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An Autopsy Case of a 5-Year-Old Child with Acute Pancreatitis Caused by Eosinophilic Granulomatosis with Polyangiitis-like Necrotizing Vasculitis. Case Rep Rheumatol 2019; 2019:9053747. [PMID: 31565459 PMCID: PMC6745468 DOI: 10.1155/2019/9053747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 08/08/2019] [Indexed: 11/18/2022] Open
Abstract
In children, acute pancreatitis has been reported in IgA vasculitis, Kawasaki disease, systemic lupus erythematosus-associated vasculitis, and juvenile dermatomyositis-associated vasculitis. However, its frequency in these vasculitides has been shown to be low. In other childhood-onset vasculitides, acute pancreatitis is seldom reported. The patient was a 5-year-old Japanese boy who suddenly presented with gastrointestinal (GI) bleeding. Therapy with antiulcer drugs successfully stopped bleeding, but subsequently, high fever, leukocytosis, and hypoxia appeared. He died 12 days after he presented with GI bleeding. An autopsy unexpectedly revealed that necrotizing vasculitis with marked eosinophilic and histiocytic infiltration of the pancreas led to acute pancreatitis, and gastric ulcer with eosinophilic infiltration was shown to be the origin of GI bleeding. In addition, eosinophilic infiltration was found in the small intestine, lungs, and bone marrow. Necrotizing vasculitis with eosinophilic and histiocytic infiltration of the pancreas, eosinophilic infiltration of the airway wall, and eosinophilic gastroenteritis with gastric ulcer were histologically confirmed, suggesting that the present case may be an early stage of eosinophilic granulomatosis with polyangiitis- (EGPA-) like vasculitis. To our knowledge, this might be the first reported case of EGPA-like vasculitis presenting with acute pancreatitis in a child.
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Kobayashi T, Kanno K, Kikuchi Y, Kakimoto M, Kawahara A, Kimura K, Ishida R, Miyamori D, Otani Y, Kishikawa N, Tazuma S. An Atypical Case of Non-asthmatic Eosinophilic Granulomatosis with Polyangiitis Finally Diagnosed by Tissue Biopsy. Intern Med 2019; 58:871-875. [PMID: 30449779 PMCID: PMC6465012 DOI: 10.2169/internalmedicine.1167-18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A 78-year-old woman with fever of unknown origin that had persisted for 3 months, systemic edema, and cervical lymphadenopathy was admitted to our hospital. Skin purpura and jaw claudication were subsequently observed. Histopathological examinations of the lymph nodes, skin, and temporal artery revealed findings characteristic of eosinophilic granulomatosis with polyangiitis (EGPA). However, she had no past medical history of asthma with modest eosinophilia. Although EGPA is a systemic vasculitis characterized by asthma and eosinophilia, various limited forms have been described. This was therefore considered to be an atypical form of non-asthmatic EGPA complicating with temporal arteritis (TA) diagnosed by tissue biopsy.
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Affiliation(s)
- Tomoki Kobayashi
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Keishi Kanno
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Yuka Kikuchi
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Masaki Kakimoto
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Akihiro Kawahara
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Kazuki Kimura
- Department of Community Based Medical System, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Ryoko Ishida
- Department of Community Based Medical System, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Daisuke Miyamori
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Yuichiro Otani
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Nobusuke Kishikawa
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Susumu Tazuma
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
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Natarajan V, Jose D, John K, Das AK. Portal Venous Thrombosis: Eosinophilic Vasculitis. J Clin Diagn Res 2017; 11:OD04-OD05. [PMID: 28511440 DOI: 10.7860/jcdr/2017/25235.9575] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 02/06/2017] [Indexed: 01/11/2023]
Abstract
Portal Vein Thrombosis (PVT) is caused by various thrombophilic states. PVT secondary to underlying vasculitis especially Churg-Strauss disease is among the rarest presentation. Here, we report a case of peripheral eosinophilia, eosinophilic ascitis and venous thrombosis involving portal vein and superior mesenteric vein diagnosed as Churg-Strauss Syndrome (CSS). He was managed with steroids and anticoagulants. Following initiation of steroids, eosinophilia and eosinophilic ascitis improved.
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Affiliation(s)
- Vasanthi Natarajan
- Assistant Professor, Department of Internal Medicine/Endocrinology, Pondicherry Institute of Medical Sciences, Puducherry, India
| | - David Jose
- Assistant Professor, Department of Internal Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
| | - Kevin John
- Senior Resident, Department of Internal Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
| | - Ashok Kumar Das
- Professor, Department of Internal Medicine/Endocrinology, Pondicherry Institute of Medical Sciences, Puducherry, India
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Chen Y, Ding Y, Liu Z, Zhang H, Liu Z, Hu W. Long-term outcomes in antineutrophil cytoplasmic autoantibody-positive eosinophilic granulomatosis with polyangiitis patients with renal involvement: a retrospective study of 14 Chinese patients. BMC Nephrol 2016; 17:101. [PMID: 27461086 PMCID: PMC4962371 DOI: 10.1186/s12882-016-0319-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 07/20/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The clinic-pathological features and outcomes of Chinese patients with antineutrophil cytoplasmic autoantibody (ANCA)-positive eosinophilic granulomatosis with polyangiitis (EGPA) and renal involvement have not been studied. METHODS Fourteen EGPA patients with renal involvement were included. All patients underwent renal biopsy. Clinic-pathological features and outcomes were retrospectively analyzed. RESULTS The most common initial symptom of EGPA was asthma (57.1 %), followed by hemoptysis (21.4 %), gross hematuria (14.3 %), and arthritis (7.1 %). All patients had positive serum ANCA (anti-MPO in 12, anti-PR3 in 2). Elevated eosinophils (median 15 %, range 10-45 %) were found in all patients. The median serum IgE level was 463 g/L (range 200-1000 g/L). All patients presented with renal dysfunction, with a median SCr of 5.4 mg/dL (range 1.47-11 mg/dL), seven patients (50 %) required initial renal replacement therapy. Thirteen patients showed hematuria and proteinuria (median 1.1 g/24 h, range 0.5-7.8 g/24 h). Renal biopsy showed pauci-immune segmental necrotizing glomerulonephritis with crescents in 13 patients and acute interstitial nephritis in one patient. Twelve patients (85.7 %) showed renal interstitial eosinophil infiltration, among whom three had eosinophilic granuloma. Among seven patients (71.4 %) who required initial dialysis, 5 discontinued dialysis, one died, one received maintenance dialysis after glucocorticoids plus immunosuppressive for induction treatment. Twelve patients were followed up for a median of 43.5 months (range 6-83 months), during follow-up, two patients progressed to end-stage renal disease, nine had chronic kidney disease with eGFR < 60 mL/min, and two patients had normal eGFR. CONCLUSIONS Renal involvement in ANCA-positive EGPA could be severe and showed varied renal histology. Although intensive immunosuppressive therapy effectively improved the renal function, the long-term renal survival was poor. Early diagnosis and treatment are essential to improve long-term renal survival.
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Affiliation(s)
- Yinghua Chen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Yuemei Ding
- Jiangsu Jiangyin People's Hospital, Jiangyin, China
| | - Zhengzhao Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Haitao Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China
| | - Weixin Hu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, 305 East Zhongshan Road, Nanjing, 210002, Jiangsu, China.
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Aly Z, Libman R, Seidman R, Arora R, Siller K, Salamon E, Katz JM. Ischemic and Hemorrhagic Strokes due to Eosinophilic Granulomatosis with Polyangiitis. J Stroke Cerebrovasc Dis 2015; 24:e279-82. [PMID: 26190306 DOI: 10.1016/j.jstrokecerebrovasdis.2015.06.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 05/07/2015] [Accepted: 06/15/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND We report a case of ischemic and hemorrhagic strokes occurring almost simultaneously in a patient diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA) previously known as Churg-Strauss vasculitis. To our knowledge, this is the first known case. METHODS A 59-year-old man presented with a 2-month history of bilateral leg weakness, difficulty ambulating, and dyesthesias. While in the hospital, he developed acute right hand weakness, and magnetic resonance imaging of the brain revealed multiple, bilateral ischemic infarcts. After a few days, he acutely became unresponsive and was found to have a large left frontal hematoma and underwent emergent hematoma evacuation. His weakness was unexplained by the infarcts based on location and so a peripheral process was suspected. RESULTS Nerve conduction studies showed severe axonal sensorimotor neuropathy. A sural nerve biopsy showed necrotizing vasculitis, consistent with EGPA. CONCLUSIONS EGPA is the rarest of the antineutrophilic cytoplasmic antibody vasculitides. The peripheral nervous system is frequently involved, but the central nervous system can also be affected. The vasculitis damages the vessel walls, which leads either to stenosis or to dilatation, resulting in ischemic or bleeding consequences which can occur simultaneously, such as in this case. Caution should be exercised when prescribing antiplatelet therapy to such patients.
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Affiliation(s)
- Zarmeneh Aly
- Department of Neurology, Cushing Neuroscience Institute, Hofstra North Shore-LIJ School of Medicine, Manhasset, New York
| | - Richard Libman
- Department of Neurology, Cushing Neuroscience Institute, Hofstra North Shore-LIJ School of Medicine, Manhasset, New York.
| | - Roberta Seidman
- Department of Pathology, Stony Brook University, Stony Brook, New York
| | - Rohan Arora
- Department of Neurology, Cushing Neuroscience Institute, Hofstra North Shore-LIJ School of Medicine, Manhasset, New York
| | - Keith Siller
- Department of Neurology, Cushing Neuroscience Institute, Hofstra North Shore-LIJ School of Medicine, Manhasset, New York
| | - Elliott Salamon
- Department of Neurology, Cushing Neuroscience Institute, Hofstra North Shore-LIJ School of Medicine, Manhasset, New York
| | - Jeffrey M Katz
- Department of Neurology, Cushing Neuroscience Institute, Hofstra North Shore-LIJ School of Medicine, Manhasset, New York
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Characteristics, prognosis, and outcomes of cutaneous ischemia and gangrene in systemic necrotizing vasculitides: A retrospective multicenter study. Semin Arthritis Rheum 2014; 43:681-8. [DOI: 10.1016/j.semarthrit.2013.09.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 09/04/2013] [Accepted: 09/13/2013] [Indexed: 11/23/2022]
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Amara AW, Bashir K, Palmer CA, Walker HC. Challenges in diagnosis of isolated central nervous system vasculitis. Brain Behav 2011; 1:57-61. [PMID: 22398982 PMCID: PMC3217675 DOI: 10.1002/brb3.12] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 07/18/2011] [Accepted: 07/27/2011] [Indexed: 12/18/2022] Open
Abstract
Isolated central nervous system (CNS) vasculitis is a rare and complicated disorder. Patients typically present with nonspecific neurologic symptoms such as headache and encephalopathy, and have variable progression and severity of the disease. Challenges to definitive diagnosis include the limitations of currently available diagnostic modalities with high likelihood of false-positive or false-negative findings. Imaging, serologic, and cerebrospinal fluid (CSF) evaluation, and even angiography can fail to establish the diagnosis. Often, brain biopsy is required. In order to illustrate these challenges, we report the case of a patient who presented with subacute cognitive decline and was ultimately diagnosed with isolated CNS eosinophilic vasculitis. Initial work-up included CSF and serologic analyses, magnetic resonance imaging (MRI), and cerebral angiography, but definitive diagnosis required brain biopsy. Immunosuppressive therapy resulted in clinical improvement and stabilization. To our knowledge, only one other case of isolated CNS eosinophilic vasculitis has been reported in the literature. We discuss the importance of a high index of clinical suspicion in cases of progressive nonspecific neurologic symptoms.
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Affiliation(s)
- Amy W. Amara
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Khurram Bashir
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Cheryl A. Palmer
- Departments of Pathology and Neurology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Harrison C. Walker
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
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El-Gamal Y. Churg-strauss syndrome in the pediatric age group. World Allergy Organ J 2008; 1:34-40. [PMID: 23283308 PMCID: PMC3650976 DOI: 10.1097/wox.0b013e3181626fde] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2007] [Accepted: 11/16/2007] [Indexed: 12/15/2022] Open
Abstract
The rate of reporting of childhood Churg-Strauss syndrome (CSS) has increased lately because of either increased awareness to the disease or a real increase in incidence. It is defined as one of the antineutrophil cytoplasmic antibody-associated vasculitides, but the antineutrophil cytoplasmic antibody positivity is less reported in pediatric cases. The cause of CSS remains unknown. Several lines of evidence suggest genetic predisposition, which may entail inherited tendency to dysregulation of the cellular immune system. With the addition of leukotriene receptor antagonists to the treatment regimen of asthma, an association to CSS was presumed. However, the nature of this relationship remains to be elucidated. In addition, some environmental factors seem to provoke transient effects that resemble the disease. Patients' symptoms are defined by various degrees of eosinophilic inflammation and necrotizing vasculitis, which may affect any organ. Three clinical stages have been described in the clinical evolution of CSS: prodromal phase involving allergic rhinitis and asthma (usually without family history of atopy), a second phase that involves peripheral eosinophilia and eosinophilic tissue infiltration, and the hallmark of the final phase is systemic vasculitis. Pulmonary disease is a central feature of pediatric CSS, but other manifestations include skin lesions, testicular pain, hypertension, seizures, and nephropathy. More subtle presentations in children include cervical lymphadenopathy, acute abdominal pain, deep venous thrombosis, oral ulceration, multiple colonic ulcers, chorea, bilateral optic neuropathy, and retinal artery occlusions. Churg-Strauss syndrome patients usually respond well to corticosteroid therapy. Several trials reported additional benefit from cyclophosphamide, azathioprine, and methotrexate, whereas the therapeutic effects of etanercept, plasma exchange, and intravenous immunoglobulin therapy are controversial. The relapse rate is approximately 25% to 30%, but corticosteroids have significantly increased survival, which now approaches greater than 75% at 5 years. However, there is limited information about survival or long-term outcome in childhood.
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Affiliation(s)
- Yehia El-Gamal
- The Pediatric Allergy and Immunology Unit, Ain Shams University, Cairo, Egypt. 98 Mohamed Farid St, Cairo 11111, Egypt
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Ferenczi K, Chang T, Camouse M, Han R, Stern R, Willis J, Cooper KD, Gilliam AC. A case of Churg-Strauss syndrome associated with antiphospholipid antibodies. J Am Acad Dermatol 2006; 56:701-4. [PMID: 17175066 PMCID: PMC2573873 DOI: 10.1016/j.jaad.2006.09.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2006] [Revised: 09/21/2006] [Accepted: 09/25/2006] [Indexed: 11/21/2022]
Abstract
Churg-Strauss syndrome (CSS) is a systemic vasculitis affecting both small- and medium-sized blood vessels, almost invariably affecting the lung, and frequently associated with cutaneous involvement. Microvascular vaso-occlusion leading to digital gangrene is not a feature of CSS. We report an unusual case of a patient with CSS with antiphospholipid antibodies who developed severe digital gangrene in addition to cutaneous vasculitis. The presence of antiphospholipid antibodies is not a feature usually seen in association with CSS. While the full clinical spectrum of CSS is still being defined, the identification of additional features associated with this syndrome might help to better understand the pathogenesis of the disease and to have an impact on both management and prognosis.
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Affiliation(s)
- Katalin Ferenczi
- Department of Dermatology, Case / University Hospitals of Cleveland, Cleveland, OH
| | - Timothy Chang
- Department of Dermatology, Case / University Hospitals of Cleveland, Cleveland, OH
| | - Melissa Camouse
- Department of Dermatology, Case / University Hospitals of Cleveland, Cleveland, OH
| | - Rujing Han
- Department of Dermatology, Case / University Hospitals of Cleveland, Cleveland, OH
| | - Robert Stern
- Department of Internal Medicine, Case / University Hospitals of Cleveland, Cleveland, OH
| | - Joseph Willis
- Department of Pathology, Case / University Hospitals of Cleveland, Cleveland, OH
| | - Kevin D. Cooper
- Department of Dermatology, Case / University Hospitals of Cleveland, Cleveland, OH
| | - Anita C. Gilliam
- Department of Dermatology, Case / University Hospitals of Cleveland, Cleveland, OH
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Abstract
We report a patient with eosinophilic prostatitis associated with Churg-Strauss syndrome. A 74-year-old man, who had been treated for asthma, underwent transurethral resection of the prostate. After the operation he had a high temperature of approximately 40 degrees C. The differential blood count revealed marked eosinophilia of 77.5%. The patient received 20-mg prednisolone and dramatically became afebrile. The pathological diagnosis was eosinophilic prostatitis. These findings strongly indicate Churg-Strauss syndrome.
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Affiliation(s)
- Hideo Kiyokawa
- Department of Urology, Komoro Kosei General Hospital , Komoro, Japan.
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Abstract
BACKGROUND Vasculitis is a primary inflammatory process of large, medium-sized, and small blood vessels. There are multiple entities particularly among small vessel vasculitides. Some are life threatening and require treatment with toxic agents. Diagnostic challenges are posed by low prevalence, controversial classification, inconsistency of clinical and pathological features, and the existence of clinical and pathological "look-alikes". Also, patients may present to a variety of medical specialists, and the diagnosis is often unexpected. The cause often is unknown. REVIEW Classification is by vessel size and then on an immunopathologic basis. Generalised and "organ-limited" forms occur. The principal clinical and pathological features are outlined for each of antibasement membrane disease, immune complex disorders including Henoch-Schönlein purpura and cryoglobulinemic vasculitis and the pauci-immune group, which is often associated with antineutrophil cytoplasmic antibody (ANCA), comprising microscopic polyangiitis, Wegener's granulomatosis, and Churg-Strauss syndrome. A brief account is given of "look-alikes" including microthrombotic conditions, which can confound the diagnosis of small vessel vasculitis. CONCLUSION Requirements for diagnosis include full disclosure of the past and present medical history with review of laboratory results, especially diagnostic immunology. Histology should be of targeted biopsies of recent active lesions in preference to blind biopsies. Sampling should be extensive using high-quality thin sections. Systematic microscopic evaluation of architectural features and cellular detail is necessary. Tissue immunofluorescence is a useful adjunct. The final opinion must take all available information into account but may ultimately depend on a critical judgement by the pathologist.
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Affiliation(s)
- David John Davies
- South Western Area Pathology Service Sydney, Liverpool, NSW 2170, Australia
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