Scientific Letter
Focal delayed post-chickenpox myelitis: Case report. A review and update
Mielitis transversa focal posvaricelosa tardía: a propósito de un caso. Revisión y puesta al día
A.B. Ariza Jiménez
, J. Martínez Antón, A. Urda Cardona
Corresponding author
Unidad de Gestión Clínica de Pediatría, Hospital Regional Universitario Materno-Infantil, Málaga, Spain
Read
8547
Timeswas read the article
2625
Total PDF
5922
Total HTML
Share statistics
array:23 [ "pii" => "S2341287914001252" "issn" => "23412879" "doi" => "10.1016/j.anpede.2014.09.002" "estado" => "S300" "fechaPublicacion" => "2015-01-01" "aid" => "1722" "copyright" => "Asociación Española de Pediatría" "copyrightAnyo" => "2014" "documento" => "simple-article" "subdocumento" => "cor" "cita" => "An Pediatr (Barc). 2015;82:41-2" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2495 "formatos" => array:3 [ "EPUB" => 140 "HTML" => 1836 "PDF" => 519 ] ] "Traduccion" => array:1 [ "es" => array:18 [ "pii" => "S1695403314004391" "issn" => "16954033" "doi" => "10.1016/j.anpedi.2014.09.006" "estado" => "S300" "fechaPublicacion" => "2015-01-01" "aid" => "1722" "copyright" => "Asociación Española de Pediatría" "documento" => "simple-article" "subdocumento" => "cor" "cita" => "An Pediatr (Barc). 2015;82:41-2" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 4408 "formatos" => array:3 [ "EPUB" => 151 "HTML" => 3676 "PDF" => 581 ] ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta científica</span>" "titulo" => "Mielitis transversa focal posvaricelosa tardía: a propósito de un caso. Revisión y puesta al día" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "41" "paginaFinal" => "42" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Focal delayed post-chickenpox myelitis. Case report. A review and update" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 764 "Ancho" => 950 "Tamanyo" => 88359 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Aumento de calibre medular en el segmento entre los cuerpos vertebrales de C3-C4, con lesión fusiforme hiperintensa (T2) que afecta la porción anterior y periférica de la médula.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A.B. Ariza Jiménez, J. Martínez Antón, A. Urda Cardona" "autores" => array:3 [ 0 => array:2 [ "nombre" => "A.B." "apellidos" => "Ariza Jiménez" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Martínez Antón" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Urda Cardona" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341287914001252" "doi" => "10.1016/j.anpede.2014.09.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287914001252?idApp=UINPBA00005H" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1695403314004391?idApp=UINPBA00005H" "url" => "/16954033/0000008200000001/v1_201501010024/S1695403314004391/v1_201501010024/es/main.assets" ] ] "itemSiguiente" => array:18 [ "pii" => "S2341287914001215" "issn" => "23412879" "doi" => "10.1016/j.anpede.2014.06.002" "estado" => "S300" "fechaPublicacion" => "2015-01-01" "aid" => "1667" "copyright" => "Asociación Española de Pediatría" "documento" => "article" "subdocumento" => "fla" "cita" => "An Pediatr (Barc). 2015;82:43.e1-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2491 "formatos" => array:3 [ "EPUB" => 159 "HTML" => 1840 "PDF" => 492 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Spanish Association of Paediatrics</span>" "titulo" => "Recommendations for the prevention of drowning" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "43.e1" "paginaFinal" => "43.e5" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recomendaciones sobre la prevención de ahogamientos" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "B. Rubio, F. Yagüe, M.T. Benítez, M.J. Esparza, J.C. González, F. Sánchez, J.J. Vila, S. Mintegi" "autores" => array:9 [ 0 => array:2 [ "nombre" => "B." "apellidos" => "Rubio" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Yagüe" ] 2 => array:2 [ "nombre" => "M.T." "apellidos" => "Benítez" ] 3 => array:2 [ "nombre" => "M.J." "apellidos" => "Esparza" ] 4 => array:2 [ "nombre" => "J.C." "apellidos" => "González" ] 5 => array:2 [ "nombre" => "F." "apellidos" => "Sánchez" ] 6 => array:2 [ "nombre" => "J.J." "apellidos" => "Vila" ] 7 => array:2 [ "nombre" => "S." "apellidos" => "Mintegi" ] 8 => array:1 [ "colaborador" => "Comité de Seguridad y Prevención de Lesiones No Intencionadas en la Infancia de la Asociación Española de Pediatría" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1695403314003257" "doi" => "10.1016/j.anpedi.2014.06.010" "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/S1695403314003257?idApp=UINPBA00005H" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287914001215?idApp=UINPBA00005H" "url" => "/23412879/0000008200000001/v1_201501110050/S2341287914001215/v1_201501110050/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2341287914001185" "issn" => "23412879" "doi" => "10.1016/j.anpede.2014.04.004" "estado" => "S300" "fechaPublicacion" => "2015-01-01" "aid" => "1617" "copyright" => "Asociación Española de Pediatría" "documento" => "article" "subdocumento" => "fla" "cita" => "An Pediatr (Barc). 2015;82:35-40" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 3019 "formatos" => array:3 [ "EPUB" => 137 "HTML" => 2329 "PDF" => 553 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Respiratory syncytial virus in immunocompromised patients in a paediatric hospital: 5 years’ experience" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "35" "paginaFinal" => "40" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Infección por virus respiratorio sincitial en los pacientes inmunodeprimidos en un hospital pediátrico: experiencia de 5 años" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "N. Domínguez-Pinilla, S. Belda Hofheinz, J.L. Vivanco Martinez, M. Baro-Fernández, J. Ruiz-Contreras, L.I. González-Granado" "autores" => array:6 [ 0 => array:2 [ "nombre" => "N." "apellidos" => "Domínguez-Pinilla" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Belda Hofheinz" ] 2 => array:2 [ "nombre" => "J.L." "apellidos" => "Vivanco Martinez" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Baro-Fernández" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Ruiz-Contreras" ] 5 => array:2 [ "nombre" => "L.I." "apellidos" => "González-Granado" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1695403314002227" "doi" => "10.1016/j.anpedi.2014.04.016" "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/S1695403314002227?idApp=UINPBA00005H" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287914001185?idApp=UINPBA00005H" "url" => "/23412879/0000008200000001/v1_201501110050/S2341287914001185/v1_201501110050/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Focal delayed post-chickenpox myelitis: Case report. A review and update" "tieneTextoCompleto" => true "saludo" => "To the Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "41" "paginaFinal" => "42" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A.B. Ariza Jiménez, J. Martínez Antón, A. Urda Cardona" "autores" => array:3 [ 0 => array:4 [ "nombre" => "A.B." "apellidos" => "Ariza Jiménez" "email" => array:1 [ 0 => "micodemas@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Martínez Antón" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Urda Cardona" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Gestión Clínica de Pediatría, Hospital Regional Universitario Materno-Infantil, Málaga, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Mielitis transversa focal posvaricelosa tardía: a propósito de un caso. Revisión y puesta al día" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 764 "Ancho" => 950 "Tamanyo" => 92470 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Thickening of the spinal cord in the segment between the bodies of the C3 and C4 vertebrae, with a high signal intensity fusiform lesion (T2) affecting the anterior and peripheral portion of the spinal cord.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Transverse myelitis (TM) is a focal inflammation of the entire thickness of the spinal cord.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Its incidence rate is 1–8/1<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>inhabitants/year.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It is typically present in patients aged 0–2 and 5–7 years with symmetric pain, progressive weakness, sensory disturbances, and bowel or bladder dysfunction.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">It is caused by an altered immune response and viral infection of the spinal cord that extends to the nerve fibres, leading to hypoxaemia, ischaemia, inflammation, and demyelinisation.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The differential diagnosis must rule out a compressive myelopathy by means of magnetic resonance imaging (MRI). After ruling out a compressive aetiology, a lumbar puncture is indicated to assess for noninflammatory causes in the absence of leukocytosis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A full recovery occurs in one-third of the patients, usually spontaneously, and factors for a poor prognosis include older age, acute onset, a protracted course, presence of supraspinal symptoms, severe denervation, normal cerebrospinal fluid, and delayed onset of recovery.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">This paper presents a singular case of delayed-onset post-chickenpox TM, as well as an update on the few existing publications on the subject.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was a 10-year-old girl presenting with a fever of 39<span class="elsevierStyleHsp" style=""></span>°C, paresthesias, pain in the right shoulder, cervicalgia, and loss of power and weakness in the upper limbs (ULs) lasting 24<span class="elsevierStyleHsp" style=""></span>h. The examination found proximal weakness of the pectoral girdle, with the left side (1/5) weaker than the right (2/5), preserved distal strength (4/5), and urinary retention requiring catheterisation for bladder drainage. Blood and urine cultures, serology tests, immunology testing, and the cytochemical study and oligoclonal bands of the CSF were all negative, except for positive tests for IgM and IgG antibodies to VZV. The latter was evidence of a previous latent infection, and the mother reported that the patient had had chickenpox a month and a half earlier, while PCR did not detect VZV in the CSF. A T2-weighted MRI scan without contrast ruled out a brain abnormality and revealed a thickening of the spinal cord and a hyperechoic fusiform lesion in the anterior and peripheral portion of the cord between C3 and C4, findings compatible with a varicella aetiology (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was treated with bolus steroids (1<span class="elsevierStyleHsp" style=""></span>g/day/5 days) and immunoglobulins (2<span class="elsevierStyleHsp" style=""></span>g/kg/day/4 days), with progressive recovery of strength in the ULs (right, 4/5; left 2/5). After discharge, at home the patient completed pharmacological treatment by tapering off steroids and started rehabilitation sessions, progressing favourably.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Transverse myelitis presents with abrupt onset of progressive weakness and sensory disturbance, usually in the lower limbs,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a> contrary to what happened in our case, with weakness in the ULs. Another atypical feature in our patient was the presence of fever. A recent history of vaccination or infection is frequent in children, although VZV is not a common cause of TM in immunocompetent children (0.01–0.3%).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The diagnosis of post-chickenpox myelitis is made by means of serological tests, CSF analysis with VZV PCR, and MRI, which typically shows inflammation of the spinal cord with fusiform-like hyperintensities on T2-weighted images with heterogeneous enhancement, and involvement of several vertebral levels, as observed in our patient.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">We based our diagnosis on the recent history of infection by VZV and the compatible clinical features and serology and MRI findings.</p><p id="par0055" class="elsevierStylePara elsevierViewall">As for the interval between the onset of TM and chickenpox, the literature describes that they occur simultaneously or that TM manifests 1–2 weeks after the appearance of the papulomacular rash,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> while our patient developed TM 6 weeks later, probably due to a delayed-type hypersensitivity cell-mediated immune response.</p><p id="par0060" class="elsevierStylePara elsevierViewall">There is no established treatment regime for post-chickenpox TM, but the literature shows that patients evolve favourably with acyclovir and steroids.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4,5</span></a> Acyclovir was not used in our patient because the previous infectious history was unknown, as the mother had not reported it during the anamnesis. Physical therapy following the acute episode can diminish neurologic deficits in these patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Thus, early initiation of these therapies is important in reducing sequelae. Recovery usually starts after 10 weeks, and can take as long as 12–24 months.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">It is worth noting that a history of vaccination against varicella was absent, so we must underscore the need to vaccinate against this virus in order to reduce the incidence of chickenpox and its complications.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In conclusion, post-chickenpox TM is an uncommon complication in immunocompetent children and must be considered in the differential diagnosis of patients with a history of varicella infection in the six weeks preceding the onset of symptoms. Magnetic resonance imaging of the spinal cord and serological tests and PCR for VZV are useful tools for diagnosing this disease. Pharmacological treatment and rehabilitation therapy must be initiated as soon as possible to reduce the sequelae.</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: Ariza Jiménez AB, Martínez Antón J, Urda Cardona A. Mielitis transversa focal posvaricelosa tardía: a propósito de un caso. Revisión y puesta al día. An Pediatr (Barc). 2015;82:41–42.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 764 "Ancho" => 950 "Tamanyo" => 92470 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Thickening of the spinal cord in the segment between the bodies of the C3 and C4 vertebrae, with a high signal intensity fusiform lesion (T2) affecting the anterior and peripheral portion of the spinal cord.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transverse myelitis caused by varicella zoster: case reports" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Yýlmaz" 1 => "K. Köseoðlu" 2 => "H.K.A. Yücel" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Braz J Infect Dis" "fecha" => "2007" "volumen" => "11" "paginaInicial" => "179" "paginaFinal" => "181" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17625754" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A case of acute transverse myelitis following chickenpox" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.Y. Kim" 1 => "E.S. Suh" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Korean J Pediatr" "fecha" => "2009" "volumen" => "52" "paginaInicial" => "380" "paginaFinal" => "384" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mielopatías agudas no traumáticas en niños y adolescentes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "H.A. Arroyo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Rev Neurol" "fecha" => "2013" "volumen" => "57" "numero" => "Suppl. 1" "paginaInicial" => "S129" "paginaFinal" => "S138" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23897140" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute transverse myelitis complicating breakthrough varicella infection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Aslan" 1 => "Z. Kurugol" 2 => "S. Gokben" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Pediatr Infect Dis J" "fecha" => "2014" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Early recovery in post varicella transverse myelitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P. Chand" 1 => "S. Ibrahim" 2 => "S.S. Zaidi" 3 => "N. Amjad" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Coll Phys Surg Pak" "fecha" => "2014" "volumen" => "24" "numero" => "Suppl. 2" "paginaInicial" => "S107" "paginaFinal" => "S108" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cervicodorsal myelitis secondary to infection by varicella zoster virus in an immunocompetent patient" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D.A. García-Estévez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Neurol" "fecha" => "2013" "volumen" => "57" "paginaInicial" => "191" "paginaFinal" => "192" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23884874" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000008200000001/v1_201501110050/S2341287914001252/v1_201501110050/en/main.assets" "Apartado" => array:4 [ "identificador" => "33442" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letter" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000008200000001/v1_201501110050/S2341287914001252/v1_201501110050/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287914001252?idApp=UINPBA00005H" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 9 | 21 |
| 2024 October | 55 | 37 | 92 |
| 2024 September | 74 | 38 | 112 |
| 2024 August | 68 | 71 | 139 |
| 2024 July | 77 | 28 | 105 |
| 2024 June | 81 | 35 | 116 |
| 2024 May | 81 | 37 | 118 |
| 2024 April | 79 | 38 | 117 |
| 2024 March | 76 | 31 | 107 |
| 2024 February | 74 | 37 | 111 |
| 2024 January | 89 | 27 | 116 |
| 2023 December | 134 | 35 | 169 |
| 2023 November | 88 | 26 | 114 |
| 2023 October | 72 | 36 | 108 |
| 2023 September | 73 | 34 | 107 |
| 2023 August | 82 | 21 | 103 |
| 2023 July | 87 | 38 | 125 |
| 2023 June | 80 | 31 | 111 |
| 2023 May | 136 | 28 | 164 |
| 2023 April | 71 | 28 | 99 |
| 2023 March | 87 | 45 | 132 |
| 2023 February | 67 | 35 | 102 |
| 2023 January | 77 | 34 | 111 |
| 2022 December | 64 | 62 | 126 |
| 2022 November | 55 | 34 | 89 |
| 2022 October | 73 | 61 | 134 |
| 2022 September | 50 | 34 | 84 |
| 2022 August | 54 | 54 | 108 |
| 2022 July | 45 | 49 | 94 |
| 2022 June | 52 | 38 | 90 |
| 2022 May | 45 | 42 | 87 |
| 2022 April | 57 | 46 | 103 |
| 2022 March | 105 | 50 | 155 |
| 2022 February | 82 | 27 | 109 |
| 2022 January | 98 | 46 | 144 |
| 2021 December | 71 | 49 | 120 |
| 2021 November | 52 | 49 | 101 |
| 2021 October | 67 | 59 | 126 |
| 2021 September | 57 | 47 | 104 |
| 2021 August | 62 | 62 | 124 |
| 2021 July | 45 | 37 | 82 |
| 2021 June | 71 | 48 | 119 |
| 2021 May | 72 | 44 | 116 |
| 2021 April | 174 | 60 | 234 |
| 2021 March | 105 | 42 | 147 |
| 2021 February | 78 | 20 | 98 |
| 2021 January | 50 | 27 | 77 |
| 2020 December | 68 | 31 | 99 |
| 2020 November | 73 | 32 | 105 |
| 2020 October | 41 | 21 | 62 |
| 2020 September | 45 | 29 | 74 |
| 2020 August | 61 | 12 | 73 |
| 2020 July | 54 | 13 | 67 |
| 2020 June | 62 | 27 | 89 |
| 2020 May | 61 | 25 | 86 |
| 2020 April | 44 | 14 | 58 |
| 2020 March | 53 | 30 | 83 |
| 2020 February | 57 | 19 | 76 |
| 2020 January | 48 | 14 | 62 |
| 2019 December | 52 | 16 | 68 |
| 2019 November | 67 | 19 | 86 |
| 2019 October | 34 | 14 | 48 |
| 2019 September | 42 | 14 | 56 |
| 2019 August | 64 | 26 | 90 |
| 2019 July | 59 | 31 | 90 |
| 2019 June | 52 | 17 | 69 |
| 2019 May | 115 | 25 | 140 |
| 2019 April | 87 | 46 | 133 |
| 2019 March | 69 | 25 | 94 |
| 2019 February | 57 | 14 | 71 |
| 2019 January | 58 | 24 | 82 |
| 2018 December | 44 | 29 | 73 |
| 2018 November | 69 | 30 | 99 |
| 2018 October | 82 | 28 | 110 |
| 2018 September | 31 | 19 | 50 |
| 2018 August | 8 | 0 | 8 |
| 2018 July | 6 | 0 | 6 |
| 2018 June | 11 | 0 | 11 |
| 2018 May | 18 | 0 | 18 |
| 2018 April | 35 | 0 | 35 |
| 2018 March | 49 | 0 | 49 |
| 2018 February | 17 | 0 | 17 |
| 2018 January | 26 | 0 | 26 |
| 2017 December | 19 | 0 | 19 |
| 2017 November | 17 | 0 | 17 |
| 2017 October | 19 | 0 | 19 |
| 2017 September | 23 | 0 | 23 |
| 2017 August | 31 | 0 | 31 |
| 2017 July | 29 | 0 | 29 |
| 2017 June | 35 | 18 | 53 |
| 2017 May | 41 | 20 | 61 |
| 2017 April | 37 | 19 | 56 |
| 2017 March | 22 | 5 | 27 |
| 2017 February | 39 | 6 | 45 |
| 2017 January | 29 | 2 | 31 |
| 2016 December | 24 | 11 | 35 |
| 2016 November | 40 | 10 | 50 |
| 2016 October | 67 | 12 | 79 |
| 2016 September | 59 | 4 | 63 |
| 2016 August | 42 | 1 | 43 |
| 2016 July | 26 | 7 | 33 |
Show all
