1
|
Thach R, Gitto L. Neonatal sepsis due to Coxsackievirus B3 complicated by liver failure and pulmonary hemorrhage. CASE REPORTS IN PERINATAL MEDICINE 2022. [DOI: 10.1515/crpm-2021-0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
Coxsackievirus B3 (CVB3) is a single-stranded RNA included in the “Human Enterovirus B” category associated with multiple, even severe, health issues in humans. Newborns are at risk of life-threatening conditions due to enteroviral infections. In newborns, the infection can be transmitted vertically, intrapartum or postpartum, and potentially through breast milk. Neonatal sepsis may result in severe complications, such as liver failure and pulmonary hemorrhage, with subsequent death.
Case presentation
A male newborn was admitted to the emergency department with fever, generalized hypotonia, hypo-reactivity to external stimuli, multiple episodes of apnea and desaturation, and metabolic acidosis. Laboratory studies revealed disseminated intravascular coagulation, and evidence of progressive multiorgan failure. Polymerase chain reaction performed on specimens collected at the time of admission returned positive for Enterovirus, specifically Coxsackievirus B3 VP1 gene. The patient eventually succumbed after several days due to severe sepsis, despite aggressive treatment with immunoglobulins and Pleconaril. An autopsy revealed hemorrhage in the lung, liver, heart, and gastric mucosa.
Conclusions
Enteroviral neonatal infections should be included in the differential diagnosis of a newborn presenting with fever, failure to thrive, and hyporeactivity, especially if symptoms arise during the classic CVB3 season. Maternal medical history should be reviewed for any possible febrile symptoms associated with a recent enterovirus infection. Aggressive treatment with immunoglobulins and, if available, Pleconaril could effectively treat the infection.
Collapse
Affiliation(s)
- Rasmey Thach
- Department of Medicine , William Beaumont Army Medical Center , El paso , TX , USA
| | - Lorenzo Gitto
- Department of Pathology , State University of New York Upstate Medical University , Syracuse , USA
| |
Collapse
|
2
|
Welde MA, Sanford CB, Mangum M, Paschal C, Jnah AJ. Pulmonary Hemorrhage in the Neonate. Neonatal Netw 2021; 40:295-304. [PMID: 34518381 DOI: 10.1891/11-t-696] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2020] [Indexed: 11/25/2022]
Abstract
Pulmonary hemorrhage (PH) is a pathology associated with significant morbidity and mortality, particularly among preterm infants in the NICU. The diagnosis is made when hemorrhagic secretions are aspirated from the trachea concurrent with respiratory decompensation that necessitates intubation or escalated support. The implementation of mechanical ventilation and widespread exogenous surfactant administration have significantly reduced respiratory morbidities. However, when PH develops, death remains the most common outcome. Treatment for PH remains primarily supportive; thus, a thorough understanding of underlying disease processes, manifestations, diagnostic testing, and current evidence is vital to enable early identification and proactive management to reduce morbidity and mortality.
Collapse
|
3
|
Zaga-Clavellina V, Diaz L, Olmos-Ortiz A, Godínez-Rubí M, Rojas-Mayorquín AE, Ortuño-Sahagún D. Central role of the placenta during viral infection: Immuno-competences and miRNA defensive responses. Biochim Biophys Acta Mol Basis Dis 2021; 1867:166182. [PMID: 34058350 DOI: 10.1016/j.bbadis.2021.166182] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/04/2021] [Accepted: 05/19/2021] [Indexed: 12/21/2022]
Abstract
Pregnancy is a unique immunological condition in which an "immune-diplomatic" dialogue between trophoblasts and maternal immune cells is established to protect the fetus from rejection, to create a privileged environment in the uterus and to simultaneously be alert to any infectious challenge. The maternal-placental-fetal interface (MPFI) performs an essential role in this immunological defense. In this review, we will address the MPFI as an active immuno-mechanical barrier that protects against viral infections. We will describe the main viral infections affecting the placenta and trophoblasts and present their structure, mechanisms of immunocompetence and defensive responses to viral infections in pregnancy. In particular, we will analyze infection routes in the placenta and trophoblasts and the maternal-fetal outcomes in both. Finally, we will focus on the cellular targets of the antiviral microRNAs from the C19MC cluster, and their effects at both the intra- and extracellular level.
Collapse
Affiliation(s)
- Verónica Zaga-Clavellina
- Departamento de Fisiología y Desarrollo Celular, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes (INPer), Ciudad de México C.P. 11000, Mexico
| | - Lorenza Diaz
- Departamento de Biología de la Reproducción, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México C.P. 14080, Mexico
| | - Andrea Olmos-Ortiz
- Departamento de Inmunobioquímica, INPer, Ciudad de México C.P. 11000, Mexico
| | - Marisol Godínez-Rubí
- Laboratorio de Investigación en Patología, Departamento de Microbiología y Patología, CUCS, Universidad de Guadalajara, Guadalajara, Jalisco 44340, Mexico
| | - Argelia E Rojas-Mayorquín
- Departamento de Ciencias Ambientales, Universidad de Guadalajara, Centro Universitario de Ciencias Biológicas y Agropecuarias, Guadalajara 45200, Mexico
| | - Daniel Ortuño-Sahagún
- Laboratorio de Neuroinmunobiología Molecular, Instituto de Investigación en Ciencias Biomédicas (IICB) CUCS, Universidad de Guadalajara, Guadalajara, Jalisco 44340, Mexico.
| |
Collapse
|
4
|
Zhang M, Wang H, Tang J, He Y, Xiong T, Li W, Qu Y, Mu D. Clinical characteristics of severe neonatal enterovirus infection: a systematic review. BMC Pediatr 2021; 21:127. [PMID: 33722228 PMCID: PMC7958388 DOI: 10.1186/s12887-021-02599-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/05/2021] [Indexed: 12/25/2022] Open
Abstract
Background Enterovirus (EV) is a common cause of infection in neonates. Neonates are at high risk of enterovirus infection with serious clinical manifestations and high lethality. This review systematically summarized the clinical characteristics of neonates with severe enteroviral infection to provide evidence for the identification and treatment of severe neonatal EV infection. Methods PubMed, Embase, and Web of Science were searched for original studies on neonates with severe EV infections from January 1, 2000, to November 27, 2020. Two reviewers independently screened the literature, extracted the data, and performed a descriptive analysis. Results In total, 66 articles with 237 cases of severe neonatal enterovirus infection were included. All neonates developed severe complications. Among them, 46.0% neonates had hepatitis or coagulopathy, 37.1% had myocarditis, 11.0% had meningoencephalitis, and 5.9% had other complications such as hemophagocytic lymphohistiocytosis and pulmonary hemorrhage. The lethality rate of neonates with severe infection was 30.4%. The highest lethality rate was 38.6%, which was observed in neonates with myocarditis. In 70.5% neonates, the age at the onset of symptoms was less than 7 days. Coxsackievirus B infection was seen in 52.3% neonates. The most common symptoms included temperature abnormalities (127, 53.6%), rash (88, 37.1%), poor feeding (58, 24.5%), and respiratory symptoms (52, 21.9%). The main treatment included transfusion of empirical antibiotics (127, 53.6%), blood components (100, 42.2%), intravenous immunoglobulin (IVIG; 97, 40.9%), mechanical ventilation (51, 21.5%), and extracorporeal membrane oxygenation (ECMO; 43, 18.1%). Additionally, antiviral medications pleconaril (14, 5.9%) and pocapavir (3, 1.3%) were administered. Conclusions Lethality was high in neonates with severe enterovirus infection, especially in those complicated with myocarditis. The most common symptoms included temperature abnormalities, rash, and poor feeding. The chief supportive treatment consisted of transfusion of blood components, mechanical ventilation, and ECMO. Empirical antibiotics and IVIG were widely used. Antiviral medications included pocapavir and pleconaril; however, more clinical evidence regarding their efficacy is needed. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02599-y.
Collapse
Affiliation(s)
- Meng Zhang
- Department of Pediatrics, West China Second Hospital, Sichuan University, No. 20, Section 3, Renmin south road, Chengdu, 610041, China.,Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, 610041, China
| | - Haoran Wang
- Department of Clinical Medicine, Sichuan University, Chengdu, 610041, China
| | - Jun Tang
- Department of Pediatrics, West China Second Hospital, Sichuan University, No. 20, Section 3, Renmin south road, Chengdu, 610041, China. .,Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, 610041, China.
| | - Yang He
- Department of Pediatrics, West China Second Hospital, Sichuan University, No. 20, Section 3, Renmin south road, Chengdu, 610041, China.,Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, 610041, China
| | - Tao Xiong
- Department of Pediatrics, West China Second Hospital, Sichuan University, No. 20, Section 3, Renmin south road, Chengdu, 610041, China.,Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, 610041, China
| | - Wenxing Li
- Department of Pediatrics, West China Second Hospital, Sichuan University, No. 20, Section 3, Renmin south road, Chengdu, 610041, China.,Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, 610041, China
| | - Yi Qu
- Department of Pediatrics, West China Second Hospital, Sichuan University, No. 20, Section 3, Renmin south road, Chengdu, 610041, China.,Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, 610041, China
| | - Dezhi Mu
- Department of Pediatrics, West China Second Hospital, Sichuan University, No. 20, Section 3, Renmin south road, Chengdu, 610041, China.,Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, 610041, China
| |
Collapse
|
5
|
Shaff MS, Love CS, Schulz EV. Neonatal Enterovirus: A Case Report in a Term Infant Requiring Air Evacuation. Neonatal Netw 2020; 39:215-221. [PMID: 32675317 DOI: 10.1891/0730-0832.39.4.215] [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: 02/05/2020] [Indexed: 06/11/2023]
Abstract
Enterovirus infections in neonates have the potential to cause a cascade of devastating clinical complications that can lead to death. Because of vague maternal symptom presentations, the diagnosis may not be obvious to antepartum adult providers. Clinicians evaluating infants in the newborn nursery and following initial hospital discharge must be alert for this potential infection. Common newborn issues, such as hyperbilirubinemia and weight loss, may be early signs of a more life-threatening diagnosis. Enterovirus infections may be responsible for a continuum of critical diagnoses in the neonate. Utilization of viral panels during the initial rule-out sepsis evaluation may provide rapid diagnosis and, ultimately, earlier response times to devastating clinical symptoms. Antepartum history and presenting features of enteroviral infections warrant rapid diagnosis with viral polymerase chain reaction detection panels to potentially reduce antibiotic usage and inpatient length of stay. The purpose of this case report is to review risk factors, presentation, and management of neonatal enterovirus infections. As this infant was born in a remote setting and required air evacuation, the logistics of this transport are also discussed.
Collapse
|
6
|
Sarmirova S, Borsanyiova M, Benkoova B, Pospisilova M, Arumugam R, Berakova K, Gomolcak P, Reddy J, Bopegamage S. Pancreas of coxsackievirus-infected dams and their challenged pups: A complex issue. Virulence 2019; 10:207-221. [PMID: 30829107 PMCID: PMC6550550 DOI: 10.1080/21505594.2019.1589364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Enteroviral infections are frequent, often asymptomatic in humans and during gravidity. The present study is an extension of our previous investigations where we had shown pancreatitis in challenged pups of CVB4-E2-infected dams. Present investigation describes the effect of gestational infection with this virus on the pancreas of both dams and their challenged pups. Gravid CD1 outbred mice were orally infected with CVB4-E2 virus at different gestation times. Pups were challenged orally with the same virus after 25 days of birth. Organs were collected at selected intervals postinfection (p.i.), and replicating virus and viral-RNA copies were analyzed. Additional readouts included histopathology and immunohistochemical (IHC) analysis for localization and identification of Ly6G+ cells (neutrophils), CD11b+ cells (macrophages), and viral protein in pancreatic tissue sections of the infected dams and their challenged pups. Our results show the presence of replicating virus in the pancreas of infected dams and their challenged pups, with inflammation leading to chronic necrotizing pancreatitis and atrophy of pancreatic acini of the dams and their offspring. IHC analysis of the infiltrating cells showed pronounced Ly6G+ neutrophils in dams only, whereas CD11b+ macrophages were present in tissues of both, the pups and the dams. Time of infection during gravidity as well as the p.i. intervals when mice were sacrificed influenced the pancreatic pathophysiology in both groups. We conclude that coxsackievirus infection during pregnancy is a risk factor for chronic affliction of the exocrine tissue and could affect endocrine pancreas in the mother and child.
Collapse
Affiliation(s)
- Sona Sarmirova
- a Enterovirus Laboratory, Institute of Microbiology , Faculty of Medicine, Slovak Medical University , Bratislava , Slovak Republic
| | - Maria Borsanyiova
- a Enterovirus Laboratory, Institute of Microbiology , Faculty of Medicine, Slovak Medical University , Bratislava , Slovak Republic
| | - Brigita Benkoova
- a Enterovirus Laboratory, Institute of Microbiology , Faculty of Medicine, Slovak Medical University , Bratislava , Slovak Republic
| | - Michaela Pospisilova
- a Enterovirus Laboratory, Institute of Microbiology , Faculty of Medicine, Slovak Medical University , Bratislava , Slovak Republic
| | - Rajkumar Arumugam
- b School of Veterinary Medicine and Biomedical Sciences , University of Nebraska-Lincoln , Lincoln , NE , USA
| | | | - Pavol Gomolcak
- d Immunohistochemical Laboratory, Medical Laboratory Pathology and Cytology , Cytopathos, s.r.o , Bratislava , Slovak Republic
| | - Jay Reddy
- b School of Veterinary Medicine and Biomedical Sciences , University of Nebraska-Lincoln , Lincoln , NE , USA
| | - Shubhada Bopegamage
- a Enterovirus Laboratory, Institute of Microbiology , Faculty of Medicine, Slovak Medical University , Bratislava , Slovak Republic
| |
Collapse
|
7
|
Abstract
A case study of a 37 weeks' gestational age male infant, presenting with bloody fluid orally shortly after birth. The presentation, etiology, diagnosis, and management of pulmonary hemorrhage are addressed.
Collapse
|
8
|
Laitinen OH, Svedin E, Kapell S, Hankaniemi MM, Larsson PG, Domsgen E, Stone VM, Määttä JAE, Hyöty H, Hytönen VP, Flodström-Tullberg M. New Coxsackievirus 2A pro and 3C pro protease antibodies for virus detection and discovery of pathogenic mechanisms. J Virol Methods 2018; 255:29-37. [PMID: 29425680 DOI: 10.1016/j.jviromet.2018.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 02/01/2018] [Accepted: 02/01/2018] [Indexed: 12/16/2022]
Abstract
Enteroviruses (EVs), such as the Coxsackie B-viruses (CVBs), are common human pathogens, which can cause severe diseases including meningitis, myocarditis and neonatal sepsis. EVs encode two proteases (2Apro and 3Cpro), which perform the proteolytic cleavage of the CVB polyprotein and also cleave host cell proteins to facilitate viral replication. The 2Apro cause direct damage to the infected heart and tools to investigate 2Apro and 3Cpro expression may contribute new knowledge on virus-induced pathologies. Here, we developed new antibodies to CVB-encoded 2Apro and 3Cpro; Two monoclonal 2Apro antibodies and one 3Cpro antibody were produced. Using cells infected with selected viruses belonging to the EV A, B and C species and immunocytochemistry, we demonstrate that the 3Cpro antibody detects all of the EV species B (EV-B) viruses tested and that the 2Apro antibody detects all EV-B viruses apart from Echovirus 9. We furthermore show that the new antibodies work in Western blotting, immunocyto- and immunohistochemistry, and flow cytometry to detect CVBs. Confocal microscopy demonstrated the expression kinetics of 2Apro and 3Cpro, and revealed a preferential cytosolic localization of the proteases in CVB3 infected cells. In summary, the new antibodies detect proteases that belong to EV species B in cells and tissue using multiple applications.
Collapse
Affiliation(s)
- Olli H Laitinen
- The Center for Infectious Medicine, Department of Medicine HS, Karolinska Institutet, Karolinska University Hospital, Stockholm, 141 86, Sweden
| | - Emma Svedin
- The Center for Infectious Medicine, Department of Medicine HS, Karolinska Institutet, Karolinska University Hospital, Stockholm, 141 86, Sweden
| | - Sebastian Kapell
- The Center for Infectious Medicine, Department of Medicine HS, Karolinska Institutet, Karolinska University Hospital, Stockholm, 141 86, Sweden
| | - Minna M Hankaniemi
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, 33520, Finland; Fimlab Laboratories, 33520 Tampere, Finland
| | - Pär G Larsson
- The Center for Infectious Medicine, Department of Medicine HS, Karolinska Institutet, Karolinska University Hospital, Stockholm, 141 86, Sweden
| | - Erna Domsgen
- The Center for Infectious Medicine, Department of Medicine HS, Karolinska Institutet, Karolinska University Hospital, Stockholm, 141 86, Sweden
| | - Virginia M Stone
- The Center for Infectious Medicine, Department of Medicine HS, Karolinska Institutet, Karolinska University Hospital, Stockholm, 141 86, Sweden
| | - Juha A E Määttä
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, 33520, Finland; Fimlab Laboratories, 33520 Tampere, Finland
| | - Heikki Hyöty
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, 33520, Finland; Fimlab Laboratories, 33520 Tampere, Finland
| | - Vesa P Hytönen
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, 33520, Finland; Fimlab Laboratories, 33520 Tampere, Finland
| | - Malin Flodström-Tullberg
- The Center for Infectious Medicine, Department of Medicine HS, Karolinska Institutet, Karolinska University Hospital, Stockholm, 141 86, Sweden; Faculty of Medicine and Life Sciences, University of Tampere, Tampere, 33520, Finland.
| |
Collapse
|
9
|
Hankaniemi MM, Laitinen OH, Stone VM, Sioofy-Khojine A, Määttä JAE, Larsson PG, Marjomäki V, Hyöty H, Flodström-Tullberg M, Hytönen VP. Optimized production and purification of Coxsackievirus B1 vaccine and its preclinical evaluation in a mouse model. Vaccine 2017; 35:3718-3725. [PMID: 28579231 DOI: 10.1016/j.vaccine.2017.05.057] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/19/2017] [Accepted: 05/20/2017] [Indexed: 10/19/2022]
Abstract
Coxsackie B viruses are among the most common enteroviruses, causing a wide range of diseases. Recent studies have also suggested that they may contribute to the development of type 1 diabetes. Vaccination would provide an effective way to prevent CVB infections, and the objective of this study was to develop an efficient vaccine production protocol for the generation of novel CVB vaccines. Various steps in the production of a formalin-inactivated Coxsackievirus B1 (CVB1) vaccine were optimized including the Multiplicity Of Infection (MOI) used for virus amplification, virus cultivation time, type of cell growth medium, virus purification method and formulation of the purified virus. Safety and immunogenicity of the formalin inactivated CVB1 vaccine was characterized in a mouse model. Two of the developed methods were found to be optimal for virus purification: the first employed PEG-precipitation followed by gelatin-chromatography and sucrose cushion pelleting (three-step protocol), yielding 19-fold increase in virus concentration (0.06µg/cm2) as compared to gold standard method. The second method utilized tandem sucrose pelleting without a PEG precipitation step, yielding 83-fold increase in virus concentration (0.24µg/cm2), but it was more labor-intensive and cannot be efficiently scaled up. Both protocols provide radically higher virus yields compared with traditional virus purification protocols involving PEG-precipitation and sucrose gradient ultracentrifugation. Formalin inactivation of CVB1 produced a vaccine that induced a strong, virus-neutralizing antibody response in vaccinated mice, which protected against challenge with CVB1 virus. Altogether, these results provide valuable information for the development of new enterovirus vaccines.
Collapse
Affiliation(s)
- Minna M Hankaniemi
- Faculty of Medicine and Life Sciences, University of Tampere, FI-33520 Tampere, Finland; Fimlab Laboratories, FI-33520 Tampere, Finland
| | - Olli H Laitinen
- Faculty of Medicine and Life Sciences, University of Tampere, FI-33520 Tampere, Finland; Fimlab Laboratories, FI-33520 Tampere, Finland
| | - Virginia M Stone
- Faculty of Medicine and Life Sciences, University of Tampere, FI-33520 Tampere, Finland; The Center for Infectious Medicine, Department of Medicine HS, Karolinska Institutet, Karolinska University Hospital Huddinge, F59, SE-141 86 Stockholm, Sweden
| | - Amirbabak Sioofy-Khojine
- Faculty of Medicine and Life Sciences, University of Tampere, FI-33520 Tampere, Finland; Fimlab Laboratories, FI-33520 Tampere, Finland
| | - Juha A E Määttä
- Faculty of Medicine and Life Sciences, University of Tampere, FI-33520 Tampere, Finland; Fimlab Laboratories, FI-33520 Tampere, Finland
| | - Pär G Larsson
- The Center for Infectious Medicine, Department of Medicine HS, Karolinska Institutet, Karolinska University Hospital Huddinge, F59, SE-141 86 Stockholm, Sweden
| | - Varpu Marjomäki
- Department of Biological and Environmental Science/Nanoscience Center, University of Jyväskylä, P.O. Box 35, FI-40014 University of Jyväskylä, Finland
| | - Heikki Hyöty
- Faculty of Medicine and Life Sciences, University of Tampere, FI-33520 Tampere, Finland; Fimlab Laboratories, FI-33520 Tampere, Finland
| | - Malin Flodström-Tullberg
- Faculty of Medicine and Life Sciences, University of Tampere, FI-33520 Tampere, Finland; The Center for Infectious Medicine, Department of Medicine HS, Karolinska Institutet, Karolinska University Hospital Huddinge, F59, SE-141 86 Stockholm, Sweden
| | - Vesa P Hytönen
- Faculty of Medicine and Life Sciences, University of Tampere, FI-33520 Tampere, Finland; Fimlab Laboratories, FI-33520 Tampere, Finland.
| |
Collapse
|