Letter to the Editor
Amyotrophic lateral sclerosis and myasthenia gravis overlap syndrome: 3 new cases
Esclerosis lateral amiotrófica y miastenia gravis (síndrome overlap): presentación de 3 nuevos casos
S. Santos-Lasaosa
, A. López-Bravo, M. Garcés-Redondo, S. Atienza-Ayala, P. Larrodé-Pellicer
Corresponding author
Servicio de Neurología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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"apellidos" => "Moniche" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0213485319300738" "doi" => "10.1016/j.nrl.2019.05.001" "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/S0213485319300738?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173580820301723?idApp=UINPBA00004N" "url" => "/21735808/0000003500000008/v1_202010030617/S2173580820301723/v1_202010030617/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Amyotrophic lateral sclerosis and myasthenia gravis overlap syndrome: 3 new cases" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "595" "paginaFinal" => "597" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "S. Santos-Lasaosa, A. López-Bravo, M. Garcés-Redondo, S. Atienza-Ayala, P. Larrodé-Pellicer" "autores" => array:5 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Santos-Lasaosa" "email" => array:1 [ 0 => "ssantos@salud.aragon.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "López-Bravo" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Garcés-Redondo" ] 3 => array:2 [ "nombre" => "S." "apellidos" => "Atienza-Ayala" ] 4 => array:2 [ "nombre" => "P." "apellidos" => "Larrodé-Pellicer" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Neurología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Esclerosis lateral amiotrófica y miastenia gravis (síndrome <span class="elsevierStyleItalic">overlap</span>): presentación de 3 nuevos casos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The association of myasthenia gravis (MG) and amyotrophic lateral sclerosis (ALS) (overlap syndrome) is infrequent in clinical practice. The available evidence suggests that immunomodulatory therapy has a protective effect in the early stages of motor neuron disease (MND).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> We present 3 cases of this overlap syndrome; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarises the characteristics of these patients.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Patient 1</span><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 52-year-old man with initial symptoms of bilateral ptsosis, diplopia, and dysphagia; 6-8 months later, he presented left brachial paresis with thenar atrophy, global hyperreflexia, and increased jaw jerk reflex. 3-Hz repetitive stimulation obtained a decrement of > 10% in the fifth potential in the abductor digiti minimi. Anti-acetylcholine receptor (anti-AChR) antibody titre was 0.74 (positive results, > 0.7), and remained stable in subsequent determinations. Fasciculations and denervation potentials were observed in an electromyography study (EMG) performed 4 months after the initial assessment. At 24 months, the patient met diagnostic criteria for class IIb MG<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and definite ALS, according to the El Escorial criteria.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Patient 2</span><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 77-year-old man who developed dysphonia and neurogenic dysphagia with fatigue. He was initially diagnosed class IIb MG: anti-AChR antibody titre was > 20 and 3-Hz repetitive stimulation of the abductor digiti minimi obtained a decrement of > 10% in the fifth potential. Treatment was started with pyridostigmine and oral prednisone, with good clinical response; at 15 months, he presented atrophy of the shoulder and pelvic girdles and right quadriceps, and exacerbation of bulbar symptoms and hyperreflexia. The EMG revealed fasciculations and denervation potentials in the deltoids, medial head of the left gastrocnemius, and the left vastus, and in the tongue.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patient 3</span><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was a 73-year-old woman with dysphonia, neurogenic dysphagia, fatigue, and exertion dyspnoea of progressive onset in the previous 2 months. 3-Hz repetitive stimulation of the facial and accessory nerves obtained a decrement of > 10% in the fifth potential. Anti-AChR antibody titre was 7.6. After diagnosis of class IIb MG,<span class="elsevierStyleSup">3</span> combined treatment with pyridostigmine and prednisone was started. Five months after onset, the patient presented anarthria. An EMG study revealed denervation activity and fasciculations in the masseter, tongue, right first interosseous muscle, abductor digiti minimi, and vastus lateralis. The subsequent clinical progression, with lack of response to treatment with immunoglobulins and plasmapheresis, as well as the findings of the neurophysiological study, confirmed the diagnosis of definite ALS.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">This association is infrequent, with only 28 cases reported in the literature,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5</span></a> and represents 2% of patients in our series. Both processes feature an immune-mediated pathogenic mechanism.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> A decrease in CD4+ Foxp3+ regulatory T cells (Tregs)<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> has been described; levels of these cells are associated with ALS progression and altered nitric oxide synthesis.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> It is also reported that muscle and neuromuscular junction involvement may already be apparent in the initial stage of ALS.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,10,11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Mulder et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> describe a decrease in action potentials in patients with ALS, which varies according to muscle analysed.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> For example, Wang et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> observed a decrease > 10% in 43% of patients with ALS and in 70% of those with MG. This finding was associated with disease progression and predominantly affected proximal muscles (frequently the trapezius) in patients with ALS, whereas distal muscles showed greater involvement in MG.</p><p id="par0035" class="elsevierStylePara elsevierViewall">When both entities coexist, MG symptoms are mainly ocular and bulbar. In these cases, immunomodulatory treatment should be considered as a diagnostic and therapeutic option.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Furthermore, positive anti-AChR antibody titres have been reported in up to 5% of patients with ALS. Although the cause is unclear, this may be related to the early involvement of the neuromuscular junction, which may also explain the higher levels of anti–low-density lipoprotein receptor–related protein 4 (anti-LRP4) antibodies in this disease.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Okuyama et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> detected higher titres during periods of more aggressive disease activity and lower titres in stages of clinical stability.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Therefore, we conclude that although the available evidence suggests that early treatment of symptoms of neuromuscular junction involvement improves survival in patients with ALS, diagnosis of ALS/MG overlap syndrome should only be considered when signs and symptoms of MND are observed in association with clinical signs of neuromuscular junction involvement (preferably ocular or bulbar signs) or positive titres of anti-AChR, anti-MuSK, or anti-LRP10 antibodies; and response to acetylcholinesterase inhibitors.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Patient 1" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Patient 2" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Patient 3" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-06-30" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Santos-Lasaosa S, López-Bravo A, Garcés-Redondo M, Atienza-Ayala S, Larrodé-Pellicer P. Esclerosis lateral amiotrófica y miastenia gravis (síndrome <span class="elsevierStyleItalic">overlap</span>): presentación de 3 nuevos casos. Neurología. 2020;35:595–597.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">AChR: acetylcholine receptor; CT: computed tomography; M: man; MND: motor neuron disease; MuSK: muscle-specific receptor tyrosine kinase; W: woman.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3 \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">W \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age of symptom onset (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">First symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ptosis/diplopia/dysphagia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diplopia/dysphagia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diplopia/dysphagia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time to MND symptom onset \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6-8 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10-12 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 months \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time to diagnosis of overlap syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 months \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anti-AChR antibodies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">> 20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anti-MuSK antibodies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Negative \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mediastinum CT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal thymus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal thymus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal thymus \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2392393.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Demographic and clinical characteristics of the patients.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Amyotrophic lateral sclerosis and myasthenia gravis overlap syndrome: a review of two cases and the associated literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 17 | 1 | 18 |
| 2024 October | 80 | 10 | 90 |
| 2024 September | 119 | 9 | 128 |
| 2024 August | 79 | 5 | 84 |
| 2024 July | 91 | 6 | 97 |
| 2024 June | 87 | 3 | 90 |
| 2024 May | 72 | 4 | 76 |
| 2024 April | 64 | 8 | 72 |
| 2024 March | 83 | 8 | 91 |
| 2024 February | 96 | 4 | 100 |
| 2024 January | 118 | 8 | 126 |
| 2023 December | 104 | 24 | 128 |
| 2023 November | 91 | 7 | 98 |
| 2023 October | 135 | 19 | 154 |
| 2023 September | 76 | 2 | 78 |
| 2023 August | 77 | 8 | 85 |
| 2023 July | 86 | 6 | 92 |
| 2023 June | 104 | 9 | 113 |
| 2023 May | 158 | 19 | 177 |
| 2023 April | 104 | 4 | 108 |
| 2023 March | 99 | 9 | 108 |
| 2023 February | 55 | 0 | 55 |
| 2023 January | 62 | 6 | 68 |
| 2022 December | 47 | 8 | 55 |
| 2022 November | 83 | 13 | 96 |
| 2022 October | 74 | 6 | 80 |
| 2022 September | 55 | 11 | 66 |
| 2022 August | 72 | 11 | 83 |
| 2022 July | 44 | 7 | 51 |
| 2022 June | 52 | 10 | 62 |
| 2022 May | 45 | 7 | 52 |
| 2022 April | 69 | 9 | 78 |
| 2022 March | 78 | 10 | 88 |
| 2022 February | 78 | 2 | 80 |
| 2022 January | 75 | 8 | 83 |
| 2021 December | 61 | 15 | 76 |
| 2021 November | 71 | 10 | 81 |
| 2021 October | 64 | 13 | 77 |
| 2021 September | 74 | 9 | 83 |
| 2021 August | 85 | 7 | 92 |
| 2021 July | 84 | 12 | 96 |
| 2021 June | 70 | 14 | 84 |
| 2021 May | 88 | 12 | 100 |
| 2021 April | 168 | 34 | 202 |
| 2021 March | 113 | 20 | 133 |
| 2021 February | 73 | 20 | 93 |
| 2021 January | 41 | 10 | 51 |
| 2020 December | 35 | 21 | 56 |
| 2020 November | 13 | 7 | 20 |
| 2020 October | 11 | 7 | 18 |
| 2020 September | 1 | 10 | 11 |
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