Letter to the Editor
Cutaneous Leishmaniasis: A Case Study in the Context of Treatment with Adalimumab
Leishmaniasis cutánea: a propósito de un caso en el contexto del tratamiento con adalimumab
Read
3593
Timeswas read the article
1226
Total PDF
2367
Total HTML
Share statistics
array:23 [ "pii" => "S2173574320301374" "issn" => "21735743" "doi" => "10.1016/j.reumae.2019.11.004" "estado" => "S300" "fechaPublicacion" => "2021-05-01" "aid" => "1387" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología" "copyrightAnyo" => "2020" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Reumatol Clin. 2021;17:304-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S1699258X20300115" "issn" => "1699258X" "doi" => "10.1016/j.reuma.2019.11.007" "estado" => "S300" "fechaPublicacion" => "2021-05-01" "aid" => "1387" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Reumatol Clin. 2021;17:304-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta al Editor</span>" "titulo" => "Leishmaniasis cutánea: a propósito de un caso en el contexto del tratamiento con adalimumab" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "304" "paginaFinal" => "305" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Cutaneous Leishmaniasis: A Case Study in the Context of Treatment with Adalimumab" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 679 "Ancho" => 905 "Tamanyo" => 79177 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lesión mucocutánea ulcerosa en vestíbulo nasal y labio superior.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Carlos Bruscas Izu, Amaya Lázaro Sánchez, M. Lourdes Alonso Alonso, Ramiro Álvarez Alegret" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Carlos" "apellidos" => "Bruscas Izu" ] 1 => array:2 [ "nombre" => "Amaya" "apellidos" => "Lázaro Sánchez" ] 2 => array:2 [ "nombre" => "M. Lourdes" "apellidos" => "Alonso Alonso" ] 3 => array:2 [ "nombre" => "Ramiro" "apellidos" => "Álvarez Alegret" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173574320301374" "doi" => "10.1016/j.reumae.2019.11.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574320301374?idApp=UINPBA00004M" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X20300115?idApp=UINPBA00004M" "url" => "/1699258X/0000001700000005/v1_202104140921/S1699258X20300115/v1_202104140921/es/main.assets" ] ] "itemAnterior" => array:19 [ "pii" => "S2173574320300666" "issn" => "21735743" "doi" => "10.1016/j.reumae.2020.06.002" "estado" => "S300" "fechaPublicacion" => "2021-05-01" "aid" => "1385" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Reumatol Clin. 2021;17:302-3" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Images in Clinical Rheumatology</span>" "titulo" => "Asymptomatic pulmonary embolism secondary to cement leakage after vertebroplasty" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "302" "paginaFinal" => "303" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Embolismo pulmonar asintomático secundario a fuga de cemento tras vertebroplastia" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1303 "Ancho" => 1500 "Tamanyo" => 145881 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Postero-anterior chest X-ray.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Cecilia Arana-Guajardo, Arnoldo Levi Cavazos-Aranda" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Ana Cecilia" "apellidos" => "Arana-Guajardo" ] 1 => array:2 [ "nombre" => "Arnoldo" "apellidos" => "Levi Cavazos-Aranda" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1699258X20300097" "doi" => "10.1016/j.reuma.2019.11.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X20300097?idApp=UINPBA00004M" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574320300666?idApp=UINPBA00004M" "url" => "/21735743/0000001700000005/v1_202104220818/S2173574320300666/v1_202104220818/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Cutaneous Leishmaniasis: A Case Study in the Context of Treatment with Adalimumab" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "304" "paginaFinal" => "305" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Carlos Bruscas Izu, Amaya Lázaro Sánchez, M. Lourdes Alonso Alonso, Ramiro Álvarez Alegret" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Carlos" "apellidos" => "Bruscas Izu" "email" => array:1 [ 0 => "carlosbruscas@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Amaya" "apellidos" => "Lázaro Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M. Lourdes" "apellidos" => "Alonso Alonso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Ramiro" "apellidos" => "Álvarez Alegret" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Reumatología, Hospital General de la Defensa, Zaragoza, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Hospital General de la Defensa, Zaragoza, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Miguel Servet, Zaragoza, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Leishmaniasis cutánea: a propósito de un caso en el contexto del tratamiento con adalimumab" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 679 "Ancho" => 905 "Tamanyo" => 79177 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ulcerous, mucocutaneous lesion in nasal vestibule and upper lip.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The biological disease-modifying anti-rheumatic drugs (DMARDs) have shown great efficacy in the treatment of certain autoimmune diseases. However, due to the immunosuppression they entail, the patient may be affected by opportunistic germs. We present the rare case, in our setting, of a patient with rheumatoid arthritis complicated by mucocutaneous leishmaniasis in the context of treatment with adalimumab.</p><p id="par0010" class="elsevierStylePara elsevierViewall">This is a 53-year-old woman who was diagnosed with seropositive rheumatoid arthritis and treated with methotrexate in 2000. In 2013, adalimumab (one injection/15 days) plus methotrexate (10<span class="elsevierStyleHsp" style=""></span>mg/week) was used due to poor progress. Since then, she has not required steroids and has remained asymptomatic with this therapeutic approach. She recently presented a mucocutaneous, erythematous and ulcerous lesion in the nasal vestibule and the upper lip that has deformed her nose (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). For this reason, she was referred to the ENT department, where a biopsy was performed and the subsequent anatomopathological study was diagnostic of leishmaniasis, both by direct vision with the Giemsa technique and by nested polymerase chain reaction. The patient had not travelled to particularly endemic areas of this disease, nor lived with animals, nor had she any record of a bite. Adalimumab was then suspended, and she was referred to the infectious disease department, where visceral involvement was ruled out and she was treated with liposomal amphotericin B, which solved the problem.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">This disease is a zoonosis caused by <span class="elsevierStyleItalic">Leishmania</span>, its <span class="elsevierStyleItalic">infantum</span> variety being the most prevalent in Spain. It is endemic in India, Bangladesh, Sudan and Brazil and it is seen, to a lesser extent, in Southern Europe. The dog is the main reservoir, and it is transmitted through the bite of the female Phlebotomus mosquito. After its bite, there can be a mucocutaneous involvement with erythematous and ulcerous lesions in the face, arms and legs. In our case it was centred in the nose, forcing us to rule out a Wegener's granulomatosis. There can also be an exclusively cutaneous form and another visceral form (kala-azar) that usually presents with fever, constitutional syndrome, adenopathy, visceromegaly and pancytopenia. Diagnosis is established by means of culture, direct vision (Giemsa technique) or polymerase chain reaction testing. Treatment is generally with amphotericin B.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The biological DMARDs were initially used in rheumatoid arthritis and, later, their indication was extended to other autoimmune diseases (spondyloarthropathies, juvenile idiopathic arthritis, skin psoriasis, Crohn’s disease, ulcerative colitis, uveitis and suppurative hidradenitis in the case of adalimumab). These drugs have the disadvantage of immunosuppression and, consequently, of encouraging infections by opportunistic germs, especially mycobacteria. More exceptionally, infections by other germs have been described, as in this case. However, they can appear not only with the biological DMARDs, since leishmaniasis has also been described in the context of treatment with conventional steroids and DMARDs. The problem is reintroducing an immunosuppressant in the event of rheumatic flare-up, since leishmaniasis relapses have been described. In this case, some authors advise using etanercept as the most recommended drug and, perhaps, it would also be a good idea to consider therapeutic targets other than anti-TNF. In any case, stricter monitoring for reactivation of leishmaniasis is always necessary.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Therefore, any patient presenting skin lesions of the characteristics described in the text and being treated with immunosuppressant drugs such as those used in autoimmune rheumatic disease, especially anti-TNF-α, should first be considered for leishmaniasis. In addition, patients treated with these drugs who travel to endemic areas of this disease should be particularly monitored.</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: Bruscas Izu C, Lázaro Sánchez A, Alonso Alonso ML, Álvarez Alegret R. Leishmaniasis cutánea: a propósito de un caso en el contexto del tratamiento con adalimumab. Reumatol Clin. 2021;17:304–305.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 679 "Ancho" => 905 "Tamanyo" => 79177 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ulcerous, mucocutaneous lesion in nasal vestibule and upper lip.</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" => "Leishmaniasis and biologic therapies for rheumatologic diseases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Cascio" 1 => "M. Iaria" 2 => "C. Iaria" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.semarthrit.2009.07.001" "Revista" => array:6 [ "tituloSerie" => "Semin Arthritis Rheum" "fecha" => "2010" "volumen" => "40" "paginaInicial" => "e3" "paginaFinal" => "e5" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19782386" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Leishmaniasis during anti-tumor necrosis factor therapy: report of 4 cases and review of the literature (adittional 28 cases)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L.S. Guedes-Barbosa" 1 => "I. Pereira da Costa" 2 => "V. Fernandes" 3 => "L.M. Henrique da Mota" 4 => "I. de Menezes" 5 => "M. Aaron Scheinberg" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.semarthrit.2013.01.006" "Revista" => array:6 [ "tituloSerie" => "Semin Arthritis Rheum" "fecha" => "2013" "volumen" => "43" "paginaInicial" => "152" "paginaFinal" => "157" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23777708" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Relapsing cutaneous leishmaniasis in a patient treated with humira" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E. Otte" 1 => "M. Christiansen" 2 => "E. Petersen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Infect Dis" "fecha" => "2015" "volumen" => "11" "paginaInicial" => "7" "paginaFinal" => "10" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Leishmaniasis visceral en una paciente con artritis reumatoide en tratamiento con adalimumab: descripción del caso y revisión de la literatura médica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D. Moreno" 1 => "P. Martínez" 2 => "J. Berbegal" 3 => "M. Femenia" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eimc.2009.03.017" "Revista" => array:6 [ "tituloSerie" => "Enferm Infecc Microbiol Clin" "fecha" => "2010" "volumen" => "28" "paginaInicial" => "261" "paginaFinal" => "262" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19729230" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Leishmaniasis cutánea. Una infección oportunista" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.J. Moreno Martínez" 1 => "M.J. Moreno Ramos" 2 => "P. Sánchez Pedreño" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.reuma.2016.06.005" "Revista" => array:6 [ "tituloSerie" => "Reumatol Clin" "fecha" => "2017" "volumen" => "13" "paginaInicial" => "181" "paginaFinal" => "182" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27642092" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Leishmaniasis in the era of tumor necrosis factor alpha antagonist therapy – a research agenda for Europe" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. Zanger" 1 => "S. Gabrysch" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2807/1560-7917.es2013.18.30.20542" "Revista" => array:5 [ "tituloSerie" => "Euro Surveill" "fecha" => "2013" "volumen" => "18" "paginaInicial" => "20542" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23929182" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Visceral leishmaniasis in a patient taking adalimumab for rheumatoid arthritis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C.E. Berry" 1 => "J. Tsai" 2 => "A. Tierney" 3 => "R. Pickles" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5694/mja12.11003" "Revista" => array:6 [ "tituloSerie" => "Med J Aust" "fecha" => "2013" "volumen" => "198" "paginaInicial" => "331" "paginaFinal" => "333" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23545033" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Leishmaniasis in immunosuppressed individuals" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J. Van Griensven" 1 => "E. Carrillo" 2 => "R. López-Vélez" 3 => "L. Lynen" 4 => "J. Moreno" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/1469-0691.12556" "Revista" => array:6 [ "tituloSerie" => "Clin Microbiol Infect" "fecha" => "2014" "volumen" => "20" "paginaInicial" => "286" "paginaFinal" => "299" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24450618" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cutaneous leishmaniasis in a patient with ankylosing spondylitis using adalimumab" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K.W. Gomes" 1 => "A.N. Benevides" 2 => "F.J. Vieira" 3 => "M.P. Burlamaqui" 4 => "A. Vieira Mde" 5 => "L.M. Fontenelle" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Bras Reumatol" "fecha" => "2012" "volumen" => "52" "paginaInicial" => "447" "paginaFinal" => "452" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22641598" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Leishmaniasis, autoinmune rheumatic disease, and anti-tumor necrosis factor therapy, Europe" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "I.D. Xynos" 1 => "M.G. Tektonidou" 2 => "D. Pikazis" 3 => "N.V. Sipsas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3201/eid1506.090101" "Revista" => array:6 [ "tituloSerie" => "Emerg Infect Dis" "fecha" => "2009" "volumen" => "15" "paginaInicial" => "956" "paginaFinal" => "959" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19523302" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000001700000005/v1_202104220818/S2173574320301374/v1_202104220818/en/main.assets" "Apartado" => array:4 [ "identificador" => "43295" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000001700000005/v1_202104220818/S2173574320301374/v1_202104220818/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574320301374?idApp=UINPBA00004M" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 8 | 18 |
| 2024 October | 46 | 40 | 86 |
| 2024 September | 66 | 26 | 92 |
| 2024 August | 71 | 32 | 103 |
| 2024 July | 89 | 22 | 111 |
| 2024 June | 89 | 39 | 128 |
| 2024 May | 68 | 26 | 94 |
| 2024 April | 60 | 24 | 84 |
| 2024 March | 75 | 26 | 101 |
| 2024 February | 49 | 22 | 71 |
| 2024 January | 53 | 26 | 79 |
| 2023 December | 53 | 25 | 78 |
| 2023 November | 48 | 36 | 84 |
| 2023 October | 49 | 29 | 78 |
| 2023 September | 57 | 37 | 94 |
| 2023 August | 59 | 25 | 84 |
| 2023 July | 43 | 21 | 64 |
| 2023 June | 60 | 29 | 89 |
| 2023 May | 55 | 24 | 79 |
| 2023 April | 59 | 22 | 81 |
| 2023 March | 68 | 31 | 99 |
| 2023 February | 62 | 36 | 98 |
| 2023 January | 71 | 13 | 84 |
| 2022 December | 87 | 43 | 130 |
| 2022 November | 80 | 32 | 112 |
| 2022 October | 103 | 34 | 137 |
| 2022 September | 95 | 35 | 130 |
| 2022 August | 92 | 54 | 146 |
| 2022 July | 85 | 43 | 128 |
| 2022 June | 66 | 32 | 98 |
| 2022 May | 68 | 41 | 109 |
| 2022 April | 73 | 63 | 136 |
| 2022 March | 67 | 57 | 124 |
| 2022 February | 53 | 37 | 90 |
| 2022 January | 64 | 37 | 101 |
| 2021 December | 29 | 51 | 80 |
| 2021 November | 40 | 43 | 83 |
| 2021 October | 5 | 5 | 10 |
Show all
