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Asimismo&#44; desde el 2010 diferentes autoridades sanitarias&#44; como la Agencia Espa&#241;ola de Medicamentos y Productos Sanitarios &#40;AEMPS&#41;&#44; la Administraci&#243;n de Alimentos y Medicamentos &#40;FDA&#41;&#44; la Organizaci&#243;n Panamericana de la Salud &#40;OPS&#41; o la Therapeutic Good Administration &#40;TGA&#41;&#44; han alertado de los severos efectos secundarios relacionados con su consumo<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;4</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A continuaci&#243;n&#44; presentamos el primer caso descrito en la literatura de un s&#237;ndrome pierde sal cerebral que se manifest&#243; con hiponatremia severa como reacci&#243;n adversa al consumo de di&#243;xido de cloro&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Se trata de un var&#243;n de 61 a&#241;os sin antecedentes personales&#44; y no vacunado frente al SARS-CoV-2&#44; que comenz&#243; a consumir por voluntad propia de forma diaria di&#243;xido de cloro con la creencia de prevenir la infecci&#243;n&#46; A las 2 semanas present&#243; cuadro encefalop&#225;tico de instauraci&#243;n progresiva con bradipsiquia&#44; desrealizaci&#243;n&#44; irritabilidad e inquietud&#46; A la exploraci&#243;n f&#237;sica se evidenci&#243; deshidrataci&#243;n cut&#225;neo-mucosa&#46; Se realiz&#243; tomograf&#237;a computarizada &#40;TC&#41; craneal que revel&#243; edema cerebral e hipertensi&#243;n intracraneal idiop&#225;tica &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Se realizaron fondo de ojo y punci&#243;n lumbar resultando normales&#46; En anal&#237;tica sangu&#237;nea se objetiv&#243;&#58; sodio 112<span class="elsevierStyleHsp" style=""></span>mEq&#47;l&#44; cloro 77<span class="elsevierStyleHsp" style=""></span>mEq&#47;l&#44; osmolaridad plasm&#225;tica 230<span class="elsevierStyleHsp" style=""></span>mOsm&#47;kg y &#225;cido &#250;rico 2&#44;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; 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con restablecimiento paulatino del estado neurol&#243;gico y normalizaci&#243;n de par&#225;metros anal&#237;ticos &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Se realiz&#243; un diagn&#243;stico diferencial de otras posibles causas de hiponatremia&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">El consumo de di&#243;xido de cloro ha aumentado de forma exponencial durante la pandemia debido a la divulgaci&#243;n de informaci&#243;n err&#243;nea en medios de comunicaci&#243;n y redes sociales sobre su posible efecto profil&#225;ctico en el desarrollo de una infecci&#243;n por SARS-CoV-2&#46; Las reacciones adversas m&#225;s frecuentes del mismo son insuficiencia respiratoria&#44; alteraciones del ritmo card&#237;aco&#44; insuficiencia hep&#225;tica aguda&#44; hipotensi&#243;n&#44; alteraciones gastrointestinales o lesi&#243;n renal aguda<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6</span></a>&#46; Se han descrito cuadros digestivos graves vinculados al consumo de esta sustancia que podr&#237;an causar hiponatremia secundaria a la situaci&#243;n de p&#233;rdidas del paciente&#46; Hasta el momento&#44; en la literatura no se ha comunicado la aparici&#243;n de un s&#237;ndrome pierde sal cerebral tras la ingesta de esta sustancia&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">En el caso descrito se estable como diagn&#243;stico de presunci&#243;n un s&#237;ndrome pierde sal cerebral&#44; caracterizado por hiponatremia &#40;sodio plasm&#225;tico inferior a 135<span class="elsevierStyleHsp" style=""></span>mEq&#47;l&#41;&#44; hipot&#243;nica &#40;osmolaridad plasm&#225;tica &#60;<span class="elsevierStyleHsp" style=""></span>280<span class="elsevierStyleHsp" style=""></span>mOsm&#47;kg&#41;&#44; hipovol&#233;mica &#40;presencia de signos de deshidrataci&#243;n&#41;&#44; con p&#233;rdidas renales de sodio con sodio urinario &#62;<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>mEq&#47;l y osmolaridad urinaria alta &#40;&#62;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mOsm&#47;kg&#41; acompa&#241;ada de hipouricemia &#40;&#225;cido &#250;rico inferior a 4<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; y una excreci&#243;n fraccional de &#225;cido &#250;rico &#40;FEUa&#41; elevada &#40;&#62;<span class="elsevierStyleHsp" style=""></span>10-12&#37;&#41;&#46; La severidad del cuadro se encontraba determinada por la aparici&#243;n de cl&#237;nica neurol&#243;gica de instauraci&#243;n lenta y progresiva&#44; siendo descartada organicidad encef&#225;lica mediante prueba de imagen y punci&#243;n lumbar&#46; Por lo tanto&#44; los datos cl&#237;nicos y anal&#237;ticos expuestos&#44; la ausencia de tratamiento diur&#233;tico y los niveles plasm&#225;ticos dentro de la normalidad de urea&#44; creatinina&#44; cortisol y aldosterona sugieren el diagn&#243;stico de s&#237;ndrome pierde sal cerebral<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">La patogenia del mismo es poco conocida y suele ser transitorio con resoluci&#243;n completa en semanas&#44; resultando fundamental el diagn&#243;stico diferencial con el s&#237;ndrome de secreci&#243;n inadecuada de ADH &#40;SIADH&#41;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a>&#46; La FEUa ayuda en el diagn&#243;stico diferencial del s&#237;ndrome pierde sal con el SIADH&#44; puesto que en el s&#237;ndrome pierde sal&#44; como ocurre en nuestro caso&#44; la FEUa es mayor del 11&#37; y no se corrige tras la normalizaci&#243;n de la natremia<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Aplicando el algoritmo de causalidad del Sistema Espa&#241;ol del Farmacovigilancia &#40;SEF&#41; en este caso&#44; es probable que el cuadro se trate de una reacci&#243;n adversa relacionada con el di&#243;xido de cloro al existir una secuencia temporal evidente entre su ingesta y la aparici&#243;n de la cl&#237;nica&#44; as&#237; como una resoluci&#243;n completa del mismo al suspender el agente&#44; aunque actualmente se desconoce el motivo por el cual el di&#243;xido de cloro puede causar hiponatremia&#44; debido a que su agente activo es el di&#243;xido de sodio&#44; podr&#237;a postularse como teor&#237;a una reacci&#243;n renal al exceso del agente activo&#44; clorito de sodio&#44; que provoque un aumento de p&#233;rdidas urinarias de sodio&#44; que mantenido en el tiempo derivan en una hiponatremia establecida de forma subaguda como ocurre en el caso descrito&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Consideramos relevante el caso descrito ante la necesidad de concienciar a la poblaci&#243;n de los diversos efectos adversos relacionados con esta sustancia&#44; y la nula evidencia que acredite el empleo de la misma en la prevenci&#243;n de infecci&#243;n SARS-CoV-2&#44; evitando as&#237; su consumo&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financiaci&#243;n</span><p id="par0055" class="elsevierStylePara elsevierViewall">No se ha recibido financiaci&#243;n por ninguna entidad financiadora&#46;</p></span></span>"
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                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Sodio&#44; mEq&#47;l&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">72&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">119&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">67&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">135&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">102&nbsp;\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
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                  \t\t\t\t">Potasio&#44; mEq&#47;l&nbsp;\t\t\t\t\t\t\n
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Carta al Director
Síndrome pierde sal cerebral asociado a ingesta de dióxido de cloro utilizado para la prevención de infección por SARS-CoV-2
Cerebral salt-wasting syndrome associated with ingestion of chlorine dioxide used to prevent SARS-CoV-2 infection
Elena Hernández García
Autor para correspondencia
elena_46hg@hotmail.com

Autor para correspondencia.
, Vanesa García Chumillas, Juan de Dios López-González Gila, Carlos Alberto Mañero Rodríguez
Servicio de Nefrología, Hospital Universitario Clínico San Cecilio, Granada, España
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Asimismo&#44; desde el 2010 diferentes autoridades sanitarias&#44; como la Agencia Espa&#241;ola de Medicamentos y Productos Sanitarios &#40;AEMPS&#41;&#44; la Administraci&#243;n de Alimentos y Medicamentos &#40;FDA&#41;&#44; la Organizaci&#243;n Panamericana de la Salud &#40;OPS&#41; o la Therapeutic Good Administration &#40;TGA&#41;&#44; han alertado de los severos efectos secundarios relacionados con su consumo<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;4</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A continuaci&#243;n&#44; presentamos el primer caso descrito en la literatura de un s&#237;ndrome pierde sal cerebral que se manifest&#243; con hiponatremia severa como reacci&#243;n adversa al consumo de di&#243;xido de cloro&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Se trata de un var&#243;n de 61 a&#241;os sin antecedentes personales&#44; y no vacunado frente al SARS-CoV-2&#44; que comenz&#243; a consumir por voluntad propia de forma diaria di&#243;xido de cloro con la creencia de prevenir la infecci&#243;n&#46; A las 2 semanas present&#243; cuadro encefalop&#225;tico de instauraci&#243;n progresiva con bradipsiquia&#44; desrealizaci&#243;n&#44; irritabilidad e inquietud&#46; A la exploraci&#243;n f&#237;sica se evidenci&#243; deshidrataci&#243;n cut&#225;neo-mucosa&#46; Se realiz&#243; tomograf&#237;a computarizada &#40;TC&#41; craneal que revel&#243; edema cerebral e hipertensi&#243;n intracraneal idiop&#225;tica &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Se realizaron fondo de ojo y punci&#243;n lumbar resultando normales&#46; En anal&#237;tica sangu&#237;nea se objetiv&#243;&#58; sodio 112<span class="elsevierStyleHsp" style=""></span>mEq&#47;l&#44; cloro 77<span class="elsevierStyleHsp" style=""></span>mEq&#47;l&#44; osmolaridad plasm&#225;tica 230<span class="elsevierStyleHsp" style=""></span>mOsm&#47;kg y &#225;cido &#250;rico 2&#44;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; excreci&#243;n fraccionada de &#250;rico &#40;FEUa&#41; al ingreso&#58; 15&#44;4&#37; y tras 72<span class="elsevierStyleHsp" style=""></span>h con normalizaci&#243;n de la natremia&#44; FEUa&#58; 11&#44;4&#37;&#46; En gasometr&#237;a venosa se objetiv&#243; pH 7&#44;42&#44; bicarbonato &#40;HCO<span class="elsevierStyleInf">3</span>&#41; 21<span class="elsevierStyleHsp" style=""></span>mmol&#47;l&#44; CO<span class="elsevierStyleInf">2</span> 42<span class="elsevierStyleHsp" style=""></span>mmHg&#46; Resto sin hallazgos a destacar&#46; En an&#225;lisis urinario&#58; sodio 72<span class="elsevierStyleHsp" style=""></span>mEq&#47;l&#44; potasio 30<span class="elsevierStyleHsp" style=""></span>mEq&#47;l&#44; cloro 55<span class="elsevierStyleHsp" style=""></span>mEq&#47;l&#44; &#225;cido &#250;rico 15&#44;4<span class="elsevierStyleHsp" style=""></span>mg&#47;dl y osmolaridad 224<span class="elsevierStyleHsp" style=""></span>mOsm&#47;kg&#46; Se retir&#243; de forma inmediata el di&#243;xido de cloro inici&#225;ndose tratamiento para reposici&#243;n hidroelectrol&#237;tica seg&#250;n d&#233;ficit de sodio progresivamente&#44; con restablecimiento paulatino del estado neurol&#243;gico y normalizaci&#243;n de par&#225;metros anal&#237;ticos &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Se realiz&#243; un diagn&#243;stico diferencial de otras posibles causas de hiponatremia&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">El consumo de di&#243;xido de cloro ha aumentado de forma exponencial durante la pandemia debido a la divulgaci&#243;n de informaci&#243;n err&#243;nea en medios de comunicaci&#243;n y redes sociales sobre su posible efecto profil&#225;ctico en el desarrollo de una infecci&#243;n por SARS-CoV-2&#46; Las reacciones adversas m&#225;s frecuentes del mismo son insuficiencia respiratoria&#44; alteraciones del ritmo card&#237;aco&#44; insuficiencia hep&#225;tica aguda&#44; hipotensi&#243;n&#44; alteraciones gastrointestinales o lesi&#243;n renal aguda<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6</span></a>&#46; Se han descrito cuadros digestivos graves vinculados al consumo de esta sustancia que podr&#237;an causar hiponatremia secundaria a la situaci&#243;n de p&#233;rdidas del paciente&#46; Hasta el momento&#44; en la literatura no se ha comunicado la aparici&#243;n de un s&#237;ndrome pierde sal cerebral tras la ingesta de esta sustancia&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">En el caso descrito se estable como diagn&#243;stico de presunci&#243;n un s&#237;ndrome pierde sal cerebral&#44; caracterizado por hiponatremia &#40;sodio plasm&#225;tico inferior a 135<span class="elsevierStyleHsp" style=""></span>mEq&#47;l&#41;&#44; hipot&#243;nica &#40;osmolaridad plasm&#225;tica &#60;<span class="elsevierStyleHsp" style=""></span>280<span class="elsevierStyleHsp" style=""></span>mOsm&#47;kg&#41;&#44; hipovol&#233;mica &#40;presencia de signos de deshidrataci&#243;n&#41;&#44; con p&#233;rdidas renales de sodio con sodio urinario &#62;<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>mEq&#47;l y osmolaridad urinaria alta &#40;&#62;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mOsm&#47;kg&#41; acompa&#241;ada de hipouricemia &#40;&#225;cido &#250;rico inferior a 4<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; y una excreci&#243;n fraccional de &#225;cido &#250;rico &#40;FEUa&#41; elevada &#40;&#62;<span class="elsevierStyleHsp" style=""></span>10-12&#37;&#41;&#46; La severidad del cuadro se encontraba determinada por la aparici&#243;n de cl&#237;nica neurol&#243;gica de instauraci&#243;n lenta y progresiva&#44; siendo descartada organicidad encef&#225;lica mediante prueba de imagen y punci&#243;n lumbar&#46; Por lo tanto&#44; los datos cl&#237;nicos y anal&#237;ticos expuestos&#44; la ausencia de tratamiento diur&#233;tico y los niveles plasm&#225;ticos dentro de la normalidad de urea&#44; creatinina&#44; cortisol y aldosterona sugieren el diagn&#243;stico de s&#237;ndrome pierde sal cerebral<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">La patogenia del mismo es poco conocida y suele ser transitorio con resoluci&#243;n completa en semanas&#44; resultando fundamental el diagn&#243;stico diferencial con el s&#237;ndrome de secreci&#243;n inadecuada de ADH &#40;SIADH&#41;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a>&#46; La FEUa ayuda en el diagn&#243;stico diferencial del s&#237;ndrome pierde sal con el SIADH&#44; puesto que en el s&#237;ndrome pierde sal&#44; como ocurre en nuestro caso&#44; la FEUa es mayor del 11&#37; y no se corrige tras la normalizaci&#243;n de la natremia<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Aplicando el algoritmo de causalidad del Sistema Espa&#241;ol del Farmacovigilancia &#40;SEF&#41; en este caso&#44; es probable que el cuadro se trate de una reacci&#243;n adversa relacionada con el di&#243;xido de cloro al existir una secuencia temporal evidente entre su ingesta y la aparici&#243;n de la cl&#237;nica&#44; as&#237; como una resoluci&#243;n completa del mismo al suspender el agente&#44; aunque actualmente se desconoce el motivo por el cual el di&#243;xido de cloro puede causar hiponatremia&#44; debido a que su agente activo es el di&#243;xido de sodio&#44; podr&#237;a postularse como teor&#237;a una reacci&#243;n renal al exceso del agente activo&#44; clorito de sodio&#44; que provoque un aumento de p&#233;rdidas urinarias de sodio&#44; que mantenido en el tiempo derivan en una hiponatremia establecida de forma subaguda como ocurre en el caso descrito&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Consideramos relevante el caso descrito ante la necesidad de concienciar a la poblaci&#243;n de los diversos efectos adversos relacionados con esta sustancia&#44; y la nula evidencia que acredite el empleo de la misma en la prevenci&#243;n de infecci&#243;n SARS-CoV-2&#44; evitando as&#237; su consumo&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financiaci&#243;n</span><p id="par0055" class="elsevierStylePara elsevierViewall">No se ha recibido financiaci&#243;n por ninguna entidad financiadora&#46;</p></span></span>"
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                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3396367.png"
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        "descripcion" => array:1 [
          "es" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Evoluci&#243;n de par&#225;metros anal&#237;ticos</p>"
        ]
      ]
    ]
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      "titulo" => "Bibliograf&#237;a"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
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            0 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "1"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chlorine dioxide and chlorine derivatives for the prevention or treatment of COVID-19&#58; A systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46; Burela"
                            1 => "A&#46; Hern&#225;ndez-V&#225;squez"
                            2 => "D&#46; Comand&#233;"
                            3 => "V&#46; Peralta"
                            4 => "F&#46; Fiestas"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rev Per&#250; Med Exp Salud P&#250;blica"
                        "fecha" => "2020"
                        "volumen" => "37"
                        "paginaInicial" => "605"
                        "paginaFinal" => "610"
                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0055"
              "etiqueta" => "2"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Action modes of chlorine dioxide--a review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "M&#46; Wei"
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