Case and Research Letters
Acute Generalized Exanthematous Pustulosis Due to Milk Thistle (Silybum marianum) Tea
Pustulosis exantemática generalizada aguda debida a una infusión de cardo mariano (Silybum marianum)
A. Ramírez-Santos
, A. Pérez-Bustillo, B. González-Sixto, O. Suárez-Amor, M.A. Rodríguez-Prieto
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Servicio de Dermatología, Hospital de León, León, Spain
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Ramírez-Santos, A. Pérez-Bustillo, B. González-Sixto, O. Suárez-Amor, M.A. Rodríguez-Prieto" "autores" => array:5 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Ramírez-Santos" "email" => array:1 [ 0 => "quili79@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Pérez-Bustillo" ] 2 => array:2 [ "nombre" => "B." "apellidos" => "González-Sixto" ] 3 => array:2 [ "nombre" => "O." "apellidos" => "Suárez-Amor" ] 4 => array:2 [ "nombre" => "M.A." "apellidos" => "Rodríguez-Prieto" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Dermatología, Hospital de León, León, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pustulosis exantemática generalizada aguda debida a una infusión de cardo mariano <span class="elsevierStyleItalic">(Silybum marianum)</span>" ] ] "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" => 714 "Ancho" => 952 "Tamanyo" => 112678 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multiple nonfollicular pustules on an erythematous, edematous base.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Acute generalized exanthematous pustulosis (AGEP) is a rare disease that has been linked to certain drugs, such as antibiotics, antifungal agents, anticonvulsants, and antihypertensive agents.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> Other possible triggers that have been described include infection, pregnancy, allergens, spider bites, iodinated contrast media, herbal medicinal products, and tumors.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In some cases, however, the causative agent cannot be identified.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Several hypotheses that have been proposed to explain the pathogenesis of this skin reaction involve T lymphocytes and cytokines and posit that they are responsible for the characteristic neutrophilia and the aggregates of neutrophils in the histological picture of AGEP. It is recognized that previous sensitization, including contact sensitization, could explain some of these drug eruptions, and patch testing is positive in up to 80% of drug-related cases.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A 45-year-old man with hyperuricemia on treatment with allopurinol for the previous 3 years consulted for an acute disorder that had started on the trunk 48<span class="elsevierStyleHsp" style=""></span>hours earlier and had spread to the face and limbs; he also reported fever and general malaise. Physical examination revealed erythema and edema of the skin of the face, trunk, and limbs—including the skinfolds and the palms—associated with multiple nonfollicular pustules (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). There were also lesions on the oral mucosa and erosions on the lips. He did not report a history of infection and there had been no changes in the dose of his usual medication or new treatments added in the previous 3 months. However, he did remember taking milk-thistle infusions for a week before the onset of symptoms. The preparation, bought in a herbalist shop, contained dried seeds and was used by the patient to prevent dyspepsia. Histopathology of a lesion showed intraepidermal pustules, with edema of the papillary dermis and a predominantly neutrophilic perivascular inflammatory infiltrate. No acanthosis or papillomatosis was observed. The results of additional tests were as follows: white cell count, 16 500/μL (normal range, 4000-11 000/μL) (neutrophils, 10 000/μL [normal range, 2000-7500/μL]; eosinophils, 600/μL [normal range, 40-400/μL]); creatinine, 2.2<span class="elsevierStyleHsp" style=""></span>mg/dL (normal value, <1.1<span class="elsevierStyleHsp" style=""></span>mg/dl), and C-reactive protein, 256<span class="elsevierStyleHsp" style=""></span>mg/L (normal value, <12<span class="elsevierStyleHsp" style=""></span>mg/L). Culture of the pustules and blood cultures were negative. Serology for hepatitis B and C viruses, Epstein-Barr virus, and cytomegalovirus was negative. The patient did not recall having taken milk-thistle infusions previously, had no known drug allergies, and did not report any personal or family history of psoriasis. The findings of the medical history and of the additional tests were consistent with the clinical suspicion of acute generalized exanthematous pustulosis. Furthermore, the criteria proposed by Roujeau<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> were satisfied and, based on the validation scale proposed by the study group of the European study of severe cutaneous adverse reactions (EuroSCAR),<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> a definitive diagnosis of AGEP could be made. Treatment was started with oral prednisone at a dose of 0.5<span class="elsevierStyleHsp" style=""></span>mg/kg in a tapering regimen, in addition to emollients and fluid support. The clinical course was favorable, with resolution of the lesions and normalization of the complete blood count and renal function within 15 days. Patch testing was performed with the standard European series (Marti i Tor, Spain) 8 weeks after resolution of the condition. In addition, the hospital pharmacy prepared a 10% aqueous solution of the product supplied by the patient, which contained dried milk-thistle seeds. The results at 48 and 96<span class="elsevierStyleHsp" style=""></span>hours were positive (++), with an eczematous reaction at the site of application of the milk-thistle preparation. Other allergens in the patch tests were negative at the same time intervals. The results obtained with the same milk-thistle preparation in 10 control cases were negative. The patient has presented no further episodes after a year of follow-up.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Milk thistle <span class="elsevierStyleItalic">(Silybum marianum)</span> is a natural product that has been known for a long time and has been used for the treatment and prevention of diseases of the liver and gallbladder, as well as in some types of cancer.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In traditional medicine, it has been used to treat hormonal alterations in women, digestive tract problems, acne, and psoriasis. It has also been claimed that milk thistle detoxifies environmental toxins, alcohol, and copious meals. The active substance is a flavonoid complex called silymarin, which has anti-inflammatory properties, regulating certain mediators such as tumor necrosis factor and interleukins 1 and 6. In some European countries, products are available that contain known and established doses of the active substance (between 70% and 80% silymarin). However, the doses and additives are frequently unclear in many preparations obtained in health-food and herbalist shops, where milk thistle is sold in the form of capsules and tablets or as leaves and seeds that are used to prepare infusions. The active substance, silymarin, reduces the activity of the cytochrome P450 complex and may affect the clearance of some drugs, although no interactions have been reported to date. Silymarin is generally considered to be safe and well tolerated, and serious adverse effects are rare. Gastrointestinal discomfort and diarrhea have been reported,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> as well as skin manifestations, such as itching, rash, eczema, and anaphylaxis.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> After a review of the currently available literature, we believe this to be the first reported case of acute generalized exanthematous pustulosis due to milk thistle. However, we cannot be certain that the causative agent was the milk thistle because it could also have been one of the additives, which were not listed on the packet. Nor was it possible to exclude an interaction with allopurinol.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Although there is widespread use of herbal medicines in present-day society, the reporting of cutaneous adverse effects is not common, although cases of allergic contact dermatitis, Stevens-Johnson syndrome, photodermatoses, pellagra, and angioedema have been described. We have found 3 articles that describe the association of AGEP with herbal medicines.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–9</span></a> The first report makes no reference to any specific plant, as the composition of the product was unknown (products bought in health-food and herbalist shops and at street stalls sometimes lack labels or the labels do not list all of the components and concentrations).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The second was a case of AGEP in a patient who took a medicinal product that contained only <span class="elsevierStyleItalic">Ginkgo biloba,</span><a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and the third article described a case related to the ingestion of chicken cooked with <span class="elsevierStyleItalic">Rhus.</span><a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> As patch testing was not possible in any of the above cases, diagnosis was based on the temporal relationship and the fact that the problem resolved and did not recur after withdrawal of the causative agent.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We believe it is important to report this case because it illustrates the relevance of herbal medicines, often considered innocuous, in the appearance of skin lesions. As dermatologists, we should consider this possibility and take an appropriate medical history as, like health professionals, the patients do not usually take these products into account and fail to report their use.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Ramírez-Santos A, et al. Pustulosis exantemática generalizada aguda debida a una infusión de cardo mariano (<span class="elsevierStyleItalic">Silybum marianum)</span>. Actas Dermosifiliogr.2011;102:744-745.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 714 "Ancho" => 952 "Tamanyo" => 112678 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multiple nonfollicular pustules on an erythematous, edematous base.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute generalized exanthematous pustulosis: analisis of 63 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.C. Roujeau" 1 => "P. Bioulac-Sage" 2 => "C. Bouseau" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Dermatol" "fecha" => "1991" "volumen" => "127" "paginaInicial" => "1333" "paginaFinal" => "1338" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1832534" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk Factors for acute generalized exanthematous pustulosis (AGEP): results of a multinational case-control study (EuroSCAR)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Sidoroff" 1 => "A. Dunant" 2 => "C. Viboud" 3 => "S. Halevy" 4 => "J.S. Bavinck" 5 => "L. Naldi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2133.2007.08156.x" "Revista" => array:6 [ "tituloSerie" => "Br J Dermatol" "fecha" => "2007" "volumen" => "157" "paginaInicial" => "989" "paginaFinal" => "996" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17854366" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diltiazem-induced acute generalized exanthemic pustulosis: a case and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Fernández-Ruiz" 1 => "F. López-Medrano" 2 => "F. García-Ruiz" 3 => "J.L. Rodríguez-Peralto" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Actas Dermosifiliogr" "fecha" => "2009" "volumen" => "100" "paginaInicial" => "725" "paginaFinal" => "727" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19775556" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Path testing in severe Cutaneous adverse drug reactions, including Stevens-Johnson syndrome and toxic epidermal necrolisis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Wolkenstein" 1 => "O. Chosidow" 2 => "M.L. Flechet" 3 => "O. Robbiola" 4 => "M. Paul" 5 => "L. Dume" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Contact Dermatitis" "fecha" => "1996" "volumen" => "35" "paginaInicial" => "234" "paginaFinal" => "236" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8957644" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Milk thistle" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "F. Rainone" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am Fam Physician" "fecha" => "2005" "volumen" => "72" "paginaInicial" => "1285" "paginaFinal" => "1288" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16225032" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Milk thistle (<span class="elsevierStyleItalic">Silybum marianum</span>) an ancient botanical medicine for modern times" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "S.M. Ross" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.HNP.0000334924.77174.6d" "Revista" => array:6 [ "tituloSerie" => "Holist Nurs Pract" "fecha" => "2008" "volumen" => "22" "paginaInicial" => "299" "paginaFinal" => "300" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18758279" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute generalized exanthematous pustulosis triggered by intake of herbal medications" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Manzur" 1 => "K.A. Kivani" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-4632.2006.02968.x" "Revista" => array:6 [ "tituloSerie" => "Int J Dermatol" "fecha" => "2006" "volumen" => "45" "paginaInicial" => "1247" "paginaFinal" => "1248" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17040456" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute generalised exanthematous pustulosis induced by the herbal remedy Ginkgo biloba" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R.S. Pennisi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Med J Aust" "fecha" => "2006" "volumen" => "184" "paginaInicial" => "583" "paginaFinal" => "584" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16768668" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute generalized exanthematous pustulosis induced by Rhus (lacquer)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.A. Min" 1 => "H.J. Park" 2 => "B.K. Cho" 3 => "J.Y. Lee" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2009.03.023" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2010" "volumen" => "63" "paginaInicial" => "166" "paginaFinal" => "167" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20542183" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010200000009/v1_201304241238/S1578219011001016/v1_201304241238/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/15782190/0000010200000009/v1_201304241238/S1578219011001016/v1_201304241238/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219011001016?idApp=UINPBA000044" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 11 | 9 | 20 |
| 2024 Octubre | 85 | 72 | 157 |
| 2024 Septiembre | 104 | 47 | 151 |
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| 2023 Noviembre | 86 | 32 | 118 |
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| 2023 Septiembre | 85 | 44 | 129 |
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| 2023 Febrero | 68 | 27 | 95 |
| 2023 Enero | 45 | 43 | 88 |
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| 2022 Abril | 56 | 44 | 100 |
| 2022 Marzo | 67 | 50 | 117 |
| 2022 Febrero | 58 | 36 | 94 |
| 2022 Enero | 53 | 41 | 94 |
| 2021 Diciembre | 50 | 42 | 92 |
| 2021 Noviembre | 58 | 49 | 107 |
| 2021 Octubre | 66 | 41 | 107 |
| 2021 Septiembre | 53 | 39 | 92 |
| 2021 Agosto | 45 | 32 | 77 |
| 2021 Julio | 34 | 27 | 61 |
| 2021 Junio | 39 | 38 | 77 |
| 2021 Mayo | 43 | 42 | 85 |
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| 2021 Marzo | 59 | 34 | 93 |
| 2021 Febrero | 35 | 20 | 55 |
| 2021 Enero | 29 | 15 | 44 |
| 2020 Diciembre | 28 | 10 | 38 |
| 2020 Noviembre | 19 | 21 | 40 |
| 2020 Octubre | 22 | 15 | 37 |
| 2020 Septiembre | 46 | 11 | 57 |
| 2020 Agosto | 25 | 11 | 36 |
| 2020 Julio | 28 | 12 | 40 |
| 2020 Junio | 40 | 22 | 62 |
| 2020 Mayo | 29 | 12 | 41 |
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| 2020 Marzo | 37 | 24 | 61 |
| 2020 Febrero | 11 | 3 | 14 |
| 2020 Enero | 0 | 2 | 2 |
| 2019 Diciembre | 4 | 0 | 4 |
| 2019 Septiembre | 6 | 0 | 6 |
| 2019 Junio | 0 | 9 | 9 |
| 2019 Mayo | 2 | 21 | 23 |
| 2019 Abril | 0 | 3 | 3 |
| 2019 Marzo | 0 | 12 | 12 |
| 2019 Febrero | 2 | 0 | 2 |
| 2019 Enero | 1 | 0 | 1 |
| 2018 Diciembre | 0 | 1 | 1 |
| 2018 Noviembre | 4 | 0 | 4 |
| 2018 Septiembre | 2 | 4 | 6 |
| 2018 Agosto | 0 | 3 | 3 |
| 2018 Mayo | 0 | 7 | 7 |
| 2018 Marzo | 1 | 0 | 1 |
| 2018 Febrero | 32 | 6 | 38 |
| 2018 Enero | 40 | 9 | 49 |
| 2017 Diciembre | 46 | 13 | 59 |
| 2017 Noviembre | 37 | 10 | 47 |
| 2017 Octubre | 39 | 7 | 46 |
| 2017 Septiembre | 37 | 8 | 45 |
| 2017 Agosto | 35 | 20 | 55 |
| 2017 Julio | 36 | 11 | 47 |
| 2017 Junio | 39 | 14 | 53 |
| 2017 Mayo | 54 | 10 | 64 |
| 2017 Abril | 29 | 16 | 45 |
| 2017 Marzo | 34 | 54 | 88 |
| 2017 Febrero | 28 | 14 | 42 |
| 2017 Enero | 39 | 14 | 53 |
| 2016 Diciembre | 46 | 16 | 62 |
| 2016 Noviembre | 39 | 19 | 58 |
| 2016 Octubre | 47 | 23 | 70 |
| 2016 Septiembre | 37 | 17 | 54 |
| 2016 Agosto | 55 | 17 | 72 |
| 2016 Julio | 24 | 10 | 34 |
| 2016 Junio | 12 | 7 | 19 |
| 2016 Mayo | 7 | 10 | 17 |
| 2016 Abril | 2 | 23 | 25 |
| 2016 Marzo | 10 | 15 | 25 |
| 2016 Febrero | 8 | 15 | 23 |
| 2016 Enero | 10 | 18 | 28 |
| 2015 Diciembre | 16 | 12 | 28 |
| 2015 Noviembre | 10 | 17 | 27 |
| 2015 Octubre | 18 | 1 | 19 |
| 2015 Septiembre | 13 | 11 | 24 |
| 2015 Agosto | 15 | 1 | 16 |
| 2015 Julio | 65 | 10 | 75 |
| 2015 Junio | 47 | 3 | 50 |
| 2015 Mayo | 76 | 12 | 88 |
| 2015 Abril | 62 | 13 | 75 |
| 2015 Marzo | 55 | 7 | 62 |
| 2015 Febrero | 81 | 9 | 90 |
| 2015 Enero | 51 | 12 | 63 |
| 2014 Diciembre | 143 | 9 | 152 |
| 2014 Noviembre | 53 | 11 | 64 |
| 2014 Octubre | 57 | 17 | 74 |
| 2014 Septiembre | 44 | 10 | 54 |
| 2014 Agosto | 42 | 16 | 58 |
| 2014 Julio | 56 | 18 | 74 |
| 2014 Junio | 77 | 15 | 92 |
| 2014 Mayo | 81 | 15 | 96 |
| 2014 Abril | 71 | 14 | 85 |
| 2014 Marzo | 70 | 19 | 89 |
| 2014 Febrero | 51 | 17 | 68 |
| 2014 Enero | 55 | 18 | 73 |
| 2013 Diciembre | 66 | 16 | 82 |
| 2013 Noviembre | 49 | 15 | 64 |
| 2013 Octubre | 18 | 7 | 25 |
| 2013 Septiembre | 18 | 13 | 31 |
| 2013 Agosto | 24 | 17 | 41 |
| 2013 Julio | 9 | 33 | 42 |
| 2013 Junio | 13 | 32 | 45 |
| 2013 Mayo | 12 | 21 | 33 |
| 2013 Abril | 20 | 26 | 46 |
| 2013 Marzo | 20 | 21 | 41 |
| 2013 Febrero | 28 | 6 | 34 |
| 2013 Enero | 22 | 8 | 30 |
| 2012 Diciembre | 15 | 4 | 19 |
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