Case report
Cutaneous Sarcoidosis: Preamble of a Paucisymptomatic Systemic Disease
Sarcoidosis cutánea: el preámbulo de una enfermedad sistémica paucisintomática
Marco Aurelio Ramírez Huarangaa,
, Claudia Carolina Ramos Rodríguezb,e, Iris Violeta de la Rocha Vediac, Mónica García Arpad, Cristina Murillo Lázaroe, María Bellón Guardiaf
Corresponding author
a Servicio de Reumatología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
b Servicio de Dermatología, Hospital Daniel Alcides Carrión, Callao, Peru
c Servicio de Medicina Interna, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
d Servicio de Dermatología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
e Servicio de Anatomía-Patológica, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
f Servicio de Medicina Nuclear, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
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] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Daniel Alcides Carrión, Callao, Peru" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Anatomía-Patológica, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Sarcoidosis cutánea: el preámbulo de una enfermedad sistémica paucisintomática" ] ] "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" => 1478 "Ancho" => 1500 "Tamanyo" => 211400 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Nuclear medicine study of case no. 1. (A) Scintigraphic study showing an active inflammatory process affecting upper and lower limbs, mediastinal lymph nodes, lung parenchyma, bone and left gluteal muscle. (B.1) Positron emission tomography (PET) study showing mediastinal lymph node involvement prior to treatment. (B.2) PET study following treatment.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Sarcoidosis is a systemic granulomatous disease of unknown etiology and with a wide range of clinical signs. It occurs throughout the entire world, affecting more women than men (2:1), and the distribution by age is bimodal (25–35 and 45–55 years). The histological hallmark is the presence of uniform noncaseating granulomas with few peripheral lymphocytes (naked granulomas).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Pulmonary involvement is the most common clinical sign (90%), followed by cutaneous (35%), hepatosplenic, ocular and exocrine (parotid) gland involvement, whereas central nervous system, cardiac, upper respiratory tract and musculoskeletal involvement are less frequent, but more severe.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Although cutaneous involvement in sarcoidosis can develop throughout the course of the disease, it is most frequently present at the onset (30%). Thus, biopsy and histopathological study of the lesion will enable an early diagnosis.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Reports</span><p id="par0015" class="elsevierStylePara elsevierViewall">We present a series of three patients in whom the first finding was an apparently isolated skin lesion. Given the characteristics of the lesion, the initial results of supplemental tests and a histopathological study compatible with cutaneous sarcoidosis, a more comprehensive study was carried out, which revealed asymptomatic/paucisymptomatic systemic involvement. Treatment was begun with systemic prednisone at 0.5<span class="elsevierStyleHsp" style=""></span>mg/kg body weight/day in a tapering regimen, associated with 5–6 months of methotrexate administration in cases nos. 1 and 3, after which an improvement was observed in the clinical findings and supplemental test results (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Cutaneous sarcoidosis is relatively common and constitutes a diagnostic challenge for medical specialists, as it may be an early symptom of probable asymptomatic systemic involvement (9%–37%), the extent of which will be proportional to the affected body surface area.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Although, in the past, the cutaneous manifestations were not considered to be implicated in the prognosis of the disease,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> at the present time, there are increasing reports of this real and strong association, which, in fact, constitutes the only initial sign in over 50%–80% of the cases.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The prognosis of sarcoidosis is generally good, with spontaneous resolution in nearly 60% of those affected. However, some patients progress to a chronic disease with a mortality of 1%–6%.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> The risk factors for progression are black race, age >40 years, lupus pernio, extensive cutaneous involvement, nasal mucosal involvement, chronic uveitis, chronic hypercalcemia, nephrocalcinosis, bone lesions, highly elevated angiotensin-converting enzyme levels, abnormal findings in the study of the bronchoalveolar lavage sample (CD4/CD8>3.5, lymphocytosis<span class="elsevierStyleHsp" style=""></span>>28%), neurosarcoidosis and cardiac involvement.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Positron emission tomography currently constitutes a useful tool in the diagnosis and follow-up of sarcoidosis, even in cases of occult or asymptomatic involvement. It is more sensitive and requires a 3-fold lower radiation dose than gallium scintigraphy.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment is based on the administration of high-dose systemic corticosteroids (oral prednisone at a dose of 0.5<span class="elsevierStyleHsp" style=""></span>mg/kg<span class="elsevierStyleHsp" style=""></span>bw/day) in a tapering regimen, associated in some cases with immunosuppressive drugs. The list of the latter is long and, to date, there are no studies with a high level of evidence and grade of recommendation that demonstrate the superiority of any given agent over the others. However, the available studies recommend the use of methotrexate (10–15<span class="elsevierStyleHsp" style=""></span>mg/week) as the drug of choice.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Thus, the presence of suggestive lesions should activate a protocol of supplemental tests aimed at confirming the lesion type and assessing the extent of the disease; on the basis of the results, and in view of the poor prognosis associated with the detected risk factors, the decision will be made to begin systemic therapy in order to prevent future complications.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical Disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres589273" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec604910" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres589274" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec604909" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case Reports" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 9 => array:2 [ "identificador" => "xack198228" "titulo" => "Acknowledgements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-10-26" "fechaAceptado" => "2015-02-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec604910" "palabras" => array:3 [ 0 => "Cutaneous sarcoidosis" 1 => "Systemic granulomatous disease" 2 => "Mediastinal lymphadenopathy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec604909" "palabras" => array:3 [ 0 => "Sarcoidosis cutánea" 1 => "Enfermedad granulomatosa sistémica" 2 => "Adenopatías mediastínicas" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sarcoidosis is a systemic granulomatous disease with a wide range of clinical manifestations. Skin involvement is an early, frequent and accessible location for a histopathological study. Several risk factors have been described to determine the likelihood of systemic involvement of an apparent cutaneous condition. Early diagnosis and systemic treatment could prevent future complications.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A series of three cases is presented in which the initial diagnosis was cutaneous sarcoidosis, but it was actually the first manifestation of a systemic disease. A review of this topic is also presented.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La sarcoidosis es una enfermedad granulomatosa sistémica con un gran abanico de manifestaciones clínicas, siendo la afectación cutánea una de las más precoces, frecuentes y accesible de un estudio histopatológico. En la actualidad, se han descrito varios factores de riesgo que determinarán la probable afectación sistémica de una aparente afectación cutánea única. Esta correcta valoración establecerá el inicio de un tratamiento sistémico, previniendo de esta forma futuras complicaciones.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se presenta a continuación una serie de 3 casos de sarcoidosis cutánea como primera manifestación de una enfermedad sistémica paucisintomática y se hace una revisión del tema.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ramírez Huaranga MA, Ramos Rodríguez CC, de la Rocha Vedia IV, García Arpa M, Murillo Lázaro C, Bellón Guardia M. Sarcoidosis cutánea: el preámbulo de una enfermedad sistémica paucisintomática. Reumatol Clin. 2015;11:395–397.</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" => 1478 "Ancho" => 1500 "Tamanyo" => 211400 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Nuclear medicine study of case no. 1. (A) Scintigraphic study showing an active inflammatory process affecting upper and lower limbs, mediastinal lymph nodes, lung parenchyma, bone and left gluteal muscle. (B.1) Positron emission tomography (PET) study showing mediastinal lymph node involvement prior to treatment. (B.2) PET study following treatment.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 856 "Ancho" => 1400 "Tamanyo" => 463339 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">(A) Hematoxylin and eosin (HE) ×40: naked granulomas predominantly in subcutaneous connective tissue. (B) HE ×400: granulomas mainly occupying lobules with some isolated Langerhans cells (arrow).</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">ACE: angiotensin-converting enzyme; CT: computed tomography; NV: normal value; PET: positron emission tomography.</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"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case no. 1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case no. 2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case no. 3 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age (years)/sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51/woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44/woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63/man (black race) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Presenting symptom \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hardened, painful, erythematous lesion measuring 4<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>cm in proximal third of right forearm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">History: painful subcutaneous nodules in anterior tibial region \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pruritic, scaly, erythematous plaques on face and frontal part of the scalp \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Dermatopathologic diagnosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cutaneous sarcoidosis with specific subcutaneous-like lesion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cutaneous sarcoidosis with nonspecific erythema nodosum-like lesion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cutaneous sarcoidosis with specific maculopapular-type lesion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Supplemental tests \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ACE<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>100 (NV 8–52<span class="elsevierStyleHsp" style=""></span>mg/dl).PET: cutaneous, mediastinal lymph node, pulmonary, bone and muscle involvement (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ACE<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mg/dlPET: mediastinal lymph node, pulmonary and bone involvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ACE<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mg/dlCT: pulmonary and lymph node involvement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Biopsy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Skin: sarcoid-like, noncaseating granulomatous dermatitis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lymph node: infiltrated by sarcoid-like, noncaseating granulomas \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Skin: multiple sarcoid-like noncaseating granulomas \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Prednisone 30<span class="elsevierStyleHsp" style=""></span>mg/day and methotrexate 10<span class="elsevierStyleHsp" style=""></span>mg/week \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Prednisone 0.5<span class="elsevierStyleHsp" style=""></span>mg/kg<span class="elsevierStyleHsp" style=""></span>bw/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Prednisone 0.5<span class="elsevierStyleHsp" style=""></span>mg/kg<span class="elsevierStyleHsp" style=""></span>bw/day and methotrexate 12.5<span class="elsevierStyleHsp" style=""></span>mg/week \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab962318.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Clinical 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Lower" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.00060612" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2013" "volumen" => "41" "paginaInicial" => "1424" "paginaFinal" => "1438" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23397302" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack198228" "titulo" => "Acknowledgements" "texto" => "<p id="par0065" class="elsevierStylePara elsevierViewall">We thank the Departments of Pathology and Nuclear Medicine of Hospital General Universitario de Ciudad Real, Spain, for the facilities provided.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000001100000006/v1_201512160151/S2173574315001045/v1_201512160151/en/main.assets" "Apartado" => array:4 [ "identificador" => "43296" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case report" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000001100000006/v1_201512160151/S2173574315001045/v1_201512160151/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574315001045?idApp=UINPBA00004M" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 5 | 10 |
| 2024 October | 42 | 27 | 69 |
| 2024 September | 57 | 11 | 68 |
| 2024 August | 69 | 39 | 108 |
| 2024 July | 59 | 43 | 102 |
| 2024 June | 79 | 46 | 125 |
| 2024 May | 63 | 31 | 94 |
| 2024 April | 54 | 41 | 95 |
| 2024 March | 74 | 38 | 112 |
| 2024 February | 40 | 29 | 69 |
| 2024 January | 60 | 31 | 91 |
| 2023 December | 43 | 27 | 70 |
| 2023 November | 45 | 44 | 89 |
| 2023 October | 40 | 35 | 75 |
| 2023 September | 75 | 48 | 123 |
| 2023 August | 122 | 30 | 152 |
| 2023 July | 42 | 23 | 65 |
| 2023 June | 53 | 27 | 80 |
| 2023 May | 47 | 26 | 73 |
| 2023 April | 32 | 30 | 62 |
| 2023 March | 52 | 35 | 87 |
| 2023 February | 50 | 29 | 79 |
| 2023 January | 27 | 30 | 57 |
| 2022 December | 44 | 25 | 69 |
| 2022 November | 83 | 42 | 125 |
| 2022 October | 55 | 34 | 89 |
| 2022 September | 51 | 31 | 82 |
| 2022 August | 57 | 41 | 98 |
| 2022 July | 38 | 41 | 79 |
| 2022 June | 51 | 35 | 86 |
| 2022 May | 43 | 47 | 90 |
| 2022 April | 50 | 50 | 100 |
| 2022 March | 60 | 50 | 110 |
| 2022 February | 43 | 58 | 101 |
| 2022 January | 56 | 41 | 97 |
| 2021 December | 44 | 48 | 92 |
| 2021 November | 45 | 47 | 92 |
| 2021 October | 61 | 53 | 114 |
| 2021 September | 45 | 46 | 91 |
| 2021 August | 39 | 48 | 87 |
| 2021 July | 48 | 42 | 90 |
| 2021 June | 37 | 45 | 82 |
| 2021 May | 53 | 51 | 104 |
| 2021 April | 69 | 95 | 164 |
| 2021 March | 66 | 42 | 108 |
| 2021 February | 37 | 29 | 66 |
| 2021 January | 25 | 32 | 57 |
| 2020 December | 32 | 17 | 49 |
| 2020 November | 27 | 21 | 48 |
| 2020 October | 18 | 19 | 37 |
| 2020 September | 43 | 29 | 72 |
| 2020 August | 32 | 16 | 48 |
| 2020 July | 22 | 23 | 45 |
| 2020 June | 40 | 16 | 56 |
| 2020 May | 28 | 9 | 37 |
| 2020 April | 33 | 22 | 55 |
| 2020 March | 12 | 6 | 18 |
| 2020 February | 1 | 0 | 1 |
| 2018 May | 6 | 0 | 6 |
| 2018 April | 38 | 4 | 42 |
| 2018 March | 34 | 14 | 48 |
| 2018 February | 35 | 6 | 41 |
| 2018 January | 19 | 3 | 22 |
| 2017 December | 25 | 6 | 31 |
| 2017 November | 30 | 4 | 34 |
| 2017 October | 24 | 8 | 32 |
| 2017 September | 21 | 10 | 31 |
| 2017 August | 21 | 8 | 29 |
| 2017 July | 32 | 12 | 44 |
| 2017 June | 46 | 9 | 55 |
| 2017 May | 60 | 8 | 68 |
| 2017 April | 57 | 8 | 65 |
| 2017 March | 30 | 7 | 37 |
| 2017 February | 19 | 12 | 31 |
| 2017 January | 30 | 15 | 45 |
| 2016 December | 70 | 19 | 89 |
| 2016 November | 57 | 15 | 72 |
| 2016 October | 58 | 19 | 77 |
| 2016 September | 52 | 5 | 57 |
| 2016 August | 43 | 4 | 47 |
| 2016 July | 30 | 7 | 37 |
| 2016 May | 1 | 0 | 1 |
| 2016 January | 0 | 62 | 62 |
| 2015 December | 3 | 28 | 31 |
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