Cases and Research Letters
Chronic Multifocal Paracoccidioidomycosis in an Immunocompetent Adult
Paracoccidioidomicosis crónica multifocal de tipo adulto en paciente inmunocompetente
B. Di MartinoOrtiz
, M.L. Rodríguez-Oviedo, M. Rodríguez-Masi
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Cátedra de Dermatología, Hospital de Clínicas, Facultad de Ciencias Médicas, Universidad Nacional de Asunción, Paraguay
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Di MartinoOrtiz, M.L. Rodríguez-Oviedo, M. Rodríguez-Masi" "autores" => array:3 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "Di MartinoOrtiz" "email" => array:1 [ 0 => "beatrizdimartino@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M.L." "apellidos" => "Rodríguez-Oviedo" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Rodríguez-Masi" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Cátedra de Dermatología, Hospital de Clínicas, Facultad de Ciencias Médicas, Universidad Nacional de Asunción, Paraguay" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Paracoccidioidomicosis crónica multifocal de tipo adulto en paciente inmunocompetente" ] ] "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" => 1116 "Ancho" => 900 "Tamanyo" => 107278 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical picture. Multiple spotty erythematous plaques on the lower lip, mulberry-like in appearance.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Paracoccidioidomycosis (PCM) is a deep systemic mycosis caused by <span class="elsevierStyleItalic">Paracoccidioides brasiliensis</span>, a thermally dimorphic fungus that grows as a yeast at 37<span class="elsevierStyleHsp" style=""></span>°C and in mycelial form at 25<span class="elsevierStyleHsp" style=""></span>°C. It is endemic in rural areas of Central and South America. In natural conditions, humans are the only known host. The source of the infection is soil contaminated with the fungus and the most common route of entry is the airway, giving rise to a primary infection in the lungs, which is often asymptomatic, particularly in young patients. From the lungs, infection spreads via the blood and lymph to the skin, mucous membranes, lymph nodes, and other organs.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 50-year-old male agricultural worker from Paraguay (South America) who presented with a 4-month history of lesions in the mouth, on the palmar surface of the third finger of his left hand, and on the plantar surface of his right great toe. These were accompanied by swelling of the lip, pain, weight loss of 10 kg since the onset of the condition, and a feeling of fever, particularly at night. The patient reported no underlying disease or any history of trauma. He had been a smoker for many years.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Physical examination revealed a swollen lower lip with marked infiltration and induration as well as multiple eroded, mulberry-like, erythematous papules giving the lesion a cobblestone appearance (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The lesions on the fingers and toes were small ulcers with well-defined borders and clean bases (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The most relevant laboratory findings were eosinophilia (7%) and an erythrocyte sedimentation rate of 78<span class="elsevierStyleHsp" style=""></span>mm in the first hour. The patient tested negative for human immunodeficiency virus (HIV) and had a Venereal Disease Research Laboratory test result of 1:2. Chest radiography showed a mild interstitial infiltrate at the base of both lungs and histopathology revealed an intense granulomatous reaction in the dermis, with numerous multinucleated giant cells containing small, round, thick-walled structures with double contour membrane, some with surface buds and others showing multiple budding. These cells stained positively with periodic acid-Schiff stain (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Treatment with itraconazole 200 mg/d achieved a good therapeutic response at initial monthly assessments. The patient is now in his eighth month of treatment and the therapy will be continued for at least another 4 months.</p><p id="par0030" class="elsevierStylePara elsevierViewall">PCM is a deep mycosis that primarily affects male agricultural workers. The male to female ratio is approximately 9 to 1. In women, the infection occurs before menarche or after menopause. <span class="elsevierStyleItalic">P brasiliensis</span> has cytoplasmic receptors for 17-β-estradiol, a female hormone that inhibits the mycelial-to-yeast transformation, an essential step in the establishment of infection. The age of affected patients ranges between 15-24 years and 65-74 years, with incidence peaking in the older patients.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Clinically, the condition can presents as PCM infection (which can be asymptomatic or subclinical or else a symptomatic primary infection) or PCM disease, which can be acute or chronic. There are several forms of PCM disease, including juvenile (affecting children and adolescents), adult (unifocal or multifocal), and residual disease. The most frequent clinical form is chronic multifocal disease with pulmonary and mucocutaneous involvement. In HIV-positive patients with acquired immunodeficiency syndrome the clinical features are those of the acute juvenile form but with the addition of granulomatous mucosal lesions and diffuse pulmonary involvement.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">There are numerous clinical manifestations, which include general symptoms, enlarged lymph nodes and lesions in the lungs, bones, and other organs, including (in order of frequency) the gastrointestinal tract, liver, spleen, and adrenal glands. The lymph nodes may suppurate and become necrotic, giving rise to fistulas similar to those observed in tuberculosis.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The most common manifestations are mucocutaneous lesions; when these affect the mucosas of the nose, mouth, pharynx, and larynx, they can take 3 forms: <span class="elsevierStyleItalic">a)</span> de Aguiar Pupo stomatitis (mulberry stomatitis); <span class="elsevierStyleItalic">b)</span> inflamed and deformed lips (tapir lip); and <span class="elsevierStyleItalic">c)</span> infiltrative, vegetative, and ulcerative lesions. Cutaneous lesions take various forms as follows: papular, vegetating papular-pustular, ulcerative-vegetative, and papular-tuberous with pinpoint hemorrhages and a mulberry-like appearance. In the nasal region crusted ulcerated lesions that destroy the septum mimic American cutaneous leishmaniasis, one of the diseases that should be included in the differential diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">PCM is diagnosed on the basis of 2 types of findings: <span class="elsevierStyleItalic">a)</span> Epidemiological information obtained from the medical history; and <span class="elsevierStyleItalic">b)</span> Demonstration and isolation of the fungus using any of the following methods: direct microscopic examination of exudate from lesions using potassium hydroxide smear or Giemsa or Groccot staining; culture on Saboureaud or blood agar; or histopathologic procedures demonstrating ‘pilot's wheel’ structures either within multinucleated giant cells or floating free in areas of suppuration. In the present case, the patient was a male agricultural worker and a smoker, and fungal structures were identified in a biopsy specimen.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The first-line treatment is oral itraconazole 200-400 mg/d for 6 to 12 months in mild cases and 12 to 18 months in moderate cases. Severe disease is treated with intravenous amphotericin B.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Di Martino Ortiz B, Rodríguez-Oviedo ML, Rodríguez-Masi M. Paracoccidioidomicosis crónica multifocal de tipo adulto en paciente inmunocompetente. Actas Dermosifiliogr.2012;103:645-646.</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" => 1116 "Ancho" => 900 "Tamanyo" => 107278 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical picture. Multiple spotty erythematous plaques on the lower lip, mulberry-like in appearance.</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" => 1057 "Ancho" => 900 "Tamanyo" => 105388 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Clinical picture. Small ulcer with smooth borders and a clean base on the plantar surface of the great toe on the right foot.</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" => 581 "Ancho" => 1401 "Tamanyo" => 271254 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Histopathology. A, Capsule with intense granulomatous reaction (hemoxylin-eosin, original magnification ×10). B, Giant cell containing spores with surface budding (periodic acid-Schiff, original magnification ×40).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paracoccidiodomicosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R. Negroni" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "Micología médica" "paginaInicial" => "263" "paginaFinal" => "273" "serieFecha" => "1993" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Micología médica ilustrada. México" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R. Arenas" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:2 [ "fecha" => "2004" "editorial" => "Interamericana McGraw-Hill" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paracoccidioidomycosis: case report and review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "B.J. Manns" 1 => "B.W. Baylis" 2 => "S.J. Urbanski" 3 => "A.P. Gibb" 4 => "H.R. Rabin" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "1996" "volumen" => "23" "paginaInicial" => "1026" "paginaFinal" => "1032" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8922797" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tropical dermatology: Fungal tropical deseases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "O. Lupi" 1 => "S.K. Tyring" 2 => "M.R. McGinnis" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2005" "volumen" => "53" "paginaInicial" => "935" "paginaFinal" => "938" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Martinez R. Blastomicose Sul-Americana (Paracoccidioidomicose). In: Veronesi R, editor. Tratado de infectología. Sao Paulo: Atheneu; 1997. p. 1081–111." ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lesión infiltrada en el labio superior" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B. Di Martino" 1 => "M. Rodriguez" 2 => "O. Knopflemacher" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Actas Dermosifiliogr" "fecha" => "2008" "volumen" => "99" "paginaInicial" => "413" "paginaFinal" => "414" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18501176" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paracoccidiodomicosis en paciente HIV+" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Agüero Zaputovich" 1 => "L. Cardozo" 2 => "B. Di Martino" 3 => "G. Valdovinos" 4 => "M. Rodríguez Masi" 5 => "O. Knopfelmacher" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Esp Patol" "fecha" => "2008" "volumen" => "41" "paginaInicial" => "150" "paginaFinal" => "153" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010300000007/v1_201304241318/S1578219012002272/v1_201304241318/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/15782190/0000010300000007/v1_201304241318/S1578219012002272/v1_201304241318/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219012002272?idApp=UINPBA000044" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 4 | 11 | 15 |
| 2024 Octubre | 57 | 40 | 97 |
| 2024 Septiembre | 71 | 25 | 96 |
| 2024 Agosto | 89 | 56 | 145 |
| 2024 Julio | 93 | 38 | 131 |
| 2024 Junio | 87 | 46 | 133 |
| 2024 Mayo | 89 | 29 | 118 |
| 2024 Abril | 77 | 23 | 100 |
| 2024 Marzo | 89 | 26 | 115 |
| 2024 Febrero | 77 | 21 | 98 |
| 2024 Enero | 58 | 31 | 89 |
| 2023 Diciembre | 93 | 19 | 112 |
| 2023 Noviembre | 74 | 26 | 100 |
| 2023 Octubre | 64 | 20 | 84 |
| 2023 Septiembre | 66 | 32 | 98 |
| 2023 Agosto | 49 | 18 | 67 |
| 2023 Julio | 52 | 33 | 85 |
| 2023 Junio | 56 | 22 | 78 |
| 2023 Mayo | 56 | 28 | 84 |
| 2023 Abril | 39 | 18 | 57 |
| 2023 Marzo | 50 | 24 | 74 |
| 2023 Febrero | 63 | 18 | 81 |
| 2023 Enero | 43 | 25 | 68 |
| 2022 Diciembre | 70 | 32 | 102 |
| 2022 Noviembre | 26 | 28 | 54 |
| 2022 Octubre | 46 | 19 | 65 |
| 2022 Septiembre | 29 | 25 | 54 |
| 2022 Agosto | 33 | 43 | 76 |
| 2022 Julio | 27 | 26 | 53 |
| 2022 Junio | 31 | 25 | 56 |
| 2022 Mayo | 30 | 34 | 64 |
| 2022 Abril | 40 | 32 | 72 |
| 2022 Marzo | 31 | 54 | 85 |
| 2022 Febrero | 33 | 30 | 63 |
| 2022 Enero | 49 | 36 | 85 |
| 2021 Diciembre | 59 | 36 | 95 |
| 2021 Noviembre | 74 | 38 | 112 |
| 2021 Octubre | 78 | 48 | 126 |
| 2021 Septiembre | 54 | 36 | 90 |
| 2021 Agosto | 25 | 27 | 52 |
| 2021 Julio | 78 | 26 | 104 |
| 2021 Junio | 47 | 34 | 81 |
| 2021 Mayo | 58 | 34 | 92 |
| 2021 Abril | 71 | 44 | 115 |
| 2021 Marzo | 45 | 24 | 69 |
| 2021 Febrero | 48 | 18 | 66 |
| 2021 Enero | 30 | 15 | 45 |
| 2020 Diciembre | 33 | 12 | 45 |
| 2020 Noviembre | 30 | 19 | 49 |
| 2020 Octubre | 24 | 7 | 31 |
| 2020 Septiembre | 26 | 9 | 35 |
| 2020 Agosto | 25 | 16 | 41 |
| 2020 Julio | 31 | 12 | 43 |
| 2020 Junio | 36 | 25 | 61 |
| 2020 Mayo | 32 | 20 | 52 |
| 2020 Abril | 33 | 15 | 48 |
| 2020 Marzo | 43 | 20 | 63 |
| 2020 Febrero | 8 | 0 | 8 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 8 | 1 | 9 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Octubre | 0 | 2 | 2 |
| 2019 Septiembre | 10 | 1 | 11 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 1 | 5 |
| 2019 Junio | 4 | 2 | 6 |
| 2019 Mayo | 7 | 18 | 25 |
| 2019 Abril | 4 | 1 | 5 |
| 2019 Marzo | 0 | 9 | 9 |
| 2019 Febrero | 4 | 0 | 4 |
| 2019 Enero | 1 | 0 | 1 |
| 2018 Diciembre | 5 | 0 | 5 |
| 2018 Noviembre | 6 | 0 | 6 |
| 2018 Octubre | 7 | 0 | 7 |
| 2018 Septiembre | 4 | 0 | 4 |
| 2018 Junio | 0 | 17 | 17 |
| 2018 Mayo | 0 | 42 | 42 |
| 2018 Abril | 0 | 20 | 20 |
| 2018 Marzo | 3 | 6 | 9 |
| 2018 Febrero | 33 | 11 | 44 |
| 2018 Enero | 37 | 5 | 42 |
| 2017 Diciembre | 38 | 10 | 48 |
| 2017 Noviembre | 32 | 3 | 35 |
| 2017 Octubre | 32 | 12 | 44 |
| 2017 Septiembre | 38 | 20 | 58 |
| 2017 Agosto | 55 | 19 | 74 |
| 2017 Julio | 29 | 16 | 45 |
| 2017 Junio | 50 | 9 | 59 |
| 2017 Mayo | 53 | 6 | 59 |
| 2017 Abril | 38 | 6 | 44 |
| 2017 Marzo | 39 | 17 | 56 |
| 2017 Febrero | 32 | 17 | 49 |
| 2017 Enero | 28 | 6 | 34 |
| 2016 Diciembre | 43 | 4 | 47 |
| 2016 Noviembre | 53 | 9 | 62 |
| 2016 Octubre | 70 | 7 | 77 |
| 2016 Septiembre | 56 | 7 | 63 |
| 2016 Agosto | 44 | 10 | 54 |
| 2016 Julio | 45 | 13 | 58 |
| 2016 Junio | 8 | 12 | 20 |
| 2016 Mayo | 4 | 19 | 23 |
| 2016 Abril | 3 | 0 | 3 |
| 2016 Marzo | 8 | 0 | 8 |
| 2016 Febrero | 5 | 3 | 8 |
| 2016 Enero | 7 | 2 | 9 |
| 2015 Diciembre | 5 | 3 | 8 |
| 2015 Noviembre | 13 | 1 | 14 |
| 2015 Octubre | 10 | 3 | 13 |
| 2015 Septiembre | 10 | 8 | 18 |
| 2015 Agosto | 11 | 2 | 13 |
| 2015 Julio | 89 | 12 | 101 |
| 2015 Junio | 45 | 6 | 51 |
| 2015 Mayo | 84 | 9 | 93 |
| 2015 Abril | 69 | 12 | 81 |
| 2015 Marzo | 63 | 11 | 74 |
| 2015 Febrero | 63 | 5 | 68 |
| 2015 Enero | 61 | 11 | 72 |
| 2014 Diciembre | 59 | 6 | 65 |
| 2014 Noviembre | 46 | 9 | 55 |
| 2014 Octubre | 65 | 18 | 83 |
| 2014 Septiembre | 65 | 13 | 78 |
| 2014 Agosto | 22 | 5 | 27 |
| 2014 Julio | 18 | 3 | 21 |
| 2014 Junio | 37 | 2 | 39 |
| 2014 Mayo | 42 | 5 | 47 |
| 2014 Abril | 43 | 4 | 47 |
| 2014 Marzo | 47 | 8 | 55 |
| 2014 Febrero | 39 | 11 | 50 |
| 2014 Enero | 46 | 8 | 54 |
| 2013 Diciembre | 50 | 11 | 61 |
| 2013 Noviembre | 26 | 9 | 35 |
| 2013 Octubre | 35 | 10 | 45 |
| 2013 Septiembre | 17 | 10 | 27 |
| 2013 Agosto | 14 | 8 | 22 |
| 2013 Julio | 10 | 10 | 20 |
| 2013 Junio | 14 | 23 | 37 |
| 2013 Mayo | 20 | 12 | 32 |
| 2013 Abril | 18 | 14 | 32 |
| 2013 Marzo | 21 | 9 | 30 |
| 2013 Febrero | 39 | 9 | 48 |
| 2013 Enero | 47 | 4 | 51 |
| 2012 Diciembre | 27 | 4 | 31 |
| 2012 Noviembre | 0 | 2 | 2 |
| 2012 Octubre | 0 | 2 | 2 |
| 2012 Septiembre | 0 | 2 | 2 |
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