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Wang Z, Zhang Y, Li G, Huang L, Chen J. Dedicator of cytokinesis 8 deficiency and hyperimmunoglobulin E syndrome: A case report. Medicine (Baltimore) 2022; 101:e28807. [PMID: 35119052 PMCID: PMC8812656 DOI: 10.1097/md.0000000000028807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Hyperimmunoglobulin E syndrome (HIES) is a rare and complex immunoregulatory multisystem disorder characterized by recurrent eczema, skin and sinopulmonary infections, elevated serum immunoglobulin E levels, and eosinophilia. Onset is most likely in childhood, although infrequent adult cases have been reported. Early diagnosis is important. The use of the National Institutes of Health scoring system and the HIES signal transducer and activation of transcription 3 score can standardize the diagnosis of HIES. PATIENT CONCERNS A 19-year-old woman presented with complaints of dry cough, pyrexia, dyspnea, and recurrent pneumonia. She had a history of milk allergy, recurrent eczema, suppurative otitis media, chalazia, and aphthous ulcers. Her parents had a consanguineous marriage. DIAGNOSIS HIES; severe pneumonia. INTERVENTIONS Voriconazole (200 mg iv 2 times/d) and flucytosine (1 g orally 4 times/d) for 3 weeks were administered, followed by oral administration of fluconazole for 3 weeks. OUTCOMES The patient experienced near-complete remission of her respiratory symptoms. The patient was followed-up for one and a half years. During the follow-up, the patient presented again with cough and dyspnea and was again admitted to hospital. After being hospitalized for 3 weeks of antibiotic treatment, the patient experienced near-complete relief of her respiratory symptoms. LESSONS Regardless of patient age, it is important to consider the possibility of HIES when a patient has recurrent eczema, skin and sinopulmonary infections, elevated serum immunoglobulin E levels, and eosinophilia. Early diagnosis and intervention are essential to improve prognosis.
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Affiliation(s)
- Zhaojun Wang
- Department of Pulmonary and Critical care Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
- Department of Critical Care Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Yanan Zhang
- Department of Pulmonary and Critical care Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Gang Li
- Central of Medical Laboratory, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Lingyan Huang
- Department of Pathology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
| | - Juan Chen
- Department of Pulmonary and Critical care Medicine, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
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Fang J, Yang Q, Pi B. Delayed diagnosis of hyperimmunoglobulin E syndrome with STAT3 mutation in mainland China: a case report and literature review. J Int Med Res 2021; 49:3000605211008073. [PMID: 33900869 PMCID: PMC8755649 DOI: 10.1177/03000605211008073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Hyperimmunoglobulin E syndrome (HIES) is a rare immunologic disorder. Typical clinical features of HIES include recurrent bacterial pneumonia, lung cysts, characteristic facial features, and newborn dermatitis. The varied clinical presentation can lead to a delayed diagnosis. We herein present a sporadic case of HIES in a man who initially presented with a longstanding history of intractable skin abscesses.
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Affiliation(s)
- Jiazhui Fang
- Department of Liver and Infectious Diseases, Sir Run Run Shaw Hospital, Hangzhou, China
| | - Qiao Yang
- Department of Liver and Infectious Diseases, Sir Run Run Shaw Hospital, Hangzhou, China
| | - Borui Pi
- Department of Liver and Infectious Diseases, Sir Run Run Shaw Hospital, Hangzhou, China
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Zhao R, Wang C, Sun C, Jiang K, Wu S, Pan F, Zeng Z, Hu Y, Dong X. A Novel STAT3 Mutation in a Patient with Hyper-IgE Syndrome Diagnosed with a Severe Necrotizing Pulmonary Infection. J Asthma Allergy 2021; 14:219-227. [PMID: 33737815 PMCID: PMC7966388 DOI: 10.2147/jaa.s295516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/05/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Autosomal dominant hyper-IgE syndrome (HIES) is a rare primary immune deficiency syndrome caused mainly by mutations in the signal transducer and activator of transcription 3 (STAT3) gene. More information on STAT3 mutations is still needed, and further investigation is warranted. A girl with HIES carrying a novel STAT3 mutation who had no obvious apparent symptoms but presented with a severe necrotizing pulmonary infection is described here. We analysed dynamic changes in blood cells and a series of inflammatory factors in the bronchoalveolar lavage fluid (BALF) before and after each bronchoscopic lavage to relieve her severe pulmonary abscess. Patients and Methods Whole-exome sequencing and Sanger sequencing were used to identify novel STAT3 mutations. Flow cytometry was used for immune analysis of Th17 cells and inflammatory cytokines. Results A novel de novo mutation in STAT3 (c.1552C>T, p.Arg518*) was identified in this patient. The number of eosinophils decreased after each bronchoscopy procedure. Elevated interleukin (IL)-8 and IL-1β levels were detected in her right lung BALF in the acute phase, but they were reduced after four bronchoscopic lavage procedures and the administration of antimicrobial medicine. Conclusion More information on STAT3 mutations is needed to investigate the relationship between the genotype and HIES phenotype. Bronchoscopic lavages are recommended instead of surgery to relieve acute severe pulmonary abscesses and necrotizing pulmonary infections in paediatric patients with HIES.
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Affiliation(s)
- Ran Zhao
- Department of Respiratory, Shanghai Children's Hospital, Shanghai Jiaotong University, Shanghai, 200062, People's Republic of China
| | - Chao Wang
- Department of Respiratory, Shanghai Children's Hospital, Shanghai Jiaotong University, Shanghai, 200062, People's Republic of China
| | - Chao Sun
- Department of Respiratory, Shanghai Children's Hospital, Shanghai Jiaotong University, Shanghai, 200062, People's Republic of China
| | - Kun Jiang
- Department of Respiratory, Shanghai Children's Hospital, Shanghai Jiaotong University, Shanghai, 200062, People's Republic of China
| | - Shengnan Wu
- Clinical Laboratory of Shanghai Children's Hospital, Shanghai Jiaotong University, Shanghai, 200062, People's Republic of China
| | - Fen Pan
- Clinical Laboratory of Shanghai Children's Hospital, Shanghai Jiaotong University, Shanghai, 200062, People's Republic of China
| | - Zeyu Zeng
- Department of Respiratory, Shanghai Children's Hospital, Shanghai Jiaotong University, Shanghai, 200062, People's Republic of China
| | - Yijing Hu
- Department of Respiratory, Shanghai Children's Hospital, Shanghai Jiaotong University, Shanghai, 200062, People's Republic of China
| | - Xiaoyan Dong
- Department of Respiratory, Shanghai Children's Hospital, Shanghai Jiaotong University, Shanghai, 200062, People's Republic of China
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Zhu X, Zhu J. CD4 T Helper Cell Subsets and Related Human Immunological Disorders. Int J Mol Sci 2020; 21:E8011. [PMID: 33126494 PMCID: PMC7663252 DOI: 10.3390/ijms21218011] [Citation(s) in RCA: 120] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/24/2020] [Accepted: 10/26/2020] [Indexed: 02/07/2023] Open
Abstract
The immune system plays a critical role in protecting hosts from the invasion of organisms. CD4 T cells, as a key component of the immune system, are central in orchestrating adaptive immune responses. After decades of investigation, five major CD4 T helper cell (Th) subsets have been identified: Th1, Th2, Th17, Treg (T regulatory), and Tfh (follicular T helper) cells. Th1 cells, defined by the expression of lineage cytokine interferon (IFN)-γ and the master transcription factor T-bet, participate in type 1 immune responses to intracellular pathogens such as mycobacterial species and viruses; Th2 cells, defined by the expression of lineage cytokines interleukin (IL)-4/IL-5/IL-13 and the master transcription factor GAΤA3, participate in type 2 immune responses to larger extracellular pathogens such as helminths; Th17 cells, defined by the expression of lineage cytokines IL-17/IL-22 and the master transcription factor RORγt, participate in type 3 immune responses to extracellular pathogens including some bacteria and fungi; Tfh cells, by producing IL-21 and expressing Bcl6, help B cells produce corresponding antibodies; whereas Foxp3-expressing Treg cells, unlike Th1/Th2/Th17/Tfh exerting their effector functions, regulate immune responses to maintain immune cell homeostasis and prevent immunopathology. Interestingly, innate lymphoid cells (ILCs) have been found to mimic the functions of three major effector CD4 T helper subsets (Th1, Th2, and Th17) and thus can also be divided into three major subsets: ILC1s, ILC2s, and ILC3s. In this review, we will discuss the differentiation and functions of each CD4 T helper cell subset in the context of ILCs and human diseases associated with the dysregulation of these lymphocyte subsets particularly caused by monogenic mutations.
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Affiliation(s)
- Xiaoliang Zhu
- Molecular and Cellular Immunoregulation Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Jinfang Zhu
- Molecular and Cellular Immunoregulation Section, Laboratory of Immune System Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
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Matsuyama T, Kubli SP, Yoshinaga SK, Pfeffer K, Mak TW. An aberrant STAT pathway is central to COVID-19. Cell Death Differ 2020. [PMID: 33037393 DOI: 10.1038/s41418‐020‐00633‐7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
COVID-19 is caused by SARS-CoV-2 infection and characterized by diverse clinical symptoms. Type I interferon (IFN-I) production is impaired and severe cases lead to ARDS and widespread coagulopathy. We propose that COVID-19 pathophysiology is initiated by SARS-CoV-2 gene products, the NSP1 and ORF6 proteins, leading to a catastrophic cascade of failures. These viral components induce signal transducer and activator of transcription 1 (STAT1) dysfunction and compensatory hyperactivation of STAT3. In SARS-CoV-2-infected cells, a positive feedback loop established between STAT3 and plasminogen activator inhibitor-1 (PAI-1) may lead to an escalating cycle of activation in common with the interdependent signaling networks affected in COVID-19. Specifically, PAI-1 upregulation leads to coagulopathy characterized by intravascular thrombi. Overproduced PAI-1 binds to TLR4 on macrophages, inducing the secretion of proinflammatory cytokines and chemokines. The recruitment and subsequent activation of innate immune cells within an infected lung drives the destruction of lung architecture, which leads to the infection of regional endothelial cells and produces a hypoxic environment that further stimulates PAI-1 production. Acute lung injury also activates EGFR and leads to the phosphorylation of STAT3. COVID-19 patients' autopsies frequently exhibit diffuse alveolar damage (DAD) and increased hyaluronan (HA) production which also leads to higher levels of PAI-1. COVID-19 risk factors are consistent with this scenario, as PAI-1 levels are increased in hypertension, obesity, diabetes, cardiovascular diseases, and old age. We discuss the possibility of using various approved drugs, or drugs currently in clinical development, to treat COVID-19. This perspective suggests to enhance STAT1 activity and/or inhibit STAT3 functions for COVID-19 treatment. This might derail the escalating STAT3/PAI-1 cycle central to COVID-19.
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Affiliation(s)
- Toshifumi Matsuyama
- Department of Pathology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shawn P Kubli
- Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | | | - Klaus Pfeffer
- Institute of Medical Microbiology and Hospital Hygiene, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Tak W Mak
- Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada. .,Department of Medical Biophysics and Department of Immunology, University of Toronto, 101 College Street, Toronto, ON, M5G 1L7, Canada. .,Department of Medicine, University of Hong Kong, Pok Fu Lam, 999077, Hong Kong.
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An aberrant STAT pathway is central to COVID-19. Cell Death Differ 2020; 27:3209-3225. [PMID: 33037393 PMCID: PMC7545020 DOI: 10.1038/s41418-020-00633-7] [Citation(s) in RCA: 193] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/20/2020] [Accepted: 09/24/2020] [Indexed: 02/07/2023] Open
Abstract
COVID-19 is caused by SARS-CoV-2 infection and characterized by diverse clinical symptoms. Type I interferon (IFN-I) production is impaired and severe cases lead to ARDS and widespread coagulopathy. We propose that COVID-19 pathophysiology is initiated by SARS-CoV-2 gene products, the NSP1 and ORF6 proteins, leading to a catastrophic cascade of failures. These viral components induce signal transducer and activator of transcription 1 (STAT1) dysfunction and compensatory hyperactivation of STAT3. In SARS-CoV-2-infected cells, a positive feedback loop established between STAT3 and plasminogen activator inhibitor-1 (PAI-1) may lead to an escalating cycle of activation in common with the interdependent signaling networks affected in COVID-19. Specifically, PAI-1 upregulation leads to coagulopathy characterized by intravascular thrombi. Overproduced PAI-1 binds to TLR4 on macrophages, inducing the secretion of proinflammatory cytokines and chemokines. The recruitment and subsequent activation of innate immune cells within an infected lung drives the destruction of lung architecture, which leads to the infection of regional endothelial cells and produces a hypoxic environment that further stimulates PAI-1 production. Acute lung injury also activates EGFR and leads to the phosphorylation of STAT3. COVID-19 patients' autopsies frequently exhibit diffuse alveolar damage (DAD) and increased hyaluronan (HA) production which also leads to higher levels of PAI-1. COVID-19 risk factors are consistent with this scenario, as PAI-1 levels are increased in hypertension, obesity, diabetes, cardiovascular diseases, and old age. We discuss the possibility of using various approved drugs, or drugs currently in clinical development, to treat COVID-19. This perspective suggests to enhance STAT1 activity and/or inhibit STAT3 functions for COVID-19 treatment. This might derail the escalating STAT3/PAI-1 cycle central to COVID-19.
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Lin L, Wang Y, Sun B, Liu L, Ying W, Wang W, Zhou Q, Hou J, Yao H, Hu L, Sun J, Wang X. The clinical, immunological and genetic features of 12 Chinese patients with STAT3 mutations. Allergy Asthma Clin Immunol 2020; 16:65. [PMID: 32944025 PMCID: PMC7491347 DOI: 10.1186/s13223-020-00462-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/10/2020] [Indexed: 01/08/2023] Open
Abstract
Background Loss-of-function (LOF) mutations in signal transducer and activator of transcription 3 (STAT3) is one of the causes of STAT3 hyperimmunoglobulin E (IgE) syndrome (STAT3-HIES), while gain-of-function (GOF) mutations in STAT3 lead to immune dysregulation diseases. We retrospectively analyzed the age, common clinical symptoms, immunologic and molecular manifestations in 11 patients with LOF STAT3 mutations and 1 patient with a GOF STAT3 mutation. Methods Twelve patients were enrolled in our study. Serum immunoglobulin measurements, lymphocyte subset detection and whole-exome sequencing were performed. Results The median age at diagnosis of STAT3-HIES patients was 4.74 years. Eczema, recurrent respiratory infections, fevers, abscesses and Staphylococcus aureus infections were the classic manifestations. Elevated serum IgE levels are not always observed in conjunction with high eosinophil counts. A moderate viral DNA load was also measured in peripheral blood mononuclear cells. We noticed that c. 1144C>T was the most common mutation site, followed by c.1311C>A. Additionally, c.1311C>A and c. 1826G>C are two novel mutations. Eight patients achieved notable improvement after receiving intravenous immunoglobulin. Conclusion We updated the current knowledge of this topic. We found an earlier median age at diagnosis, a higher survival rate, and a general lack of nonimmunological abnormalities; we also described the treatment details and novel mutations involve in STAT3-HIES and compared STAT3 LOF and GOF mutations.
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Affiliation(s)
- Li Lin
- Department of Clinical Immunology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102 China
| | - Ying Wang
- Department of Clinical Immunology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102 China
| | - Bijun Sun
- Department of Clinical Immunology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102 China
| | - Luyao Liu
- Department of Clinical Immunology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102 China
| | - Wenjing Ying
- Department of Clinical Immunology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102 China
| | - Wenjie Wang
- Department of Clinical Immunology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102 China
| | - Qinhua Zhou
- Department of Clinical Immunology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102 China
| | - Jia Hou
- Department of Clinical Immunology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102 China
| | - Haili Yao
- Department of Clinical Immunology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102 China
| | - Liyuan Hu
- Department of Neonatology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102 China
| | - Jinqiao Sun
- Department of Clinical Immunology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102 China
| | - Xiaochuan Wang
- Department of Clinical Immunology, Children's Hospital of Fudan University, 399 Wanyuan Road, Shanghai, 201102 China
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Xiang Q, Zhang L, Liu X, Wang S, Wang T, Xiao M, Zhao X, Jiang L. Autosomal dominant hyper IgE syndrome from a single centre in Chongqing, China (2009-2018). Scand J Immunol 2020; 91:e12885. [PMID: 32248557 DOI: 10.1111/sji.12885] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/16/2020] [Accepted: 03/24/2020] [Indexed: 11/28/2022]
Abstract
Autosomal dominant hyper IgE syndrome (AD-HIES) caused by STAT3 gene mutation is a rare primary immunodeficiency disease. To better understand the disease, we described the clinical characteristics of 20 AD-HIES patients in Chongqing, China and explored the effect of mutations in different domains of STAT3 gene on the function of STAT3 protein by Western blot and confocal microscopy. The mean age at onset was 0.12 years. The mean age at diagnosis was 5.31 years. The most common presentation was eczema, pneumonia, skin abscesses and chronic mucocutaneous candidiasis. Seven patients suffered from BCG complications. R382W/Q were identified in 12 patients, V637M mutation in three patients. Three patients have died. The phosphorylated STAT3 was expressed more in wild-type(WT) and R382W mutant STAT3 in the cytoplasm of COS7 cells with epidermal growth factor(EGF) stimulation, less in the V637M mutation and T620S mutation. Dynamic observation showed that STAT3 cytoplasmic accumulation and nuclear translocation occurred rapidly after EGF stimulation in WT-STAT3-GFP, the time of accumulation and nuclear translocation was later and the expression was less in R382W-STAT3-GFP compared with WT-STAT3-GFP, followed by V637M and T620S mutation. These results suggested that our patients had earlier onset, diagnostic age and higher rate of BCG complications. However, our patients had higher incidence of mortality though the earlier diagnostic age. We did not find a significant genotype/phenotype correlation, but Src homology 2 domain mutations (V637M and T620S) had a greater effect on STAT3 phosphorylation and nuclear translocation than DNA-binding domain mutation (R382W) in vitro.
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Affiliation(s)
- Qingqing Xiang
- Clinical Immunology Laboratory, Pediatric Research Institute, Chongqing Key Laboratory of Child Infection and Immunity, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R China
| | - Luying Zhang
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing, P.R China
| | - Xia Liu
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, P.R China
| | - Shiyu Wang
- Clinical Immunology Laboratory, Pediatric Research Institute, Chongqing Key Laboratory of Child Infection and Immunity, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R China
| | - Tao Wang
- Clinical Immunology Laboratory, Pediatric Research Institute, Chongqing Key Laboratory of Child Infection and Immunity, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R China
| | - Min Xiao
- Clinical Immunology Laboratory, Pediatric Research Institute, Chongqing Key Laboratory of Child Infection and Immunity, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R China
| | - Xiaodong Zhao
- Laboratory Biosafety-2, Pediatric Research Institute, Chongqing Key Laboratory of Child Infection and Immunity, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R China
| | - Liping Jiang
- Clinical Immunology Laboratory, Pediatric Research Institute, Chongqing Key Laboratory of Child Infection and Immunity, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, P.R China
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