Letter to the Editor
Cough variant asthma induced by Lophomonas blattarum
Asma tusígena inducida por Lophomonas blattarum
Zhehao Xu, Shitong Zhang, Ruiyun Liang
Corresponding author
Department of General Practice, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Yingfeng Road No. 33, Haizhu District, Guangzhou, Guangdong, China
Read
7
Timeswas read the article
2
Total PDF
5
Total HTML
Share statistics
array:23 [ "pii" => "S0025775323006541" "issn" => "00257753" "doi" => "10.1016/j.medcli.2023.09.023" "estado" => "S300" "fechaPublicacion" => "2024-03-08" "aid" => "6467" "copyright" => "Elsevier España, S.L.U.. All rights reserved" "copyrightAnyo" => "2023" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2024;162:256-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:19 [ "pii" => "S0025775323005778" "issn" => "00257753" "doi" => "10.1016/j.medcli.2023.08.012" "estado" => "S300" "fechaPublicacion" => "2024-03-08" "aid" => "6430" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Med Clin. 2024;162:258" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Imagen médica</span>" "titulo" => "Gossypiboma abdominal como causa de síndrome constitucional" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "258" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Abdominal gossypiboma as a cause of constitutional syndrome" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 655 "Ancho" => 1005 "Tamanyo" => 81498 ] ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Antonio Rosales-Castillo, Antonio Bustos-Merlo, María Lucía Tornero-Divieso" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Antonio" "apellidos" => "Rosales-Castillo" ] 1 => array:2 [ "nombre" => "Antonio" "apellidos" => "Bustos-Merlo" ] 2 => array:2 [ "nombre" => "María Lucía" "apellidos" => "Tornero-Divieso" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020624000512" "doi" => "10.1016/j.medcle.2023.08.014" "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/S2387020624000512?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775323005778?idApp=UINPBA00004N" "url" => "/00257753/0000016200000005/v1_202402251117/S0025775323005778/v1_202402251117/es/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S002577532300653X" "issn" => "00257753" "doi" => "10.1016/j.medcli.2023.09.022" "estado" => "S300" "fechaPublicacion" => "2024-03-08" "aid" => "6466" "copyright" => "Elsevier España, S.L.U." "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2024;162:254-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta al Editor</span>" "titulo" => "Ascitis pancreática como forma de presentación del síndrome de pancreatitis, paniculitis y poliartritis" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "254" "paginaFinal" => "255" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Pancreatic ascites as a presentation of pancreatitis, panniculitis and polyarthritis syndrome" ] ] "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" => 1173 "Ancho" => 2458 "Tamanyo" => 612205 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Piel con paniculitis lobular en la que principalmente destaca una extensa necrosis grasa con intenso infiltrado inflamatorio neutrofílico, células basofílicas correspondientes a células adiposas fantasma, y lipófagos. El infiltrado se extiende a septos y a dermis próxima.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Antonio Bustos-Merlo, Laura Gallo-Padilla, Jessica Ramírez-Taboada" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Antonio" "apellidos" => "Bustos-Merlo" ] 1 => array:2 [ "nombre" => "Laura" "apellidos" => "Gallo-Padilla" ] 2 => array:2 [ "nombre" => "Jessica" "apellidos" => "Ramírez-Taboada" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2387020624000548" "doi" => "10.1016/j.medcle.2023.09.022" "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/S2387020624000548?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S002577532300653X?idApp=UINPBA00004N" "url" => "/00257753/0000016200000005/v1_202402251117/S002577532300653X/v1_202402251117/es/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Cough variant asthma induced by <span class="elsevierStyleItalic">Lophomonas blattarum</span>" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "256" "paginaFinal" => "257" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Zhehao Xu, Shitong Zhang, Ruiyun Liang" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Zhehao" "apellidos" => "Xu" ] 1 => array:2 [ "nombre" => "Shitong" "apellidos" => "Zhang" ] 2 => array:4 [ "nombre" => "Ruiyun" "apellidos" => "Liang" "email" => array:1 [ 0 => "13416361966@126.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of General Practice, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Yingfeng Road No. 33, Haizhu District, Guangzhou, Guangdong, China" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Asma tusígena inducida por <span class="elsevierStyleItalic">Lophomonas blattarum</span>" ] ] "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" => 1044 "Ancho" => 2167 "Tamanyo" => 226870 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Microscopic manifestations of <span class="elsevierStyleItalic">Lophomonas blattarum</span>.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> (A) Microscopic view of <span class="elsevierStyleItalic">Lophomonas blattarum</span> (×400): <span class="elsevierStyleItalic">L. blattarum</span>, ovoid in microscopic form, can distinguish anterior and posterior ends, and has a rounded coat with nuclear contents. (B) Microscopic view of <span class="elsevierStyleItalic">Lophomonas blattarum</span> (×1000, staining): <span class="elsevierStyleItalic">L. blattarum</span> deforms into an ellipsoid and purplish-brown color after staining.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary infection with <span class="elsevierStyleItalic">Lophomonas blattarum</span> (<span class="elsevierStyleItalic">L. blattarum</span>) is hardly seen in clinical practice, often leading to misdiagnosis. The examination results usually demonstrate that the content of eosinophils in alveolar lavage fluid is significantly increased, or the content of eosinophils and immunoglobulin E on a routine blood test is increased. Nevertheless, the final correct diagnosis usually relies on the identification of the morphology. The first case of infection with it was reported in 1992 in China.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> This article summarizes and analyzes the diagnosis and treatment of a case of pulmonary blattarum treated in our hospital to further enhance the understanding of the disease.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 34-year-old male patient has a 17-year history of chronic urticaria and has been undergoing daily treatment with levocetirizine 5<span class="elsevierStyleHsp" style=""></span>mg. In January 2022, he developed a paroxysmal dry cough without obvious inducement, accompanied by white phlegm, shortness of breath, and chest tightness. The pulmonary function examination conducted in Wuhan revealed mild negative results on the bronchodilation test and diagnosed with lung infection. Despite receiving levofloxacin, the symptoms persisted.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In May 2022, the patient sought outpatient care at our hospital. Physical examination revealed a barrel-shaped chest. Laboratory tests showed: white blood cell count of 8.22<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L, eosinophils count of 0.72<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L, C-reactive protein count of 5.50<span class="elsevierStyleHsp" style=""></span>mg/L, IgE count of 515<span class="elsevierStyleHsp" style=""></span>IU/ml and an increased eosinophils percentage of 8.8%. The pulmonary function examination showed a 31.6% decrease in FEV1 following inhalation of histamine 8<span class="elsevierStyleHsp" style=""></span>mg (positive histamine stimulation test). A chest CT scan confirmed the presence of pulmonary infection and bronchial asthma. He was prescribed budesonide/fomoterol inhalation, in addiction to montelukast, compound methoxyphenamine capsules, and procaterol. The symptoms had improved compared to before, but were prone to recurrence, indicating the need for further treatment.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was hospitalized in May 2022. Rheumatological immune-related tests, aspergillus antibody testing, allergen screening, and bone marrow cytology yielded normal results. Given ceftizoxime sodium 2<span class="elsevierStyleHsp" style=""></span>g bid for a week for intravenous anti-infection treatment, the effect was not satisfactory. Later, hormonotherapy 40<span class="elsevierStyleHsp" style=""></span>mg iv was added for further treatment, considering the infection of Trichomonas. After confirmation, metronidazole 0.5<span class="elsevierStyleHsp" style=""></span>g qd was added for intravenous anti-trichomonas treatment. Following the above treatment, the patient's symptoms improved, and he was eventually discharged.</p><p id="par0025" class="elsevierStylePara elsevierViewall">During the follow-up period, the patient remained in good condition. The most recent blood routine showed a white blood cell count of 7.42<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L, eosinophils count of 0.57<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L (5.700% eosinophil percentage). A chest CT scan showed no significant abnormalities, indicating a substantial improvement.</p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">L. blattarum</span>, a parasitic protozoan, tends to live in a viscous environment. It can invade various tissues and organs of the human body through airway transmission and other means.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> While it primarily infects immunocompromised patients it is relatively rare in children. As shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, the increasing prevalence of bronchoscopic alveolar lavage has simplified the identification of this parasite.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Due to its nonspecific symptoms, it is commonly confused with bronchial asthma. The patient, initially presented with prolonged cough, sputum, and elevated IgE levels, leading to a diagnosis of cough variant asthma. The diagnosis was supported by lung function tests, while allergen screening yielded negative results.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Conventional management commenced with empirical antibiotic therapy and treatment for bronchial asthma, but resulted in no response and gradual deterioration. Fortunately, the presence of <span class="elsevierStyleItalic">L. blattarum</span> was detected in the bronchoalveolar lavage fluid. The accurate diagnosis was challenging due to the coexistence of cough variant asthma and chronic urticaria, both contributing to the increased eosinophil count, leading to some confusion.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Given the rarity of <span class="elsevierStyleItalic">L. blattarum</span>, there is a limited number of reported cases of pulmonary infection, and a unified treatment plan has yet to be established. Currently, oral or intravenous metronidazole or tinidazole is considered the mainstay of treatment for adults weighing more than 40<span class="elsevierStyleHsp" style=""></span>kg. In this case, the patient initially received intravenous ornidazole at a dose of 500<span class="elsevierStyleHsp" style=""></span>mg daily for 5 days, which resulted in significant improvement.</p><p id="par0050" class="elsevierStylePara elsevierViewall">By microscopy, distinguishing <span class="elsevierStyleItalic">L. blattarum</span> from normal bronchial ciliated epithelial cells poses a challenge. Furthermore, due to the lack of specific clinical manifestations, most clinicians currently face the difficulties in identifying the parasite, resulting in misdiagnosis or missed diagnosis and subsequent delays in initiating timely treatment. Moreover, the adverse reactions induced by empiric antibiotic therapy and hormone abuse impose unnecessary burdens on the patients. Hence, medical workers should exercise great caution and conduct thorough examinations and analyses in immunocompromised patients presenting with respiratory symptoms such as cough, sputum, asthma, shortness of breath and allergies to ensure an accurate diagnose.</p><p id="par0055" class="elsevierStylePara elsevierViewall">To sum up, the clinical features, transmission routes and pathogenesis of <span class="elsevierStyleItalic">L. blattarum</span> are still not well understood. There is a need for more precise and cost-effective molecular diagnostic techniques to enhance the accuracy of parasite detection, overcoming the limitations associated with morphological characteristics.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethics declaration</span><p id="par0060" class="elsevierStylePara elsevierViewall">The patients’ informed consent has been obtained for this study.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">All authors have no conflicts of interest. On behalf of all authors, the corresponding author states that there is no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethics declaration" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1044 "Ancho" => 2167 "Tamanyo" => 226870 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Microscopic manifestations of <span class="elsevierStyleItalic">Lophomonas blattarum</span>.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> (A) Microscopic view of <span class="elsevierStyleItalic">Lophomonas blattarum</span> (×400): <span class="elsevierStyleItalic">L. blattarum</span>, ovoid in microscopic form, can distinguish anterior and posterior ends, and has a rounded coat with nuclear contents. (B) Microscopic view of <span class="elsevierStyleItalic">Lophomonas blattarum</span> (×1000, staining): <span class="elsevierStyleItalic">L. blattarum</span> deforms into an ellipsoid and purplish-brown color after staining.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A case report of human respiratory hyperflagellate" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.X. Chen" 1 => "Z.X. Meng" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "J Jiangxi Med Coll" "fecha" => "1992" "volumen" => "32" "paginaInicial" => "96" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0030" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary Infection with <span class="elsevierStyleItalic">Lophomonas blattarum</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Q. Ding" 1 => "K. Shen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s12098-020-03311-1" "Revista" => array:6 [ "tituloSerie" => "Indian J Pediatr" "fecha" => "2021" "volumen" => "88" "paginaInicial" => "23" "paginaFinal" => "27" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32592000" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0035" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis and treatment of <span class="elsevierStyleItalic">Lophomonas blattarum</span> infection" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.G. Yang" 1 => "Z. Yang" 2 => "Y. Yang" 3 => "B. Yue" 4 => "S.L. Zheng" 5 => "N. Yan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3969/j.issn.1673-4130.2014.03.024" "Revista" => array:2 [ "tituloSerie" => "Int J Lab Med" "fecha" => "2014" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0040" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnosis and treatment of <span class="elsevierStyleItalic">Lophomonas blattarum</span> infection in 26 patients with bacterial pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y.L. Shi" 1 => "L.H. Li" 2 => "Y. Liao" 3 => "X.N. Li" 4 => "X.Y. Huang" 5 => "J. Liu" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Zhongguo Ji Sheng Chong Xue Yu Ji Sheng Chong Bing Za Zhi" "fecha" => "2007" "volumen" => "25" "paginaInicial" => "430" "paginaFinal" => "431" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18442004" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00257753/0000016200000005/v1_202402251117/S0025775323006541/v1_202402251117/en/main.assets" "Apartado" => array:4 [ "identificador" => "66430" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas al Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00257753/0000016200000005/v1_202402251117/S0025775323006541/v1_202402251117/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775323006541?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 March | 3 | 1 | 4 |
| 2024 February | 1 | 0 | 1 |
| 2023 December | 1 | 1 | 2 |
