Case report
Purulent pericarditis: A rare diagnosis
Pericardite purulenta: um diagnóstico raro
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"733" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Doença cardíaca grave numa situação invulgar de polineuropatia amiloidótica familiar tipo-I" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "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" => 720 "Ancho" => 3335 "Tamanyo" => 386686 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Echocardiographic findings at age 66. M-mode revealed a dilated left atrium (56 mm) (A), an enlarged left ventricular cavity (58.47 mm) with wall thickening (15.11 mm) and a small pericardial effusion (B). Doppler showed diastolic transmitral flow with an E/A-wave ratio of 2.39 and a deceleration time of 147 ms (C).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Miguel Oliveira Santos, Dulce Brito" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Miguel" "apellidos" => "Oliveira Santos" ] 1 => array:2 [ "nombre" => "Dulce" "apellidos" => "Brito" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913002493?idApp=UINPBA00004E" "url" => "/21742049/0000003200000009/v1_201312060118/S2174204913002493/v1_201312060118/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2174204913002481" "issn" => "21742049" "doi" => "10.1016/j.repce.2012.12.005" "estado" => "S300" "fechaPublicacion" => "2013-09-01" "aid" => "312" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" 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=> array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 9 => array:3 [ "nombre" => "José Pedro" "apellidos" => "Saraiva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 10 => array:3 [ "nombre" => "Oliveira" "apellidos" => "Santos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Serviço de Cardiologia, Centro Hospital Tondela-Viseu, Viseu, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidade de Cuidados Intensivos Polivalente, Centro Hospital-Tondela, Viseu, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Pericardite purulenta: um diagnóstico raro" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1247 "Ancho" => 995 "Tamanyo" => 112058 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray (A) and transthoracic echocardiography (B) at admission.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pericardial disease mainly manifests as pericarditis and/or pericardial effusion (PE) and is caused by a variety of etiologies, including infection, inflammation and neoplasms, or iatrogenic, traumatic or metabolic origin, or unknown (idiopathic).</p><p id="par0010" class="elsevierStylePara elsevierViewall">It may occur in isolation, or be one component, of lesser or greater clinical importance, in the presentation of entities with systemic involvement.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case reports</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 1</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 39-year-old woman, with no history of disease and not taking regular medication, came to the emergency department for right lower back pain and worsening dyspnea on moderate exertion of one week's duration. She reported no fever, cough or expectoration, and was normotensive, with tachyarrhythmia and mild hypoxemic respiratory failure. Laboratory tests showed signs of inflammation and infection, the ECG revealed atrial fibrillation with rapid ventricular rate (≈115 bpm), and the chest X-ray showed increased cardiothoracic index and segmental infiltrate in the mid third of the right hemithorax (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was admitted with a diagnosis of community-acquired pneumonia, and empirical antibiotic therapy was begun with ceftriaxone and azithromycin. Thoracic computed tomography (CT) on the second day of hospitalization showed bilateral lung condensations, bilateral pleural effusion and PE, which on transthoracic echocardiography (TTE) measured 10 mm at the posterior wall in diastole, with no signs of cardiac tamponade. On the same day, there was a sudden deterioration of the clinical setting, evolving to septic shock, and the patient was transferred to the intensive care unit. Inotropic support was required for three days, but chemical cardioversion to sinus rhythm was achieved on the second day. On the third day, multisusceptible <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> was identified in blood samples collected at admission and therapy was begun with penicillin G. Respiratory and hemodynamic stabilization was achieved from the fourth day, although the patient still required mechanical ventilation and remained febrile, with no resolution of the infection on laboratory tests. The cardiac silhouette was still enlarged and serial TTE showed progressive worsening of the PE, which measured 20 mm at the posterior wall in diastole on the 10th day, with signs of cardiac tamponade (<a class="elsevierStyleCrossRefs" href="#fig0010">Figures 2 and 3</a>A). Pericardiocentesis was therefore performed for diagnostic purposes and drainage, 800 cc of fibrinous purulent fluid being drained (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>B), which was negative on bacteriological study, both direct and in culture. Screening for acid-alcohol resistant bacilli (AARB) was also negative. Subsequent TTE revealed resolution of the effusion, accompanied by clinical, radiological and laboratory improvement (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>). Screening for immune deficiency diseases was negative. The patient presented no constrictive pattern on TTE at 12-month follow-up.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Case 2</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 33-year-old man had a history of congenital hypogammaglobulinemia (diagnosed in 2001), chronic alcoholism and recurrent pneumonia, the last episode (in 2005) having been complicated by pleural effusion requiring decortication. He had taken no medication since 2005. He came to the emergency department for fever and worsening dyspnea over the previous five days. At admission, he was febrile, prostrate, tachycardic and hypotensive. Laboratory tests showed marked elevation of inflammatory and infectious parameters and arterial blood gas analysis revealed hypoxemic respiratory failure. A chest X-ray showed a markedly enlarged cardiac silhouette, with no parenchymal lung lesions; TTE was therefore performed, which confirmed the presence of a PE, measuring 23 mm at the posterior wall in diastole, with abnormal motion and diastolic collapse of the right atrial free wall (<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>A and B).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In view of the setting of septic/obstructive shock, the patient was transferred to the intensive care unit, and diagnostic and therapeutic pericardiocentesis was performed, 700 cc of purulent fluid being drained (<a class="elsevierStyleCrossRef" href="#fig0030">Figure 6</a>).</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Thoracic CT following pericardiocentesis showed a moderate PE, a small right pleural effusion and an area of parenchymal condensation in the superior and posterior segments of the left lower lobe, with air bronchograms, highly suggestive of inflammation.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient remained in cardiocirculatory shock and required inotropic support until the seventh day of hospitalization. Initially, the fluid drained was purulent, and then became serofibrinous. On the ninth day, the absence of pericardial fluid and evidence of a considerable reduction in the effusion (to 3 mm) at the posterior wall in diastole led to removal of the drain. Empirical antibiotic therapy with ceftriaxone and vancomycin had been begun at admission, which was changed to penicillin G on the third day following confirmation of multisusceptible <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> bacteremia. The presence of pneumococcus with the same susceptibility was confirmed in pericardial fluid, and screening for AARB was negative. Immunoglobulin was administered for four days, which was well tolerated and without complications. Fever returned on the 14th day, and TTE revealed a 15-mm PE at the posterior wall in diastole; repeat thoracic CT showed loci of pleural empyema. The patient was transferred to the thoracic surgery department of Coimbra University Hospitals, where he underwent surgical drainage and decortication of both pleurae, pericardiotomy and creation of a pleuropericardial window, resulting in considerable improvement in clinical and laboratory parameters (<a class="elsevierStyleCrossRef" href="#fig0035">Figure 7</a>).</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The patient presented no constrictive pattern on TTE at 12-month follow-up.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Pericardial effusion</span><p id="par0050" class="elsevierStylePara elsevierViewall">PE may develop as a result of pericarditis or arise as an epiphenomenon of greater or less clinical significance in a range of systemic disorders. The etiology of moderate PE is idiopathic in 29% of cases, but can be iatrogenic (16%), or due to neoplasms (13%), myocardial infarction (8%), uremia (6%), connective tissue or thyroid disease (5%) or infection (2%).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The etiological distribution of PE of acute presentation with cardiorespiratory symptoms is different: neoplasm (33%), idiopathic (14%), acute pericarditis (12%), trauma (12%), uremia (6%), post-pericardiotomy (5%) and infection (5%, 4% bacterial).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">It is essential to exclude PE in the following clinical contexts:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0065" class="elsevierStylePara elsevierViewall">acute pericarditis;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0070" class="elsevierStylePara elsevierViewall">enlarged cardiac silhouette without pulmonary congestion;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0075" class="elsevierStylePara elsevierViewall">severe hemodynamic deterioration following an acute coronary event, heart surgery or invasive cardiac procedure; and</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0080" class="elsevierStylePara elsevierViewall">persistent unexplained fever, whether or not the cause is determined.</p></li></ul></p><p id="par0085" class="elsevierStylePara elsevierViewall">A systematic approach to PE involves three stages<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">1.</span><p id="par0090" class="elsevierStylePara elsevierViewall">confirmation by TTE;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">2.</span><p id="par0095" class="elsevierStylePara elsevierViewall">assessment of hemodynamic repercussions (covering a wide spectrum of severity from benign to life-threatening, depending on its volume, the rate at which the effusion accumulates and pericardial elasticity); and</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">3.</span><p id="par0100" class="elsevierStylePara elsevierViewall">determination of etiology.</p></li></ul></p><p id="par0105" class="elsevierStylePara elsevierViewall">With regard to etiological determination, certain clinical contexts justify a non-invasive approach, including recent myocardial infarction, hypothyroidism and renal failure. In other cases, diagnosis is based on clinical evaluation as well as biochemical and bacteriological study of pericardial fluid or of the pericardium itself.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Pericardiocentesis has limited diagnostic value (6% of cases) in acute pericarditis. In patients with large chronic effusions, analysis of pericardial fluid leads to a definitive diagnosis in 36% and a probable diagnosis in 40%.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Pericardiocentesis guided by echography or fluoroscopy is formally indicated<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> in cases of:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">1.</span><p id="par0120" class="elsevierStylePara elsevierViewall">cardiac tamponade;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">2.</span><p id="par0125" class="elsevierStylePara elsevierViewall">effusion of >20 mm that does not respond after a week of conservative treatment with non-steroidal anti-inflammatory drugs; and</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">3.</span><p id="par0130" class="elsevierStylePara elsevierViewall">clinical suspicion of purulent, tuberculous or neoplastic pericarditis.</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Purulent pericarditis</span><p id="par0135" class="elsevierStylePara elsevierViewall">Purulent pericarditis is defined as an infection in the pericardial space that produces macroscopically or microscopically purulent fluid. It may be primary (extremely rare) or secondary to another infectious process. There are five pathogenic mechanisms that can lead to invasion of the pericardial space in secondary purulent pericarditis<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>:<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">1.</span><p id="par0140" class="elsevierStylePara elsevierViewall">contiguous spread from an intrathoracic site;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">2.</span><p id="par0145" class="elsevierStylePara elsevierViewall">hematogenous spread;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">3.</span><p id="par0150" class="elsevierStylePara elsevierViewall">extension from a myocardial site;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">4.</span><p id="par0155" class="elsevierStylePara elsevierViewall">perforating injury or surgery;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">5.</span><p id="par0160" class="elsevierStylePara elsevierViewall">extension from a subdiaphragmatic site.</p></li></ul></p><p id="par0165" class="elsevierStylePara elsevierViewall">Pneumococcus is more commonly associated with contiguous spread from an intrathoracic site, while <span class="elsevierStyleItalic">Staphylococcus aureus</span> is more often involved in hematogenous spread.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Purulent pericarditis is nowadays very rare, occurring most frequently in individuals with previous pericardial disease treated by chemotherapy, and in those who have undergone cardiac surgery or are receiving dialysis; immunosuppression, alcoholism and chest trauma are predisposing factors.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Before the advent of antibiotic therapy, it was a common complication of pneumonia, endocarditis, meningitis and other infections of varying severity, including of bone, skin and the ear.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">A retrospective analysis of a Spanish hospital population of 593 601 patients between 1972 and 1991 found 33 cases of purulent pericarditis, of which only 19 (57%) were diagnosed in life, basically because the diagnosis was not considered.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents a review of the literature, covering etiology, bacteriology, associated comorbidities, treatment and outcome.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">A patient with sepsis and a known underlying disease that explains the presence of PE makes prompt diagnosis of purulent pericarditis more difficult.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The diagnosis can only be confirmed by pericardiocentesis (which in such cases in therapeutic) by means of macroscopic examination of the fluid, which has the biochemical characteristics of an exudate and should be subjected to microscopic study, direct and in culture, to screen for bacteria, fungi and AARB.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Treatment must include drainage of the pericardial space, combined with systemic antibiotic therapy, initially empirical (vancomycin and ceftriaxone or imipenem, meropenem or piperacillin-tazobactam, together with fluconazole in immunocompromised patients), and then adjusted according to the results of microbiological study; local antibiotic therapy confers no benefit. Antibiotic therapy should be continued for at least 28 days, or until fever has subsided and there are no laboratory signs of infection.</p><p id="par0190" class="elsevierStylePara elsevierViewall">The strategy adopted to achieve complete drainage of the pericardial space will depend on the human and technical resources of the institution treating the patient<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,11</span></a>:<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">1.</span><p id="par0195" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Pericardiocentesis.</span> This is the simplest and fastest method, but is often ineffective in draining thick, loculated fibrinous fluid. It also the technique that most frequently leads to development of constrictive pericarditis. Intrapericardial infusion of fibrinolytics can increase its therapeutic efficacy but is associated with complications, and is thus not generally recommended.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">2.</span><p id="par0200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Pericardiotomy</span> (creating a pericardial window, subxiphoid if an isolated procedure). This is the method recommended in the European Society of Cardiology guidelines, since it is associated with a higher success rate and a lower incidence of constrictive pericarditis.</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">3.</span><p id="par0205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Pericardiectomy.</span> This is associated with mortality of 8% but it is the approach than resolves all situations, even the most complicated (adhesions, loculated effusions or persistent infection).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></li></ul></p><p id="par0210" class="elsevierStylePara elsevierViewall">Without drainage of the pericardial space, purulent pericarditis leads inexorably to death. Mortality in patients who are promptly diagnosed and appropriately treated is 40%, generally due to cardiac tamponade, septic shock or constriction. Mortality increases the longer diagnosis and treatment are delayed, and is higher in those with <span class="elsevierStyleItalic">S. aureus</span> infection and in malnourished patients.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusions</span><p id="par0215" class="elsevierStylePara elsevierViewall">The interest of these two cases resides mainly in the question of the approach to adopt in a septic patient with PE. Effusions with persistent fever, of known or unknown origin, should always raise the possibility of purulent pericarditis. This is true for both immunocompromised patients and previously healthy individuals who, even if they have no predisposing condition, have the same risk if they develop pneumonia – the main cause of purulent pericarditis identified in various series.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,7–10</span></a> In addition, although a diagnosis of purulent pericarditis is more likely the closer the primary infection site is to the pericardium, septic emboli from a suppurative site can lead to pericardial, myocardial or mediastinal spread through bronchial arteries without involving the rest of the systemic circulation,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> which was the most likely mechanism in the first case presented.</p><p id="par0220" class="elsevierStylePara elsevierViewall">Prompt diagnosis of purulent pericarditis and initiation of appropriate treatment are the mainstays of successful management of this rare but potentially lethal entity.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres296948" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec280614" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres296949" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec280613" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Case reports" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Case 2" ] ] ] 6 => array:3 [ "identificador" => "sec0025" "titulo" => "Discussion" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Pericardial effusion" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Purulent pericarditis" ] ] ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-07-25" "fechaAceptado" => "2013-04-11" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec280614" "palabras" => array:5 [ 0 => "Bacterial pericarditis" 1 => "Purulent pericarditis" 2 => "Pericardial effusion" 3 => "Tamponade" 4 => "Pneumonia" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec280613" "palabras" => array:5 [ 0 => "Pericardite bacteriana" 1 => "Pericardite purulenta" 2 => "Derrame pericárdico" 3 => "Tamponamento" 4 => "Pneumonia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The authors present two cases of purulent pericarditis secondary to pneumococcus pneumonia, a rare entity in the antibiotic era, one of them in an apparently healthy person. A systematized diagnostic approach to moderate pericardial effusion is presented, together with a review of purulent pericarditis. The presence of pericardial effusion with persistent fever with or without known etiology, particularly in the immunocompromised but also in the apparently healthy patient, should always raise the possibility of purulent pericarditis.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Os autores apresentam dois casos de pericardite purulenta secundária a pneumonia por <span class="elsevierStyleItalic">pneumococos</span>, um deles num doente sem antecedentes patológicos conhecidos. É feita uma sistematização da abordagem diagnóstica ao derrame pericárdico de moderadas dimensões e uma revisão da pericardite purulenta, uma entidade muito rara na era da antibioterapia. A constatação de derrame pericárdico com quadro de febre persistente, com ou sem origem conhecida, fundamentalmente no doente com compromisso imune, mas também no aparentemente saudável, deve levantar-se sempre a possibilidade de pericardite purulenta.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ferreira dos Santos L, Moreira D, Ribeiro P, et al. Pericardite purulenta: um diagnóstico raro. Rev Port Cardiol. 2013;32:721–727.</p>" ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 836 "Ancho" => 994 "Tamanyo" => 67325 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray at admission.</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" => 823 "Ancho" => 995 "Tamanyo" => 60664 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray on the 10th day.</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" => 588 "Ancho" => 1362 "Tamanyo" => 102675 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiography prior to pericardiocentesis (A) and pericardial fluid of purulent appearance (B).</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 801 "Ancho" => 994 "Tamanyo" => 61804 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray at discharge.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1247 "Ancho" => 995 "Tamanyo" => 112058 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray (A) and transthoracic echocardiography (B) at admission.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1115 "Ancho" => 995 "Tamanyo" => 128843 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Pericardial fluid of purulent appearance.</p>" ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 935 "Ancho" => 994 "Tamanyo" => 67053 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray at discharge.</p>" ] ] 7 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "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"><td 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" style="border-bottom: 2px solid black">Study \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Number of patients \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Comorbidities \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Origin of infection \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Bacteriology \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Outcome \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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">Sagrista-Sauleda et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33 \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">Alcoholism, rheumatoid arthritis, ulcerous colitis (n=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">Pneumonia (n=10)Peritonsilar abscess, cervical abscess, mediastinitis (n=5)Sepsis (skin, oral cavity, parenteral nutrition, colon cancer) (n=4)Periodontal infection, oral abscess, mediastinitis (n=3)Biliary tract infection (n=3)Urinary tract infection (n=2)Catheter-related sepsis, including temporary pacemaker (n=2)Post-traumatic subphrenic abscess (n=1)Meningitis (n=1)Mastoiditis (n=1)Liver transplant (n=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"><span class="elsevierStyleItalic">Peptococcus</span> sp., Gram-negative, anaerobic (n=1)<span class="elsevierStyleItalic">Streptococcus milleri</span> (n=1)<span class="elsevierStyleItalic">Streptococcus pneumoniae</span> (n=2)<span class="elsevierStyleItalic">Streptococcus mitis</span>, <span class="elsevierStyleItalic">Bacteroides</span> sp., Gram-negative, anaerobic (n=1)<span class="elsevierStyleItalic">Staphylococcus aureus</span> (n=2)<span class="elsevierStyleItalic">Clostridium septicum</span> (n=1)<span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> (n=2)<span class="elsevierStyleItalic">Escherichia coli</span> (n=1)<span class="elsevierStyleItalic">Staphylococcus aureus, S. mitis</span>, <span class="elsevierStyleItalic">P. aeruginosa</span> (n=1)<span class="elsevierStyleItalic">Klebsiella</span> sp., <span class="elsevierStyleItalic">E. faecalis, Proteus</span> sp. (n=1)<span class="elsevierStyleItalic">E. coli</span>, <span class="elsevierStyleItalic">Klebsiella</span> sp. (n=1)<span class="elsevierStyleItalic">E. coli</span>, anaerobic (n=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">Pericardiocentesis followed by pericardiectomy (n=12)Pericardiectomy as initial approach (n=4)Pericardiocentesis (n=2)Post-mortem diagnosis (n=14) \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">Death (n=3, due to renal failure n=1, complications due to pericardial disease n=2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Kauffman et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">118 \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">Chronic alcoholism (n=2), hypogammaglobulinemia (n=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">Pneumonia (n=81)Pneumonia and empyema (n=58)Otitis media (n=6)Arthritis (n=2)Subcutaneous abscess (n=2)Meningitis (n=1)Endocarditis (n=1)None identified (n=2)NB Some patients had more than one site of infection. \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"><span class="elsevierStyleItalic">S. pneumoniae</span> (all patients) \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">None (n=52)Pericardiectomy (n=49)Pericardiectomy + antibiotic therapy (n=10)Pericardiocentesis (n=1)Pericardiocentesis + antibiotic therapy (n=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">Death (n=64, including all who received no treatment, 19 who underwent pericardiectomy only, and one who underwent pericardiocentesis only) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Rubin et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 \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">Liver failure (n=2)Uremia (n=1)Diabetes (n=3)Leukopenia (n=1)Third degree burns (n=2)Acute lymphoblastic leukemia (n=1)Iatrogenic immunosuppression (n=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">Esophageal perforation following thoracic surgery (n=2)Wound infection following thoracic surgery (n=6)Pneumonia (n=6)Mediastinal abscess (n=1)Infective endocarditis (n=3)Intramyocardial abscess (n=2)Bacteremia (n=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"><span class="elsevierStyleItalic">S. aureus</span> (n=8)<span class="elsevierStyleItalic">S. pneumoniae</span> (n=2)<span class="elsevierStyleItalic">Haemophilus influenzae</span> (n=2)<span class="elsevierStyleItalic">Neisseria meningitidis</span> (n=1)<span class="elsevierStyleItalic">P. aeruginosa</span> (n=1)<span class="elsevierStyleItalic">Bacteroides</span> spp. (n=1)<span class="elsevierStyleItalic">Salmonella typhimurium</span> (n=1)<span class="elsevierStyleItalic">Nocardia asteroides</span> (n=1)<span class="elsevierStyleItalic">S. mitis</span> (n=1)Mixed bacterial infections (n=2)<span class="elsevierStyleItalic">Candida</span> spp. (n=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">Antibiotic therapy + pericardiocentesis (n=11)Antibiotic therapy without pericardiocentesis (n=15) \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">Death (n=15, patients who received antibiotic therapy only) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><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">Klacsmann et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">200 \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">Chronic renal disease (n=16)Cancer (13)Acute myocardial infarction (n=2)Diabetes, myeloproliferative disease (n=10)Sickle-cell anemia (n=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">Pneumonia (n=104)Bacteremia (n=44)Endocarditis/myocardial abscess (n=30)Perforating chest injury (n=18)Suppurative subdiaphragmatic lesion (n=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"><span class="elsevierStyleItalic">Pneumococcus</span> sp. (n=69)<span class="elsevierStyleItalic">Staphylococcus</span> sp. (n=38)<span class="elsevierStyleItalic">Streptococcus</span> sp. (n=21)<span class="elsevierStyleItalic">Proteus</span> sp., <span class="elsevierStyleItalic">E. coli</span>, <span class="elsevierStyleItalic">Pseudomonas</span> sp., <span class="elsevierStyleItalic">Klebsiella</span> sp. (n=25)<span class="elsevierStyleItalic">Salmonella</span>/<span class="elsevierStyleItalic">Shigella</span> (n=4)<span class="elsevierStyleItalic">N. meningitidis</span> (n=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">Post-mortem diagnosis (n=200) \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">Death (all patients) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab433148.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Purulent pericarditis: brief review of the literature.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pericardial diseases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 19 | 10 | 29 |
| 2024 October | 115 | 76 | 191 |
| 2024 September | 118 | 58 | 176 |
| 2024 August | 116 | 46 | 162 |
| 2024 July | 90 | 54 | 144 |
| 2024 June | 77 | 34 | 111 |
| 2024 May | 111 | 46 | 157 |
| 2024 April | 77 | 39 | 116 |
| 2024 March | 88 | 44 | 132 |
| 2024 February | 72 | 36 | 108 |
| 2024 January | 100 | 38 | 138 |
| 2023 December | 66 | 36 | 102 |
| 2023 November | 90 | 38 | 128 |
| 2023 October | 80 | 39 | 119 |
| 2023 September | 73 | 39 | 112 |
| 2023 August | 56 | 38 | 94 |
| 2023 July | 81 | 23 | 104 |
| 2023 June | 54 | 30 | 84 |
| 2023 May | 117 | 41 | 158 |
| 2023 April | 91 | 16 | 107 |
| 2023 March | 96 | 37 | 133 |
| 2023 February | 84 | 30 | 114 |
| 2023 January | 60 | 19 | 79 |
| 2022 December | 77 | 20 | 97 |
| 2022 November | 105 | 31 | 136 |
| 2022 October | 83 | 28 | 111 |
| 2022 September | 44 | 38 | 82 |
| 2022 August | 69 | 37 | 106 |
| 2022 July | 65 | 33 | 98 |
| 2022 June | 46 | 21 | 67 |
| 2022 May | 64 | 38 | 102 |
| 2022 April | 48 | 32 | 80 |
| 2022 March | 90 | 34 | 124 |
| 2022 February | 101 | 25 | 126 |
| 2022 January | 178 | 24 | 202 |
| 2021 December | 107 | 33 | 140 |
| 2021 November | 88 | 43 | 131 |
| 2021 October | 126 | 44 | 170 |
| 2021 September | 112 | 31 | 143 |
| 2021 August | 121 | 32 | 153 |
| 2021 July | 81 | 44 | 125 |
| 2021 June | 86 | 24 | 110 |
| 2021 May | 71 | 39 | 110 |
| 2021 April | 162 | 58 | 220 |
| 2021 March | 170 | 28 | 198 |
| 2021 February | 126 | 22 | 148 |
| 2021 January | 111 | 16 | 127 |
| 2020 December | 111 | 4 | 115 |
| 2020 November | 106 | 21 | 127 |
| 2020 October | 114 | 13 | 127 |
| 2020 September | 166 | 17 | 183 |
| 2020 August | 38 | 11 | 49 |
| 2020 July | 100 | 10 | 110 |
| 2020 June | 74 | 14 | 88 |
| 2020 May | 85 | 13 | 98 |
| 2020 April | 120 | 18 | 138 |
| 2020 March | 120 | 9 | 129 |
| 2020 February | 185 | 29 | 214 |
| 2020 January | 149 | 21 | 170 |
| 2019 December | 116 | 26 | 142 |
| 2019 November | 143 | 16 | 159 |
| 2019 October | 149 | 10 | 159 |
| 2019 September | 200 | 26 | 226 |
| 2019 August | 109 | 14 | 123 |
| 2019 July | 120 | 25 | 145 |
| 2019 June | 125 | 17 | 142 |
| 2019 May | 157 | 27 | 184 |
| 2019 April | 167 | 23 | 190 |
| 2019 March | 236 | 21 | 257 |
| 2019 February | 263 | 35 | 298 |
| 2019 January | 193 | 18 | 211 |
| 2018 December | 209 | 30 | 239 |
| 2018 November | 232 | 23 | 255 |
| 2018 October | 320 | 41 | 361 |
| 2018 September | 100 | 14 | 114 |
| 2018 August | 133 | 16 | 149 |
| 2018 July | 81 | 4 | 85 |
| 2018 June | 121 | 8 | 129 |
| 2018 May | 110 | 9 | 119 |
| 2018 April | 161 | 10 | 171 |
| 2018 March | 182 | 6 | 188 |
| 2018 February | 82 | 8 | 90 |
| 2018 January | 66 | 8 | 74 |
| 2017 December | 79 | 8 | 87 |
| 2017 November | 55 | 12 | 67 |
| 2017 October | 72 | 11 | 83 |
| 2017 September | 75 | 11 | 86 |
| 2017 August | 72 | 19 | 91 |
| 2017 July | 78 | 11 | 89 |
| 2017 June | 133 | 9 | 142 |
| 2017 May | 227 | 13 | 240 |
| 2017 April | 117 | 8 | 125 |
| 2017 March | 240 | 36 | 276 |
| 2017 February | 238 | 7 | 245 |
| 2017 January | 108 | 6 | 114 |
| 2016 December | 71 | 10 | 81 |
| 2016 November | 122 | 8 | 130 |
| 2016 October | 206 | 11 | 217 |
| 2016 September | 222 | 24 | 246 |
| 2016 August | 46 | 4 | 50 |
| 2016 July | 36 | 13 | 49 |
| 2016 June | 27 | 12 | 39 |
| 2016 May | 27 | 23 | 50 |
| 2016 April | 121 | 2 | 123 |
| 2016 March | 179 | 19 | 198 |
| 2016 February | 181 | 32 | 213 |
| 2016 January | 145 | 25 | 170 |
| 2015 December | 153 | 10 | 163 |
| 2015 November | 148 | 18 | 166 |
| 2015 October | 151 | 19 | 170 |
| 2015 September | 123 | 22 | 145 |
| 2015 August | 161 | 32 | 193 |
| 2015 July | 177 | 12 | 189 |
| 2015 June | 119 | 12 | 131 |
| 2015 May | 93 | 17 | 110 |
| 2015 April | 115 | 26 | 141 |
| 2015 March | 122 | 16 | 138 |
| 2015 February | 125 | 17 | 142 |
| 2015 January | 117 | 14 | 131 |
| 2014 December | 120 | 19 | 139 |
| 2014 November | 105 | 12 | 117 |
| 2014 October | 173 | 18 | 191 |
| 2014 September | 114 | 11 | 125 |
| 2014 August | 94 | 12 | 106 |
| 2014 July | 90 | 14 | 104 |
| 2014 June | 81 | 10 | 91 |
| 2014 May | 97 | 20 | 117 |
| 2014 April | 89 | 18 | 107 |
| 2014 March | 115 | 21 | 136 |
| 2014 February | 92 | 19 | 111 |
| 2014 January | 85 | 24 | 109 |
| 2013 December | 49 | 20 | 69 |
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