Case and Research Letter
Non-AIDS Kaposi sarcoma in the external ear
Sarcoma de Kaposi del oído externo, no asociado con SIDA
a Dermatology Department, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (Isabial), Alicante, Spain
b Immunology Department, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (Isabial), Alicante, Spain
c Medicina Clinica Department, Dermatology Area, Miguel Hernández University, Sant Joan D’Alacant, Alicante, Spain
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Francés Rodríguez, A. Bouret Lebrón, C. Muñoz Ruíz, J. Bañuls Roca" "autores" => array:4 [ 0 => array:4 [ "nombre" => "L." "apellidos" => "Francés Rodríguez" "email" => array:1 [ 0 => "frances.rodriguez.laura@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" => "A." "apellidos" => "Bouret Lebrón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Muñoz Ruíz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Bañuls Roca" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Dermatology Department, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (Isabial), Alicante, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Immunology Department, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (Isabial), Alicante, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Medicina Clinica Department, Dermatology Area, Miguel Hernández University, Sant Joan D’Alacant, Alicante, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Sarcoma de Kaposi del oído externo, no asociado con SIDA" ] ] "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" => 1148 "Ancho" => 1500 "Tamanyo" => 215760 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Polypoid lesion of the right ear.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Kaposi sarcoma (KS) is an uncommon, malignant, multifocal systemic disease derived from the proliferation of endothelial cells. The disease has predominant cutaneous involvement and follows a benign course, but in severe cases it can affect other organs, especially the gastrointestinal tract and the lungs. In 1994, Chang et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> demonstrated that human herpesvirus type 8 (HHV-8) infection is involved in the etiology of KS. Its presence has been detected in over 90% of biological tissues affected, and it is now considered a valuable diagnostic marker of the disease. Classic KS (described in 1872 by Moritz Kaposi) is the most common form of KS, and it usually affects elderly males of Eastern European or Mediterranean origin. Clinically, it manifests as red-bluish papules, plaques, and nodules on the lower extremities that exhibit a slow but steady growth. There are 4 types of KS: classic KS, endemic (African) KS, immunocompromised (iatrogenic) KS (related to aggressive immunosuppressive treatment), and AIDS-related (epidemic) KS. A new variant related to homosexuality was recently described in men who have sex with men: non-human immunodeficiency virus (HIV)-associated KS.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe a rare presentation of KS of the external ear in an immunocompetent patient. A 77-year-old woman came to our dermatology department with a firm, slow-growing, red-bluish nodule measuring 1.4<span class="elsevierStyleHsp" style=""></span>cm in diameter on the anterior helix of the right pinna (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). She was otherwise well and had no relevant past history of skin disorders, other medical conditions, or associated immunosuppression. The tumor was painless, and there was no bleeding or lymphadenopathy. It had a vascular appearance, and the tentative diagnosis was pyogenic granuloma, although other diagnoses considered were amelanotic melanoma, epidermoid carcinoma, Merkel cell carcinoma, and atypical fibroxanthoma. The lesion was excised completely, and histologic examination revealed a proliferation of fine, irregular vascular channels, with erythrocyte extravasation and minimal pleomorphism and mitotic activity (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Positive staining of spindle cells with CD31, CD34, and HHV-8 was consistent with a diagnosis of KS (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Laboratory tests only revealed hyperglycemia. Serology and polymerase chain reaction results were both positive for HHV-8. Serology for HIV, cytomegalovirus, herpes zoster virus, Epstein–Barr virus, HHV-6, and HHV-7 was negative. To rule out gastrointestinal disease, we performed a fecal occult blood test and an endoscopy, but observed no pathological findings. A whole-body computed tomography scan showed no other visceral disease. Screening laboratory tests to evaluate cellular immunity (total lymphocyte count, T-cell, B-cell, and natural killer-cell enumeration using flow cytometry) and functional assessment of helper T (T<span class="elsevierStyleInf">H</span>) cells based on T<span class="elsevierStyleInf">H</span>1 and T<span class="elsevierStyleInf">H</span>2 cytokine production were normal, but early response to stimulation measured by detection of intracellular adenosine triphosphate (ATP) synthesis in T cells (Immuknow, Viracor IBT Laboratories Inc.) was low. This suggested defective T-cell activation because the production of intracellular ATP is one of the first steps in cellular activation. During 2 years of follow-up, no recurrences, new lesions, or new immunosuppressive diseases have been detected.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The head is a common site for multiple lesions in HIV patients with KS. However, the presence of a solitary lesion on the ear of an immunocompetent patient is a very rare finding, and very few cases of KS have been reported on the pinna in patients without a history of immunodeficiency (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Like our patient, most of the patients described in the literature are elderly, with the exception of a healthy 36-year-old white man. We do not know why certain vascular proliferations, such as angiolymphoid hyperplasia with eosinophilia, have a special predilection for the pinna, but we hypothesize that the sum of certain traumatic/infectious factors in an acral area with complex, fine, and insufficient vascularization could make access difficult for immune cells. All these conditions could favor the occurrence of these vascular tumors in certain individuals with immune dysfunction that has not been adequately studied. We highlight the importance of contemplating KS in the differential diagnosis of tumors with a vascular appearance involving the ears in immunologically competent individuals.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "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" => 1148 "Ancho" => 1500 "Tamanyo" => 215760 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Polypoid lesion of the right ear.</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" => 1241 "Ancho" => 1659 "Tamanyo" => 827822 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Proliferation of fine, irregular vascular channels, with erythrocyte extravasation (hematoxylin–eosin staining, original magnification ×20).</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" => 1234 "Ancho" => 1650 "Tamanyo" => 741404 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Nuclear positivity for human herpes virus 8 (hematoxylin–eosin staining, original magnification ×20).</p>" ] ] 3 => 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="spar0025" class="elsevierStyleSimplePara elsevierViewall">EBV, Epstein–Barr virus; HHV, human herpes virus; HIV, human immunodeficiency virus; ND, not determinated.</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">Author(s) \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">Year \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, y \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">Geographic/ethnic origin \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">No. of lesions/location \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">HIV \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">HHV-8 \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">Naunton and Stoller<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1960 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">North American \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1/Right helix<br>1/Lip \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \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">Gibbs<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1968 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">North-American \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multiple nodules on each ear<br>1/Left foot \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \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">Stearns et al.<a class="elsevierStyleCrossRef" href="#bib0070"><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="char" valign="top">1983 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Indian \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1/Left external auditory meatus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \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">Babuccu et al.<a class="elsevierStyleCrossRef" href="#bib0075"><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="char" valign="top">2003 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">White \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1/Left pinna \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HIV<span class="elsevierStyleSup">−</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HHV-8<span class="elsevierStyleSup">+</span> \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">Colletti et al.<a class="elsevierStyleCrossRef" href="#bib0080"><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="char" valign="top">2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">White \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1/Right pinna \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HIV<span class="elsevierStyleSup">−</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HHV-8<span class="elsevierStyleSup">+</span> \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">Izquierdo Cuenca et al.<a class="elsevierStyleCrossRef" href="#bib0085"><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="char" valign="top">2012 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">White \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2/Right pinna \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HIV<span class="elsevierStyleSup">−</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HHV-8<span class="elsevierStyleSup">+</span> \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">Busi et al.<a class="elsevierStyleCrossRef" href="#bib0090"><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="char" valign="top">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">White \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1/Right right pinna and external auditory canal<br>Multiple lesions on right arm and left leg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HIV<span class="elsevierStyleSup">−</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HHV-8<span class="elsevierStyleSup">+</span> (also HHV-4<span class="elsevierStyleSup">+</span> and EBV<span class="elsevierStyleSup">+</span>) \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">Our case \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2013 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">White \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1/Right pinna \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HIV<span class="elsevierStyleSup">−</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">HHV-8<span class="elsevierStyleSup">+</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1260385.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Cases of Kaposi sarcoma involving the external ear of patients without AIDS.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Twenty years of KSHV" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Y. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 12 | 24 |
| 2024 October | 83 | 34 | 117 |
| 2024 September | 99 | 23 | 122 |
| 2024 August | 109 | 42 | 151 |
| 2024 July | 95 | 27 | 122 |
| 2024 June | 117 | 31 | 148 |
| 2024 May | 120 | 31 | 151 |
| 2024 April | 99 | 26 | 125 |
| 2024 March | 123 | 22 | 145 |
| 2024 February | 97 | 30 | 127 |
| 2024 January | 78 | 28 | 106 |
| 2023 December | 95 | 14 | 109 |
| 2023 November | 105 | 17 | 122 |
| 2023 October | 104 | 17 | 121 |
| 2023 September | 71 | 29 | 100 |
| 2023 August | 63 | 9 | 72 |
| 2023 July | 93 | 22 | 115 |
| 2023 June | 60 | 18 | 78 |
| 2023 May | 66 | 25 | 91 |
| 2023 April | 79 | 18 | 97 |
| 2023 March | 63 | 21 | 84 |
| 2023 February | 52 | 25 | 77 |
| 2023 January | 36 | 26 | 62 |
| 2022 December | 57 | 35 | 92 |
| 2022 November | 31 | 24 | 55 |
| 2022 October | 34 | 19 | 53 |
| 2022 September | 27 | 36 | 63 |
| 2022 August | 24 | 26 | 50 |
| 2022 July | 18 | 29 | 47 |
| 2022 June | 30 | 19 | 49 |
| 2022 May | 65 | 24 | 89 |
| 2022 April | 77 | 22 | 99 |
| 2022 March | 60 | 38 | 98 |
| 2022 February | 78 | 21 | 99 |
| 2022 January | 90 | 31 | 121 |
| 2021 December | 44 | 32 | 76 |
| 2021 November | 58 | 39 | 97 |
| 2021 October | 63 | 56 | 119 |
| 2021 September | 67 | 37 | 104 |
| 2021 August | 115 | 25 | 140 |
| 2021 July | 85 | 23 | 108 |
| 2021 June | 123 | 26 | 149 |
| 2021 May | 93 | 33 | 126 |
| 2021 April | 317 | 46 | 363 |
| 2021 March | 102 | 23 | 125 |
| 2021 February | 100 | 19 | 119 |
| 2021 January | 78 | 15 | 93 |
| 2020 December | 49 | 14 | 63 |
| 2020 November | 46 | 18 | 64 |
| 2020 October | 43 | 8 | 51 |
| 2020 September | 30 | 12 | 42 |
| 2020 August | 19 | 11 | 30 |
| 2020 July | 20 | 13 | 33 |
| 2020 June | 24 | 25 | 49 |
| 2020 May | 17 | 9 | 26 |
| 2020 April | 20 | 15 | 35 |
| 2020 March | 21 | 11 | 32 |
| 2020 February | 6 | 3 | 9 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 4 | 0 | 4 |
| 2019 November | 4 | 0 | 4 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 3 | 0 | 3 |
| 2019 May | 5 | 0 | 5 |
| 2019 April | 2 | 3 | 5 |
| 2019 March | 2 | 0 | 2 |
| 2019 February | 6 | 0 | 6 |
| 2019 January | 3 | 0 | 3 |
| 2018 December | 3 | 0 | 3 |
| 2018 November | 3 | 0 | 3 |
| 2018 October | 3 | 0 | 3 |
| 2018 September | 2 | 0 | 2 |
| 2018 February | 16 | 4 | 20 |
| 2018 January | 37 | 10 | 47 |
| 2017 December | 34 | 6 | 40 |
| 2017 November | 30 | 8 | 38 |
| 2017 October | 23 | 6 | 29 |
| 2017 September | 17 | 7 | 24 |
| 2017 August | 21 | 7 | 28 |
| 2017 July | 13 | 5 | 18 |
| 2017 June | 22 | 11 | 33 |
| 2017 May | 25 | 7 | 32 |
| 2017 April | 25 | 13 | 38 |
| 2017 March | 14 | 13 | 27 |
| 2017 February | 18 | 8 | 26 |
| 2017 January | 7 | 11 | 18 |
| 2016 December | 49 | 26 | 75 |
| 2016 November | 13 | 8 | 21 |
Show all
