Scientific Letter
Atypical Chlamydia psittaci Pneumonia. Four Related Cases
Neumonía atípica por Chlamydia psittaci. Cuatro casos relacionados
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Cuatro casos relacionados" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Psittacosis is a globally distributed zoonotic disease caused by <span class="elsevierStyleItalic">Chlamydia psittaci</span> (<span class="elsevierStyleItalic">C. psittaci</span>), an intracellular bacteria.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> Birds constitute its main reservoir and the mechanism of transmission is direct contact or inhalation of respiratory secretions or dry feces of infected birds.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> Individuals with occupational or recreational exposure to various birds have a greater risk of infection.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> Psittacosis generally occurs sporadically, but outbreaks have been reported.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> Presentation varies from subclinical infection to severe sepsis and multisystemic involvement.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3,4</span></a> We describe an outbreak of 4 cases of <span class="elsevierStyleItalic">C. psittaci</span> pneumonia, the focus of infection being a store selling birds (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case 1</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 47-year-old man was admitted with a 5-day history of dyspnea and fever. On admission, he presented tachypnea and crackles in the right lung base, respiratory failure (RF) (PaO<span class="elsevierStyleInf">2</span> 55<span class="elsevierStyleHsp" style=""></span>mmHg), neutrophilia (91%), elevated C-reactive protein (CRP) (49<span class="elsevierStyleHsp" style=""></span>mg/dl), procalcitonin (PCT) 1<span class="elsevierStyleHsp" style=""></span>mg/ml, and alveolar infiltrate in the right lower lobe. Antibiotic treatment with ceftriaxone, levofloxacin and doxycycline was administered for 2 weeks, followed by oseltamivir for 5 days. After 24<span class="elsevierStyleHsp" style=""></span>h he developed respiratory failure and progressive radiological infiltration, renal failure and shock, so was admitted to the intensive care unit (ICU). Invasive mechanical ventilation was initiated, with noradrenaline 0.4<span class="elsevierStyleHsp" style=""></span>mcg/kg/min and extrarenal depuration. In view of the lack of response, veno-venous extracorporeal membrane oxygenation support (ECMO) was required. Progress was slow and weaning prolonged, and the patient was discharged from the ICU after 60 days, and from the hospital 81 days after admission. <span class="elsevierStyleItalic">C. psittaci</span> DNA was detected in respiratory samples (nasopharyngeal exudate and tracheal aspirate) by polymerase chain reaction (PCR). No other microorganisms were found, including influenza virus. Immunofluorescence testing for <span class="elsevierStyleItalic">C. psittaci</span> serology was positive (IgG seroconversion 1:256 after 14 days from the first sample).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case 2</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 22-year-old man was admitted with a 1-week history of fever, dry cough, and general malaise. Physical examination showed fever, arterial hypertension, tachycardia, and crackles in the entire right hemithorax. The patient presented respiratory failure (PaO<span class="elsevierStyleInf">2</span> 53<span class="elsevierStyleHsp" style=""></span>mmHg), neutrophilia (87%), elevated CRP 58<span class="elsevierStyleHsp" style=""></span>mg/dl, clotting disorders with prothrombin activity 55%, and multilobar infiltrate in right lung. He received high-flow oxygen therapy in the ICU. Ceftriaxone, levofloxacin and doxycycline were administered for 2 weeks. <span class="elsevierStyleItalic">C. psittaci</span> serology was positive, with IgG seroconversion (1:256) in convalescent serum. All other microbiological results were negative, including <span class="elsevierStyleItalic">C. psittaci</span> PCR of nasopharygeal exudate. Clinical symptoms and radiological signs resolved after 6 weeks.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case 3</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 20-year-old man was admitted with a 1-week history of fever, cough with white sputum, and general malaise. Physical examination revealed fever and crackles in the right lung base. Clinical laboratory results showed neutrophilia (84%), CRP 41<span class="elsevierStyleHsp" style=""></span>mg/dl and prothrombin activity 58%. Chest radiograph revealed alveolar infiltrate in the left lower lobe. Treatment began with azithromycin (discontinued on day 3), ceftriaxone, and doxycycline lasting 10 days. The patient showed clinical, analytical and radiological improvement. IgG seroconversion (1:256) observed in convalescent serum. All other microbiological results were negative, including <span class="elsevierStyleItalic">C. psittaci</span> PCR of nasopharygeal exudate. At 1 month, the patient was asymptomatic and radiological images were resolved.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Case 4</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 52-year-old woman was admitted with a 1-week history of fever, cough, and mucous expectoration, with a tendency toward arterial hypertension. Respiratory failure (PaO<span class="elsevierStyleInf">2</span> 57<span class="elsevierStyleHsp" style=""></span>mmHg), neutrophilia (87%), raised CRP (39<span class="elsevierStyleHsp" style=""></span>mg/dl), procalcitonin 30<span class="elsevierStyleHsp" style=""></span>ng/ml, and right bilobar infiltrate. Treatment began with ceftriaxone and azithromycin and continued for 10 days. PCR of nasal exudate was negative for <span class="elsevierStyleItalic">C. psittaci</span>, and IgG seroconversion (1:256) was observed in the convalescent serum. All other microbiological results were negative. At 1 month, the patient was asymptomatic and radiological images had resolved.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Outbreaks of psittacosis have been described primarily in individuals exposed to birds, for example, veterinary surgeons and employees of stores selling animals.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> Other outbreaks of psittacosis associated with occupational exposure in bird farms have been described.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">5,6</span></a> We report an outbreak of 4 cases of psittacosis with different degrees of severity, ranging from mild pneumonia to multiorgan failure requiring ECMO and a prolonged ICU stay. All of the subjects visited a bird store which sold <span class="elsevierStyleItalic">Agapornis</span> (love birds) that showed signs of disease. The infection may be indistinguishable from other atypical pneumonias, so the history of exposure to birds was key to guiding the suspected diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3,7</span></a> Severity may vary widely, from mild respiratory infection to full-blown disease, requiring intensive care and even ECMO.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> Diagnosis is based on the clinical examination, epidemiological history, and laboratory confirmation using direct (culture, PCR) or indirect (serology) methods.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> Given the complexity of culturing <span class="elsevierStyleItalic">C. psittaci</span> (biosafety level 3) and the unavailability of commercial molecular methods (PCR), diagnosis is based on serologies.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1,8</span></a> In the cases discussed here, serological confirmation was obtained when specific IgG seroconversion was detected at 14–17 days after the initial sample, except for case 3, in whom it was detected in a third sample obtained at 37 days. In all cases detection of specific IgM in the acute phase was negative. DNA detection of <span class="elsevierStyleItalic">C. psittaci</span> was performed in respiratory samples from all patients using a non-commercial PCR technique,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> but this was positive in the most severe case only. <span class="elsevierStyleItalic">C. psittaci</span> infections are very rare in humans and molecular tests are not standardized, so these techniques have not been widely evaluated in clinical samples, and sensitivity and specificity data are scant.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Tetracyclines, macrolides and quinolones are the best empirical treatments for intracellular bacteria.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> Our cases were initially treated in different hospital departments (emergency room, UCI) by different physicians, thus explaining the different treatment regimens. Antibiotic cover was maintained on the pulmonology ward with a betalactam and an antibiotic with intracellular action. Improvement is generally observed 48<span class="elsevierStyleHsp" style=""></span>h after starting antibiotic treatment.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Case 2" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Case 3" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Case 4" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Arenas-Valls N, Chacón S, Pérez A, del Pozo R. Neumonía atípica por <span class="elsevierStyleItalic">Chlamydia psittaci</span>. Cuatro casos relacionados. Arch Bronconeumol. 2017;53:277–279.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CRP: C-reactive protein; ICU: Intensive Care Unit.</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="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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">Case 1 \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">Case 2 \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">Case 3 \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">Case 4 \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">Exposure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Customer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Employee \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Employee \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Employee \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">Place admitted \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ICU \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hospital ward \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hospital ward \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">Days admitted \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \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">CRP (mg/ml) admission \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">58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39 \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">CRP (mg/ml) 72<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 \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">Chest radiograph admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Infiltrate both lower lobes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Alveolar infiltrate 3 right lobes<br> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Alveolar infiltrate right lower lobe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Alveolar infiltrate right upper and middle lobe \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">Chest radiograph at 1 month \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bilateral infiltrate consistent with ARDS \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">Normal \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Complications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Septic shock Multiorgan failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Septic shock \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Severe sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Severe sepsis \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"><span class="elsevierStyleItalic">C. psittaci</span> serology \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">+ \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1406680.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Comparative Characteristics of the Cases.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chlamydia psittaci: update on an underestimated zoonotic agent" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.R. 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"serieFecha" => "2015" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0110" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Community-acquired pneumonia related to intracellular pathogens" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Cilloniz" 1 => "A. Torres" 2 => "M. Niederman" 3 => "M. van der Eerden" 4 => "J. Chalmers" 5 => "T. Welte" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00134-011-2180-x" "Revista" => array:3 [ "tituloSerie" => "Intensive Care Med" "fecha" => "2016" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21365313" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:3 [ "titulo" => "Acknowledgements" "texto" => "<p id="par0040" class="elsevierStylePara elsevierViewall">The authors would like to thank Dr. Carlos José Álvarez of the Respiratory Medicine Department of the Hospital 12 de Octubre for his critical review of the manuscript, and Dr. Nerea García Benzaquén, of the Department of Emerging Rare and Biologically Aggressive Zoonosis of the Center for Veterinary Health Surveillance (VIVASET) of the Universidad Complutense, Madrid, for performing <span class="elsevierStyleItalic">C. psittaci</span> DNA molecular dectection assays. We would also like to thank Sara Álvarez and Lidia Sotillo, medical students at the Universidad Complutense, Madrid, for their clinical interest in these cases.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005300000005/v1_201704280925/S1579212917300897/v1_201704280925/en/main.assets" "Apartado" => array:4 [ "identificador" => "49861" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005300000005/v1_201704280925/S1579212917300897/v1_201704280925/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212917300897?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
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| 2024 November | 3 | 4 | 7 |
| 2024 October | 48 | 33 | 81 |
| 2024 September | 55 | 9 | 64 |
| 2024 August | 87 | 37 | 124 |
| 2024 July | 53 | 22 | 75 |
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| 2024 May | 90 | 35 | 125 |
| 2024 April | 52 | 30 | 82 |
| 2024 March | 53 | 22 | 75 |
| 2024 February | 44 | 23 | 67 |
| 2023 March | 10 | 1 | 11 |
| 2023 February | 60 | 35 | 95 |
| 2023 January | 43 | 39 | 82 |
| 2022 December | 91 | 42 | 133 |
| 2022 November | 95 | 38 | 133 |
| 2022 October | 85 | 45 | 130 |
| 2022 September | 79 | 39 | 118 |
| 2022 August | 56 | 47 | 103 |
| 2022 July | 59 | 59 | 118 |
| 2022 June | 70 | 40 | 110 |
| 2022 May | 81 | 34 | 115 |
| 2022 April | 89 | 60 | 149 |
| 2022 March | 75 | 56 | 131 |
| 2022 February | 86 | 41 | 127 |
| 2022 January | 68 | 25 | 93 |
| 2021 December | 64 | 45 | 109 |
| 2021 November | 57 | 57 | 114 |
| 2021 October | 55 | 58 | 113 |
| 2021 September | 54 | 62 | 116 |
| 2021 August | 65 | 51 | 116 |
| 2021 July | 33 | 29 | 62 |
| 2021 June | 60 | 63 | 123 |
| 2021 May | 58 | 42 | 100 |
| 2021 April | 208 | 94 | 302 |
| 2021 March | 109 | 24 | 133 |
| 2021 February | 62 | 32 | 94 |
| 2021 January | 48 | 21 | 69 |
| 2020 December | 78 | 53 | 131 |
| 2020 November | 58 | 40 | 98 |
| 2020 October | 62 | 26 | 88 |
| 2020 September | 44 | 14 | 58 |
| 2020 August | 51 | 17 | 68 |
| 2020 July | 60 | 30 | 90 |
| 2020 June | 84 | 12 | 96 |
| 2020 May | 62 | 13 | 75 |
| 2020 April | 57 | 23 | 80 |
| 2020 March | 72 | 13 | 85 |
| 2020 February | 56 | 28 | 84 |
| 2020 January | 37 | 21 | 58 |
| 2019 December | 69 | 34 | 103 |
| 2019 November | 49 | 25 | 74 |
| 2019 October | 53 | 14 | 67 |
| 2019 September | 67 | 17 | 84 |
| 2019 August | 48 | 12 | 60 |
| 2019 July | 37 | 17 | 54 |
| 2019 June | 40 | 13 | 53 |
| 2019 May | 57 | 12 | 69 |
| 2019 April | 71 | 10 | 81 |
| 2019 March | 57 | 23 | 80 |
| 2019 February | 51 | 15 | 66 |
| 2019 January | 49 | 19 | 68 |
| 2018 December | 48 | 17 | 65 |
| 2018 November | 75 | 24 | 99 |
| 2018 October | 51 | 26 | 77 |
| 2018 September | 20 | 8 | 28 |
| 2018 July | 1 | 0 | 1 |
| 2018 May | 10 | 1 | 11 |
| 2018 April | 32 | 10 | 42 |
| 2018 March | 24 | 5 | 29 |
| 2018 February | 17 | 13 | 30 |
| 2018 January | 19 | 5 | 24 |
| 2017 December | 24 | 6 | 30 |
| 2017 November | 24 | 7 | 31 |
| 2017 October | 18 | 9 | 27 |
| 2017 September | 36 | 10 | 46 |
| 2017 August | 44 | 13 | 57 |
| 2017 May | 0 | 1 | 1 |
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