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Ruffer N, Kosch R, Weisel K, Kötter I, Krusche M. [Hemophagocytic lymphohistiocytosis and macrophage activation syndrome : A multidisciplinary challenge]. Z Rheumatol 2024; 83:376-386. [PMID: 38267764 DOI: 10.1007/s00393-023-01472-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 01/26/2024]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome that is characterized by hyperferritinemia, cytopenia, disseminated intravascular coagulopathy and functional disorders of the liver and the central nervous system. The term macrophage activation syndrome is predominantly used for secondary HLH in the context of autoimmune diseases (e.g., systemic juvenile idiopathic arthritis). In addition, malignancies and genetic inborn errors of immunity can predispose to the development of HLH. Infections (e.g., Epstein-Barr virus) in turn represent possible triggers of an acute episode. Due to the unspecific manifestation of the disease, a systematic evaluation of the organ systems is recommended in the clinical and laboratory analytical clarification of hyperinflammatory syndromes. In general, the treatment should be carried out by a multidisciplinary team with expertise in rheumatology, hematological oncology, infectious diseases and intensive care medicine. The primary treatment of HLH usually consists of glucocorticoids and in cases of a rapid deterioration of the condition anakinra (interleukin 1 block) and intravenous immunoglobulins can be employed. Treatment of the underlying disease should be consequently carried out in parallel, together with antimicrobial treatment.
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Affiliation(s)
- Nikolas Ruffer
- Sektion Rheumatologie und entzündliche Systemerkrankungen, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Ricardo Kosch
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Katja Weisel
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Ina Kötter
- Sektion Rheumatologie und entzündliche Systemerkrankungen, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Martin Krusche
- Sektion Rheumatologie und entzündliche Systemerkrankungen, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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Tulling AJ, Holierhoek MG, Jansen-Hoogendijk AM, Hoste L, Haerynck F, Tavernier SJ, Oostenbrink R, Buysse CMP, Bannier MAGE, Bekhof J, Breukels M, Hammer SC, Jacobs MAM, Kamps AWA, van der Linden JW, Lebon A, Oudshoorn JH, Tramper-Stranders GA, Vastert SJ, Wieringa JW, Terheggen-Lagro SWJ, Wildenbeest JG, von Asmuth EGJ, van den Akker EB, van Gijn ME, Lugthart G, Buddingh EP. Serum proteomics reveals hemophagocytic lymphohistiocytosis-like phenotype in a subset of patients with multisystem inflammatory syndrome in children. Clin Immunol 2024; 264:110252. [PMID: 38744408 DOI: 10.1016/j.clim.2024.110252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/10/2024] [Accepted: 05/10/2024] [Indexed: 05/16/2024]
Abstract
Children with Multisystem Inflammatory Syndrome in Children (MIS-C) can present with thrombocytopenia, which is a key feature of hemophagocytic lymphohistiocytosis (HLH). We hypothesized that thrombocytopenic MIS-C patients have more features of HLH. Clinical characteristics and routine laboratory parameters were collected from 228 MIS-C patients, of whom 85 (37%) were thrombocytopenic. Thrombocytopenic patients had increased ferritin levels; reduced leukocyte subsets; and elevated levels of ASAT and ALAT. Soluble IL-2RA was higher in thrombocytopenic children than in non-thrombocytopenic children. T-cell activation, TNF-alpha and IFN-gamma signaling markers were inversely correlated with thrombocyte levels, consistent with a more pronounced cytokine storm syndrome. Thrombocytopenia was not associated with severity of MIS-C and no pathogenic variants were identified in HLH-related genes. This suggests that thrombocytopenia in MIS-C is not a feature of a more severe disease phenotype, but the consequence of a distinct hyperinflammatory immunopathological process in a subset of children.
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Affiliation(s)
- Adam J Tulling
- Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, the Netherlands
| | - Marloes G Holierhoek
- Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Levi Hoste
- Primary Immunodeficiency Research Lab (PIRL), Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium; Center for Primary Immunodeficiency, Jeffrey Modell Diagnosis and Research Center, Ghent University Hospital, Ghent, Belgium
| | - Filomeen Haerynck
- Primary Immunodeficiency Research Lab (PIRL), Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium; Center for Primary Immunodeficiency, Jeffrey Modell Diagnosis and Research Center, Ghent University Hospital, Ghent, Belgium
| | - Simon J Tavernier
- Primary Immunodeficiency Research Lab (PIRL), Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium; Center for Primary Immunodeficiency, Jeffrey Modell Diagnosis and Research Center, Ghent University Hospital, Ghent, Belgium
| | - Rianne Oostenbrink
- Department of General Pediatrics, Sophia Children's Hospital, Erasmus MC, Rotterdam, the Netherlands
| | - Corinne M P Buysse
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Michiel A G E Bannier
- Department of Pediatrics, MosaKids Children's Hospital, University Medical Center Maastricht, Maastricht, the Netherlands
| | - Jolita Bekhof
- Department of Pediatrics, Isala Hospital, Zwolle, the Netherlands
| | - Mijke Breukels
- Department of Pediatrics, Elkerliek Hospital, Helmond, the Netherlands
| | - Sanne C Hammer
- Department of Pediatrics, Amphia Hospital, Breda, the Netherlands
| | - Monique A M Jacobs
- Department of Pediatrics, Slingeland Hospital, Doetinchem, the Netherlands
| | - Arvid W A Kamps
- Department of Pediatrics, Martini Hospital, Groningen, the Netherlands
| | | | - Ankie Lebon
- Department of Pediatrics, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | | | | | - Sebastiaan J Vastert
- Department of Pediatric Rheumatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jantien W Wieringa
- Department of Pediatrics, Haaglanden Medical Center, the Hague, the Netherlands
| | - Suzanne W J Terheggen-Lagro
- Department of Pediatric Pulmonology and Allergy, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Joanne G Wildenbeest
- Department of Pediatric Infectious Diseases, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Erik G J von Asmuth
- Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, the Netherlands
| | - Erik B van den Akker
- Leiden Computational Biology Center, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands; The Delft Bioinformatics Lab, Pattern Recognition & Bioinformatics, Delft University of Technology, Delft, the Netherlands
| | - Marielle E van Gijn
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Gertjan Lugthart
- Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, the Netherlands
| | - Emilie P Buddingh
- Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, the Netherlands.
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Marques MC, Rubin D, Shuldiner E, Datta M, Schmitz E, Cruz GG, Patt A, Bennett E, Grom A, Foell D, Gattorno M, Bohnsack J, Yeung RSM, Prahalad S, Mellins E, Anton J, Len CA, Oliveira S, Woo P, Ozen S, Deng Z, Ombrello MJ. Enrichment of Rare Variants of Hemophagocytic Lymphohistiocytosis Genes in Systemic Juvenile Idiopathic Arthritis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.13.24304215. [PMID: 38529491 PMCID: PMC10962746 DOI: 10.1101/2024.03.13.24304215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
Objective To evaluate whether there is an enrichment of rare variants in familial hemophagocytic lymphohistiocytosis (HLH) genes and systemic juvenile idiopathic arthritis (sJIA) with or without macrophage activation syndrome (MAS). Methods Targeted sequencing of HLH genes (LYST, PRF1, RAB27A, STX11, STXBP2, UNC13D) was performed in sJIA subjects from an established cohort. Sequence data from control subjects were obtained in silico (dbGaP:phs000280.v8.p2). Rare variant association testing (RVT) was performed with sequence kernel association test (SKAT) package. Significance was defined as p<0.05 after 100,000 permutations. Results Sequencing data from 524 sJIA cases were jointly called and harmonized with exome-derived target data from 3000 controls. Quality control operations produced a set of 481 cases and 2924 ancestrally-matched control subjects. RVT of sJIA cases and controls revealed a significant association with rare protein-altering variants (minor allele frequency [MAF]<0.01) of STXBP2 (p=0.020), and ultra-rare variants (MAF<0.001) of STXBP2 (p=0.007) and UNC13D (p=0.045). A subanalysis of 32 cases with known MAS and 90 without revealed significant association of rare UNC13D variants (p=0.0047). Additionally, sJIA patients more often carried ≥2 HLH variants than did controls (p=0.007), driven largely by digenic combinations involving LYST. Conclusion We identified an enrichment of rare HLH variants in sJIA patients compared with healthy controls, driven by STXBP2 and UNC13D. Biallelic variation in HLH genes was associated with sJIA, driven by LYST. Only UNC13D displayed enrichment in patients with MAS. This suggests that HLH variants may contribute to the pathophysiology of sJIA, even without MAS.
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Affiliation(s)
- Mariana Correia Marques
- Translational Genetics and Genomics Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, USA
| | - Danielle Rubin
- Translational Genetics and Genomics Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, USA
| | - Emily Shuldiner
- Translational Genetics and Genomics Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, USA
| | - Mallika Datta
- Translational Genetics and Genomics Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, USA
| | - Elizabeth Schmitz
- Translational Genetics and Genomics Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, USA
| | - Gustavo Gutierrez Cruz
- Genomic Technology Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, USA
| | - Andrew Patt
- Translational Genetics and Genomics Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, USA
| | - Elizabeth Bennett
- Translational Genetics and Genomics Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, USA
| | - Alexei Grom
- Rheumatology, Cincinnati Children`s Hospital Medical Center, Cincinnati, USA
| | - Dirk Foell
- Department of Pediatric Rheumatology and Immunology, University Hospital Muenster, Muenster, Germany
| | - Marco Gattorno
- Unit Rheumatology and Autoinflammatory Diseases, IRCCS Istituto G. Gaslini, Genoa, Italy
| | - John Bohnsack
- Department of Pediatrics, University of Utah Eccles School of Medicine, Salt Lake City, USA
| | - Rae S M Yeung
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Sampath Prahalad
- Emory University school of Medicine, Atlanta, USA
- Children's Healthcare of Atlanta, Atlanta, USA
| | - Elizabeth Mellins
- Department of Pediatrics, Program in Immunology, Stanford University, Stanford, USA
| | - Jordi Anton
- Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | | | - Sheila Oliveira
- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Seza Ozen
- Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Zuoming Deng
- Biodata Mining and Discovery Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, USA
| | - Michael J Ombrello
- Translational Genetics and Genomics Section, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, USA
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Stadermann A, Haar M, Riecke A, Mayer T, Neumann C, Bauer A, Schulz A, Nagarathinam K, Gebauer N, Böhm S, Groß M, Grunert M, Müller M, Witte H. Late Onset of Primary Hemophagocytic Lymphohistiocytosis (HLH) with a Novel Constellation of Compound Heterozygosity Involving Two Missense Variants in the PRF1 Gene. Int J Mol Sci 2024; 25:2762. [PMID: 38474010 DOI: 10.3390/ijms25052762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 02/12/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare but in most cases life-threatening immune-mediated disease of the hematopoietic system frequently associated with hematologic neoplasms. Here, we report on a case in which we detected a novel constellation of two missense variants affecting the PRF1 gene, leading to de novo primary HLH. Diagnostics included a comprehensive clinical work-up and standard methods of hematopathology as well as extended molecular genomics based on polymerase chain reaction (PCR) reactions and the calculation of three-dimensional molecule reconstructions of PRF1. Subsequently, a comprehensive review of the literature was performed, which showed that this compound heterozygosity has not been previously described. The patient was a 20-year-old female. Molecular diagnostics revealed two heterozygous missense variants in the PRF1 gene (A91V and R104C) on exon 2. Apart from the finding of two inconclusive genetic variants, all clinical criteria defined by the HLH study group of Histiocyte Society were met at initial presentation. The final diagnosis was made in cooperation with the Consortium of German HLH-reference centers. Here, chemotherapy did not lead to sufficient sustained disease control. Therefore, the decision for allogenic hematopoietic stem cell transplantation (alloHSCT) was made. Hitherto, the duration of response was 6 months. Due to severe and unmanageable hepatic graft-versus-host disease (GvHD), the patient died. We report on a novel constellation of a compound heterozygosity containing two missense variants on exon 2 of the PRF1 gene. To the authors' best knowledge, this is the first presentation of a primary HLH case harboring this genomic constellation with late-onset clinical manifestation.
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Affiliation(s)
- Alina Stadermann
- Department of Hematology and Oncology, Bundeswehrkrankemhaus Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Markus Haar
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251 Hamburg, Germany
| | - Armin Riecke
- Department of Hematology and Oncology, Bundeswehrkrankemhaus Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Thomas Mayer
- Department of Hematology and Oncology, Bundeswehrkrankemhaus Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Christian Neumann
- Department of Hematology and Oncology, Bundeswehrkrankemhaus Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Arthur Bauer
- Department of Hematology and Oncology, Bundeswehrkrankemhaus Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Ansgar Schulz
- Department of Pediatric Medicine, University Hospital Ulm, Eythstraße 24, 89075 Ulm, Germany
| | - Kumar Nagarathinam
- Institute of Biochemistry, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Niklas Gebauer
- Department of Hematology and Oncology, University Hospital Schleswig-Holstein Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Svea Böhm
- Institute for Immunodeficiency, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 115, 79106 Freiburg, Germany
- Division of Pediatric Stem Cell Transplantation and Immunology, Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Miriam Groß
- Institute for Immunodeficiency, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 115, 79106 Freiburg, Germany
| | - Michael Grunert
- Department of Nuclear Medicine, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
- Department of Nuclear Medicine, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Matthias Müller
- Department of Hematology and Oncology, Bundeswehrkrankemhaus Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Hanno Witte
- Department of Hematology and Oncology, Bundeswehrkrankemhaus Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
- Department of Hematology and Oncology, University Hospital Schleswig-Holstein Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
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Khan R, Ji W, Guzman-Rivera J, Madhvi A, Andrews T, Richlin B, Suarez C, Gaur S, Cuddy W, Singh AR, Bukulmez H, Kaelber D, Kimura Y, Ganapathi U, Michailidis IE, Ukey R, Moroso-Fela S, Kuster JK, Casseus M, Roy J, Kleinman LC, Horton DB, Lakhani SA, Gennaro ML. A genetically modulated Toll-like-receptor-tolerant phenotype in peripheral blood cells of children with multisystem inflammatory syndrome. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.02.24301686. [PMID: 38370700 PMCID: PMC10871447 DOI: 10.1101/2024.02.02.24301686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
Dysregulated innate immune responses contribute to multisystem inflammatory syndrome in children (MIS-C), characterized by gastrointestinal, mucocutaneous, and/or cardiovascular injury occurring weeks after SARS-CoV-2 exposure. To investigate innate immune functions in MIS-C, we stimulated ex vivo peripheral blood cells from MIS-C patients with agonists of Toll-like receptors (TLR), key innate immune response initiators. We found severely dampened cytokine responses and elevated gene expression of negative regulators of TLR signaling. Increased plasma levels of zonulin, a gut leakage marker, were also detected. These effects were also observed in children enrolled months after MIS-C recovery. Moreover, cells from MIS-C children carrying rare genetic variants of lysosomal trafficking regulator (LYST) were less refractory to TLR stimulation and exhibited lysosomal and mitochondrial abnormalities with altered energy metabolism. Our results strongly suggest that MIS-C hyperinflammation and/or excessive or prolonged stimulation with gut-originated TLR ligands drive immune cells to a lasting refractory state. TLR hyporesponsiveness is likely beneficial, as suggested by excess lymphopenia among rare LYST variant carriers. Our findings point to cellular mechanisms underlying TLR hyporesponsiveness; identify genetic determinants that may explain the MIS-C clinical spectrum; suggest potential associations between innate refractory states and long COVID; and highlight the need to monitor long-term consequences of MIS-C.
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Affiliation(s)
- Rehan Khan
- Public Health Research Institute, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, NJ
| | - Weizhen Ji
- Pediatric Genomics Discovery Program, Department of Pediatrics, Yale University School of Medicine, New Haven, CT 06510
| | - Jeisac Guzman-Rivera
- Public Health Research Institute, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, NJ
| | - Abhilasha Madhvi
- Public Health Research Institute, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, NJ
| | - Tracy Andrews
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ
| | - Benjamin Richlin
- Pediatric Clinical Research Center, and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Christian Suarez
- Pediatric Clinical Research Center, and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Sunanda Gaur
- Department of Pediatrics, Clinical Research Center, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Aalok R Singh
- Maria Fareri Children's Hospital, Valhalla, NY
- New York Medical College, Valhalla, NY
| | - Hulya Bukulmez
- Department of Pediatrics, Division of Rheumatology, MetroHealth System, Cleveland OH
| | - David Kaelber
- Department of Pediatrics, Division of Rheumatology, MetroHealth System, Cleveland OH
- Center for Clinical Informatics Research and Education, MetroHealth System, Cleveland OH
- Department of Internal Medicine, Pediatrics, and Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland OH
| | - Yukiko Kimura
- Hackensack University Medical Center, Hackensack Meridian School of Medicine, Nutley, NJ
| | - Usha Ganapathi
- Public Health Research Institute, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, NJ
| | - Ioannis E Michailidis
- Public Health Research Institute, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, NJ
| | - Rahul Ukey
- Public Health Research Institute, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, NJ
| | - Sandra Moroso-Fela
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - John K Kuster
- Pediatric Genomics Discovery Program, Department of Pediatrics, Yale University School of Medicine, New Haven, CT 06510
| | - Myriam Casseus
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Jason Roy
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ
| | - Lawrence C Kleinman
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Department of Global Urban Health, Rutgers School of Public Health, Piscataway, NJ
| | - Daniel B Horton
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, NJ
| | - Saquib A Lakhani
- Pediatric Genomics Discovery Program, Department of Pediatrics, Yale University School of Medicine, New Haven, CT 06510
| | - Maria Laura Gennaro
- Public Health Research Institute, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, NJ
- Department of Medicine, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, NJ
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