Case report
Diffuse Interstitial Lung Disease as a First Manifestation of Waldenström's Macroglobulinemia: Case Report and Review of the Literature
Enfermedad pulmonar intersticial difusa como primera manifestación de macroglobulinemia de Waldenström: descripción de un caso y revisión de la literatura
Angélica Consuegraa, Pedro J. Marcosa,
, Rubén Vázquezb, Jorge Pomboc, Guillermo Debénb, Héctor Verea-Hernandoa
Corresponding author
a Servicio de Neumología, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
b Servicio de Hematología, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
c Servicio de Anatomía Patológica, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
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(B) Lung parenchyma with an area of patchy lymphocytic infiltration, alternating with an area of lung parenchyma with no significant histological changes.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Wäldestrom's macroglobulinemia (WM) is a lymphoid malignancy characterized by infiltration of the bone marrow, lymph nodes or other tissues by small mature lymphocytes showing plasmacytoid differentiation. It is associated with the presence of an IgM monoclonal band and generally has a low degree of aggressiveness. The incidence of pulmonary manifestations is low, and it is even rarer for pulmonary disease to constitute the onset of the disease. We present the first case reported in the Spanish literature of interstitial lung disease as the initial presentation of WM and a review of the literature.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Characteristics</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 73-year-old male ex-smoker was referred to our hospital with chronic cough. Pulmonary auscultation revealed bilateral basal fine end inspiratory crepitations. No lymphadenopathy or hepatosplenomegaly was observed. The chest X-ray showed mild diffuse opacity on both lower fields. High-resolution computed tomography (CT) showed interstitial involvement with mainly peripheral thickening of the interlobular septa of the left lung, associated with bilateral, patchy areas of ground glass opacities, mainly in the peripheral regions (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Clinical laboratory tests reported an ESR of 88<span class="elsevierStyleHsp" style=""></span>mm with normal or negative blood panel, glucose, urea, creatinine, transaminases, lactate dehydrogenase (LDH), antinuclear antibodies (ANA), anti-DNA, extractable nuclear antigen (ENA), monoclonal IgM of 3450<span class="elsevierStyleHsp" style=""></span>mg/dl, and negative urine Bence–Jones protein.</p><p id="par0020" class="elsevierStylePara elsevierViewall">A lung biopsy was performed by video-assisted thoracoscopy (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B), revealing areas of pulmonary parenchyma with no significant histological changes, alternating with lymphoid infiltration due to small lymphocytes with plasmacytoid differentiation in some areas. The immunohistochemical phenotype was CD20+, CD79a+, CD23−, cyclin D1−, EBER−, CD15 and CD30−. MiB proliferation index was low and predominantly distributed in the subpleural and peribronchial regions, with the presence of histiocytes. Accordingly, this examination was compatible with a diagnosis of lymphoplasmacytic lymphoma. A bone marrow test was performed, showing infiltration by lymphoplasmacytoid cells, with the following immunophenotypes: CD19+, CD45+ strong, CD5−, CD23−, CD20+, CD22+, CD79b+, FMC7+ weak, CD25+, CD38+ variable, and IgM+ and monoclonal cytoplasmic kappa light chains.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In view of these results, a diagnosis of non-Hodgkin lymphoplasmacytic lymphoma with pulmonary and bone marrow involvement was made and rituximab treatment was initiated. In the subsequent check-ups, the cough resolved and IgM levels fell. Most of the lesions on CT resolved, and only some areas of interlobular septal thickening persisted, mainly in the peripheral bases.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Lymphoproliferative lesions affecting the lung are rare. Among these, primary lymphomas, defined as clonal lymphoid proliferation isolated from the lung, are even more uncommon, representing an estimated 1% of all lymphomas and 0.5% of all lung tumors. Pleuropulmonary involvement in WM is infrequent and the most typical respiratory symptoms are dyspnea and cough. In the early case descriptions, only pneumonia and pleural effusion were identified as pulmonary manifestations of WM,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> but later reviews have shown that the spectrum of respiratory involvement is wider. Interstitial pulmonary involvement, as such, is exceptional and may be underreported.</p><p id="par0035" class="elsevierStylePara elsevierViewall">After performing a search of the literature in the PubMed and Medline databases, we only found 7 articles<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–8</span></a> describing cases in which the disease presented as a pulmonary event (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Among these, we did not find any cases similar to the one discussed here, which presented initially as diffuse interstitial lung disease.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Although there are studies that support bronchoscopy (transbronchial biopsy and bronchoalveolar lavage)<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> as methods for the diagnosis of lymphoproliferative disorders of the lung, others claim that the efficacy of these methods is poor,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> with diagnostic yields of between 15% and 30%. These results suggest that surgical biopsy may be the procedure of choice for the diagnosis of lymphoma in potentially operable patients. In our case, given the good clinical status of the patient and as a minimally invasive approach using video-assisted thoracoscopy via a single port could be used, we opted for surgical biopsy. The pathological findings suggested a differential diagnosis of lymphoid interstitial pneumonia, lymph node hyperplasia or even hypersensitivity pneumonitis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In this patient, the laboratory finding of monoclonal gammopathy suggested a diagnostic hypothesis of a lymphoproliferative process. This was subsequently confirmed with the histological testing. In WM, the lymphoid infiltration may have a histological component of plasmacytoid lymphocytes or small mature lymphocytes. For this reason, immunohistochemistry or flow cytometric immunophenotyping is essential for differentiating this entity from other lymphoproliferative processes, such as lymphocytic lymphoma or follicular lymphoma (grade I) that also involve the proliferation and accumulation of small lymphocytes.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Finally, the test results and a review of the literature confirmed a non-low grade Hodgkin's lymphoma with plasmacytoid differentiation, compatible with a diagnosis of WM.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "xres327140" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec308809" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres327139" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec308810" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical Characteristics" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-01-21" "fechaAceptado" => "2013-05-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec308809" "palabras" => array:3 [ 0 => "Waldenström's macroglobulinemia" 1 => "Interstitial lung disease" 2 => "Lymphoma" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec308810" "palabras" => array:3 [ 0 => "Macroglobulinemia de Waldenström" 1 => "Enfermedad pulmonar intersticial" 2 => "Linfoma" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Waldenström's macroglobulinemia (WM) is a lymphoid malignancy characterized by infiltration, mainly of the bone marrow and lymph nodes, by small mature lymphocytes showing plasmacytoid differentiation, associated with an IgM monoclonal band, and in general, a low degree of aggressiveness. We present the first case reported in the Spanish literature of interstitial lung disease presenting as MW and we review the literature.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La macroglobulinemia de Waldenström (MW) es una neoplasia linfoide caracterizada por una infiltración principalmente de la médula ósea y del ganglio linfático por linfocitos pequeños maduros o con diferenciación plasmocitoide, con banda monoclonal IgM asociada, y en general un bajo grado de agresividad. Presentamos el primer caso publicado en la literatura española de enfermedad pulmonar intersticial difusa como forma de presentación de una MW y realizamos una revisión de la literatura.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Consuegra A, Marcos PJ, Vázquez R, Pombo J, Debén G, Verea-Hernando H. Enfermedad pulmonar intersticial difusa como primera manifestación de macroglobulinemia de Waldenström: descripción de un caso y revisión de la literatura. Arch Bronconeumol. 2014;50:151–153.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 767 "Ancho" => 997 "Tamanyo" => 195759 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) High-resolution computed tomography showing interstitial involvement, characterized by mainly peripheral interlobular septal thickening associated with areas of ground glass opacities. (B) Lung parenchyma with an area of patchy lymphocytic infiltration, alternating with an area of lung parenchyma with no significant histological changes.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">BMB: bone marrow biopsy. TBB: transbronchial biopsy. OLB: open lung biopsy. VTLB: video-assisted thorascopic lung biopsy.</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"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Author (year) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Ref. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No. of cases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Respiratory symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Radiological findings \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Diagnostic method \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hull (1982) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyspnea, cough \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infiltration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BMB, TBB \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bruno (1968) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyspnea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mass, pleural effusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TBB, OLB \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Winterbauer (1974) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyspnea, cough or asymptomatic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infiltration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BMB, autopsy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moeschlin (1966) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyspnea, cough \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infiltration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">OLB \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Strunge (1969) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyspnea, hemoptysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infiltration, mass, pleural effusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Autopsy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fadil (1998) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyspnea, cough \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infiltration, mass, pleural effusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BMB, TBB \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Butí (1984) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyspnea on effort \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infiltration, pleural effusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pleural biopsy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case described \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cough \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Interstitial lung disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VTLB \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab478834.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" 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Esteban" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "1984" "volumen" => "82" "paginaInicial" => "320" "paginaFinal" => "322" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clonality and phenotyping analysis of alveolar lymphocytes is suggestive of pulmonary MALT lymphoma" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Borie" 1 => "M. Wislez" 2 => "M. Antoine" 3 => "J. Fleury-Feith" 4 => "G. Thabut" 5 => "B. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 1 | 8 |
| 2024 October | 103 | 15 | 118 |
| 2024 September | 86 | 26 | 112 |
| 2024 August | 114 | 47 | 161 |
| 2024 July | 105 | 27 | 132 |
| 2024 June | 108 | 43 | 151 |
| 2024 May | 99 | 34 | 133 |
| 2024 April | 56 | 33 | 89 |
| 2024 March | 45 | 21 | 66 |
| 2024 February | 42 | 19 | 61 |
| 2023 March | 10 | 2 | 12 |
| 2023 February | 77 | 15 | 92 |
| 2023 January | 93 | 48 | 141 |
| 2022 December | 97 | 34 | 131 |
| 2022 November | 86 | 29 | 115 |
| 2022 October | 84 | 50 | 134 |
| 2022 September | 66 | 28 | 94 |
| 2022 August | 81 | 49 | 130 |
| 2022 July | 77 | 42 | 119 |
| 2022 June | 81 | 46 | 127 |
| 2022 May | 87 | 52 | 139 |
| 2022 April | 93 | 45 | 138 |
| 2022 March | 104 | 58 | 162 |
| 2022 February | 108 | 81 | 189 |
| 2022 January | 138 | 66 | 204 |
| 2021 December | 122 | 57 | 179 |
| 2021 November | 111 | 55 | 166 |
| 2021 October | 105 | 64 | 169 |
| 2021 September | 63 | 55 | 118 |
| 2021 August | 71 | 91 | 162 |
| 2021 July | 62 | 31 | 93 |
| 2021 June | 67 | 49 | 116 |
| 2021 May | 115 | 44 | 159 |
| 2021 April | 193 | 107 | 300 |
| 2021 March | 91 | 37 | 128 |
| 2021 February | 73 | 31 | 104 |
| 2021 January | 56 | 29 | 85 |
| 2020 December | 71 | 35 | 106 |
| 2020 November | 72 | 31 | 103 |
| 2020 October | 50 | 17 | 67 |
| 2020 September | 99 | 12 | 111 |
| 2020 August | 95 | 17 | 112 |
| 2020 July | 68 | 22 | 90 |
| 2020 June | 82 | 18 | 100 |
| 2020 May | 93 | 23 | 116 |
| 2020 April | 68 | 21 | 89 |
| 2020 March | 56 | 19 | 75 |
| 2020 February | 101 | 33 | 134 |
| 2020 January | 88 | 26 | 114 |
| 2019 December | 95 | 27 | 122 |
| 2019 November | 70 | 18 | 88 |
| 2019 October | 100 | 24 | 124 |
| 2019 September | 79 | 20 | 99 |
| 2019 August | 61 | 27 | 88 |
| 2019 July | 63 | 24 | 87 |
| 2019 June | 83 | 16 | 99 |
| 2019 May | 79 | 35 | 114 |
| 2019 April | 71 | 36 | 107 |
| 2019 March | 103 | 36 | 139 |
| 2019 February | 72 | 34 | 106 |
| 2019 January | 82 | 26 | 108 |
| 2018 December | 78 | 40 | 118 |
| 2018 November | 109 | 41 | 150 |
| 2018 October | 134 | 24 | 158 |
| 2018 September | 52 | 23 | 75 |
| 2018 May | 22 | 0 | 22 |
| 2018 April | 71 | 12 | 83 |
| 2018 March | 74 | 6 | 80 |
| 2018 February | 73 | 10 | 83 |
| 2018 January | 53 | 10 | 63 |
| 2017 December | 50 | 7 | 57 |
| 2017 November | 45 | 1 | 46 |
| 2017 October | 75 | 6 | 81 |
| 2017 September | 60 | 7 | 67 |
| 2017 August | 87 | 22 | 109 |
| 2017 July | 86 | 5 | 91 |
| 2017 June | 95 | 26 | 121 |
| 2017 May | 77 | 5 | 82 |
| 2017 April | 70 | 7 | 77 |
| 2017 March | 73 | 12 | 85 |
| 2017 February | 54 | 7 | 61 |
| 2017 January | 63 | 6 | 69 |
| 2016 December | 86 | 8 | 94 |
| 2016 November | 89 | 13 | 102 |
| 2016 October | 135 | 20 | 155 |
| 2016 September | 165 | 27 | 192 |
| 2016 August | 99 | 12 | 111 |
| 2016 July | 47 | 12 | 59 |
| 2016 March | 2 | 0 | 2 |
| 2016 February | 1 | 0 | 1 |
| 2015 December | 3 | 0 | 3 |
| 2015 October | 61 | 3 | 64 |
| 2015 September | 69 | 15 | 84 |
| 2015 August | 60 | 26 | 86 |
| 2015 July | 65 | 17 | 82 |
| 2015 June | 54 | 18 | 72 |
| 2015 May | 60 | 19 | 79 |
| 2015 April | 62 | 13 | 75 |
| 2015 March | 65 | 19 | 84 |
| 2015 February | 60 | 21 | 81 |
| 2015 January | 43 | 13 | 56 |
| 2014 December | 38 | 12 | 50 |
| 2014 November | 49 | 12 | 61 |
| 2014 October | 41 | 17 | 58 |
| 2014 September | 38 | 15 | 53 |
| 2014 August | 49 | 18 | 67 |
| 2014 July | 52 | 10 | 62 |
| 2014 May | 0 | 2 | 2 |
| 2014 April | 0 | 1 | 1 |
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