Brief report
Articular Manifestations in Patients With Lyme Disease
Manifestaciones articulares en enfermos de Lyme
María Esther Vázquez-Lópeza,
, Carolina Díez-Morrondob, Amalia Sánchez-Andradec, Robustiano Pego-Reigosad, Pablo Díaze, Manuel Castro-Gagof
Corresponding author
a Servicio de Pediatría, Hospital Universitario Lucus Agusti, Lugo, Spain
b Unidad de Reumatología, Hospital del Bierzo, Ponferrada, León, Spain
c Servicio de Reumatología, Hospital Universitario Lucus Agusti, Lugo, Spain
d Servicio de Neurología, Hospital Universitario Lucus Agusti, Lugo, Spain
e Unidad de Epidemiología, Zoonosis y Salud Pública, Facultad de Veterinaria, Universidad de Santiago de Compostela, Lugo, Spain
f Servicio de Neuropediatría, Hospital Clínico Universitario, Santiago de Compostela, La Coruña, Spain
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Hospital Universitario Lucus Agusti, Lugo, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Unidad de Epidemiología, Zoonosis y Salud Pública, Facultad de Veterinaria, Universidad de Santiago de Compostela, Lugo, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Neuropediatría, Hospital Clínico Universitario, Santiago de Compostela, La Coruña, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manifestaciones articulares en enfermos de Lyme" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Lyme disease (LD) is a zoonosis of cosmopolitism distribution caused by Gram-negative bacteria, pertaining to the <span class="elsevierStyleItalic">Borrelia burgdorferi</span> (<span class="elsevierStyleItalic">B. burgdorferi</span>) <span class="elsevierStyleItalic">sensu lato</span>. It is transmitted by the tick bite, principally by the <span class="elsevierStyleItalic">Ixodes ricinus</span> in Spain.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The disease can affect multiple organs and systems and, thus, its clinical spectrum is highly varied. It can involve the skin, heart, nervous system and joints, following a time process in phases. Phase I (early local) includes erythema migrans (EM); phase II (early diffuse), with joint, neurological and cardiac clinical signs; and phase III (late diffuse), with chronic arthritis, acrodermatitis chronica atrophicans and late neuroborreliosis.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,2</span></a> However, the clinical findings of each phase can be overlapped, and some patients can show signs of late infection without previous manifestations of early infection.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Musculoskeletal signs, such as arthralgia and myalgia, are observed more often in phase II of the disease, whereas arthritis is more frequent in phase III.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3–5</span></a> For this reason, after weeks or months, those patients who have not been diagnosed and treated can develop oligoarthritis in large joints<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3,4</span></a> or an intermittent monoarthritis, especially in the knee.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The diagnostic of LD, except in the case of EM, requires microbiological confirmation (enzyme-linked immunosorbent assay [ELISA] or western blot).<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> Moreover, a tick bite must have been possible, and that can be the result of an exhaustive clinical history.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3,7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The prognosis of LD is good, whenever an early diagnosis is reached and a proper antibiotic therapy against <span class="elsevierStyleItalic">Borrelia</span> has been initiated. In contrast, a delay in the diagnosis and in the administration of treatment can be associated with a more elevated morbidity.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2,4,8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The objective of this study is to determine the percentage of patients with LD whose joint signs, outcome and response to treatment could be identified, based on the data from the case records.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients</span><p id="par0035" class="elsevierStylePara elsevierViewall">A retrospective, descriptive, observational study was performed (2006–2013) to examine our knowledge of the joint manifestations of LD. Lucus Augusti Teaching Hospital in Lugo, in the northwestern coastal area of Spain, cover a mean of 223,374 persons. We reviewed 108 case reports of LD, confirmed according to the epidemiology alert of the Centers for Disease Control and Prevention of the United States.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> We selected patients with given joint findings, and collected the data corresponding to their major clinical signs, adjunctive texts, administrative therapy and outcome. Moreover, we took into account the age, sex and habitat (rural or urban) of the patients and whether anyone remembered the tick bite. Rural centers were those with less than 2000 population (n=118 447) and the rest were urban centers (n=104 927). The disease phase (I, II, III) was determined according to the criteria established by the different authors.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,10</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">Of the 108 individuals confirmed as LD patients, 15.7% (n=17 patients) had joint signs and all of them had ELISA (IgG and IgM VIDAS<span class="elsevierStyleSup">®</span> Lyme; bioMérieux, St. Louis, Missouri, United States) and positive IgG western blot to <span class="elsevierStyleItalic">Borrelia</span> species (EUROLINE-WB, Euroimmun AG, Lübeck, Germany). In all, 64.7% had arthritis, 29.4% arthralgia and 5.9% bursitis. The knee was the most frequently affected joint. Patients with LD with no joint manifestations had skin, neurological or cardiac involvement.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Of the 11 patients with arthritis, 72.7% associated neurological, dermatological and cardiac signs (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), and the majority (90.9%) were in phase III. In 1 patient (case no. 5) in whom EM was observed, a diagnosis was performed early; in the rest, the mean delay to diagnosis was 402 days. Antibiotic therapy was administrated in 90.9% of the patients with arthritis; however, 3 had neurological secondary effects (radicular pain in arm) and 2 developed relapsing chronic arthritis, for which they received corticosteroids and methotrexate. An increase in the number of leukocytes, mostly referring to polymorphonuclear cells, was found in the joint fluid. Moreover, the synovial fluid of the pediatric child who developed relapsing chronic monoarthritis in her left knee was sent to the Spanish Microbiological Center (<span class="elsevierStyleItalic">Instituto de Salud Carlos III</span>, Madrid, Spain), where it was identified, by polymerase chain reaction (PCR), as <span class="elsevierStyleItalic">Borrelia garinii</span> (<span class="elsevierStyleItalic">B. garinii</span>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The 6 patients who had arthralgia or bursitis were associated with dermatological, neurological and cardiac signs. In all, 33.3% were in phase I. In one of these patients (case no. 12), a biopsy was performed in the skin affected by EM, and <span class="elsevierStyleItalic">Borrelia afzelii</span> (<span class="elsevierStyleItalic">B. afzelii</span>) by PCR. In all, 83.3% received antibiotic therapy and they had no secondary effects. In contrast, one patient who had bursitis, in which there was a diagnosis delay of 1277 days, had not had treatment and presented with neurological secondary effects.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The joint signs were somewhat more superior in the women (52.9%). The age of the patients ranged between 4 and 87 years (mean and median was 58 years), and there was a minor prevalence in joint manifestations in patients under 15 years (5.9%).</p><p id="par0060" class="elsevierStylePara elsevierViewall">All of the patients resided in the rural environment, and 52.9% remembered the tick bite. The majority of the patients (70%) were diagnosed between the months of June and August.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">In all the patients with rheumatology clinic, the most affected joint was the knee, followed to a smaller extend by hand and ankle. The results coincide, in general, with those proposed by other authors.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3,4,8,11–14</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Arthralgia and bursitis, without associated arthritis, were relatively frequent, and were mostly observed in phase II of the disease.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Arthritis was the predominant sign, and most of the patients were in phase III, or late diffuse phase. There was a considerable delay in the diagnosis, which agrees with other studies.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> Cytology of the joint fluid, as in septic arthritis, usually showed an increase in the leukocyte count, with a predominance of neutrophils.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> This means that, on occasions, the differential diagnosis with respect to these 2 entities was difficult, and can even signify that these patients be subjected to aggressive and unnecessary treatments, like surgical drainage.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> For this reason, in patients, in endemic LD regions, with monoarthritis or oligoarthritis, especially if the knee is the affected joint, a differential diagnosis should be done with other arthritis.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> In 2 of the patients, using PCR, <span class="elsevierStyleItalic">B. garinii</span> was isolated in the joint fluid and <span class="elsevierStyleItalic">B. afzelii</span> in skin with EM. This agrees with the fact that, in Europe, these 2 genera, together with <span class="elsevierStyleItalic">B. burgdorferi sensu stricto</span>, are the most frequently related to joint and dermatological signs.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> To most of the patients with arthritis with no associated neurological signs, oral doxycycline or amoxicillin was administered as the treatment of choice.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> The case of not having an adequate response to the initial therapy would mean the indication of a new antibiotic cycle of the administration, which would be 2 or 3 successive weeks. However, depending on the outcome to date, it would be of novel disease-modifying antirheumatic drugs, such as methotrexate, or intraarticular corticosteroid therapy, as was done here in cases no. 1 and 9.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5,6,12</span></a> In cases no. 7 and 8 of this study, in accordance with international guidelines, intravenous ceftriaxone was administered during 21 days, given that it was associated with the neurological signs. There were no residual joint manifestations following treatment in 88.2% of the patients, a finding that agrees with the good outcome expected after therapy, according to the reports by other authors.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4,5,12,14</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">We found no significantly different sex-related factors, coinciding with the data from other studies.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> In contrast, with respect to the age of presentation, we observed no bimodal distribution pointed out by other authors.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">All of the patients resided in rural regions, which placed them in greater risk of tick bites and, thus, in the mode of acquiring the disease.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">7,15</span></a> Approximately one half of the patients did not remember the history of their bites. This may be because they are not painful or because the ticks, especially if they are not fed or are young, are difficult to see.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2,7</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Of the results observed in this study, we deduce that, in regions with a high risk of tick bites, it is necessary to add LD to the differential diagnosis in the case of joint involvement with these manifestations, which will help to establish adequate early therapy to prevent secondary effects. A detailed case report is essential to point to the way to joint disease in the epidemiologic setting of the region.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ethical Disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Protection of human and animal subjects</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Confidentiality of data</span><p id="par0100" 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="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Right to privacy and informed consent</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of Interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres752417" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec754806" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres752416" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec754807" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of Interest" ] 10 => array:2 [ "identificador" => "xack250153" "titulo" => "Acknowledgments" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-06-25" "fechaAceptado" => "2015-10-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec754806" "palabras" => array:4 [ 0 => "Articular manifestations" 1 => "Lyme disease" 2 => "Differential diagnosis" 3 => "Treatment and evolution" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec754807" "palabras" => array:4 [ 0 => "Manifestaciones articulares" 1 => "Enfermedad de Lyme" 2 => "Diagnóstico diferencial" 3 => "Tratamiento y evolución" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To determine the percentage of Lyme patients with articular manifestations in NW Spain and to know their evolution and response to treatment.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective study (2006–2013) was performed using medical histories of confirmed cases of Lyme disease showing articular manifestations. Clinical and laboratory characteristics, together with the treatment and evolution of the patients, were analyzed.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Seventeen out of 108 LD confirmed patients (15.7%) showed articular manifestations. Regarding those 17 patients, 64.7%, 29.4% and 5.9% presented arthritis, arthralgia and bursitis, respectively. The knee was the most affected joint. Articular manifestations were often associated to neurological, dermatological and cardiac pathologies. Otherwise, most patients were in Stage III. The 11.8% of the cases progressed to a recurrent chronic arthritis despite the administration of an appropriate treatment.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Lyme disease patients showing articular manifestations should be included in the diagnosis of articular affections in areas of high risk of hard tick bite, in order to establish a suitable and early treatment and to avoid sequels.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Determinar el porcentaje de pacientes con clínica articular entre los enfermos de Lyme en el NO de España y conocer su evolución y respuesta al tratamiento.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realizó un estudio retrospectivo (2006-2013) revisando las historias clínicas de los enfermos de Lyme con clínica articular. Se analizaron las manifestaciones clínicas, los datos de laboratorio, el tratamiento y la evolución de los enfermos.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Diecisiete de 108 pacientes confirmados como enfermos de Lyme (15,7%) presentaban clínica articular. De estos 17, el 64,7% presentó artritis, el 29,4% artralgias y el 5,9% bursitis. La rodilla fue la articulación más afectada. La clínica articular se asoció frecuentemente a manifestaciones neurológicas, dermatológicas o cardíacas. La mayoría de los pacientes estaban en fase <span class="elsevierStyleSmallCaps">iii</span>. El 11,8% evolucionó a artritis crónica recidivante, aunque recibieron tratamiento adecuado.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En zonas con elevado riesgo de picadura por garrapatas, la presencia de clínica articular debe hacernos sospechar la posibilidad de una enfermedad de Lyme con objeto de establecer de forma precoz un tratamiento adecuado que evite secuelas.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Please cite this article as: Vázquez-López ME, Díez-Morrondo C, Sánchez-Andrade A, Pego-Reigosa R, Díaz P, Castro-Gago M. Manifestaciones articulares en enfermos de Lyme. Reumatol Clin. 2016;12:327–330.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">DD, diagnosis delay; EM, erythema migrans; im, intramuscular; iv, intravenous; JF, joint fluid; Leuk, leukocytes; M, man; PCR, polymerase chain reaction; PMN, polymorphonuclear; po, <span class="elsevierStyleItalic">per os</span>; sc, subcutaneous; TR, treatment reiterated; W, woman.</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="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. case \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">Clinical manifestations \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">Phase \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">DD (days) \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">Cytology (JF) PCR \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">Antibiotic (days/route of administration) TR \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">Secondary effects \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">Sex \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">Age (years) \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="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Leuk: 19 627 (88% PMN).<br>PCR in JF: <span class="elsevierStyleItalic">B. garinii</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Amoxicillin (28/po)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><br>Ceftriaxone (15/iv)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><br>Methotrexate (sc)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><br>Intraarticular corticosteroid<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Relapsing chronic arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">W \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1380 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Leuk: 28 500 (90% PMN) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Doxycycline (60/po) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">W \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Leuk: 32 000 (85% PMN) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Doxycycline (30/po) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">W \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arthritis<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>EM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">150 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not available \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Doxycycline (21/po) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">W \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arthritis<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>EM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not available \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Doxycycline (21/po) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">W \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arthritis<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>radicular pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">450 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not available \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Radicular pain in arm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">W \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arthritis<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>facial paralysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">300 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not available \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ceftriaxone (21/iv) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arthritis<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>meningitis and radicular pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not available \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ceftriaxone (21/iv) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">W \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arthritis<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>EM<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>radicular pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Leuk: 39 440 (99% PMN) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Doxycycline (60/po)<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>. Methotrexate (sc)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> Intraarticular corticosteroid<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Relapsing chronic arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arthritis<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>radicular pain<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>arrhythmia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not available \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Doxycycline (21/po)<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a><br>Amoxicillin-clavulanic (10/po)<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a><br>Ciprofloxacin (30/po)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Radicular pain in arm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arthritis<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>EM<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>meningitis and radicular pain<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>arrhythmia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">730 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not available \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Doxycycline (21/po)<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a><br>Ciprofloxacin (10/po)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Radicular pain in arm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arthralgia<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>EM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PCR in skin (EM): <span class="elsevierStyleItalic">B. afzelii</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Doxycycline (60/po) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arthralgia<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>EM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not available \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Doxycycline (21/po) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">W \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arthralgia<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>radicular pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not available \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Azithromycin (10/po) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arthralgia<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>radicular pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not available \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Doxycycline (30/po) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">W \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arthralgia<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>radicular pain<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>arrhythmia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not available \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ceftriaxone (27/iv) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bursitis<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>radicular pain<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>arrhythmia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1277 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not available \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Loss of strength and radicular pain in arm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1245371.png" ] ] ] "notaPie" => array:4 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">In 2012.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">In 2013.</p>" ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">In 2011.</p>" ] 3 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "d" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">In 2006.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Characteristics of Patients With Lyme Disease on Joint Manifestations.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 13 | 9 | 22 |
| 2024 October | 71 | 27 | 98 |
| 2024 September | 41 | 27 | 68 |
| 2024 August | 63 | 64 | 127 |
| 2024 July | 46 | 26 | 72 |
| 2024 June | 54 | 29 | 83 |
| 2024 May | 50 | 31 | 81 |
| 2024 April | 60 | 31 | 91 |
| 2024 March | 41 | 24 | 65 |
| 2024 February | 49 | 40 | 89 |
| 2024 January | 34 | 23 | 57 |
| 2023 December | 42 | 30 | 72 |
| 2023 November | 58 | 29 | 87 |
| 2023 October | 65 | 32 | 97 |
| 2023 September | 89 | 32 | 121 |
| 2023 August | 31 | 16 | 47 |
| 2023 July | 31 | 31 | 62 |
| 2023 June | 48 | 18 | 66 |
| 2023 May | 40 | 26 | 66 |
| 2023 April | 36 | 10 | 46 |
| 2023 March | 78 | 22 | 100 |
| 2023 February | 65 | 31 | 96 |
| 2023 January | 27 | 13 | 40 |
| 2022 December | 70 | 35 | 105 |
| 2022 November | 63 | 31 | 94 |
| 2022 October | 54 | 25 | 79 |
| 2022 September | 40 | 31 | 71 |
| 2022 August | 55 | 38 | 93 |
| 2022 July | 37 | 36 | 73 |
| 2022 June | 31 | 28 | 59 |
| 2022 May | 31 | 33 | 64 |
| 2022 April | 48 | 38 | 86 |
| 2022 March | 39 | 42 | 81 |
| 2022 February | 45 | 32 | 77 |
| 2022 January | 26 | 40 | 66 |
| 2021 December | 23 | 34 | 57 |
| 2021 November | 34 | 45 | 79 |
| 2021 October | 55 | 65 | 120 |
| 2021 September | 35 | 51 | 86 |
| 2021 August | 34 | 52 | 86 |
| 2021 July | 37 | 22 | 59 |
| 2021 June | 39 | 31 | 70 |
| 2021 May | 40 | 46 | 86 |
| 2021 April | 101 | 75 | 176 |
| 2021 March | 49 | 27 | 76 |
| 2021 February | 35 | 30 | 65 |
| 2021 January | 34 | 23 | 57 |
| 2020 December | 34 | 23 | 57 |
| 2020 November | 93 | 22 | 115 |
| 2020 October | 90 | 23 | 113 |
| 2020 September | 38 | 34 | 72 |
| 2020 August | 22 | 25 | 47 |
| 2020 July | 35 | 34 | 69 |
| 2020 June | 19 | 16 | 35 |
| 2020 May | 34 | 23 | 57 |
| 2020 April | 24 | 24 | 48 |
| 2020 March | 11 | 8 | 19 |
| 2020 February | 1 | 0 | 1 |
| 2018 May | 4 | 1 | 5 |
| 2018 April | 28 | 8 | 36 |
| 2018 March | 47 | 11 | 58 |
| 2018 February | 25 | 8 | 33 |
| 2018 January | 25 | 8 | 33 |
| 2017 December | 34 | 18 | 52 |
| 2017 November | 26 | 14 | 40 |
| 2017 October | 25 | 10 | 35 |
| 2017 September | 29 | 8 | 37 |
| 2017 August | 26 | 13 | 39 |
| 2017 July | 31 | 18 | 49 |
| 2017 June | 38 | 14 | 52 |
| 2017 May | 44 | 21 | 65 |
| 2017 April | 40 | 23 | 63 |
| 2017 March | 31 | 15 | 46 |
| 2017 February | 20 | 17 | 37 |
| 2017 January | 38 | 27 | 65 |
| 2016 December | 67 | 43 | 110 |
| 2016 November | 58 | 38 | 96 |
| 2016 October | 20 | 15 | 35 |
| 2016 September | 15 | 12 | 27 |
| 2016 August | 6 | 4 | 10 |
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