Case Report
Rhinocerebral mucormycosis to the rise? The impact of the worldwide diabetes epidemic
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The impact of the worldwide diabetes epidemic" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "196" "paginaFinal" => "199" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Erick Martínez-Herrera, Angélica Julián-Castrejón, María Guadalupe Frías-De-León, Gabriela Moreno-Coutiño" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Erick" "apellidos" => "Martínez-Herrera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Angélica" "apellidos" => "Julián-Castrejón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "María Guadalupe" "apellidos" => "Frías-De-León" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:4 [ "nombre" => "Gabriela" "apellidos" => "Moreno-Coutiño" "email" => array:1 [ 0 => "gmorenocoutino@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Hospital Regional de Alta Especialidad de Ixtapaluca, Ixtapaluca, México" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "General Hospital Dr. Manuel Gea González Calzada de Tlalpan, Tlalpan, Ciudad de México, México" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "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" => 1509 "Ancho" => 1505 "Tamanyo" => 175908 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0110" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Clinical picture of a patient before and after extensive surgery.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Diabetes mellitus (DM) is one of the leading morbimortality diseases worldwide, with over 425 million affected individuals, particularly in low/medium income countries. Risk factors include an unhealthy sedentary lifestyle, diet high in refined sugar and fat, and genetic susceptibility<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">It is associated to numerous complications and comorbidities such as neutrophil dysfunction and impaired humoral immunity that predispose to fungal infections<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Rhinocerebral mucormycosis is an opportunistic fungal infection of non-septate hyaline hyphae which are ubiquitous saprophytes that are easily isolated from decomposing vegetation and high fructose fruits, soil, manure, and human orifices<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Despite adequate treatment, this infection has high mortality (40%–63%), and its prevalence has increased, probably due to the growing number and higher survival rates of immunosuppressed patients<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a>. Most infections are life threatening, as the fungus has particular affinity for vascular walls that cause irreversible damage through thrombosis and ischemic necrosis. <a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1 and 2</a> present biopsy specimens taken from patients for diagnosis, and the fungus can be seen invading the normal tissue.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The well identified predisposing factors are ketoacidosis by decompensated diabetes mellitus, advanced kidney failure, drug abuse, immunosuppressive treatment, or any other disease that causes neutropenia or polynuclear neutrophil deficit<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–7</span></a>.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Initially, most patients complain of symptoms similar to acute bacterial sinusitis, but rapid deterioration occurs with alterations in the visual acuity, facial edema, and necrotic areas, which are the hallmarks of the disease, either on the face or intraorally. Orbit involvement occurs in 66%–100% of the cases and any contiguous region may also be involved<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Timely diagnosis is fundamental for a positive outcome, so treatment with amphotericin B should be initiated on clinical presumption. Also, aggressive surgical debridement is fundamental, as removing the necrotic areas will reduce the fungal burden and will also facilitate the antifungal’s action<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a>. Amphotericin B improves survival rate up to 55%, adding to the results of surgical debridement. Another option is posaconazole and hyperbaric oxygen<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5,7</span></a>.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Cases report</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors present seven cases of diabetic patients that attended this tertiary care hospital with rhinocerebral mucormycosis (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). They were three males and four females, with ages ranging from 18–64 years (<a class="elsevierStyleCrossRefs" href="#fig0015">Figures 3 and 4</a>). One of them was referred to another hospital because of lack of space, another did not accept surgery, and another died before the surgery was performed. Of the four patients who underwent surgery, two died in the postsurgical period and the other two were discharged for improvement after several weeks. All of them received amphotericin B as part of the treatment, including those who did not undergo surgery.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">All of the patients acquired the fungal infection prior to the hospitalization, except for one patient who was admitted to the hospital for a nephrotic infection that resulted in nephrectomy; after several days she developed mucormycosis symptoms.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Of the three patients who died, two of them had metabolic dyscontrol and all presented ketoacidosis at some point during the disease.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">The diagnosis of mucormycosis requires clinical suspicion and quick action, as the fungal invasion of the vessels advances rapidly. Its diagnosis is considered an emergency. Ideally, it must include mycological diagnosis with a direct exam and a culture that grows in 24<span class="elsevierStyleHsp" style=""></span>hours. Also, to determine the extent of the damage, imaging tests are of great help, such as tomography. Surgical debridement provides a chance to cure, and material for histopathological confirmation. The main differential diagnosis is invasive aspergillosis.</p><p id="par0060" class="elsevierStylePara elsevierViewall">DM is a global burden with a rise in prevalence and incidence during the last decade, and besides being directly related to death, it is also very associated to serious morbidity and disability.</p><p id="par0065" class="elsevierStylePara elsevierViewall">For example, in the Mexican population, since the year 2000, DM is the leading cause of death among women and the second in men, representing 15% of deaths. Up to 90% of the cases are related to obesity, and 72% of Mexican adults are obese<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>. Thus, the public health system must simultaneously address these two diseases as an epidemiological emergency. This scenario may also be observed in other countries, particularly those of Latin America that have similarities to Mexico, which must also be aware of this risk.</p><p id="par0070" class="elsevierStylePara elsevierViewall">These seven cases were related to this metabolic disease, supporting that mucormycosis is an opportunistic fungal infection that affects critically ill patients of any age and with any kind of immunosuppression, particularly those living with diabetes.</p><p id="par0075" class="elsevierStylePara elsevierViewall">These cases are an example of what may become a more and more frequent diagnosis in the near future if this obesity epidemic is not reverted or at least slowed down.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0080" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors’ contributions</span><p id="par0085" class="elsevierStylePara elsevierViewall">Erick Martínez-Herrera: Data collection, analysis, and interpretation; effective participation in research orientation.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Angélica Julián-Castrejón: Effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases.</p><p id="par0095" class="elsevierStylePara elsevierViewall">María Guadalupe Frías-De-León: Data collection, analysis, and interpretation; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Gabriela Moreno Coutiño: Approval of the final version of the manuscript; study conception and planning; critical review of the literature; critical review of the manuscript.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1505256" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1366012" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Cases report" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Financial support" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Authors’ contributions" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-01-14" "fechaAceptado" => "2020-06-03" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1366012" "palabras" => array:4 [ 0 => "Diabetes mellitus" 1 => "Epidemics" 2 => "Mucormycosis" 3 => "Opportunistic infections" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The authors present seven cases of rhinocerebral mucormycosis associated to diabetes mellitus, which is a disease with epidemic proportions affecting individuals worldwide, particularly in developing countries, and which poses significant morbidity and mortality. Mucormycosis is an opportunistic fungal infection with high mortality and requires an invasive therapeutic approach to save the patient’s life with significant morbidity and sequelae, thus prevention is crucial.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Martínez-Herrera E, Julián-Castrejón A, Frías-De-León MG, Moreno-Coutiño G. Rhinocerebral mucormycosis to the rise? The impact of diabetes world epidemics. An Bras Dermatol. 2021;96:196–9.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Hospital Regional de Alta Especialidad de Ixtapaluca, Ixtapaluca, México.</p>" ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 648 "Ancho" => 905 "Tamanyo" => 136991 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0100" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Fungal structures. Thick hyphae are highlighted with PAS stain, next to a small vessel (PAS stain, ×40).</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" => 853 "Ancho" => 905 "Tamanyo" => 259694 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0105" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Numerous thick hyphae are observed (Grocott-Gomori stain, ×10).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1509 "Ancho" => 1505 "Tamanyo" => 175908 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0110" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Clinical picture of a patient before and after extensive surgery.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 811 "Ancho" => 1305 "Tamanyo" => 97303 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0115" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Necrotic area and its rapid progress.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0120" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sex/age \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Initial involved area \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Surgery (qx) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evolution \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Result \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Other diseases \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M/46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Eye, palate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">qx \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgical complications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Voluntary discharge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">F/18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Maxillary area \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">qx \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Released for improvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Obesity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">F/50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right face edema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No qx \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Died before surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HAS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M/45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right eye, hard palate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No qx \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Did not accept treatment option \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Died one monthlater \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">F/64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hard palate, Left eye \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Referred, lost to follow-up \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">F/41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left side of the face \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">qx \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complications and died \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nephrotic infection \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M/51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left eye, cervical pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">qx \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Discharged for improvement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2585829.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Patient data and evolution.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diabetes in the practice of otolaryngology" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Cohen Atsmoni" 1 => "A. Brener" 2 => "Y. Roth" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Diabetes Metab Syndr" "fecha" => "2019" "volumen" => "13" "paginaInicial" => "1141" "paginaFinal" => "1150" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of type 2 diabetes in developing countries: balancing optimal glycaemic control and outcomes with affordability and accessibility to treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "V. Mohan" 1 => "K. Khunti" 2 => "S.P. Chan" 3 => "F.F. Filho" 4 => "N.Q. Tran" 5 => "K. Ramaiya" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s13300-020-00812-2" "Revista" => array:6 [ "tituloSerie" => "Diabetes Ther" "fecha" => "2020" "volumen" => "11" "paginaInicial" => "15" "paginaFinal" => "35" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32323156" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rhinocerebral mucormycosis: report of a rare case" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R. Sahota" 1 => "R. Gambhir" 2 => "S. Anand" 3 => "A. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 19 | 5 | 24 |
| 2024 Outubro | 104 | 79 | 183 |
| 2024 Setembro | 159 | 77 | 236 |
| 2024 Agosto | 163 | 116 | 279 |
| 2024 Julho | 137 | 148 | 285 |
| 2024 Junho | 133 | 91 | 224 |
| 2024 Maio | 119 | 75 | 194 |
| 2024 Abril | 120 | 92 | 212 |
| 2024 Março | 93 | 79 | 172 |
| 2024 Fevereiro | 115 | 87 | 202 |
| 2024 Janeiro | 78 | 61 | 139 |
| 2023 Dezembro | 98 | 65 | 163 |
| 2023 Novembro | 106 | 86 | 192 |
| 2023 Outubro | 75 | 98 | 173 |
| 2023 Setembro | 87 | 95 | 182 |
| 2023 Agosto | 72 | 46 | 118 |
| 2023 Julho | 74 | 58 | 132 |
| 2023 Junho | 65 | 50 | 115 |
| 2023 Maio | 78 | 39 | 117 |
| 2023 Abril | 60 | 41 | 101 |
| 2023 Março | 92 | 66 | 158 |
| 2023 Fevereiro | 69 | 48 | 117 |
| 2023 Janeiro | 66 | 53 | 119 |
| 2022 Dezembro | 94 | 49 | 143 |
| 2022 Novembro | 104 | 80 | 184 |
| 2022 Outubro | 143 | 75 | 218 |
| 2022 Setembro | 65 | 84 | 149 |
| 2022 Agosto | 72 | 52 | 124 |
| 2022 Julho | 62 | 73 | 135 |
| 2022 Junho | 78 | 74 | 152 |
| 2022 Maio | 44 | 70 | 114 |
| 2022 Abril | 54 | 72 | 126 |
| 2022 Março | 63 | 79 | 142 |
| 2022 Fevereiro | 51 | 45 | 96 |
| 2022 Janeiro | 57 | 89 | 146 |
| 2021 Dezembro | 69 | 71 | 140 |
| 2021 Novembro | 53 | 71 | 124 |
| 2021 Outubro | 70 | 92 | 162 |
| 2021 Setembro | 62 | 75 | 137 |
| 2021 Agosto | 65 | 63 | 128 |
| 2021 Julho | 61 | 64 | 125 |
| 2021 Junho | 107 | 118 | 225 |
| 2021 Maio | 170 | 129 | 299 |
| 2021 Abril | 440 | 352 | 792 |
| 2021 Março | 77 | 65 | 142 |
| 2021 Fevereiro | 11 | 12 | 23 |
| 2021 Janeiro | 2 | 2 | 4 |
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