Case for Diagnosis
Vasculitis With Lesions on the Scalp as the Only Cutaneous Manifestation
Vasculitis con lesiones en cuero cabelludo como única manifestación cutánea
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Benavente Villegas, J.M. Sánchez Motilla, N. Rausell Fontestad" "autores" => array:3 [ 0 => array:4 [ "nombre" => "F.C. Benavente" "apellidos" => "Villegas" "email" => array:1 [ 0 => "felipecbv@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" => "J.M. Sánchez" "apellidos" => "Motilla" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "N. Rausell" "apellidos" => "Fontestad" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Doctor Peset, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario Doctor Peset, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Vasculitis con lesiones en cuero cabelludo como única manifestación cutánea" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 703 "Ancho" => 1250 "Tamanyo" => 149810 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">The patient was a 65-year-old man (a nonsmoker) with a past history of nasal polyps and late-onset bronchial asthma that was very difficult to control. He had been hospitalized multiple times and was a long-term user of oral prednisone at a dosage of 15<span class="elsevierStyleHsp" style=""></span>mg daily. In April 2015, the patient was enrolled by the pulmonology department in a clinical trial that compared lebrikizumab to placebo; the first step was to gradually reduce his prednisone dosage to 2.5<span class="elsevierStyleHsp" style=""></span>mg daily. A week after this dosage was reached, the patient had an asthma exacerbation and very pruritic lesions appeared on the scalp, accompanied 15 days later by paresthesia, pain, and complete hemiplegia of the lower right limb.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed excoriated, erythematous, purpuric papules and plaques, including some with central ulceration (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). No other associated lesions were observed.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Histopathology</span><p id="par0015" class="elsevierStylePara elsevierViewall">Histologic examination revealed a cutaneous ulcer with necrotizing vasculitis and a mixed neutrophilic and eosinophilic infiltrate in perivascular and interstitial areas (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>). Cultures, Gram stain, and direct immunofluorescence were negative.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Additional Tests</span><p id="par0020" class="elsevierStylePara elsevierViewall">Blood tests revealed eosinophilia (19 620 eosinophils/μl; 72%) and perinuclear antineutrophil cytoplasmic antibodies (pANCA) (34<span class="elsevierStyleHsp" style=""></span>IU/mL; <<span class="elsevierStyleHsp" style=""></span>5 IU/mL is normal).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Electromyography revealed mononeuritis multiplex in the right leg.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Chest radiography revealed minimal bilateral pleural effusion.</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What Is Your Diagnosis?</span></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0040" class="elsevierStylePara elsevierViewall">Eosinophilic granulomatosis with polyangiitis (EGPA).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Course and Treatment</span><p id="par0045" class="elsevierStylePara elsevierViewall">Treatment was started with intravenous methylprednisolone at a dosage of 1<span class="elsevierStyleHsp" style=""></span>g daily for 5 days, followed by oral prednisone at a dosage of 1<span class="elsevierStyleHsp" style=""></span>mg/kg/d. Adequate response was achieved, except in the neurologic manifestations. The patient was then removed from the clinical trial and treatment was started with rituximab. Significant improvement was observed at subsequent follow-up visits.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Comment</span><p id="par0050" class="elsevierStylePara elsevierViewall">EGPA, previously known as Churg-Strauss syndrome, is a multisystem disease that occurs with equal frequency in both sexes and is characterized by allergic rhinitis, asthma, and severe eosinophilia.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> It is classified in the group of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides affecting small and medium-sized vessels and is the least common of the 3 entities included in this group.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Given the presence of ANCA, the alteration of type 1 and type 2 T-helper cells, the decrease in regulatory T-cells, and eosinophilia caused by both increased synthesis and decreased apoptosis, it has been suggested that EGPA may have an immunologic pathogenesis.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Several authors have reported EGPA in systemic-corticosteroid-dependent asthmatic patients following a reduction in corticosteroid dosage and the start of treatment with leukotriene modifiers and/or omalizumab.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4,5</span></a> These authors concluded that the onset of the disease was not related to the start of treatment with new drugs but to the reduction in corticosteroid dosage, and that therefore there was no causal relationship but rather an unmasking of underdiagnosed EGPA.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">EGPA develops in 3 phases: a prodromal phase, characterized by underlying atopy and late-onset asthma that is difficult to control; an eosinophilic phase, characterized by prominent blood eosinophilia; and finally a vasculitic phase, characterized by the development of necrotizing vasculitis of small and medium-sized vessels, an eosinophilic infiltrate, and in many cases vascular and extravascular granulomatosis. The vasculitic phase is characterized by constitutional symptoms and multisystemic manifestations such as mononeuritis multiplex, microhematuria, and cardiac failure, which is the most common cause of death.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Cutaneous manifestations—typical of the vasculitic phase—tend to include subcutaneous nodules, palpable purpura, and hemorrhagic maculopapular lesions. These lesions occur most frequently on the lower limbs; however, lesions on the scalp are distinctive, although not pathognomonic.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Between 40% and 60% of patients with EGPA are positive for ANCA, typically pANCA, although the presence of these antibodies does not predict activity and should not be taken into account in follow-up.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">There is no specific diagnostic test for EGPA; diagnosis relies on preestablished criteria and evidence of vasculitis in the affected organ.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Treatment involves systemic corticosteroids, sometimes in association with cyclophosphamide if cardiac, renal, or central nervous system involvement is present.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">6,7</span></a> Rituximab, mepolizumab, and omalizumab have been used in refractory cases, with disparate results.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Differential diagnosis should include other entities characterized by angiolymphoid hyperplasia with eosinophilia as well as hypereosinophilic syndrome, as these are typically not associated with asthma or histopathologic findings indicative of vasculitis.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2,6</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In conclusion, we postulate that the reduction in corticosteroid dosage was the factor that triggered systemic manifestations in our patient, since these drugs likely masked the EGPA, which had not yet entered the vasculitic phase. We highlight the characteristic presentation of vasculitic lesions on the scalp. In patients with asthma, severe eosinophilia, systemic manifestations, and skin lesions, early histologic diagnosis is essential in order to begin appropriate treatment.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Histopathology" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Additional Tests" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnosis" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Clinical Course and Treatment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Comment" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 8 => 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: Villegas FCB, Motilla JMS, Fontestad NR. Vasculitis con lesiones en cuero cabelludo como única manifestación cutánea. Actas Dermosifiliogr. 2018;109:175–176.</p>" ] ] "multimedia" => array:3 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 703 "Ancho" => 1250 "Tamanyo" => 149810 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 917 "Ancho" => 688 "Tamanyo" => 228406 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×4.</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" => 917 "Ancho" => 688 "Tamanyo" => 262203 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin-eosin, original magnification ×40.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Churg-Strauss syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Pagnoux" 1 => "P. Guilpain" 2 => "L. Guillevin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/BOR.0b013e3280119854" "Revista" => array:6 [ "tituloSerie" => "Curr Opin Rheumatol" "fecha" => "2007" "volumen" => "19" "paginaInicial" => "25" "paginaFinal" => "32" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17143092" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0045" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Churg-Strauss syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Conron" 1 => "H.L.C. Beynon" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2000" "volumen" => "55" "paginaInicial" => "870" "paginaFinal" => "877" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10992542" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0050" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Proinflammatory cytokines and autoimmunity in Churg-Strauss syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B. Hellmich" 1 => "E. Csernok" 2 => "W.L. Gross" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1196/annals.1361.053" "Revista" => array:6 [ "tituloSerie" => "Ann NY Acad Sci" "fecha" => "2005" "volumen" => "1051" "paginaInicial" => "121" "paginaFinal" => "131" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16126951" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0055" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Churg-Strauss syndrome in patients receiving montelukast as treatment for asthma" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.E. Wechsler" 1 => "D. Finn" 2 => "D. Gunawardena" 3 => "R. Westlake" 4 => "A. Barker" 5 => "S.P. Haranath" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2000" "volumen" => "117" "paginaInicial" => "708" "paginaFinal" => "713" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10712995" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0060" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Development of Churg-Strauss syndrome with controlled asthma during omalizumab treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.M. Ruppert" 1 => "G. Averous" 2 => "D. Stanciu" 3 => "N. Deroide" 4 => "S. Riehm" 5 => "V. Poindron" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaci.2007.10.040" "Revista" => array:6 [ "tituloSerie" => "J Allergy Clin Immunol" "fecha" => "2008" "volumen" => "121" "paginaInicial" => "253" "paginaFinal" => "254" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18206510" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0065" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eosinophilic granulomatosis with polyangiitis (Churg-Strauss): Clinical characteristics and long-term followup of the 383 patients enrolled in the French Vasculitis Study Group cohort" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "French Vasculitis Study Group" "etal" => true "autores" => array:6 [ 0 => "C. Comarmond" 1 => "C. Pagnoux" 2 => "M. Khellaf" 3 => "J.F. Cordier" 4 => "M. Hamidou" 5 => "J.F. Viallard" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/art.37721" "Revista" => array:6 [ "tituloSerie" => "Arthritis Rheum" "fecha" => "2013" "volumen" => "65" "paginaInicial" => "270" "paginaFinal" => "281" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23044708" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0070" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rituximab is effective in the treatment of refractory Churg-Strauss syndrome and is associated with diminished T-cell interleukin-5 production" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.J. Pepper" 1 => "M.A. Fabre" 2 => "C. Pavesio" 3 => "G. Gaskin" 4 => "R.B. Jones" 5 => "D. Jayne" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rheumatology (Oxford)" "fecha" => "2008" "volumen" => "47" "paginaInicial" => "1104" "paginaFinal" => "1105" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010900000002/v1_201803020443/S1578219017304274/v1_201803020443/en/main.assets" "Apartado" => array:4 [ "identificador" => "6154" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case for Diagnosis" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010900000002/v1_201803020443/S1578219017304274/v1_201803020443/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219017304274?idApp=UINPBA000044" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 18 | 10 | 28 |
| 2024 Octubre | 150 | 50 | 200 |
| 2024 Septiembre | 139 | 37 | 176 |
| 2024 Agosto | 235 | 60 | 295 |
| 2024 Julio | 232 | 42 | 274 |
| 2024 Junio | 183 | 45 | 228 |
| 2024 Mayo | 195 | 44 | 239 |
| 2024 Abril | 142 | 38 | 180 |
| 2024 Marzo | 191 | 29 | 220 |
| 2024 Febrero | 219 | 32 | 251 |
| 2024 Enero | 174 | 33 | 207 |
| 2023 Diciembre | 195 | 20 | 215 |
| 2023 Noviembre | 202 | 20 | 222 |
| 2023 Octubre | 145 | 36 | 181 |
| 2023 Septiembre | 145 | 29 | 174 |
| 2023 Agosto | 135 | 21 | 156 |
| 2023 Julio | 157 | 47 | 204 |
| 2023 Junio | 111 | 21 | 132 |
| 2023 Mayo | 119 | 27 | 146 |
| 2023 Abril | 110 | 26 | 136 |
| 2023 Marzo | 149 | 46 | 195 |
| 2023 Febrero | 106 | 36 | 142 |
| 2023 Enero | 88 | 34 | 122 |
| 2022 Diciembre | 81 | 44 | 125 |
| 2022 Noviembre | 54 | 28 | 82 |
| 2022 Octubre | 63 | 28 | 91 |
| 2022 Septiembre | 39 | 56 | 95 |
| 2022 Agosto | 25 | 27 | 52 |
| 2022 Julio | 30 | 42 | 72 |
| 2022 Junio | 25 | 33 | 58 |
| 2022 Mayo | 78 | 46 | 124 |
| 2022 Abril | 116 | 46 | 162 |
| 2022 Marzo | 121 | 80 | 201 |
| 2022 Febrero | 115 | 30 | 145 |
| 2022 Enero | 136 | 54 | 190 |
| 2021 Diciembre | 71 | 45 | 116 |
| 2021 Noviembre | 86 | 54 | 140 |
| 2021 Octubre | 91 | 73 | 164 |
| 2021 Septiembre | 54 | 64 | 118 |
| 2021 Agosto | 56 | 57 | 113 |
| 2021 Julio | 54 | 42 | 96 |
| 2021 Junio | 49 | 33 | 82 |
| 2021 Mayo | 68 | 65 | 133 |
| 2021 Abril | 90 | 129 | 219 |
| 2021 Marzo | 76 | 41 | 117 |
| 2021 Febrero | 91 | 49 | 140 |
| 2021 Enero | 39 | 53 | 92 |
| 2020 Diciembre | 50 | 58 | 108 |
| 2020 Noviembre | 54 | 49 | 103 |
| 2020 Octubre | 19 | 16 | 35 |
| 2020 Septiembre | 45 | 27 | 72 |
| 2020 Agosto | 28 | 35 | 63 |
| 2020 Julio | 37 | 26 | 63 |
| 2020 Junio | 43 | 38 | 81 |
| 2020 Mayo | 22 | 17 | 39 |
| 2020 Abril | 24 | 18 | 42 |
| 2020 Marzo | 36 | 14 | 50 |
| 2020 Febrero | 4 | 0 | 4 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 8 | 0 | 8 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Septiembre | 11 | 0 | 11 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 4 | 0 | 4 |
| 2019 Mayo | 5 | 0 | 5 |
| 2019 Abril | 2 | 0 | 2 |
| 2019 Marzo | 2 | 0 | 2 |
| 2019 Febrero | 2 | 0 | 2 |
| 2018 Diciembre | 5 | 0 | 5 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Septiembre | 3 | 0 | 3 |
| 2018 Abril | 1 | 0 | 1 |
| 2018 Febrero | 3 | 9 | 12 |
| 2018 Enero | 5 | 10 | 15 |
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