as well as superior and inferior airways involvement. There was no evidence of granulomatosis with polyangiitis (Wegener). She had several serum autoantibodies and a skin biopsy showed a foreign body granuloma. The diagnosis of adjuvant induced autoimmune/inflammatory syndrome was made. The pulmonary involvement was an atypical manifestation at the onset of disease.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Mujer de 59 años de edad, la cual cuenta con antecedente de aplicación de material oleoso en los glúteos hace 11 años; posteriormente hace 18 meses comienza con cuadro de poliartritis aditivas simétricas, así como afección en las vías aéreas superior e inferior, sin evidencia de alteración por granulomatosis con poliangeitis (Wegener). Presenta en suero autoanticuerpos, y se toma biopsia de piel donde se observa granuloma por cuerpo extraño. Se concluye con síndrome autoinmune/inflamatorio inducido por adyuvante, en el que la afección pulmonar es una manifestación atípica en la presentación inicial de la enfermedad.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Flores Padilla G, Mora Mendoza B, Pedraza Montenegro A. Síndrome autoinmune/inflamatorio inducido por adyuvante que debuta con manifestaciones pulmonares y articulares. Reumatol Clin. 2014;10:406–408.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1316 "Ancho" => 1498 "Tamanyo" => 265346 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Skin biopsy of gluteal region with foreign body granuloma with calcifications, vascular proliferation, necrosis and areas of sclerosis. (B) Superficial skin necrosis, gluteal region, right side view. (C) Plain chest CT-AR, panlobular emphysema. (D) Lower limb CT, with confluent hyperdense nodular lesions in both buttocks that spread to the thigh and posterior leg region suggesting calcifications.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">ANA, antinuclear antibodies; Ab, antibodies; Anti-CCP, anti-CCP antibody; Anti-DNA, anti-DNA antibodies; DHL, lactic dehydrogenase; CRP, C-reactive protein; PT, prothrombin time; TSH, thyroid stimulating hormone; APTT, activated thromboplastin time; ESR, erythrocyte sedimentation rate.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Glucose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">92<span class="elsevierStyleHsp" style=""></span>mg/dl \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26<span class="elsevierStyleHsp" style=""></span>mg/dl \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Creatinine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.45<span class="elsevierStyleHsp" style=""></span>mg/dl \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DHL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">659<span class="elsevierStyleHsp" style=""></span>U/l \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sodium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">137<span class="elsevierStyleHsp" style=""></span>mEq/l \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Potassium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.06<span class="elsevierStyleHsp" style=""></span>mEq/l \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chlorine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 mEq/l \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.8<span class="elsevierStyleHsp" style=""></span>s \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">APTT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23.8<span class="elsevierStyleHsp" style=""></span>s \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leukocytes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12<span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>cells/mcL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hemoglobin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.1<span class="elsevierStyleHsp" style=""></span>g/dl \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Platelets \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">357<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>mcl \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anti-DNA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7<span class="elsevierStyleHsp" style=""></span>U/ml (negative below 20) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ANA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">185 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IgM anticardiolipin Ab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.3 (negative less than 13) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IgG anticardiolipin Ab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.0 (negative below 20) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ESR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CRP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.76<span class="elsevierStyleHsp" style=""></span>mg/dl (0–0.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TSH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.81<span class="elsevierStyleHsp" style=""></span>McU/l (0.27–4.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Free T4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.07<span class="elsevierStyleHsp" style=""></span>ng/dl (0.93–1.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rheumatoid factor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">192.7<span class="elsevierStyleHsp" style=""></span>U/ml (0–14) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anti-CCP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">More than 200<span class="elsevierStyleHsp" style=""></span>UI \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab571542.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Results of Laboratory Tests.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Anti-CCP, anti-CCP antibody; Anti-DNA, anti-DNA antibodies; RF, rheumatoid factor.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Source: Meroni.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. <span class="elsevierStyleItalic">History of the application of an external substance which acts as an adjuvant</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. <span class="elsevierStyleItalic">Appearance of typical clinical manifestations</span>: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Myalgia, myositis or muscle weakness \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Joint pain and/or arthritis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Chronic fatigue, unrefreshing sleep or sleep disorders \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neurological manifestations (especially those related to demyelination) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cognitive disorder, memory loss \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fever, dry mouth \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3. <span class="elsevierStyleItalic">Improvement by removing inducing agents</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4. <span class="elsevierStyleItalic">Biopsy of the affected tissue with typical findings</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5. <span class="elsevierStyleItalic">Biochemical markers of autoimmune disease (RF, Anti-CCP, Anti-DNA, etc.)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab571541.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Suggested Criteria for Autoimmune/Inflammatory Syndrome Induced by Adjuvants.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Human adjuvant disease induced by foreign substances: a new model of ASIA (Shoenfeld's syndrome)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "O. Vera-Lastra" 1 => "G. Medina" 2 => "M. del P. Cruz-Domínguez" 3 => "P. Ramírez" 4 => "J.A. Gayosso-Rivera" 5 => "H. Anduaga-Domínguez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/0961203311429317" "Revista" => array:7 [ "tituloSerie" => "Lupus" "fecha" => "2012" "volumen" => "21" "paginaInicial" => "128" "paginaFinal" => "135" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22235042" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0022534710047531" "estado" => "S300" "issn" => "00225347" ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Autoimmune or auto-inflammatory syndrome induced by adjuvants (ASIA): old truths and a new syndrome?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P.L. Meroni" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaut.2010.10.004" "Revista" => array:6 [ "tituloSerie" => "J Autoimmun" "fecha" => "2011" "volumen" => "36" "paginaInicial" => "1" "paginaFinal" => "3" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21051205" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "‘ASIA’ – Autoimmune/inflammatory syndrome induced by adjuvants" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Y. Shoenfeld" 1 => "N. Agmon-Levin" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Autoimmun" "fecha" => "2011" "volumen" => "3" "paginaInicial" => "4" "paginaFinal" => "8" "itemHostRev" => array:3 [ "pii" => "S0022534709017480" "estado" => "S300" "issn" => "00225347" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "ASIA – Autoimmune syndromes induced by adjuvants: rare, but worth considering" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E. Toubi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Isr Med Assoc J" "fecha" => "2012" "volumen" => "14" "paginaInicial" => "121" "paginaFinal" => "124" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22693796" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0302283810010043" "estado" => "S300" "issn" => "03022838" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mechanisms of environmental influence on human autoimmunity: a national institute of environmental health sciences expert panel workshop" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Selmi" 1 => "P. Leung" 2 => "D. Sherr" 3 => "M. Díaz" 4 => "J.F. Nyland" 5 => "M. Monestier" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaut.2012.05.007" "Revista" => array:6 [ "tituloSerie" => "J Autoimmun" "fecha" => "2012" "volumen" => "39" "paginaInicial" => "272" "paginaFinal" => "284" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22749494" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The spectrum of ASIA: autoimmune (auto-inflammatory) syndrome induced by adjuvants" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "N. Agmon-Levin" 1 => "G.R.V. Hughes" 2 => "Y. Shoenfeld" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/0961203311429316" "Revista" => array:6 [ "tituloSerie" => "Lupus" "fecha" => "2012" "volumen" => "21" "paginaInicial" => "118" "paginaFinal" => "120" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22235040" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000001000000006/v1_201410180251/S2173574314000781/v1_201410180251/en/main.assets" "Apartado" => array:4 [ "identificador" => "17376" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Case Report" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000001000000006/v1_201410180251/S2173574314000781/v1_201410180251/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574314000781?idApp=UINPBA00004M" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 4 | 8 |
| 2024 October | 56 | 25 | 81 |
| 2024 September | 50 | 19 | 69 |
| 2024 August | 68 | 30 | 98 |
| 2024 July | 67 | 30 | 97 |
| 2024 June | 68 | 35 | 103 |
| 2024 May | 49 | 30 | 79 |
| 2024 April | 73 | 28 | 101 |
| 2024 March | 66 | 32 | 98 |
| 2024 February | 35 | 24 | 59 |
| 2024 January | 41 | 24 | 65 |
| 2023 December | 40 | 30 | 70 |
| 2023 November | 44 | 32 | 76 |
| 2023 October | 56 | 30 | 86 |
| 2023 September | 56 | 32 | 88 |
| 2023 August | 44 | 13 | 57 |
| 2023 July | 48 | 24 | 72 |
| 2023 June | 51 | 23 | 74 |
| 2023 May | 67 | 26 | 93 |
| 2023 April | 49 | 14 | 63 |
| 2023 March | 56 | 29 | 85 |
| 2023 February | 66 | 20 | 86 |
| 2023 January | 70 | 24 | 94 |
| 2022 December | 64 | 36 | 100 |
| 2022 November | 70 | 31 | 101 |
| 2022 October | 64 | 38 | 102 |
| 2022 September | 64 | 41 | 105 |
| 2022 August | 58 | 44 | 102 |
| 2022 July | 53 | 41 | 94 |
| 2022 June | 66 | 34 | 100 |
| 2022 May | 71 | 39 | 110 |
| 2022 April | 62 | 54 | 116 |
| 2022 March | 75 | 47 | 122 |
| 2022 February | 72 | 30 | 102 |
| 2022 January | 73 | 40 | 113 |
| 2021 December | 58 | 40 | 98 |
| 2021 November | 56 | 45 | 101 |
| 2021 October | 77 | 45 | 122 |
| 2021 September | 64 | 43 | 107 |
| 2021 August | 60 | 39 | 99 |
| 2021 July | 104 | 36 | 140 |
| 2021 June | 69 | 31 | 100 |
| 2021 May | 70 | 34 | 104 |
| 2021 April | 184 | 68 | 252 |
| 2021 March | 102 | 36 | 138 |
| 2021 February | 85 | 23 | 108 |
| 2021 January | 111 | 36 | 147 |
| 2020 December | 58 | 22 | 80 |
| 2020 November | 127 | 27 | 154 |
| 2020 October | 201 | 13 | 214 |
| 2020 September | 59 | 24 | 83 |
| 2020 August | 41 | 17 | 58 |
| 2020 July | 24 | 13 | 37 |
| 2020 June | 46 | 19 | 65 |
| 2020 May | 35 | 17 | 52 |
| 2020 April | 29 | 17 | 46 |
| 2020 March | 22 | 7 | 29 |
| 2018 May | 7 | 0 | 7 |
| 2018 April | 54 | 8 | 62 |
| 2018 March | 87 | 5 | 92 |
| 2018 February | 52 | 8 | 60 |
| 2018 January | 28 | 5 | 33 |
| 2017 December | 55 | 8 | 63 |
| 2017 November | 37 | 7 | 44 |
| 2017 October | 50 | 8 | 58 |
| 2017 September | 51 | 10 | 61 |
| 2017 August | 62 | 9 | 71 |
| 2017 July | 62 | 17 | 79 |
| 2017 June | 89 | 15 | 104 |
| 2017 May | 92 | 10 | 102 |
| 2017 April | 79 | 9 | 88 |
| 2017 March | 91 | 14 | 105 |
| 2017 February | 65 | 5 | 70 |
| 2017 January | 75 | 12 | 87 |
| 2016 December | 120 | 19 | 139 |
| 2016 November | 104 | 17 | 121 |
| 2016 October | 128 | 15 | 143 |
| 2016 September | 159 | 13 | 172 |
| 2016 August | 115 | 7 | 122 |
| 2016 July | 48 | 7 | 55 |
| 2016 January | 1 | 0 | 1 |
| 2015 December | 2 | 0 | 2 |
| 2015 September | 2 | 0 | 2 |
| 2015 August | 1 | 0 | 1 |
| 2015 July | 25 | 7 | 32 |
| 2015 June | 49 | 16 | 65 |
| 2015 May | 63 | 18 | 81 |
| 2015 April | 46 | 13 | 59 |
| 2015 March | 57 | 17 | 74 |
| 2015 February | 57 | 13 | 70 |
| 2015 January | 63 | 18 | 81 |
| 2014 December | 73 | 12 | 85 |
| 2014 November | 70 | 17 | 87 |
| 2014 October | 37 | 17 | 54 |
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