Case and Research Letter
Herpes Zoster in Children Vaccinated Against Varicella-Zoster Virus: Experience in our Hospital
Herpes zóster en niños vacunados contra el virus varicela zóster: experiencia en nuestro hospital
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Caro-Gutiérrez, J.L. López-Estebaranz, E. Naz-Villalba, L. Ayala-Bernaldo de Quiros" "autores" => array:4 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Caro-Gutiérrez" "email" => array:2 [ 0 => "carogutierrezd@gmail.com" 1 => "mdcaro@fhalcorcon.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.L." "apellidos" => "López-Estebaranz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Naz-Villalba" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Ayala-Bernaldo de Quiros" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Fundación Alcorcón, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Pediatría, Hospital Universitario Fundación Alcorcón, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Herpes zóster en niños vacunados contra el virus varicela zóster: experiencia en nuestro hospital" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 884 "Ancho" => 1600 "Tamanyo" => 182550 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical characteristics of the herpes zoster lesions in 4 of the patients in our series.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The introduction of the varicella zoster virus (VZV) vaccine was expected to eliminate herpes zoster (HZ) in vaccinated children. However, several years later we continue to treat cases of HZ in children. We describe 8 cases of pediatric HZ that were recorded between 2010 and 2013 during duty shifts at the dermatology service of Hospital Universitario Fundación Alcorcón. During this period the population living in the catchment area of the hospital corresponded to 247 000 inhabitants. The clinical and epidemiological characteristics of the patients are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>. A slight male predominance was observed, with a male to female ratio of 6:2. Ages ranged from 18 months to 5 years (mean, 3.5 years). All the patients had been vaccinated with a single dose between 15 and 17 months of age. The mean time from vaccination to HZ onset was 2.2 years, with the earliest case detected only 3 months after vaccination. Polymerase chain reaction (PCR) for VZV was performed in 2 cases, both of which were positive. The necessary technique for differentiation between the vaccine and wild strain was unavailable in our hospital. The most frequently affected dermatomes were those of the lower limbs. Treatment varied depending on the extent and duration of the lesions, and the discomfort reported by the patients. Treatment with oral acyclovir was required in 5 of the 8 cases; the remaining patients received topical treatments consisting of astringent soaks and antibiotic ointments. None of the patients had risk factors for immunosuppression or associated comorbidities. Just 3 patients had atopic dermatitis, but none of them had required oral corticosteroid therapy in the preceding year. Six of the 8 patients had undergone laboratory testing in the preceding month, with no abnormalities detected. A favorable clinical course was observed with the prescribed treatments. Subsequent follow-up revealed no complications such as scarring and postherpetic neuralgia or recurrences.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The VZV vaccine is a live attenuated vaccine derived from the Oka strain of VZV. Its use in children under 12 years was approved in 2003 (Varivax). Although the latest guidelines of the Spanish Association of Pediatrics recommend administering 2 doses (the first at 12-15 months and the second at 2-3 years), this dosing schedule is used by only 3 autonomous communities (Ceuta, Melilla, and Navarra). The general trend is to administer a single dose at 11 to 12 years. Between 2010 and 2013 children in Madrid received a single dose at 15 months, and vaccination was recommended for children aged 11 who were seronegative and had not been previously vaccinated. These recommendations were recently changed, and as of January 1, 2014, vaccination is only recommended for 12-year-olds who have not been previously vaccinated and have not contracted HZ.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A total absence of HZ in vaccinated children was expected with the introduction of the VZV vaccine, but several years later HZ cases continue to be recorded in both vaccinated and healthy children. PCR was performed in some of these cases, and was positive for the Oka strain.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1–4</span></a> This strain may be reactivated, causing disseminated zoster (which occurs if antibody titers are low, and is often mistaken for wild-type infection) or metameric zoster.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> The latter condition is probably underdiagnosed owing to the belief that the vaccine strain is incapable of reactivating, the rarity of HZ in children, and the fact that postvaccination HZ is relatively mild and thus may account for fewer consultations.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> Reactivation may be more frequent if titers of anti-VZV are low<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> and if a rash develops after vaccination, as it is postulated that skin lesions enable the passage of VZV to the nerves and the establishment of latent infection.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2,5</span></a> Postvaccination HZ is distinguished from HZ after primary infection mainly based on the associated lesions. Postvaccination HZ lesions are generally smaller, less painful, and contain fewer vesicles. Moreover, these lesions predominantly develop on lumbosacral rather than thoracic dermatomes, given the greater proximity of the former to the site of vaccine administration.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In conclusion, we have presented 8 cases of HZ; all patients were under 5 years of age, healthy, and had been vaccinated for VZV. Although cases of reactivation of the Oka strain of VZV have been reported, recent studies found no increase in the incidence of HZ in vaccinated children.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> However, no epidemiological studies have assessed the true incidence of HZ in children since the introduction of routine vaccination in Spain. Molecular characterization of the virus could provide more information on the incidence of HZ after VZV vaccination.</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: Caro-Gutiérrez D, López-Estebaranz J, Naz-Villalba E, Ayala-Bernaldo de Quiros L. Herpes zóster en niños vacunados contra el virus varicela zóster: experiencia en nuestro hospital. Actas Dermosifiliogr. 2015;106:329–331.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 884 "Ancho" => 1600 "Tamanyo" => 182550 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical characteristics of the herpes zoster lesions in 4 of the patients in our series.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: →→, months from vaccination to onset of herpes zoster infection; AD, atopic dermatitis; PCR, polymerase chain reaction.</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">Patient \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">AD/Asthma \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">Immunosuppression \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">Hemogram \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 at Vaccination, mo \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">→→ \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, mo \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">Site \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">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">Second Episode \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">Treatment \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Girl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">AD \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">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" 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">43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Thigh \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">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Topical \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Boy \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">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" 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">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Thigh \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \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">Oral acyclovir \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Boy \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">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" 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">56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Chest \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">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral acyclovir \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Boy \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">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" 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">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Face \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \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">Oral acyclovir \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Boy \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">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" 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">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ankle \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">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral acyclovir \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Girl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DA \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">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" 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">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Thigh \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">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Topical \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Boy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DA \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">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" 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">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Thigh \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">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Oral acyclovir \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Boy \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">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" 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">48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arm \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">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Topical \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab785733.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Clinical and Epidemiological Characteristics of Patients.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Herpes zoster after varicella immunization" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.G. Liang" 1 => "K.A. Heidelberg" 2 => "R.M. Jacobson" 3 => "M.T. McEvoy" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "1998" "volumen" => "38" "paginaInicial" => "761" "paginaFinal" => "763" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9591823" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0045" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Herpes zoster by reactivated vaccine varicella zoster virus in a healthy child" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B. Uebe" 1 => "A. Sauerbrei" 2 => "S. Burdach" 3 => "G. 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Klinman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/74715" "Revista" => array:6 [ "tituloSerie" => "Nat Med" "fecha" => "2000" "volumen" => "6" "paginaInicial" => "451" "paginaFinal" => "454" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10742154" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0055" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Herpes zoster after varicella-zoster vaccination" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Fahlbush" 1 => "U. Wesselmann" 2 => "P. 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Coplan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1542/peds.2012-3303" "Revista" => array:6 [ "tituloSerie" => "Pediatrics" "fecha" => "2013" "volumen" => "131" "paginaInicial" => "e1389" "paginaFinal" => "e1396" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23545380" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010600000004/v2_201505051007/S1578219015000621/v2_201505051007/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/15782190/0000010600000004/v2_201505051007/S1578219015000621/v2_201505051007/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219015000621?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 13 | 6 | 19 |
| 2024 October | 112 | 43 | 155 |
| 2024 September | 126 | 35 | 161 |
| 2024 August | 132 | 61 | 193 |
| 2024 July | 126 | 47 | 173 |
| 2024 June | 128 | 60 | 188 |
| 2024 May | 111 | 44 | 155 |
| 2024 April | 105 | 41 | 146 |
| 2024 March | 115 | 53 | 168 |
| 2024 February | 103 | 40 | 143 |
| 2024 January | 103 | 40 | 143 |
| 2023 December | 139 | 44 | 183 |
| 2023 November | 168 | 43 | 211 |
| 2023 October | 155 | 39 | 194 |
| 2023 September | 140 | 57 | 197 |
| 2023 August | 99 | 28 | 127 |
| 2023 July | 116 | 60 | 176 |
| 2023 June | 95 | 31 | 126 |
| 2023 May | 96 | 37 | 133 |
| 2023 April | 69 | 34 | 103 |
| 2023 March | 106 | 44 | 150 |
| 2023 February | 103 | 39 | 142 |
| 2023 January | 112 | 62 | 174 |
| 2022 December | 107 | 49 | 156 |
| 2022 November | 111 | 30 | 141 |
| 2022 October | 84 | 29 | 113 |
| 2022 September | 75 | 39 | 114 |
| 2022 August | 91 | 40 | 131 |
| 2022 July | 68 | 40 | 108 |
| 2022 June | 70 | 19 | 89 |
| 2022 May | 101 | 35 | 136 |
| 2022 April | 118 | 31 | 149 |
| 2022 March | 75 | 45 | 120 |
| 2022 February | 107 | 40 | 147 |
| 2022 January | 142 | 40 | 182 |
| 2021 December | 92 | 31 | 123 |
| 2021 November | 72 | 42 | 114 |
| 2021 October | 55 | 52 | 107 |
| 2021 September | 52 | 37 | 89 |
| 2021 August | 56 | 21 | 77 |
| 2021 July | 50 | 24 | 74 |
| 2021 June | 78 | 37 | 115 |
| 2021 May | 54 | 25 | 79 |
| 2021 April | 177 | 50 | 227 |
| 2021 March | 82 | 30 | 112 |
| 2021 February | 79 | 27 | 106 |
| 2021 January | 41 | 13 | 54 |
| 2020 December | 53 | 21 | 74 |
| 2020 November | 22 | 15 | 37 |
| 2020 October | 21 | 12 | 33 |
| 2020 September | 26 | 13 | 39 |
| 2020 August | 19 | 19 | 38 |
| 2020 July | 16 | 16 | 32 |
| 2020 June | 43 | 29 | 72 |
| 2020 May | 32 | 19 | 51 |
| 2020 April | 40 | 22 | 62 |
| 2020 March | 49 | 13 | 62 |
| 2020 February | 8 | 2 | 10 |
| 2020 January | 4 | 3 | 7 |
| 2019 December | 4 | 6 | 10 |
| 2019 November | 4 | 1 | 5 |
| 2019 September | 1 | 2 | 3 |
| 2019 August | 9 | 0 | 9 |
| 2019 July | 4 | 3 | 7 |
| 2019 June | 4 | 5 | 9 |
| 2019 May | 4 | 21 | 25 |
| 2019 April | 2 | 0 | 2 |
| 2019 March | 2 | 9 | 11 |
| 2019 January | 6 | 0 | 6 |
| 2018 December | 2 | 0 | 2 |
| 2018 November | 2 | 0 | 2 |
| 2018 October | 3 | 0 | 3 |
| 2018 September | 9 | 0 | 9 |
| 2018 February | 63 | 2 | 65 |
| 2018 January | 151 | 6 | 157 |
| 2017 December | 114 | 10 | 124 |
| 2017 November | 52 | 3 | 55 |
| 2017 October | 29 | 5 | 34 |
| 2017 September | 37 | 3 | 40 |
| 2017 August | 59 | 5 | 64 |
| 2017 July | 47 | 2 | 49 |
| 2017 June | 68 | 8 | 76 |
| 2017 May | 72 | 8 | 80 |
| 2017 April | 58 | 15 | 73 |
| 2017 March | 45 | 7 | 52 |
| 2017 February | 41 | 13 | 54 |
| 2017 January | 35 | 5 | 40 |
| 2016 December | 43 | 10 | 53 |
| 2016 November | 48 | 17 | 65 |
| 2016 October | 52 | 12 | 64 |
| 2016 September | 0 | 7 | 7 |
| 2016 August | 0 | 1 | 1 |
| 2016 July | 9 | 1 | 10 |
| 2016 June | 12 | 1 | 13 |
| 2016 May | 8 | 1 | 9 |
| 2016 April | 14 | 1 | 15 |
| 2016 March | 7 | 0 | 7 |
| 2016 February | 8 | 3 | 11 |
| 2016 January | 9 | 4 | 13 |
| 2015 December | 9 | 1 | 10 |
| 2015 November | 10 | 5 | 15 |
| 2015 September | 0 | 3 | 3 |
| 2015 August | 0 | 2 | 2 |
| 2015 July | 24 | 1 | 25 |
| 2015 June | 31 | 8 | 39 |
| 2015 May | 36 | 6 | 42 |
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