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Cutaneous fusariosis by a species of the Fusarium dimerum species complex in a patient with acute mieloblastic leukemia
Fusariosis cutánea por una especie del complejo Fusarium dimerum en una paciente con leucemia mieloblástica aguda
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(B) Complete healing after 8 months.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Elsa Vásquez-del-Mercado, Lorena Lammoglia, Roberto Arenas" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Elsa" "apellidos" => "Vásquez-del-Mercado" ] 1 => array:2 [ "nombre" => "Lorena" "apellidos" => "Lammoglia" ] 2 => array:2 [ "nombre" => "Roberto" "apellidos" => "Arenas" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130140612001076?idApp=UINPBA00004N" "url" => "/11301406/0000003000000002/v1_201305061134/S1130140612001076/v1_201305061134/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Note</span>" "titulo" => "Cutaneous fusariosis by a species of the <span class="elsevierStyleItalic">Fusarium dimerum</span> species complex in a patient with acute mieloblastic leukemia" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "119" "paginaFinal" => "121" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Carmen Collado, Laura Medina, Alfredo Zorraquino, Teresa Baeza, Consuelo Ferrer, Joaquín Plazas, María Francisca Colom" "autores" => array:7 [ 0 => array:3 [ "nombre" => "Carmen" "apellidos" => "Collado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Laura" "apellidos" => "Medina" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Alfredo" "apellidos" => "Zorraquino" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Teresa" "apellidos" => "Baeza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Consuelo" "apellidos" => "Ferrer" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "Joaquín" "apellidos" => "Plazas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 6 => array:4 [ "nombre" => "María Francisca" "apellidos" => "Colom" "email" => array:1 [ 0 => "colom@goumh.umh.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital General Universitario de Alicante, Alicante, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Vissum Corporation, I+D+i Department, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Universidad Miguel Hernández, Medical Mycology Laboratory, Alicante, Spain" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fusariosis cutánea por una especie del complejo <span class="elsevierStyleItalic">Fusarium dimerum</span> en una paciente con leucemia mieloblástica aguda" ] ] "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" => 554 "Ancho" => 1300 "Tamanyo" => 105039 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Photograph of the anterior surface of the left (A) and right (B) feet showing ulcerous lesions.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Fusarium</span> spp. are important plant pathogens and may occasionally cause infections in humans. These fungi cause a broad spectrum of infections ranging from superficial to locally invasive and disseminated processes. The clinical form depends largely on the immune status of the host and the portal of entry of the fungus.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In this document we describe the case of a patient with Acute Mieloblastic Leukemia (AML) who developed fusariosis by a species of the <span class="elsevierStyleItalic">Fusarium dimerum</span> species complex.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 74-year-old woman with a medical history of high blood pressure and dyslipidemia, was admitted to hospital with bilateral edema and pain in both legs and feet. The anterior surface of the feet presented blisters and painful ulcerous lesions with pus discharge and perilesional erythema (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). These symptoms had developed over the previous week. At that moment she was being treated with hidroclorotiazida–valsartan 25/160<span class="elsevierStyleHsp" style=""></span>mg/day. The patient had been previously admitted to primary care services and received levofloxacin 500<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h and ibuprofen 600<span class="elsevierStyleHsp" style=""></span>mg/8<span class="elsevierStyleHsp" style=""></span>h, but the situation did not improve. She also showed symptoms of cardiac failure: dyspnea, orthopnea and increased abdominal perimeter. The patient did not currently present or remember to have had fever.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Physical examination revealed a bad general status and hemodynamic compromise with BP 65/38<span class="elsevierStyleHsp" style=""></span>mmHg. The cardio-pulmonary examination showed low rhythmic tones and bilateral basal crackles. Laboratory investigations revealed signals of renal failure (creatinine: 8.73<span class="elsevierStyleHsp" style=""></span>mg/dl; glomerular filtration rate: 5<span class="elsevierStyleHsp" style=""></span>ml/min), metabolic acidosis (pH: 7.26, HCO<span class="elsevierStyleInf">3</span>: 16.2<span class="elsevierStyleHsp" style=""></span>mequiv./L), light thrombocytopenia (122<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>/μL), leukocytosis (37<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>/μL) and anemia (Hb: 7.6<span class="elsevierStyleHsp" style=""></span>mg/dl; VCM: 115.6<span class="elsevierStyleHsp" style=""></span>fl). Transaminase enzymes and coagulation were normal. After these findings, a subsequent study of bone marrow and peripheral blood resulted in the diagnosis of acute mieloblastic leukemya (AML). Hemodynamic support measures and intravenous treatment with antibiotic were established considering the renal function. Piperaziline–tazobactam 2<span class="elsevierStyleHsp" style=""></span>g/8<span class="elsevierStyleHsp" style=""></span>h and levofloxacin 250<span class="elsevierStyleHsp" style=""></span>mg/48<span class="elsevierStyleHsp" style=""></span>h were prescribed. Two samples of the curettage of the ulcer lesions were taken and sent to the microbiology laboratory. Both samples were studied under optical microscopy and cultured on sheep blood agar, blood-CNA agar, Polivitex agar, McConkey agar and Sabouraud–Cloramfenicol–Gentamicin agar. After Gram staining, microscopic observation of the sample from the right foot showed a filamentous fungus as the only detectable microorganism. The morphology of the abundant conidia suggested <span class="elsevierStyleItalic">Fusarium</span> sp. as the causative agent (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Based on this finding, a first dose of voriconazole 400<span class="elsevierStyleHsp" style=""></span>mg was administered followed by a regimen of 200<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h. The direct observation of the left foot sample was not informative.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">After two days of incubation at 37<span class="elsevierStyleHsp" style=""></span>°C, the sample from the right foot yielded a pure culture of a filamentous fungus, which was consistent with the previous Gram stain observation. An <span class="elsevierStyleItalic">Enterococcus faecalis</span> was isolated on sheep blood agar from the sample of the left foot and i.v. ampicillin (1<span class="elsevierStyleHsp" style=""></span>g/8<span class="elsevierStyleHsp" style=""></span>h) was prescribed. Additionally, two samples of peripheral blood were cultured and came out negative after 5-day incubation. Seven days after admittance to the hospital and after 5 days of treatment with voriconazole, no favorable response was obtained and the patient died.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Based on the difficulty to identify <span class="elsevierStyleItalic">Fusarium</span> at a species level, the isolate was sent to the Medical Mycology laboratory (Faculty of Medicine) where it was subcultured on Potato Dextrose Agar, Corn Meal Agar and Malt Extract Agar. Macroscopic and microscopic features were exhaustively studied and concluded in the identification of the strain as <span class="elsevierStyleItalic">F. dimerum</span> (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). For molecular identification, ITS1-ITS4 and the 5.8S region of the rDNA were amplified with specific primers in a semi-nested PCR.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The sequence of a fragment of 561 nucleotides was obtained and analyzed by comparison in GenBank and EMBL database. A similarity of 100% with the sequence of <span class="elsevierStyleItalic">Fusarium delphinoides</span> was found. <span class="elsevierStyleItalic">F. delphinoides</span> is one of the species described within the <span class="elsevierStyleItalic">F. dimerum</span> morphotype group.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Nevertheless, this finding was not enough to assess the identification within the <span class="elsevierStyleItalic">F. dimerum species complex</span>, where other species (e.g. <span class="elsevierStyleItalic">F. nectrioides</span>) could yield the same similarity of the ITS region.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The sensitivity of this isolate against conventional antifungal drugs was determined by the Sensititre YeastOne<span class="elsevierStyleSup">®</span> system.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The isolate showed resistance to all echinocandins (MICs<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>μg/ml), 5-fluorocytosine (MIC<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>64<span class="elsevierStyleHsp" style=""></span>μg/ml), itraconazole (MIC<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>16<span class="elsevierStyleHsp" style=""></span>μg/ml) and fluconazole (MIC<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>256<span class="elsevierStyleHsp" style=""></span>μg/ml), and sensitivity to amphotericin B (MIC: 1<span class="elsevierStyleHsp" style=""></span>μg/ml), voriconazole (MIC: 0.5<span class="elsevierStyleHsp" style=""></span>μg/ml) and posaconazole (MIC: 0.5<span class="elsevierStyleHsp" style=""></span>μg/ml).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Fusariosis in patients with hematological malignancies usually occurs in the shape of disseminated infections where the original site of infection of the fungus is difficult to establish.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Skin lesions lead to the diagnosis in more than 50% of patients and usually precede the fungaemia in approximately 5 days. In contrast with aspergillosis, where blood cultures are nearly always negative, fusariosis is accompanied by positive blood cultures in 40–50% of the patients.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,8</span></a> In our case, <span class="elsevierStyleItalic">F. dimerum</span> was rapidly detected in the lesions of the right foot. The absence of fever and the negative hemocultures first suggested a possible localized infection. Nevertheless, the diagnosis of AML and the deadly progress of the infection were more in accordance with the existence of fungaemia. Even though a rapid detection of the fungus and a subsequent prescription of appropriate treatment were done, the hemodynamic complications were severe and the patient died.</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Fusarium</span> has emerged as an important cause of infection in immunocompromised patients and is now considered the second most frequent mold involved in fungal infections.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Especially, the disease not only is frequent in patients with hematological malignancies but can also occur as localized infections in healthy patients.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The infection in this case was due to one of the 12 phylogenetic species belonging to the morphototype <span class="elsevierStyleItalic">F. dimerum</span>.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This fungus had been scarcely described as a causative agent of human fusariosis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Its susceptibility to antifungals showed a short spectrum of effective drugs, which is a common feature for <span class="elsevierStyleItalic">Fusarium</span> species.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The rapid detection of <span class="elsevierStyleItalic">Fusarium</span> spp. by direct microscopy is a very useful tool and allows a rapid prescription of antifungal treatment. However, it is not enough for a correct management of the infection. The diversity of species involved in fusariosis is underestimated because of the frequent lack of identification at a species level. The species distribution varies per geographic region and different species have different drug susceptibility patterns.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Therefore, complete identification of the fungi and their antifungal susceptibility patterns is of high interest to improve our knowledge about the epidemiology of the disease and how to best manage patients.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres120440" "titulo" => array:4 [ 0 => "Abstract" 1 => "Background" 2 => "Case report" 3 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec107721" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres120441" "titulo" => array:4 [ 0 => "Resumen" 1 => "Antecedentes" 2 => "Caso clínico" 3 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec107720" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 7 => array:2 [ "identificador" => "xack37624" "titulo" => "Acknowledgment" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-08-11" "fechaAceptado" => "2012-11-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec107721" "palabras" => array:3 [ 0 => "Opportunistic mycosis" 1 => "Fusariosis" 2 => "<span class="elsevierStyleItalic">Fusarium dimerum</span>" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec107720" "palabras" => array:3 [ 0 => "Micosis oportunista" 1 => "Fusariosis" 2 => "<span class="elsevierStyleItalic">Fusarium dimerum</span>" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Fusariosis is an emergent opportunistic hyalohyphomycosis produced by fungi belonging to the genus <span class="elsevierStyleItalic">Fusarium.</span> These molds are capable of producing life-threatening diseases in immunocompromised hosts, especially in those suffering from leukemia. It has also been described in immunocompetent patients, where it usually causes non-invasive localized lesions. Fusariosis in immunocompromised individuals has a high morbidity and mortality mainly because of the low sensitivity of these fungi to the antifungal drugs available.</p> <span class="elsevierStyleSectionTitle">Case report</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We describe here the case of a patient with acute mieloblastic leukemia who developed fusariosis by a species of the <span class="elsevierStyleItalic">Fusarium dimerum</span> species complex. The early diagnosis was made on the basis of microscopic observation of samples from cutaneous lesions, and voriconazole treatment was prescribed. A subsequent complete study of the fungal isolate by culture and molecular methods allowed the identification of <span class="elsevierStyleItalic">F. dimerum</span>, a species rarely described as a human pathogen. The sensitivity of the strain was tested using the Sensititre YeastOne<span class="elsevierStyleSup">®</span> commercial system, which showed sensitivity to voriconazole and posaconazole, as well as to amphotericin B. The patient died after 7 days at hospital due to an hemodynamic failure.</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Complete identification of new isolates of <span class="elsevierStyleItalic">Fusarium</span> and their antifungal susceptibility patterns is of high interest to improve our knowledge about the epidemiology of the disease and how to best manage patients.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle">Antecedentes</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La fusariosis es una hialohifomicosis oportunista, emergente, producida por hongos pertenecientes al género <span class="elsevierStyleItalic">Fusarium</span>. Estos hongos pueden provocar enfermedades que amenazan la vida en pacientes inmunodeficientes, en especial en portadores de leucemia. También se ha descrito en individuos inmunocompetentes, en los que induce lesiones localizadas, no invasivas. En pacientes inmunodeficientes, la fusariosis se asocia a una elevada morbimortalidad, sobre todo debido a la falta de sensibilidad de estos hongos a los antimicóticos disponibles.</p> <span class="elsevierStyleSectionTitle">Caso clínico</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Describimos el caso de una paciente con leucemia mieloblástica aguda que experimentó una fusariosis por una especie del complejo <span class="elsevierStyleItalic">Fusarium dimerum</span>. El diagnóstico precoz se estableció en función de la observación microscópica de muestras de las lesiones cutáneas y se prescribió tratamiento con voriconazol. Más tarde, un estudio completo del aislamiento fúngico por cultivo y métodos moleculares permitió la identificación de <span class="elsevierStyleItalic">F. dimerum</span>, una especie apenas descrita como patógeno en el ser humano. La sensibilidad de la cepa se examinó con el método comercializado Sensititre YeastOne<span class="elsevierStyleSup">®</span>, que reveló su sensibilidad a voriconazol y posaconazol, al igual que a anfotericina B. La paciente falleció a los 7 días del ingreso debido a una insuficiencia hemodinámica.</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La identificación completa de nuevos aislamientos de <span class="elsevierStyleItalic">Fusarium</span> y su patrón de sensibilidad a los antimicóticos suscita un gran interés para incrementar nuestros conocimientos sobre la epidemiología de la enfermedad y el tratamiento óptimo de los pacientes.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 554 "Ancho" => 1300 "Tamanyo" => 105039 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Photograph of the anterior surface of the left (A) and right (B) feet showing ulcerous lesions.</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" => 651 "Ancho" => 900 "Tamanyo" => 65193 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Direct microscopic observation of the right foot sample. Gram stain (1000×).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 648 "Ancho" => 1300 "Tamanyo" => 62112 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Morphology of conidiophores and conidia of <span class="elsevierStyleItalic">Fusarium dimerum.</span> Microscopic observation of a microculture on Sabouraud dextrose agar. Lactophenol blue stain (A: 200×; B: 1000×).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Disseminated fusariosis occurring in two patients despite Posaconazole prophylaxis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P. Bose" 1 => "D.H. Parekh" 2 => "J.L. Holter" 3 => "R.A. 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Xu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1128/JCM.02415-10" "Revista" => array:6 [ "tituloSerie" => "J Clin Microbiol" "fecha" => "2011" "volumen" => "49" "paginaInicial" => "1890" "paginaFinal" => "1898" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21389150" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:3 [ "identificador" => "xack37624" "titulo" => "Acknowledgment" "texto" => "<p id="par0050" class="elsevierStylePara elsevierViewall">The authors acknowledge María Abad for the professional review of the English writing of the manuscript.</p>" ] ] ] "idiomaDefecto" => "en" "url" => "/11301406/0000003000000002/v1_201305061134/S113014061200109X/v1_201305061134/en/main.assets" "Apartado" => array:4 [ "identificador" => "7995" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Notas" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/11301406/0000003000000002/v1_201305061134/S113014061200109X/v1_201305061134/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S113014061200109X?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 36 | 6 | 42 |
| 2024 September | 86 | 9 | 95 |
| 2024 August | 64 | 3 | 67 |
| 2024 July | 59 | 5 | 64 |
| 2024 June | 87 | 3 | 90 |
| 2024 May | 103 | 2 | 105 |
| 2024 April | 59 | 4 | 63 |
| 2024 March | 84 | 5 | 89 |
| 2024 February | 109 | 9 | 118 |
| 2024 January | 111 | 1 | 112 |
| 2023 December | 90 | 6 | 96 |
| 2023 November | 79 | 6 | 85 |
| 2023 October | 65 | 6 | 71 |
| 2023 September | 42 | 0 | 42 |
| 2023 August | 55 | 3 | 58 |
| 2023 July | 52 | 5 | 57 |
| 2023 June | 59 | 3 | 62 |
| 2023 May | 81 | 4 | 85 |
| 2023 April | 59 | 4 | 63 |
| 2023 March | 80 | 10 | 90 |
| 2023 February | 48 | 7 | 55 |
| 2023 January | 53 | 6 | 59 |
| 2022 December | 35 | 7 | 42 |
| 2022 November | 45 | 7 | 52 |
| 2022 October | 45 | 13 | 58 |
| 2022 September | 45 | 12 | 57 |
| 2022 August | 52 | 11 | 63 |
| 2022 July | 36 | 10 | 46 |
| 2022 June | 21 | 11 | 32 |
| 2022 May | 46 | 13 | 59 |
| 2022 April | 32 | 16 | 48 |
| 2022 March | 52 | 19 | 71 |
| 2022 February | 29 | 23 | 52 |
| 2022 January | 96 | 22 | 118 |
| 2021 December | 57 | 20 | 77 |
| 2021 November | 48 | 26 | 74 |
| 2021 October | 84 | 18 | 102 |
| 2021 September | 38 | 16 | 54 |
| 2021 August | 57 | 12 | 69 |
| 2021 July | 32 | 8 | 40 |
| 2021 June | 27 | 15 | 42 |
| 2021 May | 44 | 16 | 60 |
| 2021 April | 125 | 17 | 142 |
| 2021 March | 57 | 24 | 81 |
| 2021 February | 36 | 10 | 46 |
| 2021 January | 36 | 8 | 44 |
| 2020 December | 31 | 15 | 46 |
| 2020 November | 40 | 25 | 65 |
| 2020 October | 38 | 21 | 59 |
| 2020 September | 29 | 12 | 41 |
| 2020 August | 34 | 17 | 51 |
| 2020 July | 18 | 12 | 30 |
| 2020 June | 21 | 15 | 36 |
| 2020 May | 60 | 14 | 74 |
| 2020 April | 20 | 15 | 35 |
| 2020 March | 33 | 5 | 38 |
| 2020 February | 30 | 8 | 38 |
| 2020 January | 24 | 13 | 37 |
| 2019 December | 25 | 8 | 33 |
| 2019 November | 10 | 13 | 23 |
| 2019 October | 18 | 3 | 21 |
| 2019 September | 24 | 9 | 33 |
| 2019 August | 22 | 4 | 26 |
| 2019 July | 27 | 8 | 35 |
| 2019 June | 49 | 26 | 75 |
| 2019 May | 134 | 24 | 158 |
| 2019 April | 64 | 13 | 77 |
| 2019 March | 12 | 7 | 19 |
| 2019 February | 11 | 7 | 18 |
| 2019 January | 14 | 1 | 15 |
| 2018 December | 24 | 6 | 30 |
| 2018 November | 23 | 1 | 24 |
| 2018 October | 16 | 12 | 28 |
| 2018 September | 11 | 2 | 13 |
| 2018 August | 8 | 5 | 13 |
| 2018 July | 16 | 3 | 19 |
| 2018 June | 14 | 4 | 18 |
| 2018 May | 8 | 5 | 13 |
| 2018 April | 13 | 2 | 15 |
| 2018 March | 8 | 1 | 9 |
| 2018 February | 8 | 1 | 9 |
| 2018 January | 9 | 2 | 11 |
| 2017 December | 16 | 4 | 20 |
| 2017 November | 21 | 2 | 23 |
| 2017 October | 26 | 7 | 33 |
| 2017 September | 17 | 3 | 20 |
| 2017 August | 15 | 7 | 22 |
| 2017 July | 22 | 6 | 28 |
| 2017 June | 32 | 16 | 48 |
| 2017 May | 27 | 16 | 43 |
| 2017 April | 28 | 20 | 48 |
| 2017 March | 25 | 14 | 39 |
| 2017 February | 22 | 18 | 40 |
| 2017 January | 20 | 4 | 24 |
| 2016 December | 25 | 10 | 35 |
| 2016 November | 34 | 7 | 41 |
| 2016 October | 36 | 13 | 49 |
| 2016 September | 45 | 6 | 51 |
| 2016 August | 21 | 8 | 29 |
| 2016 July | 17 | 3 | 20 |
| 2016 June | 24 | 11 | 35 |
| 2016 May | 18 | 19 | 37 |
| 2016 April | 19 | 22 | 41 |
| 2016 March | 19 | 20 | 39 |
| 2016 February | 20 | 22 | 42 |
| 2016 January | 18 | 12 | 30 |
| 2015 December | 28 | 19 | 47 |
| 2015 November | 37 | 21 | 58 |
| 2015 October | 47 | 25 | 72 |
| 2015 September | 30 | 20 | 50 |
| 2015 August | 49 | 11 | 60 |
| 2015 July | 84 | 16 | 100 |
| 2015 June | 39 | 15 | 54 |
| 2015 May | 48 | 21 | 69 |
| 2015 April | 55 | 35 | 90 |
| 2015 March | 28 | 26 | 54 |
| 2015 February | 20 | 20 | 40 |
| 2015 January | 28 | 9 | 37 |
| 2014 December | 33 | 11 | 44 |
| 2014 November | 28 | 8 | 36 |
| 2014 October | 35 | 9 | 44 |
| 2014 September | 31 | 10 | 41 |
| 2014 August | 31 | 6 | 37 |
| 2014 July | 30 | 9 | 39 |
| 2014 June | 41 | 6 | 47 |
| 2014 May | 25 | 14 | 39 |
| 2014 April | 12 | 83 | 95 |
| 2014 March | 54 | 13 | 67 |
| 2014 February | 60 | 19 | 79 |
| 2014 January | 50 | 13 | 63 |
| 2013 December | 65 | 14 | 79 |
| 2013 November | 54 | 14 | 68 |
| 2013 October | 44 | 8 | 52 |
| 2013 September | 29 | 12 | 41 |
| 2013 August | 33 | 5 | 38 |
| 2013 July | 41 | 9 | 50 |
| 2013 June | 11 | 5 | 16 |
| 2013 May | 8 | 3 | 11 |
| 2013 March | 121 | 0 | 121 |
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