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Síndrome de Sjögren primario con derrame pleural
Primary Sjögren Syndrome With Pleural Effusion
a Servicio de Neumología, Complejo Hospitalario Clínico Universitario de Santiago de Compostela, Santiago de Compostela, España
b Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, España
c Servicio de Análisis Clínicos, Complejo Hospitalario Clínico Universitario de Santiago de Compostela, Santiago de Compostela, España
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=> "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Neumología, Complejo Hospitalario Clínico Universitario de Santiago de Compostela, Santiago de Compostela, España" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, España" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Análisis Clínicos, Complejo Hospitalario Clínico Universitario de Santiago de Compostela, Santiago de Compostela, España" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Autor para correspondencia." ] ] ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Primary Sjögren Syndrome With Pleural Effusion" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">El síndrome de Sjögren (SS) es una enfermedad autoinmune inflamatoria crónica que se caracteriza por una infiltración linfocítica de las glándulas exocrinas, especialmente salivares y lacrimales, causantes de los síntomas característicos de xeroftalmía y xerostomía, y que también puede afectar al pulmón, tiroides, riñón o al tracto hepatobiliar. La enfermedad puede presentarse de forma aislada (SS primario) o asociada a otras enfermedades del tejido conectivo (SS secundario). El derrame pleural (DP) en el SS primario está muy poco descrito en la literatura<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Presentamos el caso de una mujer de 40 años, con diabetes mellitus insulinodependiente, que consulta por xerostomía y xeroftalmía de meses de evolución y artromialgias difusas que cursaban de forma intermitente. Las constantes vitales eran normales y el único hallazgo destacable en la exploración física era limitación en la movilidad del hombro derecho. Los análisis de sangre (incluido el valor de la enzima conversora de la angiotensina) y orina rutinarios, fueron normales. A destacar, factor reumatoide 103 UI/ml (hasta 14 UI/ml), anticuerpos antinucleares (ANA) positivos (1/640) y anticuerpos anti-Ro/SS-A y anti-La/SS-B positivos e inmunoglobulina G 4.050<span class="elsevierStyleHsp" style=""></span>mg/dl. El test de Schirmer fue positivo en ambos ojos, la biopsia de la glándula salivar menor mostró infiltración linfocitaria grado 2 de Chisholm y la gammagrafía de glándulas salivares fue compatible con SS. Sobre la base de estos resultados se estableció el diagnóstico de SS primario.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Cuatro años más tarde comenzó con dolor pleurítico derecho, sin disnea, tos o expectoración, aunque sí febrícula vespertina. No traumatismo torácico previo, ni contacto con pacientes con tuberculosis. La exploración física fue anodina, salvo semiología de DP derecho. En la tomografía computarizada de tórax se visualizaron lesiones quístico-cavitarias de pared gruesa en el pulmón derecho y un pequeño DP ipsilateral. Se realizó una broncofibroscopia que fue macroscópicamente normal, la baciloscopia y PCR para Mycobacterium tuberculosis en el lavado broncoalveolar fueron negativas. El DP fue un exudado (proteínas totales líquido pleural/suero 0,7; lactato deshidrogenasa [LDH] líquido pleural 597 UI/l y LDH líquido pleural/suero 1,8), leucocitos 5.830/μl (neutrófilos 14%, linfocitos 24%, eosinófilos 16%, macrófagos 46%), con pH, glucosa, amilasa, adenosina desaminasa, marcadores tumorales y N-terminal pro-péptido natriurético cerebral normales, factor reumatoide 58,6 UI/ml, ANA positivos (1/320) y anticuerpos anti-Ro/SS-A y anti-La/SS-B positivos. Los cultivos bacteriológicos y para Mycobacterium tuberculosis, así como la citología para malignidad, fueron negativos. La prueba de la tuberculina fue positiva (12<span class="elsevierStyleHsp" style=""></span>mm). Mediante videotoracoscopia se realizó una biopsia pulmonar (bronquiolitis folicular con áreas de neumonía intersticial linfoide y numerosas células plasmáticas) y pleural (infiltración por células mononucleares). El DP desapareció tras la cirugía y no volvió a reaparecer en 2 años de seguimiento.</p><p id="par0020" class="elsevierStylePara elsevierViewall">El diagnóstico del SS se establece sobre la base de 6 criterios<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a>: 2 subjetivos (síntomas oculares y orales) y 4 objetivos que incluyen signos oculares y orales, y hallazgos histopatológicos y serológicos (ANA y anticuerpos anti-Ro/SS-A o anti-La/SS-B). El diagnóstico de SS requiere al menos 4 de los 6 criterios (incluyendo los hallazgos histopatológicos y serológicos), o 3 de los 4 criterios objetivos. Nuestra paciente presenta síntomas oculares (xeroftalmía) y orales (xerostomía), tiene un test de Schirmer positivo, la glándula salivar menor presenta una infiltración linfocitaria (con una gammagrafía salivar compatible) y los anti-Ro/SS-A y anti-La/SS-B son positivos. No se evidenciaron datos de otras enfermedades del tejido conectivo como artritis reumatoide, lupus eritematoso sistémico o esclerodermia, por lo que el diagnóstico de SS primario parece confirmado.</p><p id="par0025" class="elsevierStylePara elsevierViewall">El DP en el SS primario es muy poco frecuente. En una revisión de cuatro series que incluyen a 487 pacientes, solamente 5 SS presentaban un DP (1%) y 3 de ellos correspondían a SS secundarios (2 presentaban una artritis reumatoide y uno un lupus eritematoso sistémico)<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3,4</span></a>. No obstante, en un estudio de 573 pacientes con SS primario, el 5,7% (30/522) tenían un DP, sin que los autores proporcionen más detalles al respecto<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a>. En la literatura de habla inglesa solamente se han descrito 10 casos de SS primario y DP<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">6-15</span></a>, si bien uno parece secundario a una insuficiencia cardiaca acompañante<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a>. Aunque no existen criterios que definan cuándo un DP puede deberse a un SS primario, todos suelen presentar unas características comunes: DP uni o bilaterales que corresponden a exudados linfocíticos, con un recuento de células nucleadas comprendido entre 1.500-11.000/μl y con valores de pH, glucosa o adenosina desaminasa normales (<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>). La determinación de anticuerpos anti-Ro/SS-A, factor reumatoide y ANA no siempre se lleva a cabo para establecer el diagnóstico (6/9 [66,7%]; 4/9 [44,4% y en 2 fue negativo] y 3/9 [33,3%], respectivamente). La biopsia pleural es inespecífica y solamente muestra un infiltrado linfocitario. La evolución del DP suele ser favorable ya que la mayoría responde a los corticoides e incluso puede desaparecer de forma espontánea. En el caso que describimos, los resultados del líquido pleural confirman que el DP es debido al SS. El predominio del DP fue eosinófilo (16%), dato no descrito hasta la actualidad, si bien el recuento de células mononucleares también fue elevado (70%). Este predominio no parece atribuible a la entrada de aire o sangre en el espacio pleural, ya que la técnica no fue traumática, el líquido era seroso y solamente se hizo una toracocentesis. Los datos analíticos del líquido y el tiempo de seguimiento permiten descartar la posibilidad de que el DP fuera de otro origen (neoplásico, paraneumónico o tuberculoso, como causas más frecuentes de exudado pleural en nuestro medio). Tampoco en este periodo de seguimiento la paciente desarrolló otra enfermedad del tejido conectivo que pueda ser la responsable del DP. El DP se resolvió de forma espontánea, sin necesidad de corticoides, como se ha descrito previamente<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">En resumen, a pesar de que el DP es una manifestación poco frecuente del SS primario, esta posibilidad debe tenerse en cuenta en aquellos pacientes con esta enfermedad en los que la etiología del DP no esté clara. Su diagnóstico de certeza requiere, sin embargo, además de unas características bioquímicas determinadas, un periodo de seguimiento largo para poder descartar otras causas de DP.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Tabla 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Tabla " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">AC: anticuerpos; ADA; adenosina desaminasa; ANA; anticuerpos antinucleares; H: hombre; M: mujer; ND: no determinado; (+); positivo; (–): negativo.</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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Referencia \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sexo \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Edad \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Lateralidad \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Exudado (criterios de Light) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recuento total células nucleadas (células/μl) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recuento células nucleadas (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">AC anti-SSA y anti-SSB \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Factor reumatoide (UI/ml) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ANA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Glucosa (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ADA (U/l) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Resolución \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alvarez-Sala et al.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Predominio linfocitos \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Espontánea \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ogihara et al.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Derecho \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.600 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39% linfocitos, 57% monocitos \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">131 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Corticoides \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Suzuki et al.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Izquierdo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Corticoides<br>Ciclofosfamida \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kawamata et al.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Izquierdo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">99% mononucleares \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80,9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Corticoides \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Horita et al.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.400 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Más linfocitos que neutrófilos \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No respuesta corticoides<br>Tetraciclina intrapleural \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Teshigawara et al.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.520 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">84% linfocitos \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Corticoides \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Makimoto et al.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Predominio linfocitos \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Corticoides \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ohe et al.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Corticoides<br>Albúmina<br>Diuréticos \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ma et al.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bilateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">98% mononucleares \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75,3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hidroxicloroquina \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yamasaki et al.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Derecho \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="9" align="left" valign="top">Insuficiencia cardiaca congestiva asociada. No datos bioquímicos del líquido pleural</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Presente estudio \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Derecho \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sí \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.830 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16% eosinófilos<br>24% linfocitos<br>46% macrófagos \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58,6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">111 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Espontánea \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1526628.png" ] ] ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Características de los casos descritos de síndrome de Sjögren primario y derrame pleural</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliografía" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary involvement in Sjögren syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. 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| Year/Month | Html | Total | |
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| 2024 October | 79 | 18 | 97 |
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| 2024 April | 90 | 34 | 124 |
| 2024 March | 77 | 20 | 97 |
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| 2023 September | 5 | 1 | 6 |
| 2023 March | 36 | 9 | 45 |
| 2023 February | 120 | 36 | 156 |
| 2023 January | 108 | 40 | 148 |
| 2022 December | 147 | 35 | 182 |
| 2022 November | 198 | 34 | 232 |
| 2022 October | 150 | 46 | 196 |
| 2022 September | 108 | 47 | 155 |
| 2022 August | 118 | 63 | 181 |
| 2022 July | 95 | 61 | 156 |
| 2022 June | 99 | 45 | 144 |
| 2022 May | 112 | 47 | 159 |
| 2022 April | 145 | 66 | 211 |
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| 2021 February | 153 | 40 | 193 |
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| 2020 December | 108 | 31 | 139 |
| 2020 November | 78 | 46 | 124 |
| 2020 October | 78 | 28 | 106 |
| 2020 September | 82 | 16 | 98 |
| 2020 August | 73 | 31 | 104 |
| 2020 July | 76 | 39 | 115 |
| 2020 June | 87 | 24 | 111 |
| 2020 May | 74 | 26 | 100 |
| 2020 April | 165 | 23 | 188 |
| 2020 March | 71 | 31 | 102 |
| 2020 February | 67 | 27 | 94 |
| 2020 January | 103 | 35 | 138 |
| 2019 December | 92 | 32 | 124 |
| 2019 November | 75 | 32 | 107 |
| 2019 October | 72 | 30 | 102 |
| 2019 September | 132 | 39 | 171 |
| 2019 August | 72 | 20 | 92 |
| 2019 July | 88 | 45 | 133 |
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| 2019 May | 114 | 19 | 133 |
| 2019 April | 139 | 47 | 186 |
| 2019 March | 103 | 38 | 141 |
| 2019 February | 68 | 21 | 89 |
| 2019 January | 86 | 26 | 112 |
| 2018 December | 84 | 32 | 116 |
| 2018 November | 135 | 33 | 168 |
| 2018 October | 197 | 27 | 224 |
| 2018 September | 81 | 15 | 96 |
| 2018 July | 1 | 0 | 1 |
| 2018 June | 2 | 0 | 2 |
| 2018 May | 49 | 1 | 50 |
| 2018 April | 86 | 18 | 104 |
| 2018 March | 67 | 19 | 86 |
| 2018 February | 62 | 26 | 88 |
| 2018 January | 95 | 45 | 140 |
| 2017 December | 11 | 5 | 16 |
| 2017 November | 2 | 4 | 6 |
| 2017 October | 31 | 15 | 46 |
| 2017 September | 0 | 3 | 3 |
| 2017 August | 0 | 1 | 1 |
| 2017 July | 0 | 3 | 3 |
| 2017 June | 0 | 3 | 3 |
| 2017 May | 0 | 2 | 2 |
| 2017 April | 0 | 6 | 6 |
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