Case and Research Letter
Disseminated Sporotrichosis With Cutaneous and Testicular Involvement
Esporotricosis diseminada con afección cutánea y testicular
C.J. Espinoza-Hernández, A. Jesús-Silva, S. Toussaint-Caire, R. Arenas
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Servicio de Dermatología, Hospital General Dr. Manuel Gea González, México D.F., Mexico
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Espinoza-Hernández, A. Jesús-Silva, S. Toussaint-Caire, R. Arenas" "autores" => array:4 [ 0 => array:2 [ "nombre" => "C.J." "apellidos" => "Espinoza-Hernández" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Jesús-Silva" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Toussaint-Caire" ] 3 => array:4 [ "nombre" => "R." "apellidos" => "Arenas" "email" => array:1 [ 0 => "rarenas98@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital General Dr. Manuel Gea González, México D.F., Mexico" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding Author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Esporotricosis diseminada con afección cutánea y testicular" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 857 "Ancho" => 1500 "Tamanyo" => 189235 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, PAS-stained smear showing cigar-shaped yeast cells (original magnification ×100). B, Microscopic analysis of the culture showing sympodial conidia (lactophenol blue, original magnification ×40). C, Culture of <span class="elsevierStyleItalic">Sporothrix</span> species.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Sporotrichosis is a subcutaneous mycosis caused by the dimorphic fungus <span class="elsevierStyleItalic">Sporothrix schenckii</span>, which can have a subacute or chronic course.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This disease has a worldwide distribution<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and is an emerging infection in Europe, where it has become quite common.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The most frequent method of transmission is traumatic inoculation.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> This polymorphic mycosis has 4 clinical forms: lymphocutaneous, fixed cutaneous, disseminated, and extracutaneous. The extracutaneous and disseminated forms account for 4% of total cases<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and most often affect immunocompromised patients, in whom the fungus acts as an opportunistic agent.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Amphotericin B is the treatment of choice for systemic disseminated forms.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 54 year-old male construction worker with no relevant medical history except chronic alcohol consumption. The patient reported weight loss and intermittent fever associated with rapidly spreading dermatitis, which had developed 6 months earlier and was characterized by multiple, very painful necrotic pustules and ulcers of varying size with purulent exudate, some with a verrucous surface. The lesions affected a significant percentage of the body surface, exposing muscles and tendons (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> A-D). The patient reported that he had undergone a right radical orchiectomy in another hospital for a testicular tumor that was likely malignant.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Direct examination of the skin lesions with potassium hydroxide and staining of smears with Gram stain and periodic acid Schiff (PAS) revealed abundant, elongated, cigar-shaped yeast cells (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). Microscopic analysis of cells cultured in Sabouraud dextrose agar showed conidia arranged laterally on the hyphae (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> B), and identified the cells as <span class="elsevierStyleItalic">S schenckii</span> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C). The following bacterial aggregates were also observed: <span class="elsevierStyleItalic">Acinetobacter baumanni</span> (><span class="elsevierStyleHsp" style=""></span>250,000 colony-forming units) in a qualitative skin biopsy culture; multiresistant <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> in pustule exudate; and oxacillin-resistant <span class="elsevierStyleItalic">Staphylococcus haemolyticus</span> in a blood culture. The sporotrichin skin test was negative.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The skin biopsy showed nodular and diffuse inflammatory infiltrate, which was composed of lymphocytes, epithelioid histiocytes, multinucleated giant cells, and neutrophils, and produced suppurative granulomas and tissue necrosis (<a class="elsevierStyleCrossRef" href="#fig0015">Figs. 3</a>A and B). PAS and Grocott Gomori staining revealed abundant yeast cells, both round and elongated (<a class="elsevierStyleCrossRef" href="#fig0015">Figs. 3</a><span class="elsevierStyleHsp" style=""></span>C and D).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Histology of the tissue excised in the orchiectomy revealed similar findings; chronic granulomatous inflammation was observed with multinucleated giant cells, necrosis, and polymorphonuclear infiltration (<a class="elsevierStyleCrossRef" href="#fig0020">Figs. 4</a> A and B). Staining showed spherical and cigar-shaped spores consistent with sporotrichosis (<a class="elsevierStyleCrossRef" href="#fig0020">Figs. 4</a><span class="elsevierStyleHsp" style=""></span>C and D).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Tumor staging ruled out fungal invasion of other organs, and HIV serology was negative.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient’ wounds were dressed and he was treated with amphotericin B deoxycholate for 14 days (total cumulative dose of 1.68<span class="elsevierStyleHsp" style=""></span>g) in addition to antibiotics. The clinical course of infection was prolonged due to several complications related to treatment, associated infections, and the disease itself. These included septic shock, nephrotoxicity (acute renal failure, hypokalemia, hypomagnesemia, metabolic acidosis), liver failure, and disseminated intravascular coagulation. The patient died due to severe hemodynamic compromise.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Sporotrichosis is caused by the dimorphic fungus <span class="elsevierStyleItalic">S schenckii</span>.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The most common presentation is lymphocutaneous; extracutaneous forms are rare, and are more prevalent in immunosuppressed patients.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The case described here was classified as systemic disseminated sporotrichosis with additional extracutaneous involvement, with disseminated skin lesions, general malaise and internal organ involvement. This form is most common in immunocompromised patients.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The fungal infection was highly invasive, not only in terms of its cutaneous extension and testicular involvement, but also the degree of necrosis, depth of invasion, and the destruction of adjacent muscles and tendons. The sporotrichin skin test was anergic, indicating a poor immune response to fungal invasion by the patient. The only immunosuppression-associated factor detected was chronic alcoholism. The patient had also recently undergone orchiectomy at another institution due to clinical suspicion of a malignant testicular tumor, without prior confirmation of the nature of the lesion.</p><p id="par0055" class="elsevierStylePara elsevierViewall">It was not possible to determine the mechanism of infection, but given the patient’ profession he may have acquired the microorganism via cutaneous inoculation, as the lesions first appeared on the left hand, and later spread throughout the body by hematogenous dissemination.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Sporotrichosis is definitively diagnosed by culture of the fungus obtained from a skin biopsy. Histology is usually not diagnostic, as the yeast is present in small amounts.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However, in this patient, a large number of fungal elements were detected in the cutaneous and testicular biopsies.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The treatment of choice for extracutaneous and disseminated forms of sporotrichosis is amphotericin B, followed by long-term itraconazole administration in immunocompromised patients.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In summary, our patient’ chronic alcohol abuse led to a state of severe immunosuppression, favoring the fulminant course of sporotrichosis with significant fungal invasion, which, together with a lack of prior clinical suspicion as well as complications associated with the treatment, concurrent bacterial infections, and the mycosis itself, resulted in the patient's death.</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: Espinoza-Hernández C, Jesús-Silva A, Toussaint-Caire S, Arenas R. Esporotricosis diseminada con afección cutánea y testicular. Actas Dermosifiliogr. 2014;105:204–206.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1064 "Ancho" => 1501 "Tamanyo" => 232346 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Necrotic pustules and papules on the trunk and lower extremities. B, Ulcers and extensive necrosis on the head. C and D, Large ulcers on the left forearm with exposed tendons and muscle.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 857 "Ancho" => 1500 "Tamanyo" => 189235 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, PAS-stained smear showing cigar-shaped yeast cells (original magnification ×100). B, Microscopic analysis of the culture showing sympodial conidia (lactophenol blue, original magnification ×40). C, Culture of <span class="elsevierStyleItalic">Sporothrix</span> species.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 840 "Ancho" => 1500 "Tamanyo" => 301557 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A, Histopathology of skin samples with suppurative granuloma containing lymphocytes, epithelioid histiocytes, and multinucleated giant cells (hematoxylin-eosin, original magnification ×5). B, Higher magnification image showing phagocytosed yeast cells (hematoxylin-eosin, original magnification ×40). C, Note the abundance of yeast cells (PAS, original magnification ×20). D, Ovoid and cigar-shaped yeast cells (Gomori-Grocott, original magnification ×20).</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 805 "Ancho" => 1500 "Tamanyo" => 296530 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Testicular biopsy. A, Substitution of the testicular parenchyma with chronic granulomatous inflammation with multinucleated giant cells, areas of necrosis, and polymorphonuclear infiltration (hematoxylin-eosin, original magnification ×5). B, Higher magnification image showing abundant ovoid yeast cells (hematoxylin-eosin, original magnification ×40). C and D, Spherical and cigar-shaped spores (PAS and Gomori Grocott, original magnification ×20).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sporotrichosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R. 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Camacho" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eimc.2010.06.011" "Revista" => array:6 [ "tituloSerie" => "Enferm Infecc Microbiol Clin" "fecha" => "2011" "volumen" => "29" "paginaInicial" => "233" "paginaFinal" => "234" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21330011" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sporothrix schenckii and sporotrichosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L.M. Lopes" 1 => "A. Schubach" 2 => "R.O. Costa" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "An Acad Bras Cien" "fecha" => "2006" "volumen" => "78" "paginaInicial" => "293" "paginaFinal" => "308" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clasificación de la esporotricosis. Una propuesta con base en el comportamiento inmunológico" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Saúl" 1 => "A. Bonifaz" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Dermatología Rev Mex" "fecha" => "2011" "volumen" => "55" "paginaInicial" => "200" "paginaFinal" => "208" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sporotrichosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E. Vázquez-del Mercado" 1 => "R. Arenas" 2 => "C. Padilla-Desgarenes" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.clindermatol.2011.09.017" "Revista" => array:7 [ "tituloSerie" => "Clin Dermatol" "fecha" => "2012" "volumen" => "30" "paginaInicial" => "437" "paginaFinal" => "443" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22682194" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1552526010000142" "estado" => "S300" "issn" => "15525260" ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical Practice Guidelines for the Management of Sporotrichosis: 2007 Update by the Infectious Diseases Society of America" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Kauffman" 1 => "B. Bustamante" 2 => "S. Chapman" 3 => "E. Pappas" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "CID" "fecha" => "2007" "paginaInicial" => "1255" "paginaFinal" => "1265" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack75381" "titulo" => "Acknowledgements" "texto" => "<p id="par0075" class="elsevierStylePara elsevierViewall">We thank Dr. José G. Chanona Vilchis, Head of the Department of Surgical Pathology of the Instituto Nacional de Cancerología, for providing testicular biopsy samples and histological descriptions.</p> <p id="par0080" class="elsevierStylePara elsevierViewall">We also thank Dr. Diana Vilar Compte of the Infectious Diseases Service at the Hospital General Dr. Manuel Gea González for microbiological identification of superadded bacterial infections, and Dr. Horacio Vidrio Morgado, Surgical Oncology Resident at the Instituto Nacional de Cancerología, and Dr. Alberto de los Ríos, Internal Medicine Resident at the Hospital General Dr. Manuel Gea González, for their role in the metabolic and surgical management of the patient.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010500000002/v1_201403090058/S1578219014000274/v1_201403090058/en/main.assets" "Apartado" => array:4 [ "identificador" => "6157" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case and Research Letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010500000002/v1_201403090058/S1578219014000274/v1_201403090058/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219014000274?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 18 | 30 |
| 2024 October | 115 | 48 | 163 |
| 2024 September | 110 | 27 | 137 |
| 2024 August | 110 | 73 | 183 |
| 2024 July | 101 | 42 | 143 |
| 2024 June | 112 | 55 | 167 |
| 2024 May | 128 | 54 | 182 |
| 2024 April | 111 | 38 | 149 |
| 2024 March | 104 | 35 | 139 |
| 2024 February | 98 | 40 | 138 |
| 2024 January | 108 | 37 | 145 |
| 2023 December | 101 | 21 | 122 |
| 2023 November | 105 | 31 | 136 |
| 2023 October | 94 | 27 | 121 |
| 2023 September | 98 | 38 | 136 |
| 2023 August | 85 | 22 | 107 |
| 2023 July | 116 | 35 | 151 |
| 2023 June | 107 | 28 | 135 |
| 2023 May | 117 | 27 | 144 |
| 2023 April | 116 | 31 | 147 |
| 2023 March | 128 | 38 | 166 |
| 2023 February | 81 | 19 | 100 |
| 2023 January | 71 | 36 | 107 |
| 2022 December | 78 | 56 | 134 |
| 2022 November | 52 | 34 | 86 |
| 2022 October | 52 | 23 | 75 |
| 2022 September | 53 | 46 | 99 |
| 2022 August | 51 | 33 | 84 |
| 2022 July | 46 | 42 | 88 |
| 2022 June | 47 | 42 | 89 |
| 2022 May | 109 | 29 | 138 |
| 2022 April | 141 | 54 | 195 |
| 2022 March | 119 | 52 | 171 |
| 2022 February | 110 | 44 | 154 |
| 2022 January | 118 | 43 | 161 |
| 2021 December | 84 | 32 | 116 |
| 2021 November | 83 | 62 | 145 |
| 2021 October | 99 | 59 | 158 |
| 2021 September | 78 | 51 | 129 |
| 2021 August | 83 | 56 | 139 |
| 2021 July | 66 | 40 | 106 |
| 2021 June | 67 | 45 | 112 |
| 2021 May | 68 | 40 | 108 |
| 2021 April | 163 | 73 | 236 |
| 2021 March | 67 | 31 | 98 |
| 2021 February | 69 | 31 | 100 |
| 2021 January | 36 | 31 | 67 |
| 2020 December | 29 | 27 | 56 |
| 2020 November | 31 | 18 | 49 |
| 2020 October | 15 | 11 | 26 |
| 2020 September | 21 | 20 | 41 |
| 2020 August | 24 | 13 | 37 |
| 2020 July | 27 | 16 | 43 |
| 2020 June | 24 | 21 | 45 |
| 2020 May | 27 | 23 | 50 |
| 2020 April | 35 | 16 | 51 |
| 2020 March | 29 | 18 | 47 |
| 2020 February | 8 | 1 | 9 |
| 2020 January | 0 | 4 | 4 |
| 2019 December | 5 | 4 | 9 |
| 2019 November | 4 | 0 | 4 |
| 2019 October | 0 | 3 | 3 |
| 2019 September | 4 | 4 | 8 |
| 2019 August | 4 | 7 | 11 |
| 2019 July | 8 | 13 | 21 |
| 2019 June | 4 | 17 | 21 |
| 2019 May | 6 | 15 | 21 |
| 2019 April | 2 | 20 | 22 |
| 2019 March | 1 | 6 | 7 |
| 2019 February | 7 | 6 | 13 |
| 2019 January | 5 | 4 | 9 |
| 2018 December | 0 | 4 | 4 |
| 2018 November | 5 | 10 | 15 |
| 2018 October | 1 | 0 | 1 |
| 2018 September | 4 | 0 | 4 |
| 2018 March | 8 | 0 | 8 |
| 2018 February | 71 | 2 | 73 |
| 2018 January | 93 | 5 | 98 |
| 2017 December | 98 | 6 | 104 |
| 2017 November | 77 | 1 | 78 |
| 2017 October | 103 | 3 | 106 |
| 2017 September | 55 | 11 | 66 |
| 2017 August | 93 | 5 | 98 |
| 2017 July | 50 | 11 | 61 |
| 2017 June | 80 | 7 | 87 |
| 2017 May | 50 | 5 | 55 |
| 2017 April | 33 | 10 | 43 |
| 2017 March | 29 | 5 | 34 |
| 2017 February | 101 | 6 | 107 |
| 2017 January | 39 | 10 | 49 |
| 2016 December | 65 | 8 | 73 |
| 2016 November | 75 | 12 | 87 |
| 2016 October | 116 | 7 | 123 |
| 2016 September | 201 | 14 | 215 |
| 2016 August | 99 | 7 | 106 |
| 2016 July | 44 | 5 | 49 |
| 2016 June | 15 | 10 | 25 |
| 2016 May | 5 | 8 | 13 |
| 2016 April | 3 | 5 | 8 |
| 2016 March | 4 | 2 | 6 |
| 2016 February | 19 | 2 | 21 |
| 2016 January | 7 | 1 | 8 |
| 2015 December | 11 | 10 | 21 |
| 2015 November | 10 | 1 | 11 |
| 2015 October | 9 | 2 | 11 |
| 2015 September | 6 | 4 | 10 |
| 2015 August | 3 | 3 | 6 |
| 2015 July | 99 | 5 | 104 |
| 2015 June | 48 | 9 | 57 |
| 2015 May | 71 | 11 | 82 |
| 2015 April | 60 | 4 | 64 |
| 2015 March | 78 | 2 | 80 |
| 2015 February | 52 | 4 | 56 |
| 2015 January | 39 | 6 | 45 |
| 2014 December | 46 | 7 | 53 |
| 2014 November | 48 | 5 | 53 |
| 2014 October | 41 | 6 | 47 |
| 2014 September | 40 | 3 | 43 |
| 2014 August | 25 | 6 | 31 |
| 2014 July | 32 | 6 | 38 |
| 2014 June | 40 | 5 | 45 |
| 2014 May | 33 | 9 | 42 |
| 2014 April | 19 | 9 | 28 |
| 2014 March | 8 | 6 | 14 |
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