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 Junio | 243 | 68 | 311 |
| 2024 Mayo | 222 | 39 | 261 |
| 2024 Abril | 171 | 32 | 203 |
| 2024 Marzo | 164 | 47 | 211 |
| 2024 Febrero | 203 | 39 | 242 |
| 2024 Enero | 175 | 35 | 210 |
| 2023 Diciembre | 255 | 16 | 271 |
| 2023 Noviembre | 218 | 38 | 256 |
| 2023 Octubre | 191 | 32 | 223 |
| 2023 Septiembre | 160 | 30 | 190 |
| 2023 Agosto | 133 | 24 | 157 |
| 2023 Julio | 127 | 38 | 165 |
| 2023 Junio | 106 | 29 | 135 |
| 2023 Mayo | 134 | 35 | 169 |
| 2023 Abril | 137 | 18 | 155 |
| 2023 Marzo | 85 | 17 | 102 |
| 2023 Febrero | 106 | 28 | 134 |
| 2023 Enero | 69 | 24 | 93 |
| 2022 Diciembre | 61 | 39 | 100 |
| 2022 Noviembre | 46 | 28 | 74 |
| 2022 Octubre | 43 | 22 | 65 |
| 2022 Septiembre | 38 | 47 | 85 |
| 2022 Agosto | 32 | 40 | 72 |
| 2022 Julio | 25 | 41 | 66 |
| 2022 Junio | 28 | 26 | 54 |
| 2022 Mayo | 76 | 57 | 133 |
| 2022 Abril | 95 | 16 | 111 |
| 2022 Marzo | 140 | 54 | 194 |
| 2022 Febrero | 104 | 35 | 139 |
| 2022 Enero | 105 | 52 | 157 |
| 2021 Diciembre | 82 | 41 | 123 |
| 2021 Noviembre | 74 | 46 | 120 |
| 2021 Octubre | 74 | 54 | 128 |
| 2021 Septiembre | 81 | 50 | 131 |
| 2021 Agosto | 71 | 33 | 104 |
| 2021 Julio | 63 | 32 | 95 |
| 2021 Junio | 62 | 29 | 91 |
| 2021 Mayo | 58 | 44 | 102 |
| 2021 Abril | 81 | 62 | 143 |
| 2021 Marzo | 65 | 24 | 89 |
| 2021 Febrero | 38 | 25 | 63 |
| 2021 Enero | 20 | 17 | 37 |
| 2020 Diciembre | 27 | 10 | 37 |
| 2020 Noviembre | 28 | 22 | 50 |
| 2020 Octubre | 22 | 8 | 30 |
| 2020 Septiembre | 25 | 15 | 40 |
| 2020 Agosto | 28 | 17 | 45 |
| 2020 Julio | 17 | 20 | 37 |
| 2020 Junio | 25 | 31 | 56 |
| 2020 Mayo | 19 | 13 | 32 |
| 2020 Abril | 21 | 20 | 41 |
| 2020 Marzo | 17 | 14 | 31 |
| 2020 Febrero | 2 | 0 | 2 |
| 2019 Diciembre | 2 | 0 | 2 |
| 2019 Septiembre | 4 | 0 | 4 |
| 2019 Junio | 2 | 0 | 2 |
| 2019 Mayo | 2 | 0 | 2 |
| 2019 Abril | 0 | 3 | 3 |
| 2019 Marzo | 2 | 0 | 2 |
| 2019 Febrero | 1 | 0 | 1 |
| 2019 Enero | 4 | 0 | 4 |
| 2018 Octubre | 5 | 0 | 5 |
| 2018 Septiembre | 1 | 0 | 1 |
| 2018 Febrero | 16 | 1 | 17 |
| 2018 Enero | 28 | 10 | 38 |
| 2017 Diciembre | 32 | 21 | 53 |
| 2017 Noviembre | 26 | 4 | 30 |
| 2017 Octubre | 30 | 8 | 38 |
| 2017 Septiembre | 22 | 4 | 26 |
| 2017 Agosto | 20 | 9 | 29 |
| 2017 Julio | 18 | 11 | 29 |
| 2017 Junio | 29 | 4 | 33 |
| 2017 Mayo | 27 | 12 | 39 |
| 2017 Abril | 14 | 10 | 24 |
| 2017 Marzo | 14 | 8 | 22 |
| 2017 Febrero | 13 | 5 | 18 |
| 2017 Enero | 16 | 5 | 21 |
| 2016 Diciembre | 23 | 24 | 47 |
| 2016 Noviembre | 22 | 17 | 39 |
| 2016 Octubre | 25 | 23 | 48 |
| 2016 Julio | 0 | 4 | 4 |
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