Diagnosis at first sight
Fever of unknown origin in a laboratory worker
Fiebre de origen desconocido en una trabajadora de laboratorio
Read
1891
Timeswas read the article
391
Total PDF
1500
Total HTML
Share statistics
array:24 [ "pii" => "S2529993X18301552" "issn" => "2529993X" "doi" => "10.1016/j.eimce.2018.06.004" "estado" => "S300" "fechaPublicacion" => "2018-10-01" "aid" => "1743" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica" "copyrightAnyo" => "2017" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Enferm Infecc Microbiol Clin. 2018;36:527-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 287 "formatos" => array:2 [ "HTML" => 222 "PDF" => 65 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0213005X17302380" "issn" => "0213005X" "doi" => "10.1016/j.eimc.2017.09.006" "estado" => "S300" "fechaPublicacion" => "2018-10-01" "aid" => "1743" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Enferm Infecc Microbiol Clin. 2018;36:527-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1578 "formatos" => array:3 [ "EPUB" => 3 "HTML" => 1257 "PDF" => 318 ] ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Diagnóstico a primera vista</span>" "titulo" => "Fiebre de origen desconocido en una trabajadora de laboratorio" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "527" "paginaFinal" => "528" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Fever of unknown origin in a laboratory worker" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1191 "Ancho" => 2500 "Tamanyo" => 201605 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A) Rx de tórax PA. B) Rx de tórax lateral. Aumento hiliar derecho en relación con adenopatías.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Irene López Ramos, Jorge Galván Fernández, Antonio Orduña Domingo" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Irene" "apellidos" => "López Ramos" ] 1 => array:2 [ "nombre" => "Jorge" "apellidos" => "Galván Fernández" ] 2 => array:2 [ "nombre" => "Antonio" "apellidos" => "Orduña Domingo" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2529993X18301552" "doi" => "10.1016/j.eimce.2018.06.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X18301552?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X17302380?idApp=UINPBA00004N" "url" => "/0213005X/0000003600000008/v1_201809220817/S0213005X17302380/v1_201809220817/es/main.assets" ] ] "itemSiguiente" => array:18 [ "pii" => "S2529993X18301886" "issn" => "2529993X" "doi" => "10.1016/j.eimce.2017.11.023" "estado" => "S300" "fechaPublicacion" => "2018-10-01" "aid" => "1780" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Enferm Infecc Microbiol Clin. 2018;36:529-30" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 85 "formatos" => array:2 [ "HTML" => 46 "PDF" => 39 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "A case of human ocular dirofilariasis in a patient with multiple endocrine neoplasia in Northwest Spain" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "529" "paginaFinal" => "530" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Un caso de dirofilariasis ocular humana en el Noroeste de España en un paciente con neoplasia endocrina múltiple" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1099 "Ancho" => 2500 "Tamanyo" => 78906 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) One of the fragments of the worms removed from the subconjunctival tissue of the patient. (B) Multiplex PCR amplification of the DNA extracted from the worms removed from the patient. Lane 1: negative control; lane 2: <span class="elsevierStyleItalic">D. repens</span> positive control; lanes 3 and 4: samples obtained from the worms surgically removed from the patient; M: molecular marker, 100–1000<span class="elsevierStyleHsp" style=""></span>pb.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Inmaculada Ramírez de Ocáriz Landaberea, María F. Brezmes Valdivieso, Sara C. García Sanz, Fernando Simón Martín" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Inmaculada" "apellidos" => "Ramírez de Ocáriz Landaberea" ] 1 => array:2 [ "nombre" => "María F." "apellidos" => "Brezmes Valdivieso" ] 2 => array:2 [ "nombre" => "Sara C." "apellidos" => "García Sanz" ] 3 => array:2 [ "nombre" => "Fernando" "apellidos" => "Simón Martín" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X18301886?idApp=UINPBA00004N" "url" => "/2529993X/0000003600000008/v1_201809220812/S2529993X18301886/v1_201809220812/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2529993X18301539" "issn" => "2529993X" "doi" => "10.1016/j.eimce.2018.06.002" "estado" => "S300" "fechaPublicacion" => "2018-10-01" "aid" => "1717" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Enferm Infecc Microbiol Clin. 2018;36:525-6" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 231 "formatos" => array:2 [ "HTML" => 188 "PDF" => 43 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Diagnosis at first sight</span>" "titulo" => "Cervical tumor unusual etiology" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "525" "paginaFinal" => "526" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tumor cervical de etiología inusual" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 740 "Ancho" => 900 "Tamanyo" => 75380 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Isolation of <span class="elsevierStyleItalic">Corynebacterium pseudotuberculosis</span> in blood agar.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Alina María García de Hombre, Alejandro Bonadeo, Pino Suárez-Bordón, Mónica Sánchez-Oñoro" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Alina María" "apellidos" => "García de Hombre" ] 1 => array:2 [ "nombre" => "Alejandro" "apellidos" => "Bonadeo" ] 2 => array:2 [ "nombre" => "Pino" "apellidos" => "Suárez-Bordón" ] 3 => array:2 [ "nombre" => "Mónica" "apellidos" => "Sánchez-Oñoro" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0213005X17302112" "doi" => "10.1016/j.eimc.2017.07.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X17302112?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X18301539?idApp=UINPBA00004N" "url" => "/2529993X/0000003600000008/v1_201809220812/S2529993X18301539/v1_201809220812/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Diagnosis at first sight</span>" "titulo" => "Fever of unknown origin in a laboratory worker" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "527" "paginaFinal" => "528" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Irene López Ramos, Jorge Galván Fernández, Antonio Orduña Domingo" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Irene" "apellidos" => "López Ramos" "email" => array:1 [ 0 => "irenelora@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Jorge" "apellidos" => "Galván Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Antonio" "apellidos" => "Orduña Domingo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Radiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fiebre de origen desconocido en una trabajadora de laboratorio" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1013 "Ancho" => 2500 "Tamanyo" => 218119 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Axial images from chest CT scan with intravenous contrast. (A) Mediastinal window. (B) Lung window showing paratracheal, hilar, intrapulmonary and subcarinal right lymphadenopathy of a pathological size, measuring up to 2.9<span class="elsevierStyleHsp" style=""></span>cm.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 29-year-old woman, a professional microbiologist with no prior history of note, sought care for a fever which she had had for the past 10 days with night sweats, a feeling of pressure on the sternum, severe asthenia and persistent dry cough with no expectoration, chest pain or dyspnoea. A physical examination revealed only slight splenomegaly. Laboratory testing results were normal except for CRP and ESR, which were high. The patient reported having worked with live cultures of pathogenic microorganisms, including <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> and <span class="elsevierStyleItalic">Francisella tularensis</span>, though in these cases she worked in a biosafety level 3 laboratory and in a biological safety laminar flow cabinet.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A chest X-ray showed right hilar lymphadenopathy (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In view of these findings, a computed tomography (CT) scan was performed. This showed paratracheal, hilar, intrapulmonary and subcarinal right lymphadenopathy of a pathological size, measuring up to 2.9<span class="elsevierStyleHsp" style=""></span>cm (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Given the patient's occupational history and the fact that her condition was probably infectious in origin, a Mantoux test, an interferon gamma release assay (IGRA) and a QuantiFERON<span class="elsevierStyleSup">®</span> test as well as serologies against <span class="elsevierStyleItalic">Brucella</span>, <span class="elsevierStyleItalic">Francisella</span>, CMV and EBV were performed as complementary tests.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Clinical course</span><p id="par0025" class="elsevierStylePara elsevierViewall">The tuberculin test showed no induration after 48<span class="elsevierStyleHsp" style=""></span>h and the QuantiFERON<span class="elsevierStyleSup">®</span> test was negative. The serologies against <span class="elsevierStyleItalic">Brucella</span> and CMV were negative. The serology against anti-EBNA EBV was positive; immunochromatography against <span class="elsevierStyleItalic">F. tularensis</span> was weakly positive and microagglutination was negative.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Given the patient's clinical condition and occupational history, the radiological and serological results obtained and the possibility of pulmonary tularaemia in its initial phase, a new serology against <span class="elsevierStyleItalic">F. tularensis</span> was ordered. In addition, ciprofloxacin 500<span class="elsevierStyleHsp" style=""></span>mg was prescribed for 14 days. The patient's fever remitted in the first few days and all other symptoms remitted on completion of treatment. The serology performed with the second serum obtained after 15 days showed seroconversion of microagglutination with a titre of 1/160.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Final comments</span><p id="par0035" class="elsevierStylePara elsevierViewall">Tularaemia, an endemic zoonosis in the Spanish region of Castile and León, is mainly acquired following contact with multiple infected animal species, including hares, rodents and river crabs, or arthropods which act as vectors.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,2</span></a> The infectious dose of <span class="elsevierStyleItalic">F. tularensis</span> is the lowest of all known pathogenic bacteria (10–50 bacteria)<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a>; therefore, contamination with contaminated dust or droplets is relatively common. This means that the infectious capacity of the microorganism represents a high risk of infection for laboratory workers, despite their adoption of safety measures required for handling this type of microorganism.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">As a result of this occupational accident, measures were taken which consisted of retraining staff who worked with highly infectious microorganisms and revising laboratory safety protocols.</p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">F. tularensis</span> subspecies holarctica, the subspecies involved in this case, causes less serious clinical conditions than <span class="elsevierStyleItalic">F. tularensis</span> subspecies <span class="elsevierStyleItalic">tularensis</span>.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3,4</span></a> Transmission through tick bites and contact with animals usually results in glandular or ulceroglandular forms, with lymphadenopathy usually being the most significant symptom. When the route of acquisition is inhalation, it may present in the form of pneumonia, or more rarely typhoid (which may result from any form of acquisition) or follow a clinical course with fever and asthenia but no respiratory symptoms. In these cases, radiological findings are not always detected. When they do appear, they may vary and include hilar thickening indistinguishable from tuberculosis or lymphoma.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4,5</span></a> In routine practice, diagnostic tests for <span class="elsevierStyleItalic">F. tularensis</span> are based on serology testing, since culture is difficult and dangerous to handle and PCR techniques, despite offering faster and safer detection, are not available in all laboratories.</p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Anti-F. tularensis</span> antibodies may be demonstrated through tube agglutination, haemagglutination, enzyme immunoassay, immunochromatography or microagglutination. Agglutination titres are usually negative during the first phase of the disease and serology must be repeated with a new serum sample to demonstrate seroconversion. This usually appears 2 weeks after onset of symptoms and shows a peak titre after 4–5 weeks. Titres greater than or equal to 1/160 are considered positive.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> Antibodies may show cross-reaction with <span class="elsevierStyleItalic">Brucella</span> spp., <span class="elsevierStyleItalic">Yersinia enterocolitica</span> O:3 and O:9 and <span class="elsevierStyleItalic">Proteus</span> OX19; however, in these cases, titres against <span class="elsevierStyleItalic">F. tularensis</span> are almost always higher.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinical course" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Final comments" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: López Ramos I, Galván Fernández J, Orduña Domingo A. Fiebre de origen desconocido en una trabajadora de laboratorio. Enferm Infecc Microbiol Clin. 2018;36:527–528.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1191 "Ancho" => 2500 "Tamanyo" => 201972 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Posteroanterior chest X-ray. (B) Lateral chest X-ray. Right hilar enlargement related to lymphadenopathy.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1013 "Ancho" => 2500 "Tamanyo" => 218119 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Axial images from chest CT scan with intravenous contrast. (A) Mediastinal window. (B) Lung window showing paratracheal, hilar, intrapulmonary and subcarinal right lymphadenopathy of a pathological size, measuring up to 2.9<span class="elsevierStyleHsp" style=""></span>cm.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Molecular investigation of tularemia outbreaks, Spain, 1997–2008" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Ariza-Miguel" 1 => "A. Johansson" 2 => "M.I. Fernández-Natal" 3 => "Nistal C. Martínez-" 4 => "A. Orduña" 5 => "E.F. Rodríguez-Ferri" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3201/eid2005.130654" "Revista" => array:6 [ "tituloSerie" => "Emerg Infect Dis" "fecha" => "2014" "volumen" => "20" "paginaInicial" => "754" "paginaFinal" => "761" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24750848" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0045" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Waterborne outbreak of tularemia associated with crayfish fishing" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Anda" 1 => "J. Segura del Pozo" 2 => "J. García" 3 => "R. Escudero" 4 => "F. Peña" 5 => "M. Velasco" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3201/eid0707.010740" "Revista" => array:6 [ "tituloSerie" => "Emerg Infect Dis" "fecha" => "2001" "volumen" => "7" "paginaInicial" => "575" "paginaFinal" => "582" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11485678" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0050" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Francisella tularensis</span> (Tularemia)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R.L. Penn" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:4 [ "titulo" => "Principles and practice of infectious diseases" "paginaInicial" => "2590" "paginaFinal" => "2602" "serieFecha" => "2015" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0055" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:1 [ "host" => array:1 [ 0 => array:1 [ "Libro" => array:2 [ "fecha" => "2007" "editores" => "A.Tärnvik" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0060" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tularaemia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Tärnvik" 1 => "L. Berglund" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2003" "volumen" => "21" "paginaInicial" => "361" "paginaFinal" => "373" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12608453" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0065" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluation of a commercial immunochromatographic assay for the serologic diagnosis of tularemia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Kiliç" 1 => "B. Çelebi" 2 => "M. Yesilyurt" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.diagmicrobio.2012.05.030" "Revista" => array:6 [ "tituloSerie" => "Diagn Microbiol Infect Dis" "fecha" => "2012" "volumen" => "74" "paginaInicial" => "1" "paginaFinal" => "5" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22770772" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0070" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Laboratory diagnosis and serologic course in patients with tularemia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Dueñas A.I." 1 => "M. Ortega" 2 => "I. Garrote" 3 => "M. de Frutos" 4 => "P. Gutiérrez" 5 => "A. García-Pascual" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "2000" "volumen" => "114" "paginaInicial" => "407" "paginaFinal" => "410" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/2529993X/0000003600000008/v1_201809220812/S2529993X18301552/v1_201809220812/en/main.assets" "Apartado" => array:4 [ "identificador" => "63560" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Diagnosis at first sight" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/2529993X/0000003600000008/v1_201809220812/S2529993X18301552/v1_201809220812/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X18301552?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 7 | 1 | 8 |
| 2024 September | 14 | 1 | 15 |
| 2024 August | 15 | 4 | 19 |
| 2024 July | 7 | 6 | 13 |
| 2024 June | 9 | 2 | 11 |
| 2024 May | 18 | 2 | 20 |
| 2024 April | 15 | 8 | 23 |
| 2024 March | 16 | 3 | 19 |
| 2024 February | 42 | 5 | 47 |
| 2024 January | 60 | 4 | 64 |
| 2023 December | 39 | 2 | 41 |
| 2023 November | 51 | 2 | 53 |
| 2023 October | 18 | 4 | 22 |
| 2023 September | 20 | 2 | 22 |
| 2023 August | 17 | 4 | 21 |
| 2023 July | 10 | 2 | 12 |
| 2023 June | 26 | 5 | 31 |
| 2023 May | 49 | 3 | 52 |
| 2023 April | 33 | 0 | 33 |
| 2023 March | 30 | 4 | 34 |
| 2023 February | 16 | 9 | 25 |
| 2023 January | 58 | 4 | 62 |
| 2022 December | 19 | 4 | 23 |
| 2022 November | 18 | 5 | 23 |
| 2022 October | 24 | 8 | 32 |
| 2022 September | 20 | 10 | 30 |
| 2022 August | 31 | 10 | 41 |
| 2022 July | 11 | 5 | 16 |
| 2022 June | 13 | 4 | 17 |
| 2022 May | 16 | 8 | 24 |
| 2022 April | 17 | 10 | 27 |
| 2022 March | 31 | 6 | 37 |
| 2022 February | 36 | 4 | 40 |
| 2022 January | 50 | 5 | 55 |
| 2021 December | 19 | 9 | 28 |
| 2021 November | 10 | 6 | 16 |
| 2021 October | 11 | 10 | 21 |
| 2021 September | 7 | 5 | 12 |
| 2021 August | 15 | 10 | 25 |
| 2021 July | 15 | 2 | 17 |
| 2021 June | 20 | 10 | 30 |
| 2021 May | 18 | 10 | 28 |
| 2021 April | 35 | 12 | 47 |
| 2021 March | 28 | 10 | 38 |
| 2021 February | 14 | 7 | 21 |
| 2021 January | 20 | 10 | 30 |
| 2020 December | 36 | 10 | 46 |
| 2020 November | 28 | 6 | 34 |
| 2020 October | 12 | 4 | 16 |
| 2020 September | 25 | 8 | 33 |
| 2020 August | 18 | 6 | 24 |
| 2020 July | 23 | 10 | 33 |
| 2020 June | 9 | 10 | 19 |
| 2020 May | 20 | 7 | 27 |
| 2020 April | 11 | 3 | 14 |
| 2020 March | 23 | 2 | 25 |
| 2020 February | 15 | 5 | 20 |
| 2020 January | 19 | 0 | 19 |
| 2019 December | 27 | 10 | 37 |
| 2019 November | 7 | 2 | 9 |
| 2019 October | 13 | 7 | 20 |
| 2019 September | 8 | 3 | 11 |
| 2019 August | 7 | 1 | 8 |
| 2019 July | 10 | 6 | 16 |
| 2019 June | 13 | 8 | 21 |
| 2019 May | 70 | 21 | 91 |
| 2019 April | 22 | 3 | 25 |
| 2018 October | 5 | 0 | 5 |
| 2018 September | 11 | 2 | 13 |
Show all
