1
|
Hernandez-Trujillo V, Zhou C, Scalchunes C, Ochs HD, Sullivan KE, Cunningham-Rundles C, Fuleihan RL, Bonilla FA, Petrovic A, Rawlings DJ, de la Morena MT. A Registry Study of 240 Patients with X-Linked Agammaglobulinemia Living in the USA. J Clin Immunol 2023:10.1007/s10875-023-01502-x. [PMID: 37219739 DOI: 10.1007/s10875-023-01502-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 04/26/2023] [Indexed: 05/24/2023]
Abstract
PURPOSE To understand the natural history and clinical outcomes for patients with X-linked agammaglobulinemia (XLA) in the United States utilizing the United States Immunodeficiency Network (USIDNET) patient registry. METHODS The USIDNET registry was queried for data from XLA patients collected from 1981 to 2019. Data fields included demographics, clinical features before and after diagnosis of XLA, family history, genetic mutation in Bruton's tyrosine kinase (BTK), laboratory findings, treatment modalities, and mortality. RESULTS Data compiled through the USIDNET registry on 240 patients were analyzed. Patient year of birth ranged from 1945 to 2017. Living status was available for 178 patients; 158/178 (88.8%) were alive. Race was reported for 204 patients as follows: White, 148 (72.5%); Black/African American, 23 (11.2%); Hispanic, 20 (9.8%); Asian or Pacific Islander, 6 (2.9%), and other or more than one race, 7 (3.4%). The median age at last entry, age at disease onset, age at diagnosis, and length of time with XLA diagnosis was 15 [range (r) = 1-52 years], 0.8 [r = birth-22.3 years], 2 [r = birth-29 years], and 10 [r = 1-56 years] years respectively. One hundred and forty-one patients (58.7%) were < 18 years of age. Two hundred and twenty-one (92%) patients were receiving IgG replacement (IgGR), 58 (24%) were on prophylactic antibiotics, and 19 (7.9%) were on immunomodulatory drugs. Eighty-six (35.9%) patients had undergone surgical procedures, two had undergone hematopoietic cell transplantation, and two required liver transplantation. The respiratory tract was the most affected organ system (51.2% of patients) followed by gastrointestinal (40%), neurological (35.4%), and musculoskeletal (28.3%). Infections were common both before and after diagnosis, despite IgGR therapy. Bacteremia/sepsis and meningitis were reported more frequently before XLA diagnosis while encephalitis was more commonly reported after diagnosis. Twenty patients had died (11.2%). The median age of death was 21 years (range = 3-56.7 years). Neurologic condition was the most common underlying co-morbidity for those XLA patients who died. CONCLUSIONS Current therapies for XLA patients reduce early mortality, but patients continue to experience complications that impact organ function. With improved life expectancy, more efforts will be required to improve post-diagnosis organ dysfunction and quality of life. Neurologic manifestations are an important co-morbidity associated with mortality and not yet clearly fully understood.
Collapse
Affiliation(s)
- Vivian Hernandez-Trujillo
- Division of Allergy and Immunology, Nicklaus Children's Hospital, Miami, FL, USA
- Allergy and Immunology Care Center of South Florida, Miami Lakes, FL, USA
| | - Chuan Zhou
- Division of General Pediatrics, School of Medicine, Center for Child Health, University of Washington, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA, 98145, USA
| | - Christopher Scalchunes
- Immune Deficiency Foundation. Immune Deficiency Foundation | (primaryimmune.org), Hanover, USA
| | - Hans D Ochs
- Division of Immunology, Department of Pediatrics, University of Washington, Seattle, WA, 98101, USA
- Center for Immunity and Immunotherapies and the Program for Cell and Gene Therapy, Seattle Children's Research Institute, Seattle, WA, 98101, USA
| | - Kathleen E Sullivan
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Charlotte Cunningham-Rundles
- Division of Allergy and Clinical Immunology, Departments of Medicine and Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ramsay L Fuleihan
- Division of Pediatric Allergy, Immunology and Rheumatology, Columbia University Medical Center, New York, NY, USA
| | | | - Aleksandra Petrovic
- Division of Immunology, Department of Pediatrics, University of Washington, Seattle, WA, 98101, USA
- Center for Immunity and Immunotherapies and the Program for Cell and Gene Therapy, Seattle Children's Research Institute, Seattle, WA, 98101, USA
| | - David J Rawlings
- Division of Immunology, Department of Pediatrics, University of Washington, Seattle, WA, 98101, USA
- Center for Immunity and Immunotherapies and the Program for Cell and Gene Therapy, Seattle Children's Research Institute, Seattle, WA, 98101, USA
- Department of Immunology, University of Washington, Seattle, WA, 98101, USA
| | - M Teresa de la Morena
- Division of Immunology, Department of Pediatrics, University of Washington, Seattle, WA, 98101, USA.
| |
Collapse
|
2
|
Mechanisms underlying host defense and disease pathology in response to severe acute respiratory syndrome (SARS)-CoV2 infection: insights from inborn errors of immunity. Curr Opin Allergy Clin Immunol 2021; 21:515-524. [PMID: 34494617 DOI: 10.1097/aci.0000000000000786] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW The severe acute respiratory syndrome (SARS)-coronavirus 2 (CoV2)/COVID-19 pandemic has reminded us of the fundamental and nonredundant role played by the innate and adaptive immune systems in host defense against emerging pathogens. The study of rare 'experiments of nature' in the setting of inborn errors of immunity (IEI) caused by monogenic germline variants has revealed key insights into the molecular and cellular requirements for immune-mediated protection against infectious diseases. This review will provide an overview of the discoveries obtained from investigating severe COVID-19 in patients with defined IEI or otherwise healthy individuals. RECENT FINDINGS Genetic, serological and cohort studies have provided key findings regarding host defense against SARS-CoV2 infection, and mechanisms of disease pathogenesis. Remarkably, the risk factors, severity of disease, and case fatality rate following SARS-CoV2 infection in patients with IEI were not too dissimilar to that observed for the general population. However, the type I interferon (IFN) signaling pathway - activated in innate immune cells in response to viral sensing - is critical for anti-SARS-CoV2 immunity. Indeed, genetic variants or autoAbs affecting type I IFN function account for up to 20% of all cases of life-threatening COVID-19. SUMMARY The analysis of rare cases of severe COVID-19, coupled with assessing the impact of SARS-CoV2 infection in individuals with previously diagnosed IEI, has revealed fundamental aspects of human immunology, disease pathogenesis and immunopathology in the context of exposure to and infection with a novel pathogen. These findings can be leveraged to improve therapies for treating for emerging and established infectious diseases.
Collapse
|
3
|
Weber MS, Nicholas JA, Yeaman MR. Balancing Potential Benefits and Risks of Bruton Tyrosine Kinase Inhibitor Therapies in Multiple Sclerosis During the COVID-19 Pandemic. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2021; 8:8/6/e1067. [PMID: 34497100 PMCID: PMC8428017 DOI: 10.1212/nxi.0000000000001067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/15/2021] [Indexed: 02/06/2023]
Abstract
Bruton tyrosine kinase inhibitors (BTKis) encompass a new class of therapeutics currently being evaluated for the treatment of multiple sclerosis (MS). Whether BTKis affect COVID-19 risk or severity or reduce vaccine efficacy are important but unanswered questions. Here, we provide an overview on BTKi mechanisms relevant to COVID-19 infection and vaccination and review preliminary data on BTKi use in patients with COVID-19. BTKis block B-cell receptor– and myeloid fragment crystallizable receptor–mediated signaling, thereby dampening B-cell activation, antibody class-switching, expansion, and cytokine production. Beyond antibodies, COVID-19 severity and vaccine efficacy appear largely linked to T-cell responses and interferon induction, processes not directly affected by BTKis. Given that B cells have clear roles in antigen presentation to T cells, however, it is possible that BTKis may indirectly interfere with beneficial or detrimental T-cell responses during COVID-19 infection or vaccination. In addition to these possible effects on generating a protective immune response, BTKis may attenuate the hyperinflammatory dysregulation often seen in severe cases of COVID-19 that evolves as a key risk factor in this disease. Currently available outcomes from BTKi-treated patients with COVID-19 are discussed. Clinical trials are currently underway to evaluate the safety and efficacy of BTKis in individuals with MS. Although limited data suggest a potential benefit of BTKis on outcomes for some COVID-19 patients, data from adequately powered, prospective and randomized clinical trials are lacking. Likewise, the specific effect of BTKis on the safety and efficacy of COVID-19 vaccines remains to be determined. Any potential unknown risks that BTKi therapy may present to the patient relative to COVID-19 infection, severity, and vaccine efficacy must be balanced with the importance of timely intervention to prevent or minimize MS progression.
Collapse
Affiliation(s)
- Martin S Weber
- From the Institute of Neuropathology (M.S.W.), University Medical Center; Department of Neurology (M.S.W.), University Medical Center, Göttingen, Germany; OhioHealth Multiple Sclerosis Center (J.A.N.), Riverside Methodist Hospital, Columbus, OH; David Geffen School of Medicine (M.R.Y.), University of California, Los Angeles (UCLA); Divisions of Molecular Medicine and Infectious Diseases (M.R.Y.), Harbor-UCLA Medical Center; and Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (M.R.Y.), Torrance, CA.
| | - Jacqueline A Nicholas
- From the Institute of Neuropathology (M.S.W.), University Medical Center; Department of Neurology (M.S.W.), University Medical Center, Göttingen, Germany; OhioHealth Multiple Sclerosis Center (J.A.N.), Riverside Methodist Hospital, Columbus, OH; David Geffen School of Medicine (M.R.Y.), University of California, Los Angeles (UCLA); Divisions of Molecular Medicine and Infectious Diseases (M.R.Y.), Harbor-UCLA Medical Center; and Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (M.R.Y.), Torrance, CA
| | - Michael R Yeaman
- From the Institute of Neuropathology (M.S.W.), University Medical Center; Department of Neurology (M.S.W.), University Medical Center, Göttingen, Germany; OhioHealth Multiple Sclerosis Center (J.A.N.), Riverside Methodist Hospital, Columbus, OH; David Geffen School of Medicine (M.R.Y.), University of California, Los Angeles (UCLA); Divisions of Molecular Medicine and Infectious Diseases (M.R.Y.), Harbor-UCLA Medical Center; and Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center (M.R.Y.), Torrance, CA
| |
Collapse
|
4
|
Haematopoietic Stem Cell Transplant for Norovirus-Induced Intestinal Failure in X-linked Agammaglobulinemia. J Clin Immunol 2021; 41:1574-1581. [PMID: 34164761 PMCID: PMC8221090 DOI: 10.1007/s10875-021-01088-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/14/2021] [Indexed: 12/27/2022]
Abstract
Since the first clinical description in 1952, immunoglobulin replacement therapy remains the mainstay of treatment of patients with X-linked agammaglobulinemia (XLA). However, this therapy only replaces IgG isotype and does not compensate for the loss of Bruton tyrosine kinase in non-B-lymphocytes. Patients may still therefore develop complications despite current standard of care. Here, we describe an XLA patient with persistent chronic norovirus infection, refractory to treatment and causing intestinal failure. The patient underwent haematopoietic stem cell transplantation, curing XLA and allowed clearance of norovirus prior to humoral immunoreconstitution, suggesting non-humoral immunodeficiency in these patients.
Collapse
|
5
|
Vilela MMDS. Human Inborn Errors of Immunity (HIEI): predominantly antibody deficiencies (PADs): if you suspect it, you can detect it. J Pediatr (Rio J) 2021; 97 Suppl 1:S67-S74. [PMID: 33245895 PMCID: PMC9432301 DOI: 10.1016/j.jped.2020.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE This minireview gathers the scientific foundations of the literature on genetic errors in the development of the humoral immune system to help pediatricians suspect these defects. SOURCES A systemic search using the PubMed MEDLINE database was performed for all Predominantly Antibody Deficiencies (PADs) described in the 2020 IUIS Expert Committee for PID classification system, combined with terms for hypogammaglobulinemia. Search terms for PADs were based on the listed names and affected genes as classified by the IUIS 2020. Abstracts of the results were reviewed to find relevant case series, review articles of PADs associated with infection, opportunistic infection, autoimmunity, cytopenias, malignancies, inflammatory diseases, neurological and respiratory diseases. References from relevant articles were further reviewed for additional references. Relevant findings were grouped in accordance with the IUIS 2020 classification system. Clinical and genetic features, if known, were described. DATA SYNTHESIS PADs refer to impaired antibody production due to molecular defects intrinsic to B cells or a failure of interaction between B and T cells. The patients develop recurrent or chronic infection or respond to the antigens with dysregulation of the immune function, causing severe allergy, autoimmunity, inflammation, lymphoproliferation and malignancy. The diagnosis is a combined exercise of clinical and laboratory investigation similar to that performed by Bruton (1952). In the context of SARS-CoV-2 infection, the experience of XLA and CVID patients has been surprising. Variants in 39 genes were reported as causing PADs, but the clinical heterogeneity within each variant is not clear. CONCLUSION Bruton (1952) used clinical expertise and protein electrophoresis to identify XLA. The IUIS (2020) committee used immunoglobulins and B lymphocyte to characterize PADs. Pediatricians should suspect it to detect it and prevent morbidities that can have an astonishing and irreversible impact on the child's life.
Collapse
Affiliation(s)
- Maria Marluce Dos Santos Vilela
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Centro de Investigação em Pediatria, Departamento de Pediatria, Divisão de Alergia e Imunologia Pediátricas, Campinas, SP, Brazil.
| |
Collapse
|
6
|
Abstract
Despite recent advances in the treatment of autoimmune and inflammatory diseases, unmet medical needs in some areas still exist. One of the main therapeutic approaches to alleviate dysregulated inflammation has been to target the activity of kinases that regulate production of inflammatory mediators. Small-molecule kinase inhibitors have the potential for broad efficacy, convenience and tissue penetrance, and thus often offer important advantages over biologics. However, designing kinase inhibitors with target selectivity and minimal off-target effects can be challenging. Nevertheless, immense progress has been made in advancing kinase inhibitors with desirable drug-like properties into the clinic, including inhibitors of JAKs, IRAK4, RIPKs, BTK, SYK and TPL2. This Review will address the latest discoveries around kinase inhibitors with an emphasis on clinically validated autoimmunity and inflammatory pathways. Unmet medical needs in the treatment of autoimmune and inflammatory diseases still exist. This Review discusses the activity of kinases that regulate production of inflammatory mediators and the recent advances in developing inhibitors to target such kinases.
Collapse
|
7
|
Higer M, Cana D, Podlech J, Schadmand-Fischer S, Schwarting A, Teschner D, Theobald M, Wölfel T, Hess G. Life-threatening disseminated enterovirus infection during combined rituximab and ibrutinib maintenance treatment for mantle cell lymphoma: a case report. J Med Case Rep 2020; 14:135. [PMID: 32859260 PMCID: PMC7456041 DOI: 10.1186/s13256-020-02457-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/15/2020] [Indexed: 11/10/2022] Open
Abstract
Background Rituximab is a well-established component of treatment regimens for B-cell non-Hodgkin lymphoma. Rituximab binds the CD20 antigen on the surface of B lymphocytes, causing an enhanced clearance of malignant and benign B cells. Thus, rituximab leads to depletion of normal B lymphocytes as well, which can cause substantial immunodeficiency. Ibrutinib inhibits the Bruton tyrosine kinase and thereby B-cell activity. It is used for the treatment of different B-lymphocyte malignancies, such as mantle cell lymphoma. Recently, the combination of both drugs has been tested in various clinical scenarios. Case presentation We present a case of disseminated enterovirus infection resulting from combined rituximab and ibrutinib maintenance treatment in a 57-year-old Caucasian patient. with mantle cell lymphoma. Initially presenting with myositis symptoms, further diagnostic investigation revealed myocarditis, enteritis, myeloencephalitis, and hepatitis. These organ manifestations led to potentially life-threatening complications such as rhabdomyolysis, delirium, and heart rhythm disturbances. After treatment with high-dose intravenous immunoglobulins, virus clearance was achieved and organ functions could be restored. Conclusions This case emphasizes the risk of combined therapy with rituximab/ibrutinib for severe immune-related side effects with the necessity of continuous patient monitoring. High-dose intravenous therapy should be considered as treatment for severe enterovirus infection. In severe enterovirus infections, we recommend subtyping for the development of efficient preventive and therapeutic strategies.
Collapse
Affiliation(s)
- Maximilian Higer
- Department of Hematology, Medical Oncology & Pneumology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, D-55131, Mainz, Germany.
| | - Denis Cana
- Division of Neuropathology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Juergen Podlech
- Institute for Virology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Simin Schadmand-Fischer
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Andreas Schwarting
- Department of Internal Medicine I (Gastroenterology, Hepatology, Nephrology, Rheumatology, Infectiology and Immunology), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Daniel Teschner
- Department of Hematology, Medical Oncology & Pneumology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, D-55131, Mainz, Germany
| | - Matthias Theobald
- Department of Hematology, Medical Oncology & Pneumology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, D-55131, Mainz, Germany
| | - Thomas Wölfel
- Department of Hematology, Medical Oncology & Pneumology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, D-55131, Mainz, Germany
| | - Georg Hess
- Department of Hematology, Medical Oncology & Pneumology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, D-55131, Mainz, Germany
| |
Collapse
|
8
|
Ye B, Zhou C, Guo H, Zheng M. Effects of BTK signalling in pathogenic microorganism infections. J Cell Mol Med 2019; 23:6522-6529. [PMID: 31397086 PMCID: PMC6787465 DOI: 10.1111/jcmm.14548] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 06/22/2019] [Accepted: 07/02/2019] [Indexed: 02/06/2023] Open
Abstract
As a cytoplasmic protein tyrosine kinase, Bruton's tyrosine kinase (Btk) is widely considered as a vital kinase in many aspects of different physiologic processes. It is engaged in many important signalling pathways related to the immune response, such as the B cell receptor pathway, pattern‐recognition receptor pathway, and triggering receptor expressed on myeloid cell pathway. Recent studies have increasingly focused on the important role of Btk in various inflammatory diseases, which are related to Btk expression in myeloid innate immune cells, such as macrophages, dendritic cells and neutrophils. Although some investigations have explored the role of Btk in microbial infections, many aspects remain elusive, and some of the results are opposite and controversial. Considering the complicated and multiple roles of Btk in the immune system, we summarized the engagement of Btk signalling in various pathogenic microorganism infections, the possible mechanisms involved and its therapeutic potential in the control of infectious diseases.
Collapse
Affiliation(s)
- Bingjue Ye
- The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital of School of Medicine, Zhejiang University, Hangzhou, China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Cheng Zhou
- The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital of School of Medicine, Zhejiang University, Hangzhou, China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Huiting Guo
- The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital of School of Medicine, Zhejiang University, Hangzhou, China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Min Zheng
- The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital of School of Medicine, Zhejiang University, Hangzhou, China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| |
Collapse
|
9
|
Wells AI, Coyne CB. Enteroviruses: A Gut-Wrenching Game of Entry, Detection, and Evasion. Viruses 2019; 11:v11050460. [PMID: 31117206 PMCID: PMC6563291 DOI: 10.3390/v11050460] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 05/08/2019] [Accepted: 05/19/2019] [Indexed: 12/13/2022] Open
Abstract
Enteroviruses are a major source of human disease, particularly in neonates and young children where infections can range from acute, self-limited febrile illness to meningitis, endocarditis, hepatitis, and acute flaccid myelitis. The enterovirus genus includes poliovirus, coxsackieviruses, echoviruses, enterovirus 71, and enterovirus D68. Enteroviruses primarily infect by the fecal–oral route and target the gastrointestinal epithelium early during their life cycles. In addition, spread via the respiratory tract is possible and some enteroviruses such as enterovirus D68 are preferentially spread via this route. Once internalized, enteroviruses are detected by intracellular proteins that recognize common viral features and trigger antiviral innate immune signaling. However, co-evolution of enteroviruses with humans has allowed them to develop strategies to evade detection or disrupt signaling. In this review, we will discuss how enteroviruses infect the gastrointestinal tract, the mechanisms by which cells detect enterovirus infections, and the strategies enteroviruses use to escape this detection.
Collapse
Affiliation(s)
- Alexandra I Wells
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
- Center for Microbial Pathogenesis, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA.
| | - Carolyn B Coyne
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
- Center for Microbial Pathogenesis, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA.
- Richard K. Mellon Institute for Pediatric Research, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA.
| |
Collapse
|