Letter to the Editor
Cerebellar alterations: an infrequent presentation of neurosyphilis
Cerebelopatía por sífilis: una presentación infrecuente de neurolúes
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A–C) A head CT study performed at clinical onset (without contrast): non-specific, poorly-defined subcortical hypodense lesions in the periventricular region of both brain hemispheres and in the anterior part of the left frontal lobe (green arrows), probably related to demyelination plaques (patient previously diagnosed with MS). Study revealed no evidence of acute intracranial pathology. Unfortunately, the radiological procedure was suspended, as it was not possible to obtain a neuroimaging sequence using an iodinated contrast medium due to the psychomotor agitation of the patient in the context of a probable allergic reaction to the iodinated medium. D–L) A brain MRI study performed at 3 months (axial FLAIR sequence): images show at least 30 supratentorial hyperintense lesions (red and blue arrows). Some lesions present an ovoid morphology and others are confluent with irregular, poorly-defined borders, which is compatible with MS plaques with sharp edges. The majority of lesions are grouped around the periventricular regions (red arrows), especially in the deep white matter surrounding the temporal horns of the lateral ventricles (J–L). No contrast uptake was observed on T1-weighted sequences. No lesions were found in other regions, including all the spinal cord segments. CT: computed tomography; FLAIR: fluid-attenuated inversion recovery; MRI: magnetic resonance imaging; MS: multiple sclerosis.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. León Ruiz, A.J. Mitchell, J. Benito-León" "autores" => array:3 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "León Ruiz" ] 1 => array:2 [ "nombre" => "A.J." "apellidos" => "Mitchell" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Benito-León" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0213485318301166" "doi" => "10.1016/j.nrl.2018.03.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213485318301166?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173580820300286?idApp=UINPBA00004N" "url" => "/21735808/0000003500000006/v1_202007280641/S2173580820300286/v1_202007280641/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2173580820301231" "issn" => "21735808" "doi" => "10.1016/j.nrleng.2018.03.024" "estado" => "S300" "fechaPublicacion" => "2020-07-01" "aid" => "1218" "copyright" => "Sociedad Española de Neurología" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Neurologia. 2020;35:440-3" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Primary cytomegalovirus infection in a patient with relapsing-remitting multiple sclerosis under treatment with alemtuzumab" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "440" "paginaFinal" => "443" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Primoinfección por citomegalovirus en un paciente con esclerosis múltiple recurrente-remitente tratado con alemtuzumab" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1236 "Ancho" => 1700 "Tamanyo" => 194514 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Pulmonary high-resolution computed tomography: infiltrate predominating in both lung bases and left basal pneumonia.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "S. Eichau, R. López Ruiz, J.J. Castón Osorio, E. Ramírez, A. Domínguez-Mayoral, G. Izquierdo" "autores" => array:6 [ 0 => array:2 [ "nombre" => "S." "apellidos" => "Eichau" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "López Ruiz" ] 2 => array:2 [ "nombre" => "J.J." "apellidos" => "Castón Osorio" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Ramírez" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Domínguez-Mayoral" ] 5 => array:2 [ "nombre" => "G." "apellidos" => "Izquierdo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S021348531830118X" "doi" => "10.1016/j.nrl.2018.03.015" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S021348531830118X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173580820301231?idApp=UINPBA00004N" "url" => "/21735808/0000003500000006/v1_202007280641/S2173580820301231/v1_202007280641/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Cerebellar alterations: an infrequent presentation of neurosyphilis" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "443" "paginaFinal" => "444" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. Milla, A. Aceituno, J. Franco, A. Charte" "autores" => array:4 [ 0 => array:3 [ "nombre" => "J." "apellidos" => "Milla" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Aceituno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:4 [ "nombre" => "J." "apellidos" => "Franco" "email" => array:1 [ 0 => "Jonathan.franco@quironsalud.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 3 => array:3 [ "nombre" => "A." "apellidos" => "Charte" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Medicina Interna, Hospital Universitario Quirón Dexeus, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Neurología, Hospital Universitario Quirón Dexeus, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cerebelopatía por sífilis: una presentación infrecuente de neurolúes" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">With the era of antibiotics, the prevalence of syphilis decreased; however, it has increased in the past 10 years, with an estimated 18 million cases among people aged between 15 and 49 years.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> Global incidence is 1.5 cases per 1000 population, with higher risk in homosexual men.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> Neurosyphilis is the term used to refer to central nervous system involvement, which may develop at any stage, even in the early phase. Its manifestations include asymptomatic neurosyphilis, meningitis, meningovascular syphilis, general paresis, and tabes dorsalis, although there are also “atypical” forms, which do not meet clinical criteria for classic forms.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 52-year-old homosexual man with a history of secondary syphilis 7 years before. Diagnosis was clinical and results from the non-treponemal (rapid plasma reagin [RPR] of 1:138) and treponemal tests were positive. We administered 2.4 million units of benzathine penicillin, and improvements were observed, with RPR titres decreasing to 1:2; however, at 3 years of follow-up, the same titre persisted and he voluntarily stopped attending his periodic follow-up consultations. The patient attended the emergency department due to a 3-month history of instability and gait disorder, which had worsened in the previous week, when he also developed language impairment. Physical examination revealed mild bulbar dysarthria and dysmetria in all 4 limbs (predominantly in the right side), as well as gait ataxia with tendency to drift, increased base of support, and Romberg sign, and even falls. Ocular motility showed no alterations, muscle balance was preserved in all 4 limbs, superficial and proprioceptive sensitivity were normal, and deep tendon reflexes were present and symmetrical in all 4 limbs. In the targeted medical history interview, the patient reported that he had not presented associated sphincter alterations or neuropathic pain. A cranial and spinal cord magnetic resonance imaging study revealed chronic small vessel disease in both brain hemispheres, without involvement of the cerebellar parenchyma or spinal cord or pathological contrast uptake. A subsequent spinal cord study with somatosensory evoked potentials yielded normal results. A basic blood analysis (blood count, biochemistry, vitamin B<span class="elsevierStyleInf">12</span> and copper levels) revealed no alterations; in the syphilis serological test, RPR titre was 1:128 and VDRL titre was 1:64; the HIV serology test was negative. A lumbar puncture revealed predominantly lymphocytic pleocytosis (157<span class="elsevierStyleHsp" style=""></span>cells/mm<span class="elsevierStyleSup">3</span>), high protein levels (57<span class="elsevierStyleHsp" style=""></span>mg/dL), positive VDRL of 1:4, and positive PCR findings for <span class="elsevierStyleItalic">Treponema pallidum</span>. Differential diagnosis of rapidly progressive cerebellar syndrome should include structural cerebellar lesions (ischaemic, inflammatory, or tumour), infectious causes (HIV, Epstein-Barr virus, or cytomegalovirus), autoimmune disease, and paraneoplastic symptoms, which were ruled out in our patient. With the diagnostic suspicion of neurosyphilis of atypical presentation (due to clinical signs suggestive of cerebellar involvement with no parenchymal lesions in the cerebellum and normal spinal cord findings), we started treatment with intravenous crystalline penicillin for 14 days. One week after treatment onset, the patient's clinical symptoms improved and he was able to walk; Romberg test was negative.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The decrease in the mortality associated with HIV, due to the effectiveness of antiretroviral treatment, has caused an increase in the incidence of sexually transmitted infections, including syphilis. This has led to the reappearance of neurological manifestations (neurosyphilis).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> Untreated syphilis may result in neurological impairment in 4%-10% of patients, but cases have also been described in immunocompetent patients receiving appropriate antibiotic treatment of the primary infection.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">To our knowledge, there are no previous reports of neurosyphilis with cerebellar alterations, although the wide spectrum of clinical manifestations of syphilis is widely known; syphilis was historically known as “the great simulator.” Classic forms of presentation include syphilitic meningitis, meningovascular variant, general paresis, and tabes dorsalis. However, there is an “atypical” form that may present with unusual manifestations, such as seizures, psychiatric symptoms, altered level of consciousness, and behavioural alterations similar to those of viral or autoimmune encephalitis.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3,5</span></a> In our case, we should mention the early clinical improvement with antibiotic treatment, which may suggest that progression time was shorter; in more chronic stages, such as tabes dorsalis or general paresis, the damage is irreversible.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Another controversial issue is the indication of lumbar puncture during diagnosis of syphilis; it is currently indicated in patients with neurological, ophthalmic, or ear signs and symptoms; tertiary syphilis in another part of the body; or treatment failure (including failure to decrease titres in non-treponemal blood tests).<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> However, a more controversial recommendation is that lumbar puncture should be performed in those patients with syphilis in any stage who present high titres in non-treponemal tests during the initial diagnosis (RPR<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>1:32), regardless of whether the patient presents neurological symptoms or is HIV-positive, since in these patients, the risk of presenting asymptomatic neurosyphilis is 11 times higher than among those with lower titres.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Our patient presented high titres during the first diagnosis of secondary syphilis (RPR 1:134). Twenty percent of patients with asymptomatic neurosyphilis develop the symptomatic form during the first 10 years, especially when they present high pleocytosis or high cerebrospinal fluid protein levels. In this scenario, there is controversy regarding the actions to be taken in daily practice, as more studies are needed to assess whether it is necessary to actively screen for and treat asymptomatic neurosyphilis.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, the incidence of syphilis is increasing both in immunosuppressed and in immunocompetent patients. This leads to a higher incidence of central nervous system infection due to syphilis (neurosyphilis). Neurological symptoms may vary greatly, from the classic form to atypical manifestations. Healthcare professionals should be aware of this increasing incidence and the possibility of unusual neurological symptoms in neurosyphilis, as early treatment may prevent sequelae and improve survival, as in our patient.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Milla J, Aceituno A, Franco J, Charte A. Cerebelopatía por sífilis: una presentación infrecuente de neurolúes. Neurología. 2020;35:443–444.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global estimates of the prevalence and incidence of four curable sexually transmitted infections in 2012 based on systematic review and global reporting" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Newman" 1 => "J. Rowley" 2 => "S. Vander Hoorn" 3 => "N.S. Wijesooriya" 4 => "M. Unemo" 5 => "N. Low" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0143304" "Revista" => array:5 [ "tituloSerie" => "PLoS ONE" "fecha" => "2015" "volumen" => "10" "paginaInicial" => "e0143304" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26646541" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0050" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology, sexual risk behavior, and HIV prevention practices of men who have sex with men using GRINDR in Los Angeles, California" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.J. Landovitz" 1 => "C.H. Tseng" 2 => "M. Weissman" 3 => "M. Haymer" 4 => "B. Mendenhall" 5 => "K. Rogers" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s11524-012-9766-7" "Revista" => array:6 [ "tituloSerie" => "J Urban Health" "fecha" => "2013" "volumen" => "90" "paginaInicial" => "729" "paginaFinal" => "739" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22983721" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0055" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neurosyphilis. A study of 241 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H. Hooshmand" 1 => "M.R. Escobar" 2 => "S.W. Kopft" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.219.6.726" "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "1972" "volumen" => "219" "paginaInicial" => "726" "paginaFinal" => "729" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/5066697" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0060" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Re-evaluation of serological criteria for early syphilis treatment efficacy: progression to neurosyphilis despite therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "P. Zhou" 1 => "X. Gu" 2 => "H. Lu" 3 => "Z. Guan" 4 => "Y. Qian" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/sextrans-2011-050247" "Revista" => array:6 [ "tituloSerie" => "Sex Transm Infect" "fecha" => "2012" "volumen" => "88" "paginaInicial" => "342" "paginaFinal" => "345" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22363023" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0065" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Changes in neurosyphilis presentation: a survey on 286 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Drago" 1 => "G. Merlo" 2 => "G. Ciccarese" 3 => "A.F. Agnoletti" 4 => "E. Cozzani" 5 => "A. Rebora" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/jdv.13753" "Revista" => array:6 [ "tituloSerie" => "J Eur Acad Dermatol Venereol" "fecha" => "2016" "volumen" => "30" "paginaInicial" => "1886" "paginaFinal" => "1900" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27306850" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0070" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sexually transmitted diseases treatment guidelines, 2015" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Centers for Disease Control and Prevention" "etal" => false "autores" => array:2 [ 0 => "K.A. Workowski" 1 => "G.A. 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Eaton" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/381227" "Revista" => array:6 [ "tituloSerie" => "J Infect Dis" "fecha" => "2004" "volumen" => "189" "paginaInicial" => "369" "paginaFinal" => "376" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14745693" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0080" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2014 European guideline on the management of syphilis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Janier" 1 => "V. Hegyi" 2 => "N. Dupin" 3 => "M. Unemo" 4 => "G.S. Tiplica" 5 => "M. Potocnik" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/jdv.12734" "Revista" => array:6 [ "tituloSerie" => "J Eur Acad Dermatol Venereol" "fecha" => "2014" "volumen" => "28" "paginaInicial" => "1581" "paginaFinal" => "1593" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25348878" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735808/0000003500000006/v1_202007280641/S2173580820300298/v1_202007280641/en/main.assets" "Apartado" => array:4 [ "identificador" => "9409" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735808/0000003500000006/v1_202007280641/S2173580820300298/v1_202007280641/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173580820300298?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 1 | 7 |
| 2024 October | 15 | 0 | 15 |
| 2024 September | 48 | 9 | 57 |
| 2024 August | 40 | 8 | 48 |
| 2024 July | 35 | 3 | 38 |
| 2024 June | 20 | 4 | 24 |
| 2024 May | 27 | 3 | 30 |
| 2024 April | 21 | 5 | 26 |
| 2024 March | 29 | 5 | 34 |
| 2024 February | 29 | 6 | 35 |
| 2024 January | 26 | 2 | 28 |
| 2023 December | 44 | 12 | 56 |
| 2023 November | 26 | 2 | 28 |
| 2023 October | 45 | 10 | 55 |
| 2023 September | 23 | 2 | 25 |
| 2023 August | 20 | 3 | 23 |
| 2023 July | 21 | 4 | 25 |
| 2023 June | 44 | 9 | 53 |
| 2023 May | 46 | 3 | 49 |
| 2023 April | 57 | 3 | 60 |
| 2023 March | 32 | 3 | 35 |
| 2023 February | 17 | 9 | 26 |
| 2023 January | 23 | 4 | 27 |
| 2022 December | 22 | 7 | 29 |
| 2022 November | 23 | 4 | 27 |
| 2022 October | 22 | 7 | 29 |
| 2022 September | 17 | 6 | 23 |
| 2022 August | 30 | 9 | 39 |
| 2022 July | 16 | 9 | 25 |
| 2022 June | 23 | 10 | 33 |
| 2022 May | 13 | 6 | 19 |
| 2022 April | 34 | 9 | 43 |
| 2022 March | 42 | 13 | 55 |
| 2022 February | 42 | 6 | 48 |
| 2022 January | 21 | 9 | 30 |
| 2021 December | 6 | 11 | 17 |
| 2021 November | 25 | 10 | 35 |
| 2021 October | 30 | 8 | 38 |
| 2021 September | 21 | 13 | 34 |
| 2021 August | 33 | 7 | 40 |
| 2021 July | 19 | 6 | 25 |
| 2021 June | 26 | 12 | 38 |
| 2021 May | 28 | 7 | 35 |
| 2021 April | 52 | 13 | 65 |
| 2021 March | 20 | 9 | 29 |
| 2021 February | 21 | 11 | 32 |
| 2021 January | 14 | 11 | 25 |
| 2020 December | 12 | 8 | 20 |
| 2020 November | 10 | 9 | 19 |
| 2020 October | 13 | 3 | 16 |
| 2020 September | 12 | 15 | 27 |
| 2020 August | 21 | 14 | 35 |
| 2020 July | 4 | 8 | 12 |
| 2020 June | 0 | 10 | 10 |
| 2020 May | 0 | 5 | 5 |
| 2020 April | 0 | 5 | 5 |
| 2020 March | 0 | 2 | 2 |
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