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Oprea C, Ianache I, Vasile S, Costescu C, Tardei G, Nica M, Umlauf A, Achim C. Brain opportunistic infections and tumors in people living with HIV - still a challenge in efficient antiretroviral therapy era. J Neurovirol 2023; 29:297-307. [PMID: 37219810 PMCID: PMC10204662 DOI: 10.1007/s13365-023-01135-1] [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] [Received: 03/23/2023] [Revised: 03/23/2023] [Accepted: 04/07/2023] [Indexed: 05/24/2023]
Abstract
The aim of the study was to evaluate the incidence of brain opportunistic pathologies and survival in patients living with HIV from a Romanian tertiary center. A 15-year prospective observational study of brain opportunistic infections diagnosed in HIV-infected patients was performed at Victor Babes Hospital, Bucharest, between January 2006 and December 2021. Characteristics and survival were compared related to modes of HIV acquisition and type of opportunistic infection. A total of 320 patients were diagnosed with 342 brain opportunistic infections (incidence 9.79 per 1000 person-years), 60.2% males with median age at diagnosis of 31 years (IQR 25, 40). Median CD4 cell count and VL were 36/μL (IQR 14, 96) and 5.1 log10 copies/mL (IQR 4, 5.7) respectively. The routes of HIV acquisition were heterosexual (52.6%), parenteral route in early childhood (31.6%), injecting drug use (12.9%), men having sex with men (1.8%), and vertical (1.2%). The most common brain infections were progressive multifocal leukoencephalopathy (31.3%), cerebral toxoplasmosis (26.9%), tuberculous meningitis (19.3%), and cryptococcal meningitis (16.7%). Patients infected by parenteral mode in early childhood were younger at diagnosis of both opportunistic infection and HIV (p < 0.001 and p < 0.001, respectively), developed more frequently PML (p < 0.001), and had the lowest early (p = 0.002) and late (p = 0.019) mortality rates. Risk factors for shorter survival were age > 30 years (p = 0.001), injecting drug use (p = 0.003), CD4 + < 100/μL (p = 0.007), and VL > 5 log10 copies/mL at diagnosis (p < 0.001). The incidence and mortality rate of brain opportunistic infections were high and did not decrease significantly during the study period, due to late presentation or non-adherence to ART.
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Affiliation(s)
- Cristiana Oprea
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
- Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Bucharest, Romania.
| | - Irina Ianache
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Bucharest, Romania
| | - Sorina Vasile
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Gratiela Tardei
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Maria Nica
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Victor Babes Clinical Hospital of Infectious and Tropical Diseases, Bucharest, Romania
| | - Anya Umlauf
- Department of Psychiatry, University of California San Diego, La Jolla, San Diego, CA, USA
| | - Cristian Achim
- Department of Psychiatry, University of California San Diego, La Jolla, San Diego, CA, USA
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Human Immunodeficiency Virus. Neuroimaging Clin N Am 2023; 33:147-165. [DOI: 10.1016/j.nic.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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3
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Sakai M, Higashi M, Fujiwara T, Uehira T, Shirasaka T, Nakanishi K, Kashiwagi N, Tanaka H, Terada H, Tomiyama N. MRI imaging features of HIV-related central nervous system diseases: diagnosis by pattern recognition in daily practice. Jpn J Radiol 2021; 39:1023-1038. [PMID: 34125369 PMCID: PMC8202053 DOI: 10.1007/s11604-021-01150-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 06/01/2021] [Indexed: 01/10/2023]
Abstract
With the advent of antiretroviral therapy (ART), the prognosis of people infected with human immunodeficiency virus (HIV) has improved, and the frequency of HIV-related central nervous system (CNS) diseases has decreased. Nevertheless, mortality from HIV-related CNS diseases, including those associated with ART (e.g., immune reconstitution inflammatory syndrome) remains significant. Magnetic resonance imaging (MRI) can improve the outlook for people with HIV through early diagnosis and prompt treatment. For example, HIV encephalopathy shows a diffuse bilateral pattern, whereas progressive multifocal leukoencephalopathy, HIV-related primary CNS lymphoma, and CNS toxoplasmosis show focal patterns on MRI. Among the other diseases caused by opportunistic infections, CNS cryptococcosis and CNS tuberculosis have extremely poor prognoses unless diagnosed early. Immune reconstitution inflammatory syndrome shows distinct MRI findings from the offending opportunistic infections. Although distinguishing between HIV-related CNS diseases based on imaging alone is difficult, in this review, we discuss how pattern recognition approaches can contribute to their early differentiation.
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Affiliation(s)
- Mio Sakai
- Department of Diagnostic and Interventional Radiology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-ku, Osaka-shi, Osaka, 541-8567, Japan.
| | - Masahiro Higashi
- Department of Radiology, National Hospital Organization Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-ku, Osaka-shi, Osaka, 540-0006, Japan
| | - Takuya Fujiwara
- Department of Radiology, National Hospital Organization Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-ku, Osaka-shi, Osaka, 540-0006, Japan
| | - Tomoko Uehira
- AIDS Medical Center, National Hospital Organization Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-ku, Osaka-shi, Osaka, 540-0006, Japan
| | - Takuma Shirasaka
- AIDS Medical Center, National Hospital Organization Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-ku, Osaka-shi, Osaka, 540-0006, Japan
| | - Katsuyuki Nakanishi
- Department of Diagnostic and Interventional Radiology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-ku, Osaka-shi, Osaka, 541-8567, Japan
| | - Nobuo Kashiwagi
- Department of Future Diagnostic Radiology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hisashi Tanaka
- Department of Radiology, Osaka University Graduate School of Medicine, 2‑2, Yamadaoka, Suita, Osaka, 565‑0871, Japan
| | - Hitoshi Terada
- Department of Radiology, Toho University Sakura Medical Center, 564-1, Shimoshizu, Sakura, Chiba, 285-8741, Japan
| | - Noriyuki Tomiyama
- Department of Radiology, Osaka University Graduate School of Medicine, 2‑2, Yamadaoka, Suita, Osaka, 565‑0871, Japan
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Quevedo-Ramirez A, Montenegro-Idrogo JJ, Resurrección-Delgado C, Salazar-Mesones B, Gallardo-Cartagena J, Cornejo-Venegas G, Méndez-Guerra C, Vargas-Matos I, Chiappe-Gonzalez A. Lateral amyotrophic sclerosis-like onset after combined antiretroviral treatment initiation. IDCases 2020; 22:e00994. [PMID: 33194549 PMCID: PMC7642845 DOI: 10.1016/j.idcr.2020.e00994] [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] [Received: 05/30/2020] [Revised: 10/04/2020] [Accepted: 10/14/2020] [Indexed: 11/03/2022] Open
Abstract
Motor neuron disease (MND) have an incidence of 2 in 100 000 persons, resulting in the death of 1 in every 500 people affected. The most common disease in MND spectrum is amyotrophic lateral sclerosis (ALS). We describe the case of an ALS-like syndrome in a HIV patient. This case report presents a 38 years old male from Peru with HIV who after 2 months of combined antiretroviral treatment (cART) initiation was admitted to the hospital for spastic paraplegia. On his first admission, rapid plasma reagent (RPR) was positive and he was treated for neurosyphilis and discharged. Nevertheless, one month after, he was admitted for the second time because paraplegia persisted. Laboratory tests, electromyography and imaging were performed, and ALS was diagnosed. Normally, HIV treated patient with ALS tend to have a better prognosis, however this was not the case. In this case report, we discuss possible association between ALS and immune reconstitution inflammatory syndrome in HIV patients.
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Affiliation(s)
| | - Juan Jose Montenegro-Idrogo
- Infectious and Tropical Diseases Service, Hospital Nacional Dos de Mayo, Lima, Peru.,Facultad de Ciencias de la Salud. Universidad Científica del Sur, Lima, Peru
| | - Cristhian Resurrección-Delgado
- Infectious and Tropical Diseases Service, Hospital Nacional Dos de Mayo, Lima, Peru.,Universidad Peruana de Ciencias Aplicadas, Lima, Peru
| | | | | | | | | | - Iván Vargas-Matos
- Clínica Anglo Americana, Lima, Peru.,Universidad Peruana de Ciencias Aplicadas, Lima, Peru
| | - Alfredo Chiappe-Gonzalez
- Infectious and Tropical Diseases Service, Hospital Nacional Dos de Mayo, Lima, Peru.,Universidad Peruana de Ciencias Aplicadas, Lima, Peru
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Ghanchi H, Siddiqi I, Patchana T, Ananda A. Acquired Holmes Tremor in a Human Immunodeficiency Virus Immune Reconstitution Inflammatory Syndrome Patient Treated with Deep Brain Stimulation. World Neurosurg 2020; 141:253-259. [PMID: 32565375 DOI: 10.1016/j.wneu.2020.06.099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND The authors present a case of a 66-year-old male who was diagnosed with human immunodeficiency virus, and his medical course of highly active antiretroviral therapy was complicated with the development of immune reconstitution inflammatory syndrome, which led to development of movement disorder consisting of right-sided resting tremor, neck dystonia, and jaw clenching. CASE DESCRIPTION The patient's symptoms resembled that of rubral tremor, and he underwent placement of a deep brain stimulation electrode into the left ventral intermediate nucleus of the thalamus with significant improvement of symptoms. CONCLUSIONS This is the first reported case in the literature of a human immunodeficiency virus-positive patient's treatment course complicated with immune reconstitution inflammatory syndrome with neurologic manifestation, which was refractory to medical therapy and thus treated with deep brain stimulation.
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Affiliation(s)
- Hammad Ghanchi
- Riverside University Health System, Department of Neurosurgery, Riverside, California, USA.
| | - Imran Siddiqi
- Western University of Health Science, College of Osteopathic Medicine, Pomona, California, USA
| | - Tye Patchana
- Riverside University Health System, Department of Neurosurgery, Riverside, California, USA
| | - Ajay Ananda
- Kaiser Permanente Los Angeles Medical Center, Department of Neurosurgery, Los Angeles, California, USA
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Liu J, Li M, Gan ZQ, Wang YJ, Lin CR, Chen ZL, Jiang Y, Peng FH. Postinfectious inflammatory response syndrome in HIV-uninfected and nontransplant men after cryptococcal meningitis. Future Microbiol 2020; 15:613-621. [PMID: 32490698 DOI: 10.2217/fmb-2019-0252] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Aim: The aim of our study was to describe the characteristics of postinfectious inflammatory response syndrome (PIIRS) in HIV-uninfected and nontransplant men after cryptococcal meningitis (CM). Patients & methods: A case-control study was designed to compare HIV-uninfected and nontransplant male CM patients with and without PIIRS. Results: CM-PIIRS patients had increased rates of hearing loss, V-P shunt placement, amphotericin B treatment, higher cerebrospinal fluid pressures and Cryptococcus counts in the first CM episode. CM-PIIRS episode was characterized by higher frequencies of headache and fever, higher C-reactive protein, erythrocyte sedimentation rate, cerebrospinal fluid white blood cell (WBC) counts and modified Rankin Score. Brain MRI scans revealed the high signal lesions on axial flair imaging. Receipt of corticosteroid therapy was associated with lower rates of fever and better modified Rankin Score scores at 1 month after treatment. Conclusion: CM-PIIRS episode differs to the initial presentation, may help to identify which patients are at risk to develop PIIRS. Steroids therapy could be beneficial.
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Affiliation(s)
- Jia Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510630, China
| | - Min Li
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510630, China
| | - Zhou-Qing Gan
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510630, China
| | - Yi-Jie Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510630, China
| | - Chu-Rong Lin
- Department of Radiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510630, China
| | - Zhuo-Lin Chen
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510630, China
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510630, China
| | - Fu-Hua Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510630, China
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Meya DB, Okurut S, Zziwa G, Cose S, Boulware DR, Janoff EN. HIV-Associated Cryptococcal Immune Reconstitution Inflammatory Syndrome Is Associated with Aberrant T Cell Function and Increased Cytokine Responses. J Fungi (Basel) 2019; 5:jof5020042. [PMID: 31126019 PMCID: PMC6616503 DOI: 10.3390/jof5020042] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 04/24/2019] [Accepted: 04/29/2019] [Indexed: 12/11/2022] Open
Abstract
Cryptococcal meningitis remains a significant opportunistic infection among HIV-infected patients, contributing 15-20% of HIV-related mortality. A complication of initiating antiretroviral therapy (ART) following opportunistic infection is immune reconstitution inflammatory syndrome (IRIS). IRIS afflicts 10-30% of HIV-infected patients with cryptococcal meningitis (CM), but its immunopathogenesis is poorly understood. We compared circulating T cell memory subsets and cytokine responses among 17 HIV-infected Ugandans with CM: 11 with and 6 without CM-IRIS. At meningitis diagnosis, stimulation with cryptococcal capsule component, glucuronoxylomannan (GXM) elicited consistently lower frequencies of CD4+ and CD8+ T cell memory subsets expressing intracellular cytokines (IL-2, IFN-γ, and IL-17) among subjects who subsequently developed CM-IRIS. After ART initiation, T cells evolved to show a decreased CD8+ central memory phenotype. At the onset of CM-IRIS, stimulation more frequently generated polyfunctional IL-2+/IL-17+ CD4+ T cells in patients with CM-IRIS. Moreover, CD8+ central and effector memory T cells from CM-IRIS subjects also demonstrated more robust IL-2 responses to antigenic stimulation vs. controls. Thus, ART during CM elicits distinct differences in T cell cytokine production in response to cryptococcal antigens both prior to and during the development of IRIS, suggesting an immunologic foundation for the development of this morbid complication of CM infection.
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Affiliation(s)
- David B Meya
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 22418, Uganda.
- Department of Medicine, Center for Infectious Diseases and Microbiology Translational Research, University of Minnesota, Minneapolis, MN 55455, USA.
- School of Medicine, College of Health Sciences, Makerere University, Kampala P.O. Box 7072, Uganda.
| | - Samuel Okurut
- Infectious Diseases Institute, Makerere University, Kampala P.O. Box 22418, Uganda.
| | - Godfrey Zziwa
- Research Department, Makerere University Walter Reed Project, Plot 42, Nakasero Road, Kampala P.O. Box 1624, Uganda.
| | - Stephen Cose
- Clinical Research Department, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
- MRC/UVRI and LSHTM Uganda Research Unit, Plot 51-59 Nakiwogo Road, Entebbe P.O.Box 49, Uganda.
| | - David R Boulware
- Department of Medicine, Center for Infectious Diseases and Microbiology Translational Research, University of Minnesota, Minneapolis, MN 55455, USA.
| | - Edward N Janoff
- Mucosal and Vaccine Research Program Colorado (MAVRC), University of Colorado, Denver, Aurora, CO 80045, USA.
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8
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Infections in Immunocompromised Individuals. Clin Neuroradiol 2019. [DOI: 10.1007/978-3-319-68536-6_48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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9
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Central Nervous System–Immune Reconstitution Inflammatory Syndrome. Neuroradiology 2019. [DOI: 10.1016/b978-0-323-44549-8.00013-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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10
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Thurnher MM. Infections in Immunocompromised Individuals. Clin Neuroradiol 2018. [DOI: 10.1007/978-3-319-61423-6_48-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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11
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Lincoln CM, Fata P, Sotardi S, Pohlen M, Uribe T, Bello JA. Imaging spectrum of immunomodulating, chemotherapeutic and radiation therapy-related intracranial effects. Br J Radiol 2017; 91:20170553. [PMID: 29039692 DOI: 10.1259/bjr.20170553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE A wide range of treatment-related side effects result in specific neurologic symptoms and signs and neuroimaging features. Even to the most seasoned neuroradiologist, elucidating therapy-related side effects from other common mimics can be challenging. We provide a pictorial survey of some common and uncommon medication-induced and therapy-related neuroimaging manifestations, discuss pathophysiology and common pitfalls in imaging and diagnosis. METHODS A case-based review is utilized to depict scenarios on a routine basis in a general radiology or neuroradiology practice such as medication-induced posterior reversible encephalopathy syndrome to the more challenging cases of pseudoprogression and pseudoregression in temozolmide and bevacizumab therapy in gliobastoma treatment protocols. CONCLUSION Knowledge of the treatment-induced imaging abnormalities is essential in the accurate interpretation and diagnosis from the most routine to most challenging of clinical situations. We provide a pictorial review for the radiologist to employ in order to be an invaluable provider to our clinical colleagues and patients.
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Affiliation(s)
- Christie M Lincoln
- 1 Department of Radiology, Baylor College of Medicine , Houston, TX , USA
| | - Peter Fata
- 2 Department of Radiology, Houston Methodist , Houston, TX , USA
| | - Susan Sotardi
- 3 Department of Neuroradiology, Massachusetts General Hospital , Boston, MA , USA
| | - Michael Pohlen
- 1 Department of Radiology, Baylor College of Medicine , Houston, TX , USA
| | - Tomas Uribe
- 1 Department of Radiology, Baylor College of Medicine , Houston, TX , USA
| | - Jacqueline A Bello
- 4 Albert Einstein College of Medicine, Montefiore Medical Center , Bronx, NY , USA
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Jaganmohan D, Chakkalakkoombil SV, Beena AA, Krishnan N. Neurotuberculosis immune reconstitution inflammatory syndrome in the setting of HIV infection: A case report and review of literature. Indian J Radiol Imaging 2017; 26:446-450. [PMID: 28104935 PMCID: PMC5201071 DOI: 10.4103/0971-3026.195782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is an exaggerated immune response which can occur with various coinfections in human immunodeficiency virus (HIV) infected patients, of which the most commonly implicated in central nervous system (CNS)-IRIS are progressive multifocal leukoencephalopathy (PML), cryptococcosis, and tuberculosis (TB). TB-IRIS is a known complication of pulmonary TB or TB lymphadenitis coinfection in HIV infected patients who are on antituberculosis treatment (ATT) after the initiation of antiretroviral therapy (ART). However, development of IRIS in extrapulmonary TB such as CNS TB is very rare. Our case is that of an isolated CNS-TB-IRIS, presenting as increase in the size and perilesional edema of the ring enhancing lesions in the brain, which was observed in two sequential magnetic resonance imaging done over a period of 2 months in a retropositive patient who presented with clinical deterioration after commencement of ART. As prompt diagnosis was made and specific management aimed at IRIS was started without delay, the patient improved symptomatically.
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Affiliation(s)
- Deepasree Jaganmohan
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Sunitha V Chakkalakkoombil
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Anjana A Beena
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
| | - Nagarajan Krishnan
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India
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Kolson D. Neurologic Complications in Persons With HIV Infection in the Era of Antiretroviral Therapy. TOPICS IN ANTIVIRAL MEDICINE 2017; 25:97-101. [PMID: 28820724 PMCID: PMC5935214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Neurologic complications in persons with HIV infection are less severe in the era of potent antiretroviral therapy but remain highly prevalent. Prior to the use of antiretroviral therapy, opportunistic infections of the central nervous system (CNS) and CNS malignancy were common. Progressive multifocal leukoencephalopathy (PML), however, remains a diagnostic challenge in HIV-infected individuals, and no effective antiviral treatment for PML is currently available. Primary neurologic complications of acute HIV infection include aseptic meningitis and acute inflammatory demyelinating polyneuropathy. Among the neurologic complications of chronic HIV infection, HIV-associated neurocognitive disorders (HAND) remain most prevalent. The use of antiretroviral therapy has greatly reduced the severity of HAND, under which progressive HIV-associated dementia once predominated, to a milder chronic form of potentially disabling neurocognitive impairment. The persistence of HAND in individuals with virologic suppression suggests a need for adjunctive therapies for limiting its morbidity. This article summarizes a presentation by Dennis Kolson, MD, PhD, at the IAS-USA continuing education program, Improving the Management of HIV Disease, held in Chicago, Illinois, in May 2017.
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14
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Neurological immune reconstitution inflammatory response: riding the tide of immune recovery. Curr Opin Neurol 2016; 28:295-301. [PMID: 25887769 DOI: 10.1097/wco.0000000000000200] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW This manuscript reviews current reports about clinical aspects of immune reconstitution inflammatory syndrome (IRIS), with a particular emphasis on IRIS in the setting of progressive multifocal leukoencephalopathy (PML) and to a lesser extent on cryptococcal meningitis and HIV. RECENT FINDINGS PML prognosis has been radically improved, as it has become possible to provide immune reconstitution, although some remaining morbidity and mortality results from excess inflammation. Similar pathologic responses are seen less often, but remain clinically important in cryptococcal meningitis, and HIV. Early diagnosis and active management of PML results in optimal outcomes with survival of 75% or higher in multiple recent series. These finding apply both to natalizumab and HIV-associated PML. Cryptococcal meningitis is frequently complicated by IRIS, and early treatment with antifungal therapy preceding HIV therapy provides optimal outcomes. HIV IRIS is reduced by early therapy, which is now recommended, but even on therapy, chronic dysregulated immune responses may play important roles in ongoing HIV-associated neurocognitive disease (HAND), which is common, as well as rare but more dramatic subacute encephalopathies. SUMMARY The clinician must actively monitor and treat both opportunistic infection and the inflammatory response that is essential to recovery but may itself augment disease and injury.
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15
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Tang X, Liang Y, Zhu Y, Xie C, Yao A, Chen L, Jiang Q, Liu T, Wang X, Qian Y, Wei J, Ni W, Dai J, Jiang Z, Hou W. Anti-transferrin receptor-modified amphotericin B-loaded PLA-PEG nanoparticles cure Candidal meningitis and reduce drug toxicity. Int J Nanomedicine 2015; 10:6227-41. [PMID: 26491294 PMCID: PMC4599718 DOI: 10.2147/ijn.s84656] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Fatal fungal infections in central nervous system (CNS) can occur through hematogenous spread or direct extension. At present, hydrophobic amphotericin B (AMB) is the most effective antifungal drug in clinical trials. However, AMB is hydrophobic and therefore penetrates poorly into the CNS, and therapeutic levels of AMB are hard to achieve. The transferrin receptor (TfR/CD71) located at the blood-brain barrier mediates transferrin transcytosis. In order to enhance the receptor-mediated delivery of AMB into CNS with therapeutic level, an anti-TfR antibody (OX26)-modified AMB-loaded PLA (poly[lactic acid])-PEG (polyethylene glycol)-based micellar drug delivery system was constructed. The prepared OX26-modified AMB-loaded nanoparticles (OX26-AMB-NPs) showed significant reduction of CNS fungal burden and an increase of mouse survival time. In conclusion, OX26-AMB-NPs represent a promising novel drug delivery system for intracerebral fungal infection.
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Affiliation(s)
- Xiaolong Tang
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China ; State Key Laboratory of Virology/Institute of Medical Virology, School of Basic Medical Sciences, Wuhan University, Wuhan, People's Republic of China
| | - Yong Liang
- Clinical Laboratory, Huai'an Hospital Affiliated of Xuzhou Medical College, Huaian, People's Republic of China
| | - Yongqiang Zhu
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China ; Department of Medical Genetics, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Chunmei Xie
- School of Biotechnology, Southern Medical University, Guangzhou, People's Republic of China
| | - Aixia Yao
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China
| | - Li Chen
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China
| | - Qinglin Jiang
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China
| | - Tingting Liu
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China
| | - Xiaoyu Wang
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China
| | - Yunyun Qian
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China
| | - Jia Wei
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China
| | - Wenxuan Ni
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China
| | - Jingjing Dai
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China
| | - Zhenyou Jiang
- Department of Microbiology and Immunology, School of Medicine, Jinan University, Guangzhou, People's Republic of China ; Guangdong Key Laboratory of Molecular Immunology and Antibody Engineering, Jinan University, Guangzhou, People's Republic of China
| | - Wei Hou
- State Key Laboratory of Virology/Institute of Medical Virology, School of Basic Medical Sciences, Wuhan University, Wuhan, People's Republic of China
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16
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Narvid J, Rehani B, Talbott JF. Diagnostic Performance of Brain MRI in Immune Reconstitution Inflammatory Syndrome. J Neuroimaging 2015; 26:303-8. [PMID: 26360519 DOI: 10.1111/jon.12291] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 07/22/2015] [Accepted: 07/23/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND PURPOSE Central nervous system immune reconstitution inflammatory syndrome (CNS-IRIS) significantly negatively impacts the human immunodeficiency virus (HIV)-infected population on combination antiretroviral therapy (cART). We sought to determine the diagnostic performance of several magnetic resonance imaging (MRI) features for CNS-IRIS in a cohort of HIV+ patients recently started on cART. METHODS Our radiologic database was searched from January 2003 to September 2014 retrospectively for patients diagnosed with HIV and worsening symptoms on cART. A total of 20 patients with HIV were identified; patients were classified as having CNS-IRIS on the basis of established clinical criteria (8 patients; 12 age- and sex-matched controls). Brain MR images were obtained at a single post-cART timepoint during hospitalization for acute neurologic deterioration and blindly interpreted by two experienced neuroradiologists for the presence of four variables: intrinsic T1 hyperintensity, marginal reduced diffusion, and marginal enhancement or perivascular enhancement. RESULTS Although each individual finding showed moderate predictive accuracy, the combination of MR findings demonstrated good test characteristics: sensitivity 88% (confidence interval [CI] 62-98), specificity 79% (58-93), positive predictive value 71% (44-90%), and negative predictive value 83% (CI 52-98%). In addition, this final diagnosis demonstrated good predictive accuracy, area under curve .78 (CI .63-.91), and moderate inter-reader agreement, κ = .55. CONCLUSIONS Our findings suggest that although each individual MR finding shows only moderate diagnostic performance, the combined assessment of experienced neuroradiologists has good predictive accuracy. The absence of any described MRI findings makes the diagnosis of CNS-IRIS highly unlikely.
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Affiliation(s)
- Jared Narvid
- Division of Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA
| | - Bhavya Rehani
- Division of Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA
| | - Jason F Talbott
- Division of Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA
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17
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Bijarnia-Mahay S, Mohan N, Goyal D, Verma IC. Mitochondrial DNA depletion syndrome causing liver failure. Indian Pediatr 2015; 51:666-8. [PMID: 25129007 DOI: 10.1007/s13312-014-0475-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Mitochondrial DNA depletion syndromes are disorders of Mitochondrial DNA maintenance causing varied manifestations, including fulminant liver failure. CASE CHARACTERISTICS Two infants, presenting with severe fatal hepatopathy. OBSERVATION Raised serum lactate, positive family history (in first case), and absence of other causes of acute liver failure. OUTCOME Case 1 with homozygous mutation, c.3286C>T (p.Arg1096Cys) in POLG gene and case 2 with compound heterozygous mutations, novel c.408T>G (p.Tyr136X) and previously reported c.293C>T (p.Pro98Leu), in MPV17 gene. MESSAGE Mitochondrial DNA depletion syndrome is a rare cause of severe acute liver failure in children.
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Affiliation(s)
- Sunita Bijarnia-Mahay
- Center of Medical Genetics, Sir Ganga Ram Hospital, New Delhi; and *Department of Pediatric Gastroenterology, Hepatology and Liver Transplantation, Medanta - The Medicity, Gurgaon. Correspondence to: Dr Sunita Bijarnia-Mahay, Senior Consultant, Center of Medical Genetics, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India.
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18
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Walker NF, Scriven J, Meintjes G, Wilkinson RJ. Immune reconstitution inflammatory syndrome in HIV-infected patients. HIV AIDS (Auckl) 2015; 7:49-64. [PMID: 25709503 PMCID: PMC4334287 DOI: 10.2147/hiv.s42328] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Access to antiretroviral therapy (ART) is improving worldwide. Immune reconstitution inflammatory syndrome (IRIS) is a common complication of ART initiation. In this review, we provide an overview of clinical and epidemiological features of HIV-associated IRIS, current understanding of pathophysiological mechanisms, available therapy, and preventive strategies. The spectrum of HIV-associated IRIS is described, with a particular focus on three important pathogen-associated forms: tuberculosis-associated IRIS, cryptococcal IRIS, and Kaposi's sarcoma IRIS. While the clinical features and epidemiology are well described, there are major gaps in our understanding of pathophysiology and as a result therapeutic and preventative strategies are suboptimal. Timing of ART initiation is critical to reduce IRIS-associated morbidity. Improved understanding of the pathophysiology of IRIS will hopefully enable improved diagnostic modalities and better targeted treatments to be developed.
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Affiliation(s)
- Naomi F Walker
- Department of Medicine, Imperial College London, London, UK
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - James Scriven
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Graeme Meintjes
- Department of Medicine, Imperial College London, London, UK
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert J Wilkinson
- Department of Medicine, Imperial College London, London, UK
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- MRC National Institute of Medical Research, London, UK
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19
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Dhana AV, Howell P, Spencer D. When smear and molecular diagnostics fail: identification of tuberculosis in advanced HIV infection using the newly developed urine lipoarabinomannan lateral-flow assay. BMJ Case Rep 2014; 2014:bcr-2013-200696. [PMID: 24614769 DOI: 10.1136/bcr-2013-200696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
In HIV infection, progression of immunodeficiency is associated with increased risk of paucibacillary and disseminated forms of tuberculosis (TB). As a result, the clinical presentation may be atypical and the conventional diagnostic assays often unreliable, resulting in significant treatment delays. Here, we report a case of HIV-associated immune reconstitution inflammatory syndrome and TB meningitis. Although the smear and molecular assays were negative, Mycobacterium tuberculosis was identified in our patient using the new Determine-lipoarabinomannan (LAM) lateral-flow urine 'dip-stick' assay. This case report illustrates the clinical value of this assay for the diagnosis of TB in a subgroup of HIV-infected patients with advanced immunodeficiency. Also, although two recent studies have evaluated the use of the Determine TB-LAM assay in clinical settings, to the best of our knowledge, this is the first case report of TB diagnosed using this novel assay.
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Affiliation(s)
- Ashar Vijay Dhana
- Department of Infectious Diseases, Helen Joseph Academic Hospital, Johannesburg, Gauteng, South Africa
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20
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Wattjes MP, Richert ND, Killestein J, de Vos M, Sanchez E, Snaebjornsson P, Cadavid D, Barkhof F. The chameleon of neuroinflammation: magnetic resonance imaging characteristics of natalizumab-associated progressive multifocal leukoencephalopathy. Mult Scler 2013; 19:1826-40. [PMID: 24192217 DOI: 10.1177/1352458513510224] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Natalizumab is a monoclonal antibody against α4-integrin approved for the treatment of multiple sclerosis (MS) due to a positive effect on clinical and magnetic resonance imaging (MRI) outcome measures. However, one relatively rare but serious side effect of this drug is a higher risk of developing progressive multifocal leukoencephalopathy (PML). Since the FDA approval, more than 300 natalizumab-associated PML cases have been documented among more than 100,000 treated MS patients. MRI is a crucial tool in the surveillance of patients treated with natalizumab in order to detect possible signs of PML in the asymptomatic stage. Although classical imaging characteristics of PML are well established, MRI findings in natalizumab-associated PML, particularly in early disease stages, show rather new and heterogeneous imaging findings including different patterns of inflammation with contrast enhancement. This review provides a comprehensive overview of the heterogeneous imaging findings in natalizumab-associated PML in the context of the underlying pathophysiology, histopathology, and the diagnostic procedure. We describe the MRI patterns of PML lesion evolution and complications including immune reconstitution inflammatory syndrome (IRIS). Finally, we present guidelines to differentiate MRI findings in PML from inflammatory demyelinating lesions, to facilitate the early diagnosis of PML in patients treated with natalizumab.
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Affiliation(s)
- Mike P Wattjes
- Department of Radiology, Nuclear Medicine & PET Research, University Medical Center, The Netherlands
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21
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Roh D, Glenn MD, Petito CK, Post MJD, Verma A. Reversible severe encephalitis and word deafness following rapid immune reconstitution in AIDS: a case report. J Neurovirol 2013; 19:190-3. [PMID: 23580250 DOI: 10.1007/s13365-013-0161-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 03/06/2013] [Accepted: 03/11/2013] [Indexed: 12/16/2022]
Affiliation(s)
- David Roh
- Department of Neurology, University of Miami Miller School of Medicine, Clinical Research Building, 1120 NW 14 Street, Suite 1317, Miami, FL 33136, USA
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Gaskill PJ, Calderon TM, Coley JS, Berman JW. Drug induced increases in CNS dopamine alter monocyte, macrophage and T cell functions: implications for HAND. J Neuroimmune Pharmacol 2013; 8:621-42. [PMID: 23456305 DOI: 10.1007/s11481-013-9443-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 02/13/2013] [Indexed: 02/08/2023]
Abstract
Central nervous system (CNS) complications resulting from HIV infection remain a major public health problem as individuals live longer due to the success of combined antiretroviral therapy (cART). As many as 70 % of HIV infected people have HIV associated neurocognitive disorders (HAND). Many HIV infected individuals abuse drugs, such as cocaine, heroin or methamphetamine, that may be important cofactors in the development of HIV CNS disease. Despite different mechanisms of action, all drugs of abuse increase extracellular dopamine in the CNS. The effects of dopamine on HIV neuropathogenesis are not well understood, and drug induced increases in CNS dopamine may be a common mechanism by which different types of drugs of abuse impact the development of HAND. Monocytes and macrophages are central to HIV infection of the CNS and to HAND. While T cells have not been shown to be a major factor in HIV-associated neuropathogenesis, studies indicate that T cells may play a larger role in the development of HAND in HIV infected drug abusers. Drug induced increases in CNS dopamine may dysregulate functions of, or increase HIV infection in, monocytes, macrophages and T cells in the brain. Thus, characterizing the effects of dopamine on these cells is important for understanding the mechanisms that mediate the development of HAND in drug abusers.
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Affiliation(s)
- Peter J Gaskill
- Department of Pathology, Albert Einstein College of Medicine, Bronx, NY, USA
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