Case and Research Letters
Sarcoidosis and Tuberculosis: A Diagnostic Challenge
Sarcoidosis y tuberculosis: un desafío diagnóstico
a Servicio de Dermatología, Hospital Ernest Lluch, Zaragoza, Spain
b Servicio de Dermatología, Hospital de Barbastro, Huesca, Spain
c Interdisciplinary Research Institute (IRIBHM), Université Libre de Bruxelles (ULB). Bruselas, Bélgica
d Servicio de Dermatología, Hospital Clínico Lozano Blesa, Zaragoza, Spain
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Hematoxylin and eosin (H&E), original magnification<span class="elsevierStyleHsp" style=""></span>×2. B, Plexiform architectural pattern. The neoplastic cells form round and irregular nests in a predominantly myxoid stroma. No neural or vascular structures are visible within these nests. H&E, original magnification<span class="elsevierStyleHsp" style=""></span>×10.<span class="elsevierStyleHsp" style=""></span>C, The majority of the neoplastic cells have ovoid nuclei with inconspicuous nucleoli and eosinophilic cytoplasm with poorly defined borders. These cells are intimately associated with distinct spindle-shaped cells with delicate, elongated, hyperchromatic nuclei. D, Diffuse positivity for MiTF in the nuclei of the neoplastic cells. Original magnification<span class="elsevierStyleHsp" style=""></span>×10. E, Focal positivity for claudin-1 in the neoplastic cells. Original magnification<span class="elsevierStyleHsp" style=""></span>×10. 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Gracia-Cazaña, I. Pastushenko, M. Ara" "autores" => array:4 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "de la Fuente-Meira" "email" => array:1 [ 0 => "delafuente.sonia@gmail.com" ] "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" => "T." "apellidos" => "Gracia-Cazaña" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "I." "apellidos" => "Pastushenko" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Ara" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Ernest Lluch, Zaragoza, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital de Barbastro, Huesca, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Interdisciplinary Research Institute (IRIBHM), Université Libre de Bruxelles (ULB). Bruselas, Bélgica" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Clínico Lozano Blesa, Zaragoza, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Sarcoidosis y tuberculosis: un desafío diagnóstico" ] ] "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" => 655 "Ancho" => 800 "Tamanyo" => 106582 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythematous papules with an atrophic central zone, situated in the frontal region.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Sarcoidosis is a multiorgan disease of unknown etiology, characterized by the presence of noncaseating granulomas. Factors implicated in its etiology include certain microorganisms, such as <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span>, and a genetic predisposition.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Our patient was a 31-year-old man from Morocco who had been living in Spain for 11 years. He was seen in dermatology outpatients for evaluation of asymptomatic lesions that had been present on his forehead for 8 months and that he found unsightly. His medical history revealed that he had been on treatment with isoniazid, rifampicin, pyrazinamide, and ethambutol for 2 months for low-grade fever and dyspnea, diagnosed as pulmonary tuberculosis. He brought a discharge report from another hospital in the same Autonomous Community in Spain, with details of following additional tests: x-ray study showing a gangliopulmonary pattern, a positive QuantiFERON-TB test, and sputum culture positive for <span class="elsevierStyleItalic">M tuberculosis</span>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Physical examination revealed an erythematous annular maculopapular rash with central atrophy in the frontal region, in areas in which there were no previous scars (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Histology of a biopsy from 1 of the lesions in the frontal region revealed a granulomatous inflammatory infiltrate formed mainly of a number of Langhans-type giant cells and epithelioid cells (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Given the patient's history of tuberculosis, Ziehl-Neelsen stain and polymerase chain reaction (PCR) for mycobacteria were performed on the skin biopsy sample, with a negative result, compatible with cutaneous sarcoidosis. In view of the dermatologic findings and persistence of the patient's dyspnea, transbronchial biopsy was performed. This showed numerous granulomas with no necrosis, but with fibrosis and a discreet peripheral ring of lymphocytes; Ziehl-Neelsen stain was negative. Blood tests revealed an increase in angiotensin-converting enzyme (ACE) levels to 134<span class="elsevierStyleHsp" style=""></span>U/L (normal range, 8-55<span class="elsevierStyleHsp" style=""></span>U/L) and elevation of uric acid levels to 9.7<span class="elsevierStyleHsp" style=""></span>mg/dL (normal range, 3.5-7.0<span class="elsevierStyleHsp" style=""></span>mg/dL); the other laboratory parameters were normal.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Finally, based on both pathology results, a diagnosis of pulmonary and cutaneous sarcoidosis associated with pulmonary tuberculosis was made. Prednisone, 30<span class="elsevierStyleHsp" style=""></span>mg, was added to the antituberculous treatment and was subsequently tapered to reach a maintenance dose of 5<span class="elsevierStyleHsp" style=""></span>mg; there was a good clinical and radiologic response. The skin lesions resolved, leaving residual scars in the areas of previous central atrophy.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Sarcoidosis and tuberculosis are both granulomatous diseases that rarely occur concomitantly. In contrast to tuberculosis, sarcoidosis is noncaseating.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The most commonly affected organ in sarcoidosis is the lung, followed by skin involvement, which occurs in approximately 24% of cases. Many clinical variants have been described, including papular, plaque, psoriasiform, annular, atrophic, and mixed forms. Long-standing sarcoidosis and lupus pernio lesions typically heal leaving a scar.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> Histologically, the granulomas are formed mainly of epithelioid cells, sometimes with scattered lymphocytes peripherally; Langhans-type multinucleated giant cells may be present; they are more common in longer-standing lesions, though they have also been described in large numbers in early lesions.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The etiology of sarcoidosis remains unknown, though <span class="elsevierStyleItalic">M tuberculosis</span> has been implicated. Using PCR, Li et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a> identified DNA from <span class="elsevierStyleItalic">M tuberculosis</span> and from <span class="elsevierStyleItalic">Mycobacterium avium</span> in up to 50% of lung biopsies from patients diagnosed with sarcoidosis. Another study that looked at the etiology and pathogenesis of sarcoidosis was performed by Ding et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a> Thos authors identified genetic material related to mycobacterial heat shock proteins in 21% of skin biopsies from patients diagnosed with sarcoidosis and concluded that this infection could be a direct etiologic factor.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In clinical practice, there are few reports of patients who have presented the 2 diseases concomitantly or in whom the diagnosis of sarcoidosis was made after that of tuberculosis; these cases are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5–12</span></a> In our review, we have excluded patients who were on corticosteroid treatment for sarcoidosis and who subsequently developed tuberculosis, as the most common cause of the infection in such patients is immunosuppression.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">In patients in whom we suspect the concomitant presence of the 2 diseases, it is essential to determine whether the lesions corresponds to one or other granulomatous disease, as skin lesions mimicking sarcoidosis have been reported in patients with tuberculosis, such as the case published by Chokoeva et al.,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a> in which the diagnosis of sarcoid-like lesions was only achieved with the aid of the QuantiFERON-TB test and a positive Ziehl Neelsen stain.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Biomarkers that can differentiate between these 2 diseases have been sought. Serum markers related with sarcoidosis, including soluble interleukin-2 receptor (IL-2R), ACE, and Krebs von den Lungen-6 (KL-6), are not sufficiently sensitive or specific to separate these diagnoses. It has recently been observed that the combination of leptin and intercellular adhesion molecule-1 has a sensitivity of 86.5% and a specificity of 73.1% as a marker of sarcoidosis, and this combination could therefore be employed to differentiate the 2 conditions.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion, the diagnoses of sarcoidosis and tuberculosis are not mutually exclusive. It is likely that tuberculosis has been a triggering agent of sarcoidosis, although further studies will be necessary to determine its etiologic role. Finally, to prevent the complications of sarcoidosis, corticosteroid treatment should not be delayed.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: de la Fuente-Meira S, Gracia-Cazaña T, Pastushenko I, Ara M. Sarcoidosis y tuberculosis: un desafío diagnóstico. Actas Dermosifiliogr. 2016;107:605–607.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 655 "Ancho" => 800 "Tamanyo" => 106582 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythematous papules with an atrophic central zone, situated in the frontal region.</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" => 1268 "Ancho" => 950 "Tamanyo" => 211643 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Granulomatous inflammatory infiltrate formed of histiocytes and occasional Langhans-type giant cells. Hematoxylin and eosin, original magnification ×10.</p>" ] ] 2 => 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:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviation: NS, not specified.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age/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">Tuberculosis \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">Sarcoidosis \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">Diagnosis of Sarcoidosis \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wong et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35 y<br>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pulmonary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lymphatic and<br>pulmonary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diagnosis of sarcoidosis 15 months after the diagnosis of tuberculosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mise et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43 y<br>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pulmonary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cutaneous and pulmonary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Concomitant \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gupta et al.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65 y<br>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Renal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cutaneous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diagnosis of sarcoidosis 4 years after the diagnosis of tuberculosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ahmad et al.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55 y<br>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pulmonary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cutaneous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diagnosis of sarcoidosis 3 years after the diagnosis of tuberculosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ganguly et al.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28 y<br>Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pulmonary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cutaneous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diagnosis of sarcoidosis 9 months after the diagnosis of tuberculosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mandal et al.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38 y<br>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Miliary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pulmonary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Concomitant \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oluboyo et al.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NS<br>Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pulmonary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pulmonary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Concomitant \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Papaetis et al.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">67 y<br>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pulmonary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pulmonary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Concomitant diagnosis, although the authors state that undiagnosed sarcoidosis had been present for 8 years \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">De la Fuente et al. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31 y<br>Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pulmonary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cutaneous and pulmonary \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diagnosis of sarcoidosis 3 months after the diagnosis of tuberculosis \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1393441.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Summary of Published Cases of Sarcoidosis Associated With Tuberculosis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0075" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sarcoidosis cutánea" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Y. 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| 2024 May | 222 | 39 | 261 |
| 2024 April | 171 | 32 | 203 |
| 2024 March | 164 | 47 | 211 |
| 2024 February | 203 | 39 | 242 |
| 2024 January | 175 | 35 | 210 |
| 2023 December | 255 | 16 | 271 |
| 2023 November | 218 | 38 | 256 |
| 2023 October | 191 | 32 | 223 |
| 2023 September | 160 | 30 | 190 |
| 2023 August | 133 | 24 | 157 |
| 2023 July | 127 | 38 | 165 |
| 2023 June | 106 | 29 | 135 |
| 2023 May | 134 | 35 | 169 |
| 2023 April | 137 | 18 | 155 |
| 2023 March | 85 | 17 | 102 |
| 2023 February | 106 | 28 | 134 |
| 2023 January | 69 | 24 | 93 |
| 2022 December | 61 | 39 | 100 |
| 2022 November | 46 | 28 | 74 |
| 2022 October | 43 | 22 | 65 |
| 2022 September | 38 | 47 | 85 |
| 2022 August | 32 | 40 | 72 |
| 2022 July | 25 | 41 | 66 |
| 2022 June | 28 | 26 | 54 |
| 2022 May | 76 | 57 | 133 |
| 2022 April | 95 | 16 | 111 |
| 2022 March | 140 | 54 | 194 |
| 2022 February | 104 | 35 | 139 |
| 2022 January | 105 | 52 | 157 |
| 2021 December | 82 | 41 | 123 |
| 2021 November | 74 | 46 | 120 |
| 2021 October | 74 | 54 | 128 |
| 2021 September | 81 | 50 | 131 |
| 2021 August | 71 | 33 | 104 |
| 2021 July | 63 | 32 | 95 |
| 2021 June | 62 | 29 | 91 |
| 2021 May | 58 | 44 | 102 |
| 2021 April | 81 | 62 | 143 |
| 2021 March | 65 | 24 | 89 |
| 2021 February | 38 | 25 | 63 |
| 2021 January | 20 | 17 | 37 |
| 2020 December | 27 | 10 | 37 |
| 2020 November | 28 | 22 | 50 |
| 2020 October | 22 | 8 | 30 |
| 2020 September | 25 | 15 | 40 |
| 2020 August | 28 | 17 | 45 |
| 2020 July | 17 | 20 | 37 |
| 2020 June | 25 | 31 | 56 |
| 2020 May | 19 | 13 | 32 |
| 2020 April | 21 | 20 | 41 |
| 2020 March | 17 | 14 | 31 |
| 2020 February | 2 | 0 | 2 |
| 2019 December | 2 | 0 | 2 |
| 2019 September | 4 | 0 | 4 |
| 2019 June | 2 | 0 | 2 |
| 2019 May | 2 | 0 | 2 |
| 2019 April | 0 | 3 | 3 |
| 2019 March | 2 | 0 | 2 |
| 2019 February | 1 | 0 | 1 |
| 2019 January | 4 | 0 | 4 |
| 2018 October | 5 | 0 | 5 |
| 2018 September | 1 | 0 | 1 |
| 2018 February | 16 | 1 | 17 |
| 2018 January | 28 | 10 | 38 |
| 2017 December | 32 | 21 | 53 |
| 2017 November | 26 | 4 | 30 |
| 2017 October | 30 | 8 | 38 |
| 2017 September | 22 | 4 | 26 |
| 2017 August | 20 | 9 | 29 |
| 2017 July | 18 | 11 | 29 |
| 2017 June | 29 | 4 | 33 |
| 2017 May | 27 | 12 | 39 |
| 2017 April | 14 | 10 | 24 |
| 2017 March | 14 | 8 | 22 |
| 2017 February | 13 | 5 | 18 |
| 2017 January | 16 | 5 | 21 |
| 2016 December | 23 | 24 | 47 |
| 2016 November | 22 | 17 | 39 |
| 2016 October | 25 | 23 | 48 |
| 2016 July | 0 | 4 | 4 |
Show all
