Letter to the Editor
Secondary pulmonary alveolar proteinosis in a patient with systemic lupus erythematosus
M. Yamasakia,
, K. Kawamotoa, S. Nakanob, M. Taniwakia, N. Matsumotoa, N. Hattoric
Corresponding author
myamasanjp@yahoo.co.jp
Corresponding author at: Department of Respiratory Medicine, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, 1-9-6 Senda-machi, Naka-ku, Hiroshima 730-8619, Japan.
Corresponding author at: Department of Respiratory Medicine, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, 1-9-6 Senda-machi, Naka-ku, Hiroshima 730-8619, Japan.
a Department of Respiratory Medicine, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, Naka-ku, Hiroshima, Japan
b Department of Rheumatology, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, Naka-ku, Hiroshima, Japan
c Department of Molecular and Internal Medicine, Institute of Biomedical & Health Sciences, Hiroshima University, Minami-ku, Hiroshima, Japan
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"apellidos" => "Yamasaki" "email" => array:1 [ 0 => "myamasanjp@yahoo.co.jp" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "K." "apellidos" => "Kawamoto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "Nakano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Taniwaki" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "N." "apellidos" => "Matsumoto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "N." "apellidos" => "Hattori" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Respiratory Medicine, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, Naka-ku, Hiroshima, Japan" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Rheumatology, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, Naka-ku, Hiroshima, Japan" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Molecular and Internal Medicine, Institute of Biomedical & Health Sciences, Hiroshima University, Minami-ku, Hiroshima, Japan" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: Department of Respiratory Medicine, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, 1-9-6 Senda-machi, Naka-ku, Hiroshima 730-8619, Japan." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1036 "Ancho" => 1505 "Tamanyo" => 224697 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A–C) Computed tomography image depicting diffuse ground-glass opacities in both lung fields. (D) Bronchoalveolar lavage fluid with a markedly cloudy appearance.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary alveolar proteinosis (PAP) is a rare respiratory disease and is pathogenetically classified into the following three types: autoimmune PAP, secondary PAP (sPAP), and congenital PAP.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> sPAP is not associated with anti-granulocyte macrophage colony-stimulating factor (GM-CSF) antibody and accounts for 5–10% of PAP cases. sPAP is primarily caused by hematological disorders; sPAP caused by autoimmune diseases is extremely rare<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a>; therefore, clinicians may not always consider the possibility of sPAP when abnormal findings on chest radiography and/or computed tomography (CT) are seen in patients with autoimmune diseases. We report here, a case of sPAP in a patient with systemic lupus erythematosus (SLE).</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 70-year-old woman presented to our hospital with a 1-month history of exertional dyspnea. She was a known case of SLE and had a 37-year-history of treatment with corticosteroids and immunosuppressive agents. Her respiratory sounds were normal, and she had no fever or cough; her oxygen saturation was 94% in room air. Chest radiography and computed tomography revealed diffuse ground-glass opacities in the lung fields bilaterally (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A–C). Serum level of Krebs von den Lungen-6, a marker of interstitial pneumonia, was elevated (6416 U/mL); β-<span class="elsevierStyleSmallCaps">d</span>-glucan and cytomegalovirus antigenemia were absent. Non-infectious acute interstitial pneumonia was suspected, and a high-dose corticosteroid was administered; however, radiographic findings and symptoms did not improve. Furthermore, multiple nodules with cavitation appeared in the lower lobe of the left lung. Bronchoscopy was performed; the bronchoalveolar lavage fluid (BALF) was markedly cloudy (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D), and showed deposition of acidophilic granular material and foamy macrophages on microscopy. Additionally, <span class="elsevierStyleItalic">Nocardia</span> was detected in the nodules of the left lower lobe. Serum anti-GM-CSF antibody was absent. Finally, she was diagnosed with sPAP associated with SLE, and pulmonary nocardiosis. Early treatment of nocardiosis was necessary; therefore, antibiotics were administered, while the corticosteroid dose was tapered. Unfortunately, pulmonary nocardiosis was refractory to treatment; furthermore, complications set in due to the cytomegalovirus pneumonia and non-tuberculous mycobacteriosis. Two months later, the patient died of exacerbating infections.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In this case report, there were two important clinical observations. First, sPAP might develop in a patient with SLE. To the best of our knowledge, only one case of sPAP with SLE has been reported in the literature until date.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> According to previous reports, autoimmune diseases account for approximately 7% of the underlying causes of sPAP<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a>; however, autoimmune diseases include Behcet’s disease, Wegener’s granulomatosis, microscopic polyangiitis, Sjogren’s syndrome, and dermatomyositis.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> There are few specific diseases; therefore, every autoimmune disease should be considered as a potential cause of sPAP.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Second, chest CT findings of sPAP might be confused with those of acute interstitial pneumonia and pulmonary alveolar hemorrhage. In many cases of sPAP, such as the present one, chest CT shows ground-glass opacities in the lung fields bilaterally,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> which are also seen in acute interstitial pneumonia and diffuse alveolar hemorrhage, which are pulmonary disorders of SLE.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–8</span></a> The treatment of acute interstitial pneumonia and diffuse alveolar hemorrhage requires administration of high-dose corticosteroid and frequently an immunomodulatory agent as well. The treatment of sPAP needs to be quite different (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) but as the mechanism underlying sPAP is still uncertain, there are no specific treatment indications for sPAP This may lead to high-dose corticosteroid and/or immunomodulatory agent being administered for pulmonary infections, as in case here presented. It is therefore important that in patients with SLE and diffuse pulmonary ground-glass opacities, clinicians should consider sPAP in addition to acute interstitial pneumonia and diffuse alveolar hemorrhage in the differential diagnosis.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">sPAP has a poor prognosis compared to autoimmune PAP.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Acute interstitial pneumonia and diffuse alveolar hemorrhage associated with SLE have sudden onset with severe symptoms, while the progression of sPAP is relatively slow and symptoms are relatively mild. Regular and close follow-up on chest radiography is necessary for early detection of sPAP in patients with SLE. For early initiation of appropriate treatment, awareness of the possibility of sPAP in patients with ground-glass opacities in both lung fields is important.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Author contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Study conception and design: Masahiro Yamasaki.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Data acquisition: Masahiro Yamasaki, Kazuma Kawamoto, Shota Nakano, Masaya Taniwaki, Naoko Matsumoto, Shinji Nabeshima.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Data analysis and interpretation: Masahiro Yamasaki, Kazuma Kawamoto, Shota Nakano, Noboru Hattori.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Drafting of the manuscript: Masahiro Yamasaki.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Critical revision of the manuscript for important intellectual content: Noboru Hattori.</p><p id="par0055" class="elsevierStylePara elsevierViewall">All authors had access to the data and played a role in writing this manuscript.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Author contributions" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 2 => array:2 [ "identificador" => "xack503232" "titulo" => "Acknowledgments" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-06-16" "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1036 "Ancho" => 1505 "Tamanyo" => 224697 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A–C) Computed tomography image depicting diffuse ground-glass opacities in both lung fields. (D) Bronchoalveolar lavage fluid with a markedly cloudy appearance.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">SLE, systemic lupus erythematosus; sPAP, secondary alveolar proteinosis; AIP, acute interstitial pneumonitis; DAH, diffuse alveolar hemorrhage; HRCT, high resolution computed tomography; GGO, ground-glass opacities; BAL, bronchoalveolar lavage.</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="\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" scope="col" style="border-bottom: 2px solid black">Characteristics \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">sPAP \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">AIP in SLE \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">DAH in SLE \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Progression rate \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">Relatively slowly progression \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">Sudden onset \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">Sudden onset \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Symptoms \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">Dyspnea; cough; fever; sometimes 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">Dyspnea; cough; hemoptysis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HRCT findings \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">Diffuse GGO; patchy geographic pattern; crazy paving pattern \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">Diffuse GGO and areas of consolidation \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">Diffuse or patchy GGO and/or consolidation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BAL findings \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">Cloudy appearance; acidophilic granular material deposition and foamy macrophages \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">Incleased cellularity with activated polymorphonuclear leukocytes \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">Bloody appearance \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatment \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">Removing offending exposure or treating the underlying disorder; whole lung lavage \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">High-dose corticosteroid and/or immunomodulatory agent \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">High-dose corticosteroid and/or immunomodulatory agent, occasionally plasmapheresis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prognosis \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">Poorer than autoimmune PAP; median survival time <20 months \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">Short-time mortality of 50% \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">Short-time mortality of 50% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2479751.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Characteristics of secondary alveolar proteinosis compared to acute interstitial pneumonitis and diffuse alveolar hemorrhage in SLE.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary alveolar proteinosis in adults: pathophysiology and clinical approach" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 4 | 11 |
| 2024 October | 35 | 29 | 64 |
| 2024 September | 58 | 27 | 85 |
| 2024 August | 64 | 35 | 99 |
| 2024 July | 54 | 37 | 91 |
| 2024 June | 46 | 24 | 70 |
| 2024 May | 57 | 38 | 95 |
| 2024 April | 51 | 28 | 79 |
| 2024 March | 50 | 25 | 75 |
| 2024 February | 34 | 18 | 52 |
| 2024 January | 31 | 26 | 57 |
| 2023 December | 28 | 29 | 57 |
| 2023 November | 43 | 42 | 85 |
| 2023 October | 32 | 45 | 77 |
| 2023 September | 30 | 33 | 63 |
| 2023 August | 31 | 22 | 53 |
| 2023 July | 36 | 26 | 62 |
| 2023 June | 16 | 14 | 30 |
| 2023 May | 47 | 38 | 85 |
| 2023 April | 29 | 17 | 46 |
| 2023 March | 62 | 26 | 88 |
| 2023 February | 49 | 29 | 78 |
| 2023 January | 32 | 21 | 53 |
| 2022 December | 59 | 33 | 92 |
| 2022 November | 59 | 34 | 93 |
| 2022 October | 71 | 45 | 116 |
| 2022 September | 38 | 39 | 77 |
| 2022 August | 51 | 45 | 96 |
| 2022 July | 52 | 53 | 105 |
| 2022 June | 46 | 38 | 84 |
| 2022 May | 57 | 38 | 95 |
| 2022 April | 38 | 45 | 83 |
| 2022 March | 44 | 48 | 92 |
| 2022 February | 37 | 41 | 78 |
| 2022 January | 48 | 57 | 105 |
| 2021 December | 36 | 38 | 74 |
| 2021 November | 25 | 40 | 65 |
| 2021 October | 45 | 62 | 107 |
| 2021 September | 29 | 37 | 66 |
| 2021 August | 34 | 37 | 71 |
| 2021 July | 37 | 13 | 50 |
| 2021 June | 34 | 38 | 72 |
| 2021 May | 46 | 56 | 102 |
| 2021 April | 206 | 115 | 321 |
| 2021 March | 144 | 69 | 213 |
| 2021 February | 104 | 34 | 138 |
| 2021 January | 131 | 39 | 170 |
| 2020 December | 58 | 32 | 90 |
| 2020 November | 46 | 44 | 90 |
| 2020 October | 45 | 20 | 65 |
| 2020 September | 82 | 41 | 123 |
| 2020 August | 58 | 22 | 80 |
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