Case Letter
Eroded plaques involving the breasts: a unique location of pemphigus vulgaris
Fernando Garcia-Souto
Department of Dermatology, Valme University Hospital, Seville, Spain
Read
5125
Timeswas read the article
2687
Total PDF
2438
Total HTML
Share statistics
array:24 [ "pii" => "S0365059620301860" "issn" => "03650596" "doi" => "10.1016/j.abd.2020.03.010" "estado" => "S300" "fechaPublicacion" => "2020-09-01" "aid" => "241" "copyright" => "Sociedade Brasileira de Dermatologia" "copyrightAnyo" => "2020" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by/4.0/" "subdocumento" => "sco" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "pt" => array:19 [ "pii" => "S2666275220302587" "issn" => "26662752" "doi" => "10.1016/j.abdp.2020.03.006" "estado" => "S300" "fechaPublicacion" => "2020-09-01" "aid" => "241" "copyright" => "Sociedade Brasileira de Dermatologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by/4.0/" "subdocumento" => "sco" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "pt" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta – Caso clínico</span>" "titulo" => "Placas erosadas envolvendo as mamas: localização singular do pênfigo vulgar" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "670" "paginaFinal" => "671" ] ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 932 "Ancho" => 905 "Tamanyo" => 338628 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A), Na histopatologia observa‐se bolha intraepitelial com acantólise logo acima dos queratinócitos basais e inflamação crônica (Hematoxilina & eosina, 20×). (B), No detalhe observa‐se um infiltrado inflamatório denso incomum que consiste principalmente de linfócitos com alguns eosinófilos isolados (Hematoxilina & eosina, 20×).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Fernando Garcia‐Souto" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Fernando" "apellidos" => "Garcia‐Souto" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0365059620301860" "doi" => "10.1016/j.abd.2020.03.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620301860?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275220302587?idApp=UINPBA00008Z" "url" => "/26662752/0000009500000005/v1_202010040634/S2666275220302587/v1_202010040634/pt/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S0365059620301872" "issn" => "03650596" "doi" => "10.1016/j.abd.2020.02.012" "estado" => "S300" "fechaPublicacion" => "2020-09-01" "aid" => "242" "copyright" => "Sociedade Brasileira de Dermatologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by/4.0/" "subdocumento" => "sco" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Letter</span>" "titulo" => "A case of calciphylaxis with an unfavorable outcome" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "671" "paginaFinal" => "673" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 672 "Ancho" => 905 "Tamanyo" => 145607 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Positive Von Kossa stain on the material deposited in the dermis and blood vessel wall (arrows; ×100).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Maria Carolina Ribeiro Braga, Susana Strougo, Enoï Guedes Vilar, Sandra Maria Barbosa Durães" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Maria Carolina Ribeiro" "apellidos" => "Braga" ] 1 => array:2 [ "nombre" => "Susana" "apellidos" => "Strougo" ] 2 => array:2 [ "nombre" => "Enoï Guedes" "apellidos" => "Vilar" ] 3 => array:2 [ "nombre" => "Sandra Maria Barbosa" "apellidos" => "Durães" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S2666275220302630" "doi" => "10.1016/j.abdp.2020.02.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275220302630?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620301872?idApp=UINPBA00008Z" "url" => "/03650596/0000009500000005/v2_202011080908/S0365059620301872/v2_202011080908/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0365059620301859" "issn" => "03650596" "doi" => "10.1016/j.abd.2020.03.009" "estado" => "S300" "fechaPublicacion" => "2020-09-01" "aid" => "240" "copyright" => "Sociedade Brasileira de Dermatologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by/4.0/" "subdocumento" => "sco" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Letter</span>" "titulo" => "Ecthyma gangrenosum and severe transitory neutropenia in an immunocompetent girl" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "668" "paginaFinal" => "669" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 864 "Ancho" => 750 "Tamanyo" => 58061 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hemorrhagic blister on vulva, two days of evolution.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Pablo Vargas-Mora, Santiago García, Ligia Aranibar, Fernando Valenzuela" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Pablo" "apellidos" => "Vargas-Mora" ] 1 => array:2 [ "nombre" => "Santiago" "apellidos" => "García" ] 2 => array:2 [ "nombre" => "Ligia" "apellidos" => "Aranibar" ] 3 => array:2 [ "nombre" => "Fernando" "apellidos" => "Valenzuela" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S2666275220302599" "doi" => "10.1016/j.abdp.2020.03.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275220302599?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620301859?idApp=UINPBA00008Z" "url" => "/03650596/0000009500000005/v2_202011080908/S0365059620301859/v2_202011080908/en/main.assets" ] "en" => array:17 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Letter</span>" "titulo" => "Eroded plaques involving the breasts: a unique location of pemphigus vulgaris" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "670" "paginaFinal" => "671" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Fernando Garcia-Souto" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Fernando" "apellidos" => "Garcia-Souto" "email" => array:1 [ 0 => "fernandogarciasouto@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Dermatology, Valme University Hospital, Seville, Spain" "identificador" => "aff0005" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1040 "Ancho" => 905 "Tamanyo" => 99349 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Physical examination revealed bilateral, strikingly symmetric, well-delimited eroded plaques on both breasts.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pemphigus represents a group of infrequent autoimmune bullous diseases that affect the skin and mucous membranes, characterized by intraepidermal acantholytic blisters. The process of acantholysis is induced by the binding of circulating immunoglobulin G autoantibodies to intercellular adhesion molecules.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Precipitating factors of pemphigus diseases are poorly understood. A unique case of trauma-induced pemphigus vulgaris is reported.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A woman in her 50 s with no relevant past medical history presented with a two-month history of malaise and mildly painful cutaneous lesions predominantly involving both breasts. She denied using topical agents, oral medications, or preceding trauma. However, she did report wearing a tight bra frequently. Physical examination revealed bilateral, strikingly symmetric, well-delimited eroded plaques on both breasts (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In addition, the patient presented a few similar, smaller, isolated eroded plaques distributed on her back. The mucosae were spared. A 4-mm punch skin biopsy was performed.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Histopathology showed an intraepidermal blister with suprabasal acantholysis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). An unusual dense predominantly lymphocytic infiltrate was also observed within the dermis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). In addition, direct immunofluorescence microscopy from the perilesional skin showed abnormal intercellular deposits of IgG and C3. Thus, on the basis of clinical, histopathology, and direct immunofluorescence findings, a diagnosis of trauma-induced pemphigus vulgaris was made.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Both genetic and environmental factors may influence the development of pemphigus. However, studies on the role of trauma as a triggering factor in pemphigus are limited. The Koebner phenomenon is well known in dermatology. It involves several cutaneous diseases, among them psoriasis, vitiligo, and lichen planus.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Nevertheless, this phenomenon is seldom described in bullous autoimmune disorders such as pemphigus.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Trauma-induced pemphigus has been traditionally reported mainly after a surgery or radiation.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> An interesting retrospective study of trauma-induced pemphigus found major surgery as the most frequent trigger.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In addition, authors suggest that more conventional procedures such as periodontal procedures, blunt trauma, or even laser surgery could trigger a pemphigus. The present patient reinforces this latter suggestion, given that the only possible clear trigger might have been the continued friction with the bra.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The lag period between the exposure to trauma and the koebnerization of typical lesions is generally between ten and 20 days.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The pathogenesis of trauma-induced pemphigus is unknown and probably multifactorial, involving genetic factors, immunological factors, and environmental triggers. A possible explanation could be the exposure of pemphigus antigens in traumatized epithelium in genetically predisposed patients.</p><p id="par0035" class="elsevierStylePara elsevierViewall">However, the present patient exhibited the peculiarity of an intense inflammatory infiltrate in the dermis rarely seen previously. According to this case, an atypical intense inflammation could be a distinct histopathological feature of trauma-induced pemphigus. Further research is necessary to ascertain if greater inflammation in dermis is more related to trauma-induced pemphigus as opposed to those not related to trauma.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, this report describes a presumably new case of trauma-induced pemphigus. To the author’s knowledge, there are no prior reports of pemphigus involving predominantly the breasts with such a peculiar disposition. It is proposed that a hypothetical continuous trauma with the bra could explain this unique location.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0045" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Author's contributions</span><p id="par0050" class="elsevierStylePara elsevierViewall">Fernando Garcia-Souto: Conception and planning of the manuscript; writing and critical revision of the manuscript; approval of the final version.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Author's contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-11-14" "fechaAceptado" => "2020-03-05" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Garcia-Souto F. Eroded plaques involving the breasts: a unique location of pemphigus vulgaris. An Bras Dermatol. 2020;95. <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.abd.2020.03.010">https://doi.org/10.1016/j.abd.2020.03.010</span></p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Department of Dermatology, Valme University Hospital, Seville, Spain.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1040 "Ancho" => 905 "Tamanyo" => 99349 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Physical examination revealed bilateral, strikingly symmetric, well-delimited eroded plaques on both breasts.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 932 "Ancho" => 905 "Tamanyo" => 337901 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A), Histopathology showed intraepithelial blister with acantholysis just above the basal keratinocytes and chronic inflammation (Hematoxylin & eosin, ×20). (B), A closer view of the dermis showed an unusual dense inflammatory infiltrate consisting mainly of lymphocytes with some isolated eosinophils (Hematoxylin & eosin, ×20).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mechanisms of blister induction by autoantibodies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. Sitaru" 1 => "D. Zillikens" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Exp Dermatol" "fecha" => "2005" "volumen" => "14" "paginaInicial" => "861" "paginaFinal" => "875" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The Koebner phenomenon" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L. Sagi" 1 => "H. Trau" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Dermatol" "fecha" => "2011" "volumen" => "29" "paginaInicial" => "231" "paginaFinal" => "236" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Radiotherapy-induced pemphigus vulgaris" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "H.W. Jang" 1 => "S.H. Chun" 2 => "J.M. Lee" 3 => "J. Jeon" 4 => "T. Hashimoto" 5 => "I.H. Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Dermatol" "fecha" => "2014" "volumen" => "41" "paginaInicial" => "851" "paginaFinal" => "852" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Trauma-induced pemphigus: a case series of 36 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Daneshpazhooh" 1 => "M. Fatehnejad" 2 => "Z. Rahbar" 3 => "K. Balighi" 4 => "N. Ghandi" 5 => "M. Ghiasi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/ddg.12738" "Revista" => array:6 [ "tituloSerie" => "J Dtsch Dermatol Ges" "fecha" => "2016" "volumen" => "14" "paginaInicial" => "166" "paginaFinal" => "171" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26819113" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Koebner phenomenon in pemphigus vulgaris patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K. Balighi" 1 => "M. Daneshpazhooh" 2 => "A. Azizpour" 3 => "V. Lajevardi" 4 => "F. Mohammadi" 5 => "C. Chams-Davatchi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "JAAD Case Rep" "fecha" => "2016" "volumen" => "2" "paginaInicial" => "419" "paginaFinal" => "421" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03650596/0000009500000005/v2_202011080908/S0365059620301860/v2_202011080908/en/main.assets" "Apartado" => array:4 [ "identificador" => "82769" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Letter" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009500000005/v2_202011080908/S0365059620301860/v2_202011080908/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059620301860?idApp=UINPBA00008Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 8 | 22 |
| 2024 October | 90 | 60 | 150 |
| 2024 September | 112 | 70 | 182 |
| 2024 August | 134 | 86 | 220 |
| 2024 July | 113 | 104 | 217 |
| 2024 June | 87 | 67 | 154 |
| 2024 May | 73 | 62 | 135 |
| 2024 April | 78 | 89 | 167 |
| 2024 March | 70 | 52 | 122 |
| 2024 February | 70 | 74 | 144 |
| 2024 January | 59 | 39 | 98 |
| 2023 December | 46 | 61 | 107 |
| 2023 November | 61 | 67 | 128 |
| 2023 October | 43 | 67 | 110 |
| 2023 September | 56 | 65 | 121 |
| 2023 August | 47 | 27 | 74 |
| 2023 July | 40 | 28 | 68 |
| 2023 June | 49 | 45 | 94 |
| 2023 May | 45 | 13 | 58 |
| 2023 April | 25 | 18 | 43 |
| 2023 March | 41 | 31 | 72 |
| 2023 February | 32 | 23 | 55 |
| 2023 January | 26 | 19 | 45 |
| 2022 December | 31 | 20 | 51 |
| 2022 November | 52 | 50 | 102 |
| 2022 October | 42 | 50 | 92 |
| 2022 September | 38 | 66 | 104 |
| 2022 August | 31 | 70 | 101 |
| 2022 July | 35 | 83 | 118 |
| 2022 June | 36 | 51 | 87 |
| 2022 May | 32 | 67 | 99 |
| 2022 April | 38 | 48 | 86 |
| 2022 March | 31 | 55 | 86 |
| 2022 February | 25 | 30 | 55 |
| 2022 January | 39 | 68 | 107 |
| 2021 December | 37 | 60 | 97 |
| 2021 November | 29 | 53 | 82 |
| 2021 October | 36 | 57 | 93 |
| 2021 September | 28 | 45 | 73 |
| 2021 August | 30 | 42 | 72 |
| 2021 July | 29 | 36 | 65 |
| 2021 June | 28 | 45 | 73 |
| 2021 May | 49 | 93 | 142 |
| 2021 April | 141 | 245 | 386 |
| 2021 March | 51 | 72 | 123 |
| 2021 February | 14 | 21 | 35 |
| 2021 January | 22 | 18 | 40 |
| 2020 December | 21 | 23 | 44 |
| 2020 November | 25 | 14 | 39 |
| 2020 October | 28 | 8 | 36 |
| 2020 September | 14 | 11 | 25 |
| 2020 August | 11 | 7 | 18 |
| 2020 July | 4 | 4 | 8 |
Show all
