Letter to the Editor
Cryptococcal Meningoencephalitis in a Patient With Rheumatoid Arthritis Treated With Methotrexate and Prednisone
Meningoencefalitis criptococócica en una paciente con artritis reumatoide tratada con metotrexato y prednisona
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Trillos, Daniel Gerardo Fernández-Ávila, María C. Díaz, Juan M. Gutiérrez" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Ramiro F." "apellidos" => "Trillos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "Daniel Gerardo" "apellidos" => "Fernández-Ávila" "email" => array:1 [ 0 => "danielfernandezmd@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "María C." "apellidos" => "Díaz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Juan M." "apellidos" => "Gutiérrez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Neurología, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Reumatología, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Grupo Javeriano de Investigación en Enfermedades Reumáticas, Bogotá, Colombia" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Meningoencefalitis criptococócica en una paciente con artritis reumatoide tratada con metotrexato y prednisona" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cryptoccoccus neoformans is an encapsulated biotrophic fungus that is transmitted as an aerosol.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Its origin has been identified in <span class="elsevierStyleItalic">Eucalyptus camaldulensis</span>, its infective forms are basidiospores and encapsulated yeast, and its vector is dried bird droppings, especially from pigeons.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Cryptococcal infections were commonly found in immunocompromised persons with alterations in cellular immunity.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Since the introduction of highly active antiretroviral therapy (HAART), the incidence of these infections has decreased dramatically due to better virological and immunological control, due to the decrease in viral load and increase in CD42 cell count. Cryptococcal infections have been reported in patients with a history of prolonged use of corticosteroids, diabetes, renal disease, immunosuppressive therapy, solid organ transplant, lymphoma, sarcoidosis and idiopathic lymphopenia CD42. The cases of cryptococcal infection in patients with rheumatoid arthritis (RA) are limited to a few papers, and when reviewing the literature there are only 3 reported cases of cryptococcal meningitis as the admission diagnosis. We report the case of a young patient with RA, who was not undergoing biological therapy and presented a meningoencephalic syndrome. The patient is a 49-year-old woman with a history of RA for the past 5 years, treated with methotrexate 15<span class="elsevierStyleHsp" style=""></span>mg weekly and prednisone 15<span class="elsevierStyleHsp" style=""></span>mg/day; she came to the emergency department due to having suffered 4 days of intense occipital headache, progressive, incoherent speech, disorientation, with memory problems, drowsiness, and in the last 24<span class="elsevierStyleHsp" style=""></span>h, fever. Upon neurological examination she was markedly confused, with impaired memory, judgment and altered calculus and ocular tenderness. Laboratory tests showed: ESR: 63<span class="elsevierStyleHsp" style=""></span>mm/h; CRP 8.3<span class="elsevierStyleHsp" style=""></span>mg/dl; glucose 353<span class="elsevierStyleHsp" style=""></span>mg/dl, sodium 134<span class="elsevierStyleHsp" style=""></span>mg/dl. It was initially considered as a meningoencephalic syndrome. Lumbar puncture was performed, with an opening pressure of 31<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O, low glucose 20<span class="elsevierStyleHsp" style=""></span>mg/dl, protein of 111<span class="elsevierStyleHsp" style=""></span>mg/dl, WBC 14<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">3</span>, neutrophils 16%, lymphocytes 84 found %, gram stain + + + yeast and bacterial antigens, with encapsulated blastoconidias found after staining with China ink, compatible with <span class="elsevierStyleItalic">Criyptococcus</span> sp. Methotrexate and prednisone were discontinued or decreased. We started treatment with amphotericin B, in increasing doses up to 1<span class="elsevierStyleHsp" style=""></span>g intravenously, with an adequate clinical response and infection control. Due to the presence of <span class="elsevierStyleItalic">de novo</span> diabetes mellitus, treatment with insulin was started based on a recommendation of endocrinology.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Opportunistic CNS infections reported in patients with RA include progressive multifocal encephalopathy, aspergilloma, tuberculosis, infection with West Nile virus, bacterial meningitis, infection with rodococcus and cryptococcal meningitis; however, the patients who have been reported with these types of infection were undergoing biological therapy.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a> Cryptococcal infections reported in RA patients are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,8,9</span></a> When evaluating <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, it can be seen that most Cryptococcal infections in patients with RA present in the lungs,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> followed by skin and meninges; one case showed spreading with multiorgan involvement and deadly consequences. The average age of presentation for any cryptococcal infection is 63.8 years (range: 47–82 years); the most frequently associated drugs are methotrexate and prednisone in 75% of cases. 66% of the patients who developed infections due to this micro-organism were on biological therapy. Of the 3 patients who presented cryptococcal meningitis, only the patient reported in this case was not undergoing biological therapy.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In conclusion, we report a case of cryptococcal meningitis in a patient with RA in non-biological antirheumatic treatment (glucocorticoids and methotrexate).</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Trillos RF, Fernández-Ávila DG, Díaz MC, Gutiérrez JM. Meningoencefalitis criptococócica en una paciente con artritis reumatoide tratada con metotrexato y prednisona. Reumatol Clin. 2014;10:346–347.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Adal: adalimumab; DM2: type 2 diabetes mellitus; F: female; HXQ: hydroxychloroquine; Infl: infliximab; Lefl: leflunomide; M: male; MTX: methotrexate; Pred: prednisolone; Ritux: rituximab.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Source: based on Muñoz et al. (2007)<span class="elsevierStyleSup">.</span><a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</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=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Age/Gender \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Site of infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Comorbidity/Outcome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Reference \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><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">65/M \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">Pulmonary \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">MTX, HXQ, Infl \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">No/recovery \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">Shrestha et al. (2004) \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">44/M \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">Pulmonary \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">Pred, MTX, Lefl, Infl \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">No/recovery \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">Starrett et al. (2002) \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">69/M \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">Pulmonary \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">Pred, MTX, Infl \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">DM2/recovery \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">True et al. (2002) \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">47/F \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">Pulmonary \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">Pred, Infl \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">No/recovery \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">Arend et al. (2004) \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">61/M \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">Pulmonary \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">Pred, MTX, Lefl, Infl \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">No/recovery \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">Hage et al. (2003) \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">67/F \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">Meninges \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">Pred, MTX, Infl \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">No/recovery \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">Muñoz et al. (2007) \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">82/F \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">Pulmonary/meninges \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">Pred \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">?/Death \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">Tajiri et al. (2009) \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">80/M \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">Leather/disseminated \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">MTX, Pred \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">ERC/death \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">Diaz et al. (2010) \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">74/M \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">Skin \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">Pred \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">DM2/recovery \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">Moosbrugger et al. (2008) \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">58/F \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">Skin \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">MTX, HXQ, Adal \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">Trauma \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">Morgan et al. (2008) \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">49/F \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">Brain-meninges \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">MTX, Pred \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">DM2 <span class="elsevierStyleItalic">de novo</span>/treatment \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">Threshing et al. (2012) \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">70/M \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">Brain-meninges \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">Infl, Ritux, Pred, MTX \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">None \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">Wingfield et al. (2011) \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">Average age: 63.8 \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">Pulmonary: 50%Skin: 16%Meninges: 16%Disseminated: 8.3% \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">MTX: 75%; Pred: Infl 75%: 50%; Lefl: HXQ 16%: 16%; Adal: Biological 8.3%: 66% \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">DM2: 16%; ERC: 8.3% \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">Percentage of patients according to variables \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab553690.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cryptococcal Infections Reported in Patients With Rheumatoid Arthritis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ecology, life cycle, and infectious propagule of <span class="elsevierStyleItalic">Cryptococcus neoformans</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.H. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 1 | 3 |
| 2024 October | 45 | 35 | 80 |
| 2024 September | 33 | 18 | 51 |
| 2024 August | 54 | 28 | 82 |
| 2024 July | 38 | 30 | 68 |
| 2024 June | 54 | 35 | 89 |
| 2024 May | 52 | 32 | 84 |
| 2024 April | 50 | 22 | 72 |
| 2024 March | 32 | 27 | 59 |
| 2024 February | 28 | 15 | 43 |
| 2024 January | 56 | 27 | 83 |
| 2023 December | 24 | 32 | 56 |
| 2023 November | 26 | 29 | 55 |
| 2023 October | 32 | 33 | 65 |
| 2023 September | 56 | 43 | 99 |
| 2023 August | 51 | 19 | 70 |
| 2023 July | 30 | 36 | 66 |
| 2023 June | 28 | 28 | 56 |
| 2023 May | 59 | 22 | 81 |
| 2023 April | 23 | 8 | 31 |
| 2023 March | 39 | 25 | 64 |
| 2023 February | 55 | 26 | 81 |
| 2023 January | 25 | 23 | 48 |
| 2022 December | 35 | 41 | 76 |
| 2022 November | 40 | 33 | 73 |
| 2022 October | 44 | 27 | 71 |
| 2022 September | 35 | 40 | 75 |
| 2022 August | 29 | 40 | 69 |
| 2022 July | 33 | 46 | 79 |
| 2022 June | 45 | 25 | 70 |
| 2022 May | 33 | 40 | 73 |
| 2022 April | 41 | 51 | 92 |
| 2022 March | 54 | 42 | 96 |
| 2022 February | 48 | 31 | 79 |
| 2022 January | 65 | 35 | 100 |
| 2021 December | 30 | 38 | 68 |
| 2021 November | 38 | 45 | 83 |
| 2021 October | 46 | 62 | 108 |
| 2021 September | 29 | 45 | 74 |
| 2021 August | 36 | 51 | 87 |
| 2021 July | 33 | 33 | 66 |
| 2021 June | 29 | 41 | 70 |
| 2021 May | 47 | 32 | 79 |
| 2021 April | 82 | 61 | 143 |
| 2021 March | 39 | 24 | 63 |
| 2021 February | 55 | 23 | 78 |
| 2021 January | 44 | 17 | 61 |
| 2020 December | 26 | 29 | 55 |
| 2020 November | 31 | 19 | 50 |
| 2020 October | 25 | 17 | 42 |
| 2020 September | 49 | 24 | 73 |
| 2020 August | 28 | 30 | 58 |
| 2020 July | 22 | 16 | 38 |
| 2020 June | 42 | 28 | 70 |
| 2020 May | 31 | 15 | 46 |
| 2020 April | 41 | 14 | 55 |
| 2020 March | 26 | 11 | 37 |
| 2020 February | 1 | 0 | 1 |
| 2019 January | 1 | 0 | 1 |
| 2018 December | 2 | 0 | 2 |
| 2018 May | 4 | 0 | 4 |
| 2018 April | 45 | 6 | 51 |
| 2018 March | 46 | 9 | 55 |
| 2018 February | 22 | 3 | 25 |
| 2018 January | 17 | 3 | 20 |
| 2017 December | 27 | 6 | 33 |
| 2017 November | 37 | 6 | 43 |
| 2017 October | 39 | 3 | 42 |
| 2017 September | 40 | 10 | 50 |
| 2017 August | 52 | 9 | 61 |
| 2017 July | 49 | 10 | 59 |
| 2017 June | 68 | 16 | 84 |
| 2017 May | 73 | 6 | 79 |
| 2017 April | 50 | 11 | 61 |
| 2017 March | 53 | 2 | 55 |
| 2017 February | 24 | 4 | 28 |
| 2017 January | 34 | 5 | 39 |
| 2016 December | 77 | 13 | 90 |
| 2016 November | 50 | 11 | 61 |
| 2016 October | 70 | 8 | 78 |
| 2016 September | 91 | 6 | 97 |
| 2016 August | 79 | 19 | 98 |
| 2016 July | 37 | 4 | 41 |
| 2015 December | 2 | 0 | 2 |
| 2015 September | 1 | 0 | 1 |
| 2015 August | 2 | 0 | 2 |
| 2015 July | 23 | 7 | 30 |
| 2015 June | 38 | 11 | 49 |
| 2015 May | 70 | 15 | 85 |
| 2015 April | 86 | 16 | 102 |
| 2015 March | 67 | 8 | 75 |
| 2015 February | 70 | 6 | 76 |
| 2015 January | 59 | 13 | 72 |
| 2014 December | 55 | 11 | 66 |
| 2014 November | 35 | 6 | 41 |
| 2014 October | 51 | 19 | 70 |
| 2014 September | 23 | 12 | 35 |
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