Case report
Mesalamine-induced myocarditis following diagnosis of Crohn's disease: A case report
Miocardite induzida pela mesalamina após o diagnóstico de doença de Crohn – relato de um caso clínico
Carlos Galvão Braga
, Juliana Martins, Carina Arantes, Vítor Ramos, Catarina Vieira, Alberto Salgado, Sónia Magalhães, Adelino Correia
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Serviço de Cardiologia, Hospital de Braga, Braga, Portugal
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true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "717" "paginaFinal" => "720" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Carlos Galvão Braga, Juliana Martins, Carina Arantes, Vítor Ramos, Catarina Vieira, Alberto Salgado, Sónia Magalhães, Adelino Correia" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Carlos" "apellidos" => "Galvão Braga" "email" => array:1 [ 0 => "carlos.galvaobraga@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Juliana" "apellidos" => "Martins" ] 2 => array:2 [ "nombre" => "Carina" "apellidos" => "Arantes" ] 3 => array:2 [ "nombre" => "Vítor" "apellidos" => "Ramos" ] 4 => array:2 [ "nombre" => "Catarina" "apellidos" => "Vieira" ] 5 => array:2 [ "nombre" => "Alberto" "apellidos" => "Salgado" ] 6 => array:2 [ "nombre" => "Sónia" "apellidos" => "Magalhães" ] 7 => array:2 [ "nombre" => "Adelino" "apellidos" => "Correia" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Hospital de Braga, Braga, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Miocardite induzida pela mesalamina após o diagnóstico de doença de Crohn – relato de um caso clínico" ] ] "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" => 1524 "Ancho" => 3167 "Tamanyo" => 907041 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Electrocardiogram on day of chest pain onset: sinus rhythm and slight ST-segment elevation with upward concavity in leads I, II, III, aVF and V3–V6.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Mesalamine (5-aminosalicylic acid) is a well-known treatment for inflammatory bowel disease, often used as the first-line drug. Although rare, adverse cardiac reactions due to mesalamine have been described in the literature, and include pericarditis, myocarditis, coronary vasculitis and left ventricular dysfunction.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> We report a case of mesalamine-induced myocarditis in a patient with a recent diagnosis of Crohn's disease.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 19-year-old male with no relevant medical history, besides having been diagnosed two weeks previously with Crohn's disease for which he was medicated with mesalamine 1500 mg twice a day and budesonide 9 mg daily, was admitted to the local hospital with retrosternal chest pain radiating to the left arm. He reported no accompanying symptoms and no relieving or aggravating factors were identified. The patient had no reported previous infection. The physical examination was unremarkable and there were no signs of hemodynamic instability or heart failure. The initial 12-lead electrocardiogram revealed sinus rhythm and slight ST-segment elevation with upward concavity in leads I, II, III, aVF and V3–V6 (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). As laboratory tests showed elevated cardiac necrosis biomarkers (troponin I 9.1 ng/ml), he was transferred to our hospital for cardiological evaluation. Following admission to the cardiac care unit, he mentioned some episodes of chest pain which improved after treatment with aspirin. Repeated blood tests demonstrated a further increase in cardiac biomarkers (peak troponin I 27.3 ng/ml and peak total CK 915 IU/l) accompanied by elevation of NT-proBNP (6413 pg/ml) and inflammatory parameters (C-reactive protein 130 mg/l, 15<span class="elsevierStyleHsp" style=""></span>800 leukocytes). Remodeling therapy with ACE inhibitors and beta-blockers was also introduced, due to the moderately depressed left ventricular systolic function (ejection fraction of 38%) seen on the transthoracic echocardiogram, with global hypocontractility, although more noticeable in the posterior, inferior and lateral walls (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). Cardiac magnetic resonance imaging (MRI) with delayed gadolinium enhancement revealed multiple areas of myocardial fibrosis, mainly subepicardial, suggesting a non-ischemic pattern (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). There was no sign of myocardial infarction and the patient was therefore diagnosed with acute myocarditis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In view of mesalamine's cardiovascular toxicity as described in the literature, this drug was discontinued shortly after admission. The patient remained asymptomatic thereafter and laboratory tests were favorable (NT-proBNP 905 pg/ml and troponin I 0.13 ng/ml at discharge). Electrocardiograms showed progressive resolution of ST-segment elevation and the echocardiogram was repeated one week later, demonstrating improvement in left ventricular systolic function (ejection fraction of 45%).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Classic myocarditis refers to inflammation of the heart muscle as a result of exposure to either discrete external antigen triggers, such as viruses, bacteria, parasites or drugs, or to internal triggers such as autoimmune activation against self-antigens. Drugs can act as a direct toxic agent (anthracyclines and cocaine) or by a hypersensitivity reaction, as is thought to be the case with mesalamine and other medications (clozapine, sulfonamides, cephalosporins, penicillins and tricyclic antidepressants).<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Cardiac disease can be associated with Crohn's disease as an extraintestinal manifestation of inflammatory bowel disease or as a consequence of drug-induced side effects.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> Myocarditis associated with mesalamine is a rare but potentially serious phenomenon, generally occurring 2–4 weeks after the initial exposure to the drug, although presentation may be delayed over years, especially if steroids are used concomitantly.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Mesalamine's mechanism of action is not fully understood, but it includes inhibition of the cyclooxygenase pathway, inducing an anti-inflammatory effect in the colon. The exact mechanism for mesalamine-induced myocardial inflammation is not clearly identified, but it is thought to be a hypersensitivity reaction rather than a cytotoxic effect.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> One proposed mechanism is humoral-mediated hypersensitivity, in which antibodies formed against mesalamine cross-react with cardiac tissue causing inflammation.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The diagnosis of hypersensitivity myocarditis is supported by two facts: inflammation worsens if mesalamine is reintroduced during the acute phase,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and resolution of symptoms occurs within one week after drug discontinuation, as has been described in all reported cases.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> Eosinophilic infiltration of the myocardium on endomyocardial biopsy has also been described,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> which seems to confirm the link between mesalamine and hypersensitivity myocarditis.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In our case, the onset and resolution of symptoms were similar to those reported in the literature. Soon after discontinuing mesalamine, our patient evolved well, with progressive falls in cardiac biomarkers and improvement in left ventricular systolic function. Considering this evolution and the fact that there was no previous infection, mesalamine-induced myocarditis was considered to be the most likely diagnosis.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0035" class="elsevierStylePara elsevierViewall">This case illustrates the importance of eliciting a thorough medical history and being aware of the timing when new medications are started. It is imperative that any new onset of chest pain in the setting of inflammatory bowel disease treated with mesalamine should be evaluated via cardiac enzymes, electrocardiogram, echocardiogram and possibly cardiac MRI to rapidly diagnose any complication caused by either the inflammatory bowel disease itself or an adverse drug reaction.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflict of interests</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres276699" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec258653" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres276700" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec258654" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-12-01" "fechaAceptado" => "2012-12-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec258653" "palabras" => array:4 [ 0 => "Myocarditis" 1 => "Mesalamine" 2 => "Transthoracic echocardiography" 3 => "Cardiac magnetic resonance imaging" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec258654" "palabras" => array:4 [ 0 => "Miocardite" 1 => "Mesalamina" 2 => "Ecocardiografia transtorácica" 3 => "Ressonância magnética cardíaca" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mesalamine is a common treatment for Crohn's disease, and can be rarely associated with myocarditis through a mechanism of drug hypersensitivity. We present the case of a 19-year-old male who developed chest pain two weeks after beginning mesalamine therapy. The electrocardiogram showed slight ST-segment elevation with upward concavity in the inferolateral leads; blood tests demonstrated elevated troponin I and the echocardiogram revealed moderately depressed left ventricular systolic function with global hypocontractility. Cardiac magnetic resonance imaging confirmed the diagnosis of myocarditis, revealing multiple areas of subepicardial fibrosis. The onset of symptoms after mesalamine, and improvement of chest pain, cardiac biomarkers and left ventricular systolic function after discontinuing the drug, suggest that our patient suffered from a rare drug-hypersensitivity reaction to mesalamine.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A mesalamina é um tratamento comum para a doença de Crohn, associando-se de forma rara à miocardite aguda, através de uma reação de hipersensibilidade ao fármaco. Os autores apresentam o caso clínico de um jovem de 19 anos com aparecimento de dor torácica duas semanas após ter iniciado tratamento com mesalamina para a doença de Crohn. O eletrocardiograma mostrou um discreto supradesnivelamento do segmento ST, de concavidade ascendente, nas derivações infero-laterais; as análises revelaram elevação da troponina I e o ecocardiograma exibiu uma depressão moderada da função sistólica do ventrículo esquerdo, por hipocontractilidade global. A ressonância magnética cardíaca confirmou o diagnóstico de miocardite, evidenciando múltiplas áreas de fibrose subepicárdica. O início dos sintomas após o começo da mesalamina e a melhoria da dor torácica, biomarcadores cardíacos e função sistólica ventricular esquerda após a suspensão do medicamento, sugerem que o nosso paciente teve uma reação rara de hipersensibilidade à mesalamina.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1524 "Ancho" => 3167 "Tamanyo" => 907041 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Electrocardiogram on day of chest pain onset: sinus rhythm and slight ST-segment elevation with upward concavity in leads I, II, III, aVF and V3–V6.</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" => 1015 "Ancho" => 2333 "Tamanyo" => 181803 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Echocardiogram in parasternal short-axis view showing moderately depressed left ventricular systolic function (ejection fraction of 38%), with global hypocontractility, although more obvious in the posterior, inferior and lateral walls (A – diastole; B – systole).</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" => 948 "Ancho" => 2333 "Tamanyo" => 170329 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Cardiac magnetic resonance imaging with myocardial suppression after contrast. Late gadolinium enhancement reveals multiple areas of subepicardial myocardial fibrosis, mainly in the inferior and lateral walls, in short-axis (A) and 4-chamber views (B).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mesalamine-induced myocarditis and coronary vasculitis in a pediatric ulcerative colitis patient: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E. Perez-Colon" 1 => "G.H. Dadlani" 2 => "I. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 18 | 9 | 27 |
| 2024 Outubro | 85 | 29 | 114 |
| 2024 Setembro | 110 | 25 | 135 |
| 2024 Agosto | 78 | 32 | 110 |
| 2024 Julho | 53 | 30 | 83 |
| 2024 Junho | 47 | 29 | 76 |
| 2024 Maio | 72 | 19 | 91 |
| 2024 Abril | 40 | 31 | 71 |
| 2024 Maro | 57 | 27 | 84 |
| 2024 Fevereiro | 44 | 22 | 66 |
| 2024 Janeiro | 39 | 23 | 62 |
| 2023 Dezembro | 53 | 29 | 82 |
| 2023 Novembro | 46 | 16 | 62 |
| 2023 Outubro | 54 | 17 | 71 |
| 2023 Setembro | 42 | 21 | 63 |
| 2023 Agosto | 48 | 19 | 67 |
| 2023 Julho | 34 | 15 | 49 |
| 2023 Junho | 33 | 10 | 43 |
| 2023 Maio | 48 | 22 | 70 |
| 2023 Abril | 47 | 7 | 54 |
| 2023 Maro | 57 | 22 | 79 |
| 2023 Fevereiro | 42 | 18 | 60 |
| 2023 Janeiro | 35 | 10 | 45 |
| 2022 Dezembro | 42 | 16 | 58 |
| 2022 Novembro | 50 | 30 | 80 |
| 2022 Outubro | 40 | 23 | 63 |
| 2022 Setembro | 43 | 26 | 69 |
| 2022 Agosto | 40 | 28 | 68 |
| 2022 Julho | 39 | 26 | 65 |
| 2022 Junho | 32 | 18 | 50 |
| 2022 Maio | 26 | 31 | 57 |
| 2022 Abril | 42 | 30 | 72 |
| 2022 Maro | 30 | 31 | 61 |
| 2022 Fevereiro | 32 | 23 | 55 |
| 2022 Janeiro | 39 | 25 | 64 |
| 2021 Dezembro | 46 | 22 | 68 |
| 2021 Novembro | 66 | 36 | 102 |
| 2021 Outubro | 41 | 51 | 92 |
| 2021 Setembro | 48 | 30 | 78 |
| 2021 Agosto | 57 | 29 | 86 |
| 2021 Julho | 61 | 31 | 92 |
| 2021 Junho | 53 | 12 | 65 |
| 2021 Maio | 44 | 30 | 74 |
| 2021 Abril | 72 | 38 | 110 |
| 2021 Maro | 81 | 14 | 95 |
| 2021 Fevereiro | 83 | 29 | 112 |
| 2021 Janeiro | 42 | 14 | 56 |
| 2020 Dezembro | 36 | 13 | 49 |
| 2020 Novembro | 43 | 16 | 59 |
| 2020 Outubro | 22 | 10 | 32 |
| 2020 Setembro | 50 | 8 | 58 |
| 2020 Agosto | 27 | 5 | 32 |
| 2020 Julho | 50 | 5 | 55 |
| 2020 Junho | 41 | 9 | 50 |
| 2020 Maio | 61 | 0 | 61 |
| 2020 Abril | 42 | 11 | 53 |
| 2020 Maro | 65 | 6 | 71 |
| 2020 Fevereiro | 119 | 37 | 156 |
| 2020 Janeiro | 38 | 6 | 44 |
| 2019 Dezembro | 36 | 12 | 48 |
| 2019 Novembro | 41 | 3 | 44 |
| 2019 Outubro | 67 | 6 | 73 |
| 2019 Setembro | 95 | 12 | 107 |
| 2019 Agosto | 49 | 17 | 66 |
| 2019 Julho | 53 | 11 | 64 |
| 2019 Junho | 34 | 6 | 40 |
| 2019 Maio | 48 | 5 | 53 |
| 2019 Abril | 36 | 14 | 50 |
| 2019 Maro | 107 | 12 | 119 |
| 2019 Fevereiro | 103 | 12 | 115 |
| 2019 Janeiro | 104 | 6 | 110 |
| 2018 Dezembro | 102 | 12 | 114 |
| 2018 Novembro | 94 | 15 | 109 |
| 2018 Outubro | 160 | 21 | 181 |
| 2018 Setembro | 41 | 10 | 51 |
| 2018 Agosto | 50 | 13 | 63 |
| 2018 Julho | 48 | 7 | 55 |
| 2018 Junho | 72 | 5 | 77 |
| 2018 Maio | 62 | 15 | 77 |
| 2018 Abril | 73 | 6 | 79 |
| 2018 Maro | 90 | 7 | 97 |
| 2018 Fevereiro | 63 | 6 | 69 |
| 2018 Janeiro | 78 | 4 | 82 |
| 2017 Dezembro | 95 | 20 | 115 |
| 2017 Novembro | 67 | 5 | 72 |
| 2017 Outubro | 45 | 17 | 62 |
| 2017 Setembro | 59 | 11 | 70 |
| 2017 Agosto | 56 | 14 | 70 |
| 2017 Julho | 46 | 21 | 67 |
| 2017 Junho | 37 | 9 | 46 |
| 2017 Maio | 88 | 13 | 101 |
| 2017 Abril | 43 | 32 | 75 |
| 2017 Maro | 34 | 12 | 46 |
| 2017 Fevereiro | 72 | 7 | 79 |
| 2017 Janeiro | 38 | 14 | 52 |
| 2016 Dezembro | 50 | 15 | 65 |
| 2016 Novembro | 41 | 11 | 52 |
| 2016 Outubro | 59 | 12 | 71 |
| 2016 Setembro | 120 | 17 | 137 |
| 2016 Agosto | 46 | 8 | 54 |
| 2016 Julho | 23 | 18 | 41 |
| 2016 Junho | 3 | 19 | 22 |
| 2016 Maio | 21 | 0 | 21 |
| 2016 Abril | 62 | 3 | 65 |
| 2016 Maro | 85 | 13 | 98 |
| 2016 Fevereiro | 109 | 15 | 124 |
| 2016 Janeiro | 101 | 15 | 116 |
| 2015 Dezembro | 107 | 10 | 117 |
| 2015 Novembro | 94 | 10 | 104 |
| 2015 Outubro | 73 | 10 | 83 |
| 2015 Setembro | 111 | 14 | 125 |
| 2015 Agosto | 87 | 16 | 103 |
| 2015 Julho | 136 | 13 | 149 |
| 2015 Junho | 55 | 11 | 66 |
| 2015 Maio | 88 | 13 | 101 |
| 2015 Abril | 70 | 17 | 87 |
| 2015 Maro | 80 | 11 | 91 |
| 2015 Fevereiro | 65 | 8 | 73 |
| 2015 Janeiro | 73 | 17 | 90 |
| 2014 Dezembro | 74 | 15 | 89 |
| 2014 Novembro | 42 | 12 | 54 |
| 2014 Outubro | 62 | 11 | 73 |
| 2014 Setembro | 58 | 31 | 89 |
| 2014 Agosto | 42 | 11 | 53 |
| 2014 Julho | 64 | 12 | 76 |
| 2014 Junho | 50 | 12 | 62 |
| 2014 Maio | 56 | 14 | 70 |
| 2014 Abril | 71 | 14 | 85 |
| 2014 Maro | 104 | 23 | 127 |
| 2014 Fevereiro | 95 | 28 | 123 |
| 2014 Janeiro | 116 | 43 | 159 |
| 2013 Dezembro | 92 | 40 | 132 |
| 2013 Novembro | 100 | 38 | 138 |
| 2013 Outubro | 98 | 46 | 144 |
| 2013 Setembro | 13 | 7 | 20 |
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