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Fungal cerebral abscess in a diabetic patient successfully treated with surgery followed by prolonged antifungal therapy
Absceso cerebral por hongos en un paciente diabético tratado con éxito con cirugía seguida de terapia antimicótica prolongada
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"apellidos" => "García" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130140610000033?idApp=UINPBA00004N" "url" => "/11301406/0000002700000001/v1_201305061340/S1130140610000033/v1_201305061340/es/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Note</span>" "titulo" => "Fungal cerebral abscess in a diabetic patient successfully treated with surgery followed by prolonged antifungal therapy" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "6" "paginaFinal" => "9" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Claudio Yampolsky, Marcelo Corti, Ricardo Negroni" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Claudio" "apellidos" => "Yampolsky" "email" => array:1 [ 0 => "claudioyampolsky@fibertel.com.ar" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff1" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor1" ] ] ] 1 => array:3 [ "nombre" => "Marcelo" "apellidos" => "Corti" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff1" ] ] ] 2 => array:3 [ "nombre" => "Ricardo" "apellidos" => "Negroni" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff2" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Infectious Diseases, F.J. Muñiz Hospital, Buenos Aires, Argentina" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff1" ] 1 => array:3 [ "entidad" => "Mycology Unit, Infectious Diseases, F.J. Muñiz Hospital, Buenos Aires, Argentina" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff2" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "⁎" "correspondencia" => "corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Absceso cerebral por hongos en un paciente diabético tratado con éxito con cirugía seguida de terapia antimicótica prolongada" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig4" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 899 "Ancho" => 980 "Tamanyo" => 121046 ] ] "descripcion" => array:1 [ "en" => "<p class="elsevierStyleSimplePara elsevierViewall">Surgical purulent specimen.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p class="elsevierStylePara elsevierViewall">Intracranial fungal masses are uncommon diseases but their incidence is increasing, mostly due to the prolonged survival of patients with different immunodeficiencies. AIDS, cancer chemotherapy, hematopoietic stem cell transplantation and solid organ transplantation also contribute to the increased risk of invasive fungal infections.<a class="elsevierStyleCrossRefs" href="#bib3"><span class="elsevierStyleSup">3,7,19</span></a> The use of vascular catheters, exposure to broad-spectrum antimicrobial agents, prolonged stay in intensive care units and parenteral nutrition are recognized as risk factors for candidemia.<a class="elsevierStyleCrossRef" href="#bib17"><span class="elsevierStyleSup">17</span></a> Additionally, fungal infections of the central nervous system (CNS) account for a high proportion of opportunistic infections in patients with HIV-AIDS disease.<a class="elsevierStyleCrossRef" href="#bib24"><span class="elsevierStyleSup">24</span></a></p><p class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Candida</span>, <span class="elsevierStyleItalic">Aspergillus</span> and <span class="elsevierStyleItalic">Cryptococcus</span> are the most common fungal pathogens responsible for the majority of brain abscesses in immunocompromised patients.<a class="elsevierStyleCrossRef" href="#bib1"><span class="elsevierStyleSup">1</span></a></p><span class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p class="elsevierStylePara elsevierViewall">A 51-year-old man with history of psoriasis and type-2 diabetes, treated with metformin but with poor glycemic control, was admitted to our hospital, reporting 2 months of headaches and generalized tonic–clonic seizure episodes. He referred to a previous hospitalization 1 year before, owing to a psoas abscess due to <span class="elsevierStyleItalic">Candida albicans.</span> He did not receive statins as hypolipidemic drugs or anti-TNF drugs for psoriasis. Physical examination revealed fever (38<span class="elsevierStyleHsp" style=""></span>°C), tachycardia (102<span class="elsevierStyleHsp" style=""></span>beats/min) and weight loss (approximately 10<span class="elsevierStyleHsp" style=""></span>kg in the previous 3 months). The patient also presented a focal neurological syndrome involving paresis with weakness of his left arm. Lung auscultation was normal; abdominal examination revealed hepatomegaly; the spleen was not palpable.</p><p class="elsevierStylePara elsevierViewall">Relevant laboratory findings were anemia with hematocrit 31%, hemoglobin 9<span class="elsevierStyleHsp" style=""></span>g/mL, leukocytes 6100/mm<span class="elsevierStyleSup">3</span> (76% of PMN), platelet count 131<span class="elsevierStyleHsp" style=""></span>000/mm<span class="elsevierStyleSup">3</span> and hyperglycemia (196<span class="elsevierStyleHsp" style=""></span>g/dL) with plasma glycosylated hemoglobin (HbA1c) >7.0<span class="elsevierStyleHsp" style=""></span>g%. Renal function evaluated by the creatinine clearance was normal. Liver enzyme levels, coagulation tests and chest radiograph were normal. Blood and urine cultures for bacteriae, mycobacteriae and fungi were negative. A transthoracic echocardiogram was performed with no signs of vegetations in cardiac valves. Abdominal ultrasonography showed hepatomegaly and findings consistent with non-alcoholic hepatic steatosis.</p><p class="elsevierStylePara elsevierViewall">Videocolonoscopy was normal. Computed tomography of thorax, abdomen and pelvis was also normal. Brain magnetic resonance imaging (MRI) showed a single lesion located in the right parietal lobe with mass effect, surrounding edema and enhancement after injection of gadolinium (<a class="elsevierStyleCrossRefs" href="#fig1">Figs. 1 and 2</a>). MRI of the dorsolumbar spine was normal. Lumbar puncture was not performed because of the presence of cerebral edema and signs of mass effect on the middle line structures.</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><elsevierMultimedia ident="fig2"></elsevierMultimedia><p class="elsevierStylePara elsevierViewall">Image guided stereotactic surgical excision of the cerebral abscess was performed (<a class="elsevierStyleCrossRef" href="#fig3">Fig. 3</a>). The material was purulent (<a class="elsevierStyleCrossRef" href="#fig4">Fig. 4</a>); direct microscopic examination showed hyaline, branched and septate hyphae compatible with fungal elements. Grocott stain showed septate hyphae (<a class="elsevierStyleCrossRef" href="#fig5">Fig. 5</a>). Ziehl–Neelsen, Gram and Giemsa smears were negative. Culture of abscess material was negative. Biopsy pathological findings include wide inflammatory infiltrate with predominance of neutrophilic leukocytes.</p><elsevierMultimedia ident="fig3"></elsevierMultimedia><elsevierMultimedia ident="fig4"></elsevierMultimedia><elsevierMultimedia ident="fig5"></elsevierMultimedia><p class="elsevierStylePara elsevierViewall">Initial treatment involved manitol as antiedematous osmotic diuretic and a combination of intravenous amphotericin B deoxicolate 0.8<span class="elsevierStyleHsp" style=""></span>mg/kg/day and fluconazole 800<span class="elsevierStyleHsp" style=""></span>mg/day for 1 month. He did not receive corticosteroids as cerebral antiedematous because of the risk of making the glycemic control worse. The total accumulation dose of amphotericin B was 1500<span class="elsevierStyleHsp" style=""></span>mg. After surgery, the patient was treated with antifungal therapy based on oral fluconazole at doses of 600<span class="elsevierStyleHsp" style=""></span>mg/day for 4 months, with a good clinical and radiological evolution. Two years after the onset of neurological symptoms, he is still in good clinical condition without neurological sequelae.</p></span><span class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p class="elsevierStylePara elsevierViewall">Fungal infections of CNS are not common and they are often secondary to a focus located in the lung or the digestive tract.</p><p class="elsevierStylePara elsevierViewall">Neurofungal infections, meningitis or abscesses are associated with extremely high mortality caused by delayed onset of therapy, severe underlying disease and multiresistant fungal organisms.<a class="elsevierStyleCrossRef" href="#bib20"><span class="elsevierStyleSup">20</span></a></p><p class="elsevierStylePara elsevierViewall">One of the most frequent predisposing diseases for disseminated fungal infections is diabetes and, most recently, these complications are associated with immunocompromised status.<a class="elsevierStyleCrossRef" href="#bib12"><span class="elsevierStyleSup">12</span></a>. The rising incidence of diabetes mellitus has resulted in an increased number of cases of candidaemia, intracranial fungal masses, granulomas and abscesses, due to <span class="elsevierStyleItalic">Candida</span> species.<a class="elsevierStyleCrossRef" href="#bib21"><span class="elsevierStyleSup">21</span></a><span class="elsevierStyleItalic">C. albicans</span>, still represents the predominant species.<a class="elsevierStyleCrossRef" href="#bib23"><span class="elsevierStyleSup">23</span></a> Other risk factors for candidaemia and cerebral abscess include the presence of intravascular catheters, admission to intensive care unit, parenteral nutrition, multiple antibiotics, prolonged corticosteroid therapy, cancer chemotherapy, solid organ transplantation, AIDS and neutropenia.<a class="elsevierStyleCrossRef" href="#bib17"><span class="elsevierStyleSup">17</span></a></p><p class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Candida</span> is the fourth most common cause of bloodstream infections, and epidemiological data indicate that at least 72% of all nosocomial fungal infections and 8–15% of all nosocomial bloodstream infections are caused by <span class="elsevierStyleItalic">Candida</span> species.<a class="elsevierStyleCrossRef" href="#bib16"><span class="elsevierStyleSup">16</span></a> Additionally, autopsy series show that 1–6% of patients with systemic candidosis also have CNS involvement. This finding suggests that neurocandidiasis is frequently misdiagnosed.<a class="elsevierStyleCrossRef" href="#bib18"><span class="elsevierStyleSup">18</span></a></p><p class="elsevierStylePara elsevierViewall">Although intracranial fungal masses can be seen at any age, the majority of patients are in the third, fourth or fifth decade of their lives, as in our patient.</p><p class="elsevierStylePara elsevierViewall">These complications have also been reported in neonates, infants and young children.<a class="elsevierStyleCrossRef" href="#bib15"><span class="elsevierStyleSup">15</span></a></p><p class="elsevierStylePara elsevierViewall">Cryptococcosis is the most frequent fungal infection of the CNS, followed by aspergillosis and candidiasis.<a class="elsevierStyleCrossRef" href="#bib12"><span class="elsevierStyleSup">12</span></a> Coccidioidal meningitis is also frequently observed in endemic areas.</p><p class="elsevierStylePara elsevierViewall">Clinically, fungal infections of the CNS may be presented as disseminated meningoencephalitis or as located brain lesions or abscesses. Clinical manifestations of candidiasis include mucocutaneous involvement (especially genital, oropharyngeal and esophagical lesions), cutaneous lesions in cases of chronic mucocutaneous candidiasis, and systemic or disseminated compromise.</p><p class="elsevierStylePara elsevierViewall">Generally, invasive or disseminated candidiasis involves multiple organs. Neurocandidiasis is rarely observed during the course of disseminated candidiasis, and abscess formation in the brain is a severe complication in patients with different risk factors. Endocarditis, endophtalmitis and brain abscess are the most severe locations of candidaemia.<a class="elsevierStyleCrossRef" href="#bib15"><span class="elsevierStyleSup">15</span></a> Schelenz and Grandsden<a class="elsevierStyleCrossRef" href="#bib22"><span class="elsevierStyleSup">22</span></a> analyzed 128 cases of <span class="elsevierStyleItalic">Candida</span> bloodstream infections and the authors detected only 6% of patients with these serious complications.</p><p class="elsevierStylePara elsevierViewall">Intracranial fungal masses due to <span class="elsevierStyleItalic">Candida</span> spp. usually develop by the haematogenous spread of fungus from a source of infection generally located at the digestive or the urinary tracts. Primary candidiasis of the brain or meninges is rare; however, central nervous system involvement is reported in 18–52% in disseminated candidiasis.<a class="elsevierStyleCrossRefs" href="#bib11"><span class="elsevierStyleSup">11,14</span></a> The duration of neurological symptoms can vary from a few days to several months, as in the patient we present.<a class="elsevierStyleCrossRefs" href="#bib2"><span class="elsevierStyleSup">2,9</span></a>.</p><p class="elsevierStylePara elsevierViewall">Fungal abscesses are hypointense on T1 weight and hyperintense on T2 with a well-defined ring enhancement after gadolinium administration. These neuroimaging characteristics are similar to those observed for abscesses due to bacterial, mycobacterial and parasite pathogens.<a class="elsevierStyleCrossRefs" href="#bib4"><span class="elsevierStyleSup">4,5</span></a> However, in immunocompromised patients, fungal abscesses can appear as patchy or punctate T2 hyperintense lesions with frequent absence of enhancement post-gadolinium.<a class="elsevierStyleCrossRefs" href="#bib10"><span class="elsevierStyleSup">10,12,13</span></a> Fungal infections, including candidiasis, can rarely cause cerebrovascular involvement, usually associated with large vessel vasculitis by invasion or embolization.<a class="elsevierStyleCrossRef" href="#bib6"><span class="elsevierStyleSup">6</span></a></p><p class="elsevierStylePara elsevierViewall">Njambi et al.<a class="elsevierStyleCrossRef" href="#bib20"><span class="elsevierStyleSup">20</span></a> observed 20 cases of fungal meningitis and/or cerebral abscesses within the last 25 years. The most common etiologic agent was <span class="elsevierStyleItalic">Candida</span> spp., accounting for 9 of 20 patients. The authors point out an extremely high mortality due to the delay in the onset of a specific therapy, severe underlying diseases and multiresistant fungal organisms.</p><p class="elsevierStylePara elsevierViewall">Diagnosis of disseminated or invasive candidiasis remains difficult and is generally confirmed by direct microscopic examination of the drained pus achieved during surgical excision of the abscesses. Cultures are frequently negative, as in our patient. Although it is true that the candidial etiology of the brain lesion in our patient was not confirmed, the fungal nature of the process is doubtless due to the presence of hyaline hyphae in the direct microscopic examination (<a class="elsevierStyleCrossRef" href="#fig5">Fig. 5</a>). As the patient was diabetic and had a history of psoas abcess due to <span class="elsevierStyleItalic">C. albicans</span>, that etiology was regarded as the most possible one. The presence of hyaline hyphae is not the most habitual microscopic aspect of the <span class="elsevierStyleItalic">Candida</span> fungi, but these may produce true hyphae as well as pseudohyphae and blastoconidia. This is an interesting aspect of our case and can be explained by the host inflammatory responses in fungal infections. The Th1/Th2 responses have potentially important implications in the pathogenesis of immune reconstitution syndrome in immunodeficient patients. However, the immunopathogenesis of CNS fungal infections remains incompletely studied. Host defense mechanisms can influence the severity of fungal infections, and the clinical form of the disease depends on the patient's immune response. In the immunocompromised host, haematogenous dissemination may happen and fungal invasion of the CNS can occur.<a class="elsevierStyleCrossRef" href="#bib8"><span class="elsevierStyleSup">8</span></a> The <span class="elsevierStyleItalic">Aspergillus</span> galactomannan test is useful only for oncohematological patients with neutropenia. The glucan test is not available in Argentina due to its high cost and poor demand. Finally, the cryptococcal latex test was not carried out since the microscopic findings of the cerebral abcess were not correlated with such etiology.</p><p class="elsevierStylePara elsevierViewall">Treatment of cerebral <span class="elsevierStyleItalic">Candida</span> infection is normally based on a combination of amphotericin B deoxycolate and 5-fluorocytosine as first-line therapy. In our country, 5-fluorocytosine is not available. In patients without response to amphotericin B or those who present severe adverse events associated with this therapy, fluconazole alone or in combination with 5-fluorocytosine might be used.<a class="elsevierStyleCrossRef" href="#bib23"><span class="elsevierStyleSup">23</span></a> Novel antifungal drugs, such as caspofungin, penetrate poorly into the CNS especially if the blood–brain barrier is intact. However, voriconazole shows a good CNS concentration and might be used in patients with refractoriness or incompa- tibility to amphotericin B,<a class="elsevierStyleCrossRef" href="#bib18"><span class="elsevierStyleSup">18</span></a> although voriconazole has not been proven to be superior to fluconazole in the treatment of <span class="elsevierStyleItalic">C. albicans</span> infections, which was the species identified in the psoas abcess. Voriconazole use would have been justified in the event of therapeutic failure or resistance to fluconazole. The aim at recommending a prolonged treatment with fluconazole was to eliminate any candidiasis residual focus in a diabetic patient.</p><p class="elsevierStylePara elsevierViewall">In conclusion, uncontrolled diabetes mellitus is a significant risk factor for disseminated candidiasis. A rising trend of invasive candidiasis, including neurocandidiasis, can be observed in patients with diabetes mellitus.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:7 [ 0 => array:2 [ "identificador" => "xres120771" "titulo" => array:6 [ 0 => "Abstract" 1 => "Background" 2 => "Aims" 3 => "Methods" 4 => "Results" 5 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec108052" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres120770" "titulo" => array:6 [ 0 => "Resumen" 1 => "Antecedentes" 2 => "Objetivos" 3 => "Métodos" 4 => "Resultados" 5 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec108051" "titulo" => "Palabras clave" ] 4 => array:1 [ "titulo" => "Case report" ] 5 => array:1 [ "titulo" => "Discussion" ] 6 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2009-09-22" "fechaAceptado" => "2009-12-11" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec108052" "palabras" => array:3 [ 0 => "Cerebral abscess" 1 => "Diabetes" 2 => "<span class="elsevierStyleItalic">Candida</span>" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec108051" "palabras" => array:3 [ 0 => "Absceso cerebral" 1 => "Diabetes" 2 => "<span class="elsevierStyleItalic">Candida</span>" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Background</span><p class="elsevierStyleSimplePara elsevierViewall">Intracranial fungal masses are uncommon diseases, but their incidence is increasing, most often due to the prolonged survival of patients with different immunodeficiencies. The management of patients with intracranial fungal masses included stereotactic biopsy for diagnosis, partial or radical surgery excision and prolonged antifungal therapy.</p> <span class="elsevierStyleSectionTitle">Aims</span><p class="elsevierStyleSimplePara elsevierViewall">We report the case of a 51-year-old diabetic man with a history of psoas abscess due to <span class="elsevierStyleItalic">Candida albicans</span> 1 year before the onset of neurological symptoms, including headache and generalized tonoclonic seizures.</p> <span class="elsevierStyleSectionTitle">Methods</span><p class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance imaging showed a single lesion located in the right parietal lobe with mass effect, surrounding edema and enhancement after injection of gadolinium. The material was purulent.</p> <span class="elsevierStyleSectionTitle">Results</span><p class="elsevierStyleSimplePara elsevierViewall">Direct microscopic examination showed hyaline, branched and septate hyphae compatible with fungal elements.</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p class="elsevierStyleSimplePara elsevierViewall">Fungal infections, especially due to <span class="elsevierStyleItalic">Candida</span> species, should be considered in diabetic patients with parenchymal brain abscesses. Radical excision followed by prolonged antifungal therapy based on fluconazole or amphotericin B is necessary to improve the prognosis of this type of patients.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle">Antecedentes</span><p class="elsevierStyleSimplePara elsevierViewall">Las masas cerebrales de etiología fúngica son complicaciones poco frecuentes, pero su incidencia se ha incrementado en relación directa con la prolongación de la supervivencia de los pacientes con diferentes inmunodeficiencias. El enfoque clínico de estos pacientes incluye la biopsia estereotáctica de la lesión con fines diagnósticos, la resección quirúrgica parcial o total y el tratamiento antifúngico prolongado.</p> <span class="elsevierStyleSectionTitle">Objetivos</span><p class="elsevierStyleSimplePara elsevierViewall">Se describe el caso de un paciente diabético con antecedentes de absceso del psoas por <span class="elsevierStyleItalic">Candida albicans</span> un año antes del inicio de los síntomas neurológicos (que incluyeron cefaleas y convulsiones tónico-clónicas generalizadas).</p> <span class="elsevierStyleSectionTitle">Métodos</span><p class="elsevierStyleSimplePara elsevierViewall">Una resonancia nuclear magnética mostró una lesión única, localizada en el lóbulo parietal derecho, con refuerzo del contraste, edema perilesional y efecto de masa sobre las estructuras adyacentes. Se efectuó resección quirúrgica completa de la lesión.</p> <span class="elsevierStyleSectionTitle">Resultados</span><p class="elsevierStyleSimplePara elsevierViewall">El examen macroscópico de la misma mostró material purulento que en el examen microscópico directo evidenció la existencia de hifas hialinas, ramificadas y tabicadas compatibles con elementos fúngicos.</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p class="elsevierStyleSimplePara elsevierViewall">Las infecciones micóticas, en especial aquellas causadas por hongos del género <span class="elsevierStyleItalic">Candida</span> deben incluirse en el diagnóstico diferencial de los abscesos cerebrales en pacientes diabéticos. El tratamiento quirúrgico seguido de la administración prolongada de antifúngicos como fluconazol o anfotericina B es fundamental para mejorar la evolución y el pronóstico de estos pacientes.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 969 "Ancho" => 980 "Tamanyo" => 86097 ] ] "descripcion" => array:1 [ "en" => "<p class="elsevierStyleSimplePara elsevierViewall">T1 weighted axial MRI showing a right parietal mass with gadolinium enhancement.</p>" ] ] 1 => array:7 [ "identificador" => "fig2" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 493 "Ancho" => 980 "Tamanyo" => 93204 ] ] "descripcion" => array:1 [ "en" => "<p class="elsevierStyleSimplePara elsevierViewall">T1 coronal MRI demonstrating a parietal mass with heterogenous enhancement.</p>" ] ] 2 => array:7 [ "identificador" => "fig3" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 829 "Ancho" => 980 "Tamanyo" => 101498 ] ] "descripcion" => array:1 [ "en" => "<p class="elsevierStyleSimplePara elsevierViewall">Postoperative axial T1 MRI without lesion.</p>" ] ] 3 => array:7 [ "identificador" => "fig4" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 899 "Ancho" => 980 "Tamanyo" => 121046 ] ] "descripcion" => array:1 [ "en" => "<p class="elsevierStyleSimplePara elsevierViewall">Surgical purulent specimen.</p>" ] ] 4 => array:7 [ "identificador" => "fig5" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1226 "Ancho" => 1633 "Tamanyo" => 289354 ] ] "descripcion" => array:1 [ "en" => "<p class="elsevierStyleSimplePara elsevierViewall">Microphotography of a smear stained by Grocott methenami.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Invasive aspergillosis of the brain: radiologic–pathologic correlation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B.M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 61 | 15 | 76 |
| 2024 September | 95 | 16 | 111 |
| 2024 August | 82 | 11 | 93 |
| 2024 July | 79 | 20 | 99 |
| 2024 June | 75 | 16 | 91 |
| 2024 May | 77 | 15 | 92 |
| 2024 April | 73 | 11 | 84 |
| 2024 March | 117 | 7 | 124 |
| 2024 February | 133 | 22 | 155 |
| 2024 January | 146 | 11 | 157 |
| 2023 December | 119 | 24 | 143 |
| 2023 November | 153 | 17 | 170 |
| 2023 October | 192 | 12 | 204 |
| 2023 September | 136 | 9 | 145 |
| 2023 August | 99 | 4 | 103 |
| 2023 July | 132 | 4 | 136 |
| 2023 June | 118 | 4 | 122 |
| 2023 May | 157 | 5 | 162 |
| 2023 April | 95 | 3 | 98 |
| 2023 March | 159 | 6 | 165 |
| 2023 February | 124 | 13 | 137 |
| 2023 January | 111 | 7 | 118 |
| 2022 December | 83 | 7 | 90 |
| 2022 November | 95 | 8 | 103 |
| 2022 October | 94 | 26 | 120 |
| 2022 September | 91 | 9 | 100 |
| 2022 August | 102 | 13 | 115 |
| 2022 July | 89 | 7 | 96 |
| 2022 June | 68 | 12 | 80 |
| 2022 May | 88 | 10 | 98 |
| 2022 April | 76 | 13 | 89 |
| 2022 March | 104 | 16 | 120 |
| 2022 February | 107 | 6 | 113 |
| 2022 January | 123 | 15 | 138 |
| 2021 December | 80 | 11 | 91 |
| 2021 November | 91 | 9 | 100 |
| 2021 October | 116 | 11 | 127 |
| 2021 September | 127 | 11 | 138 |
| 2021 August | 116 | 12 | 128 |
| 2021 July | 120 | 18 | 138 |
| 2021 June | 104 | 15 | 119 |
| 2021 May | 98 | 9 | 107 |
| 2021 April | 129 | 7 | 136 |
| 2021 March | 64 | 9 | 73 |
| 2021 February | 71 | 10 | 81 |
| 2021 January | 66 | 11 | 77 |
| 2020 December | 75 | 8 | 83 |
| 2020 November | 74 | 11 | 85 |
| 2020 October | 43 | 7 | 50 |
| 2020 September | 42 | 9 | 51 |
| 2020 August | 42 | 12 | 54 |
| 2020 July | 39 | 8 | 47 |
| 2020 June | 32 | 6 | 38 |
| 2020 May | 42 | 6 | 48 |
| 2020 April | 39 | 7 | 46 |
| 2020 March | 42 | 13 | 55 |
| 2020 February | 38 | 5 | 43 |
| 2020 January | 25 | 8 | 33 |
| 2019 December | 36 | 13 | 49 |
| 2019 November | 33 | 5 | 38 |
| 2019 October | 43 | 12 | 55 |
| 2019 September | 36 | 1 | 37 |
| 2019 August | 22 | 3 | 25 |
| 2019 July | 24 | 17 | 41 |
| 2019 June | 70 | 37 | 107 |
| 2019 May | 142 | 89 | 231 |
| 2019 April | 77 | 20 | 97 |
| 2019 March | 20 | 3 | 23 |
| 2019 February | 32 | 4 | 36 |
| 2019 January | 23 | 2 | 25 |
| 2018 December | 24 | 4 | 28 |
| 2018 November | 26 | 0 | 26 |
| 2018 October | 18 | 8 | 26 |
| 2018 September | 35 | 7 | 42 |
| 2018 August | 34 | 2 | 36 |
| 2018 July | 34 | 2 | 36 |
| 2018 June | 23 | 1 | 24 |
| 2018 May | 46 | 8 | 54 |
| 2018 April | 26 | 3 | 29 |
| 2018 March | 16 | 0 | 16 |
| 2018 February | 22 | 7 | 29 |
| 2018 January | 33 | 5 | 38 |
| 2017 December | 18 | 1 | 19 |
| 2017 November | 19 | 6 | 25 |
| 2017 October | 22 | 5 | 27 |
| 2017 September | 16 | 4 | 20 |
| 2017 August | 31 | 10 | 41 |
| 2017 July | 22 | 10 | 32 |
| 2017 June | 40 | 9 | 49 |
| 2017 May | 39 | 6 | 45 |
| 2017 April | 30 | 3 | 33 |
| 2017 March | 33 | 24 | 57 |
| 2017 February | 33 | 3 | 36 |
| 2017 January | 23 | 1 | 24 |
| 2016 December | 36 | 4 | 40 |
| 2016 November | 32 | 3 | 35 |
| 2016 October | 42 | 8 | 50 |
| 2016 September | 51 | 4 | 55 |
| 2016 August | 22 | 4 | 26 |
| 2016 July | 22 | 2 | 24 |
| 2016 June | 36 | 1 | 37 |
| 2016 May | 30 | 4 | 34 |
| 2016 April | 39 | 0 | 39 |
| 2016 March | 36 | 2 | 38 |
| 2016 February | 40 | 6 | 46 |
| 2016 January | 19 | 1 | 20 |
| 2015 December | 28 | 8 | 36 |
| 2015 November | 33 | 10 | 43 |
| 2015 October | 32 | 14 | 46 |
| 2015 September | 29 | 5 | 34 |
| 2015 August | 41 | 1 | 42 |
| 2015 July | 106 | 3 | 109 |
| 2015 June | 56 | 0 | 56 |
| 2015 May | 47 | 5 | 52 |
| 2015 April | 49 | 8 | 57 |
| 2015 March | 89 | 10 | 99 |
| 2015 February | 111 | 13 | 124 |
| 2015 January | 40 | 3 | 43 |
| 2014 December | 50 | 2 | 52 |
| 2014 November | 63 | 1 | 64 |
| 2014 October | 61 | 4 | 65 |
| 2014 September | 50 | 0 | 50 |
| 2014 August | 41 | 2 | 43 |
| 2014 July | 55 | 2 | 57 |
| 2014 June | 63 | 1 | 64 |
| 2014 May | 45 | 2 | 47 |
| 2014 April | 36 | 3 | 39 |
| 2014 March | 92 | 7 | 99 |
| 2014 February | 88 | 6 | 94 |
| 2014 January | 91 | 11 | 102 |
| 2013 December | 76 | 4 | 80 |
| 2013 November | 73 | 9 | 82 |
| 2013 October | 76 | 8 | 84 |
| 2013 September | 89 | 8 | 97 |
| 2013 August | 101 | 23 | 124 |
| 2013 July | 110 | 10 | 120 |
| 2013 June | 37 | 3 | 40 |
| 2013 May | 49 | 4 | 53 |
| 2013 April | 40 | 8 | 48 |
| 2013 March | 34 | 7 | 41 |
| 2013 February | 42 | 6 | 48 |
| 2013 January | 28 | 3 | 31 |
| 2012 December | 10 | 3 | 13 |
| 2012 November | 4 | 2 | 6 |
| 2012 October | 4 | 2 | 6 |
| 2010 January | 1052 | 0 | 1052 |
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