Brief report
Solitary pleural nodule: A late paradoxical reaction to antituberculosis treatment
Nódulo pleural único: una forma de reacción paradójica tardía al tratamiento antituberculoso
D. Varona Porres
, E. Pallisa, A.L. Sánchez, Ó. Persiva
Corresponding author
Servicio de Radiodiagnóstico, Hospital Vall d’Hebron, Barcelona, Spain
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Nódulo hipoecoico de morfología ovalada adyacente a la pared costal lateral e inferior derecha, que se movilizaba con la respiración, de probable origen pleural (flechas blancas).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D. Varona Porres, E. Pallisa, A.L. Sánchez, Ó. Persiva" "autores" => array:4 [ 0 => array:2 [ "nombre" => "D." "apellidos" => "Varona Porres" ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Pallisa" ] 2 => array:2 [ "nombre" => "A.L." "apellidos" => "Sánchez" ] 3 => array:2 [ "nombre" => "Ó." 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This lesion presses against the underlying muscle and presents posterior acoustic enhancement (black arrows). (B) Pseudonodular lesions in contact with each other with a mixed internal structure (asterisk), arising from the medial band of the plantar aponeurosis, located in the medial to distal third thereof. The lesions also show posterior acoustic enhancement (black arrows).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.F. García-Gil, V. Lezcano Biosca" "autores" => array:2 [ 0 => array:2 [ "nombre" => "M.F." "apellidos" => "García-Gil" ] 1 => array:2 [ "nombre" => "V." "apellidos" => "Lezcano Biosca" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0033833820300977" "doi" => "10.1016/j.rx.2020.06.003" "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/S0033833820300977?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173510720300707?idApp=UINPBA00004N" "url" => "/21735107/0000006200000005/v2_202011090625/S2173510720300707/v2_202011090625/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2173510720300677" "issn" => "21735107" "doi" => "10.1016/j.rxeng.2020.05.004" "estado" => "S300" "fechaPublicacion" => "2020-09-01" "aid" => "1212" "copyright" => "SERAM" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Radiologia. 2020;62:400-10" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Article from a resident</span>" "titulo" => "Role of imaging in pseudotumor cerebri syndrome" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "400" "paginaFinal" => "410" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Papel de la radiología en el síndrome de pseudotumor cerebral" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 867 "Ancho" => 2093 "Tamanyo" => 128600 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Increased cerebrospinal fluid (CSF) spaces. (A) Fast imaging employing steady-state acquisition (FIESTA) balanced sequence on the sagittal plane in a patient with IIH. The filling of the dural canal of the sixth cranial nerve (Dorello's canal) with CSF is seen (white and black arrow tip). (B) FIESTA sequence coronal image with a bilateral and symmetrical increase in CSF spaces (asterisks) around the dural canals of the third cranial nerve (black arrow tips) in the lateral wall of the laterosellar space. A Meckel's cave meningocele (asterisk) associated with IIH was also identified.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D. Veiga-Canuto, J. Carreres-Polo" "autores" => array:2 [ 0 => array:2 [ "nombre" => "D." "apellidos" => "Veiga-Canuto" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Carreres-Polo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0033833820300758" "doi" => "10.1016/j.rx.2020.05.007" "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/S0033833820300758?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173510720300677?idApp=UINPBA00004N" "url" => "/21735107/0000006200000005/v2_202011090625/S2173510720300677/v2_202011090625/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Brief report</span>" "titulo" => "Solitary pleural nodule: A late paradoxical reaction to antituberculosis treatment" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "411" "paginaFinal" => "414" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "D. Varona Porres, E. Pallisa, A.L. Sánchez, Ó. Persiva" "autores" => array:4 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Varona Porres" "email" => array:1 [ 0 => "dvarona@vehebron.net" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Pallisa" ] 2 => array:2 [ "nombre" => "A.L." "apellidos" => "Sánchez" ] 3 => array:2 [ "nombre" => "Ó." "apellidos" => "Persiva" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Vall d’Hebron, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nódulo pleural único: una forma de reacción paradójica tardía al tratamiento antituberculoso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 550 "Ancho" => 905 "Tamanyo" => 41790 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Chest ultrasound. Oval-shaped hypoechoic nodule adjacent to the lateral and right lower costal wall, which mobilises with respiration, of probable pleural origin (white arrows).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">We present the case of a 24-year-old woman who visited our hospital due to right lower chest wall pain that worsened with movement. Physical examination revealed only wheezing on respiratory auscultation. She presented neither fever nor constitutional symptoms. The patient had been previously diagnosed with pleural tuberculosis (PT) and pulmonary tuberculosis which had been properly treated, and had finished treatment 4 months earlier with no symptoms or radiological findings.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A chest X-ray showed linear pulmonary opacities, loss of volume of the right upper lobe and extrapulmonary lesion projected over the right lateral costophrenic sulcus (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Computed tomography of the chest without intravenous contrast showed the presence of bronchial dilatations with a nodular lesion and loss of volume of the right upper lobe, findings suggestive of fibrotic changes related to the patient's history of pulmonary tuberculosis, and a hypodense pleural nodule with small lateral and right lower calcifications (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). A decision was made to perform ultrasound-guided fine-needle (22G) aspiration biopsy of the pleural lesion. The chest ultrasound showed an oval-shaped hypoechoic nodule adjacent to the costal wall which mobilised with respiration (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), and biopsy of this lesion yielded a purulent specimen for examination. The sample obtained consisted of a necrotic base with inflammatory remnants and a histiocytic component, and culture was positive for rifampicin- and isoniazid-sensitive <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> complex. The patient was treated with antituberculosis treatment for 6 more months, and her pleural lesion and associated symptoms completely resolved.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">PT usually presents as pleural effusion in both its primary and its post-primary form.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> PT is one of the most common forms of extrapulmonary tuberculosis and is associated with pulmonary lesions in 39–86% of cases.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> Possible complications of PT are empyema, bronchopleural or pleurocutaneous fistulas, costal erosions, residual pleural thickening and calcifications.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> The nodular pleural form is rare and there are few reports thereof in the specialised literature, especially with a single pleural nodule.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1,3–5</span></a> A tuberculous origin was suggested by the nodular form of presentation with a hypodense centre and peripheral uptake, similar to lymphadenopathy of tuberculous origin, and the unilateral distribution.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> The differential diagnosis could include pleural neoplasms (mesothelioma, metastases, lymphoma and invasive thymoma), chest wall tumours and loculated pleural effusion. Residual pleural thickening could also be included in the differential diagnosis, and is a common complication of tuberculous pleural effusion (36%), especially in elderly men, with a negative pleural fluid culture.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A paradoxical reaction to treatment consists of the growth of old lesions or the onset of new lesions during or after suitable antituberculosis treatment.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">7,8</span></a> In general, it develops 3–12 weeks after antituberculosis treatment is started.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> In one study, all the new lesions developed in the subpleural pulmonary region, mostly ipsilateral to the tuberculous pleural effusion.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> A paradoxical reaction is more common in extrapulmonary tuberculosis in HIV-negative patients<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> and pleural tuberculosis is the second most common sign of a paradoxical reaction with an incidence of 11%-23%.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> The most typical form of presentation is worsening of pre-existing pleural effusion and most patients are asymptomatic,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> unlike our case in which the form of presentation was a single pleural nodule and chest pain. Occasionally, a paradoxical reaction may occur following completion of initial antituberculosis treatment,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> though there are few cases published in the literature<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> and no cases in which the form of presentation is a single pleural nodule. There is no recommendation for treatment of a paradoxical reaction following completion of antituberculosis treatment; however, there is a good response to regular retreatment with clinical improvement in 2 months in most cases.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> The prognosis for a paradoxical response to antituberculosis treatment is excellent except in case of central nervous system impairment<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> and late improvement with multiple recurrences may precede complete resolution.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion, the presence of a single pleural nodule in patients with diagnosed and treated chest tuberculosis, even following treatment completion, may point to a paradoxical reaction to tuberculostatic drugs. Treatment continuation is necessary in case of a positive culture for <span class="elsevierStyleItalic">M. tuberculosis</span> and the presence of symptoms.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors’ contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0035" class="elsevierStylePara elsevierViewall">Study integrity: DVP.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0040" class="elsevierStylePara elsevierViewall">Study concept: DVP, EP, ALS and OP.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0045" class="elsevierStylePara elsevierViewall">Study design: DVP, EP, ALS and OP.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0050" class="elsevierStylePara elsevierViewall">Data acquisition: DVP.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5.</span><p id="par0055" class="elsevierStylePara elsevierViewall">Data analysis and interpretation: DVP.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6.</span><p id="par0060" class="elsevierStylePara elsevierViewall">Statistical processing: N/A.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7.</span><p id="par0065" class="elsevierStylePara elsevierViewall">Literature search: DVP.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8.</span><p id="par0070" class="elsevierStylePara elsevierViewall">Drafting of the study: DVP.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9.</span><p id="par0075" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually significant contributions: DVP, EP, ALS and OP.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10.</span><p id="par0080" class="elsevierStylePara elsevierViewall">Approval of the final version: DVP, EP, ALS and OP.</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1410503" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1290514" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1410502" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1290515" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Authors’ contributions" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-07-25" "fechaAceptado" => "2020-01-31" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1290514" "palabras" => array:4 [ 0 => "Thoracic tuberculosis" 1 => "Pleural nodule" 2 => "Antituberculosis treatment" 3 => "Paradoxical reaction" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1290515" "palabras" => array:4 [ 0 => "Tuberculosis torácica" 1 => "Nódulo pleural" 2 => "Tratamiento antituberculoso" 3 => "Reacción paradójica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We present the case of a young woman with a history of previously treated pleural and pulmonary tuberculosis referred to our hospital for chest pain and a single pleural nodule seen on plain chest films and chest CT. Cultures of inflammatory-type material obtained by US-guided fine-needle biopsy of the pleural lesion were positive for Mycobacterium tuberculosis complex. The diagnosis was a paradoxical reaction to antituberculosis treatment; after 6 more months of treatment, the pleural lesion and chest pain disappeared.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se presenta el caso de una mujer joven con antecedente de tuberculosis pleural y pulmonar previamente tratada, que acudió a nuestro hospital por dolor torácico y nódulo pleural único visualizado en radiografía simple y TC torácicas. Se realizó punción con aguja fina guiada por ecografía torácica de la lesión pleural con la que se obtuvo material de tipo inflamatorio para estudio con cultivo positivo para <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> complex. El diagnóstico fue de reacción paradójica al tratamiento antituberculoso y fue tratada durante 6 meses más con resolución de la lesión pleural y el dolor torácico.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Varona Porres D, Pallisa E, Sánchez AL, Persiva Ó. Nódulo pleural único: una forma de reacción paradójica tardía al tratamiento antituberculoso. Radiología. 2020;62:411–414.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 942 "Ancho" => 905 "Tamanyo" => 81151 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray in posterior–anterior projection. Linear pulmonary opacities with loss of pulmonary volume in right upper lobe (white circle) and extrapulmonary nodular lesion projected over the right lateral costophrenic sulcus with pinching thereof (white arrow).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2317 "Ancho" => 2925 "Tamanyo" => 446751 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Computed tomography without intravenous contrast (coronal, axial and sagittal planes). Hypodense pleural nodule with small lateral and right lower calcifications (white arrows) and linear pulmonary opacities with cylindrical bronchial dilatations, a pulmonary nodule measuring a millimetre, and loss of volume of the right upper lobe (black circles).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 550 "Ancho" => 905 "Tamanyo" => 41790 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Chest ultrasound. Oval-shaped hypoechoic nodule adjacent to the lateral and right lower costal wall, which mobilises with respiration, of probable pleural origin (white arrows).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Atypical presentation of pleural tuberculosis: CT findings" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "O.M. Ariyürek" 1 => "B.E. 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