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Liu ES, Wu YT, Liang WM, Kuo FY. Association of scrub typhus with the risk of venous thromboembolism and long-term mortality: a population-based cohort study. Eur J Clin Microbiol Infect Dis 2024:10.1007/s10096-024-04793-z. [PMID: 38472518 DOI: 10.1007/s10096-024-04793-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 02/26/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND The existing literature lacks studies examining the epidemiological link between scrub typhus and deep vein thrombosis (DVT) or pulmonary embolism (PE), and the long-term outcomes. The objective of this study is to explore the potential association between scrub typhus and the subsequent risk of venous thromboembolism, and long-term mortality. METHOD This nationwide cohort study identified 10,121 patients who were newly diagnosed with scrub typhus. Patients with a prior DVT or PE diagnosis before the scrub typhus infection were excluded. A comparison cohort of 101,210 patients was established from the general population using a propensity score matching technique. The cumulative survival HRs for the two cohorts were calculated by the Cox proportional hazards model. RESULT After adjusting for sex, age, and comorbidities, the scrub typhus group had an adjusted HR (95% CI) of 1.02 (0.80-1.30) for DVT, 1.11 (0.63-1.93) for PE, and 1.16 (1.08-1.25) for mortality compared to the control group. The post hoc subgroup analysis revealed that individuals younger than 55 years with a prior scrub typhus infection had a significantly higher risk of DVT (HR: 1.59; 95% CI: 1.12-2.25) and long-term mortality (HR: 1.75; 95% CI, 1.54-1.99). CONCLUSION The scrub typhus patients showed a 16% higher risk of long-term mortality. For those in scrub typhus cohort below 55 years of age, the risk of developing DVT was 1.59 times higher, and the risk of mortality was 1.75 times higher. Age acted as an effect modifier influencing the relationship between scrub typhus and risk of new-onset DVT and death.
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Affiliation(s)
- En-Shao Liu
- Cardiovascular Medical Center, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist, Kaohsiung City, 813, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Ting Wu
- Cardiovascular Medical Center, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist, Kaohsiung City, 813, Taiwan
| | - Wen-Miin Liang
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Feng-Yu Kuo
- Cardiovascular Medical Center, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist, Kaohsiung City, 813, Taiwan.
- Department of Pharmacy and Master Program, College of Pharmacy and Health Care, Tajen University, Pingtung, Taiwan.
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2
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Kim D, Cho YH, Bong JB, Kim YS, Shin BS, Kang HG. Acute ischemic stroke in Tsutsugamushi: understanding the underlying mechanisms and risk factors. BMC Neurol 2024; 24:42. [PMID: 38267851 PMCID: PMC10807141 DOI: 10.1186/s12883-024-03534-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 01/11/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Tsutsugamushi (scrub typhus) is an acute infectious febrile disease common in the Asia-Pacific region. Common symptoms of tsutsugamushi include lymphadenopathy, fever, and myalgia, and it rarely causes acute ischemic stroke (AIS). However, we hypothesized that tsutsugamushi infection could trigger AIS. METHOD We retrospectively examined patients diagnosed with AIS within 2 weeks of tsutsugamushi diagnosis at three hospitals over a 15-year period. We categorized patients who developed AIS while being treated for tsutsugamushi as the case group and those (of similar age and sex) who did not develop AIS as the control group. The case and control groups consisted of 22 and 66 participants, respectively. When a scattered pattern was observed or lesions were found in two or more vascular territories on diffusion-weighted imaging, the pattern was defined as embolic. Other patterns were defined as nonembolic. RESULTS Among the 19 patients, excluding three with transient ischemic stroke, 15 (78.9%) showed an embolic pattern. Although fever was common in the control group, it was less common in the case group. A higher D-dimer level at the time of hospitalization was associated with the development of AIS in patients with tsutsugamushi. CONCLUSIONS AIS in patients with tsutsugamushi showed an embolic rather than a non-embolic pattern on brain magnetic resonance imaging. It was more likely to occur in patients with risk factors for stroke. Tsutsugamushi patients with AIS were likely to have no fever or high D-dimer levels. We hypothesized that D-dimers play an important role in the pathophysiology, where tsutsugamushi infection increases the likelihood of AIS.
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Affiliation(s)
- Dain Kim
- Medical School, Jeonbuk National University, Jeonju, 54907, South Korea
| | - Yeon Hee Cho
- Medical School, Jeonbuk National University, Jeonju, 54907, South Korea
| | - Jeong Bin Bong
- Department of Neurology, Chosun University School of Medicine, Gwangju, 64153, South Korea
| | - Young Seo Kim
- Department of Neurology, Wonkwang University School of Medicine, Iksan, 54538, South Korea
| | - Byoung-Soo Shin
- Department of Neurology, Research Institute of Clinical Medicine of Jeonbuk National University, 20 Geonji-ro, Deokjin-gu, Jeonju-si, 54907, Jeonbuk-do, South Korea
- Biomedical Research Institute, Jeonbuk National University Medical School and Hospital, 20 Geonji-ro, Deokjin-gu, Jeonju, 54907, Jeonju, South Korea
| | - Hyun Goo Kang
- Department of Neurology, Research Institute of Clinical Medicine of Jeonbuk National University, 20 Geonji-ro, Deokjin-gu, Jeonju-si, 54907, Jeonbuk-do, South Korea.
- Biomedical Research Institute, Jeonbuk National University Medical School and Hospital, 20 Geonji-ro, Deokjin-gu, Jeonju, 54907, Jeonju, South Korea.
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Muacevic A, Adler JR, Upadhyay A, Dubey K. Disseminated Intravascular Coagulation Manifesting as Diffuse Alveolar Hemorrhage in a Scrub Typhus Patient: A Rarely Thought of Complication. Cureus 2022; 14:e32974. [PMID: 36712722 PMCID: PMC9879597 DOI: 10.7759/cureus.32974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2022] [Indexed: 12/28/2022] Open
Abstract
Scrub typhus is a common cause of an acute, unexplained febrile illness. Without proper treatment, it can lead to life-threatening complications and even death. We present the case of a 16-year-old girl who presented with complaints of fever with reddish spots all over her body for 10 days and breathing difficulty for three days. She had an episode of gum bleeding just prior to admission and two episodes of hemoptysis after admission. She had severe thrombocytopenia, a low serum fibrinogen level, raised D-dimer levels, a raised activated partial thromboplastin time as well as a raised prothrombin time, and an international normalized ratio. Her chest radiograph showed diffuse bilateral interstitial infiltrates. A diagnosis of disseminated intravascular coagulation and diffuse alveolar hemorrhage secondary to possible hematological malignancy or vector-borne infectious disease was made. She was treated with intravenous doxycycline and broad-spectrum antibiotics, along with other supportive measures. Bone marrow aspiration and biopsy showed normal trilineage differentiation, normal erythropoiesis, myelopoiesis, and megakaryopoiesis. Finally, a positive immunoglobulin M (IgM) antibody for scrub typhus clinched the diagnosis. Her condition improved over the next week, and she was discharged with the advice to continue oral doxycycline for a week. This case highlights one of the rare complications of scrub typhus, disseminated intravascular coagulation, and the importance of timely initiation of treatment in such patients.
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Tantibhedhyangkul W, Matamnan S, Longkunan A, Boonwong C, Khowawisetsut L. Endothelial Activation in Orientia tsutsugamushi Infection Is Mediated by Cytokine Secretion From Infected Monocytes. Front Cell Infect Microbiol 2021; 11:683017. [PMID: 34368012 PMCID: PMC8340038 DOI: 10.3389/fcimb.2021.683017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/06/2021] [Indexed: 12/24/2022] Open
Abstract
Scrub typhus, caused by Orientia tsutsugamushi, is a common systemic infection in Asia. Delay in diagnosis and treatment can lead to vasculitis in the visceral organs and other complications. The mechanisms that drive endothelial activation and the inflammatory response in O. tsutsugamushi infection remain unknown. In addition, the interaction between monocytes and endothelial cells is still unclear. Here we demonstrate that O. tsutsugamushi-infected human dermal microvascular endothelial cells produced moderate levels of chemokines and low levels of IL-6 and IFN-β, but not TNF or IL-1β. Recombinant TNF and cytokine-rich supernatants from infected monocytes markedly enhanced chemokine production in infected endothelial cells. We also show that TNF and monocyte supernatants, but not O. tsutsugamushi infection of endothelial cells per se, upregulated the endothelial cell surface expression of ICAM-1, E-selectin, and tissue factor. This finding was consistent with the inability of O. tsutsugamushi to induce cytokine secretion from endothelial cells. The upregulation of surface molecules after stimulation with monocyte supernatants was significantly reduced by neutralizing anti-TNF antibodies. These results suggest that endothelial cell activation and response are mainly mediated by inflammatory cytokines secreted from monocytes.
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Affiliation(s)
- Wiwit Tantibhedhyangkul
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sutthicha Matamnan
- Graduate Program in Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Research Division, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Asma Longkunan
- Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Graduate Program in Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chawikan Boonwong
- Research Division, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ladawan Khowawisetsut
- Department of Parasitology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Williams V, Menon N, Bhatia P, Biswal M, Sreedharanunni S, Jayashree M, Nallasamy K. Hyperferritinemia in children hospitalized with scrub typhus. Trop Med Health 2021; 49:15. [PMID: 33597024 PMCID: PMC7890859 DOI: 10.1186/s41182-021-00304-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 02/01/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Hyperferritinemia is increasingly associated with mortality in sepsis. Studies estimating the prevalence of hyperferritinemia in pediatric scrub typhus are limited. METHODS This was a secondary analysis of a prospective observational study (FERRIS) from a tertiary care teaching hospital in North India where 72 children with confirmed scrub typhus, 4 (5.5%) PCR positive, 55 (76.4%)-IgM ELISA positive, and 13 (18.1%)-both PCR and ELISA positive, were analyzed. Serum ferritin was measured in 62 children to identify the prevalence of hyperferritinemia and determine its association with mortality. RESULTS Hyperferritinemia (> 500 μg/L) was seen in 72.6% [n = 45] children; 26 (41.9%) were mild (500-2000 μg/L), 13 (21%) were moderate (2000-10,000 μg/L), and 6 (9.7%) were severe (> 10,000 μg/L). Early presentation to hospital (≤ 7 days of febrile illness) had more survivors than late presentation (> 7 days). Non-survivors had significantly higher PRISM III, PELOD-2, hyperlactatemia, hypoalbuminemia, organ dysfunction, need for mechanical ventilation, and need of RRT. Ferritin had poor sensitivity and specificity in predicting survival with AUC of 0.56. Organ dysfunction and risk scores as PRISM III, PELOD 2, and VIS at admission were better predictors with AUC (95% CI) of 0.72 (0.56, 0.89), 0.77 (0.63, 0.92), and 0.90 (0.78, 1.0) respectively. CONCLUSIONS Hyperferritinemia is common in scrub typhus but it did not predict survival. Organ dysfunction and risk scores were better predictors of mortality than ferritin.
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Affiliation(s)
- Vijai Williams
- Division of Pediatric Emergency and Intensive care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Sector-12, Chandigarh, 160012, India
| | - Nisha Menon
- Division of Pediatric Emergency and Intensive care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Sector-12, Chandigarh, 160012, India
| | - Prateek Bhatia
- Division of Pediatric Hematology, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Manisha Biswal
- Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Sreejesh Sreedharanunni
- Department of Hematology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Muralidharan Jayashree
- Division of Pediatric Emergency and Intensive care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Sector-12, Chandigarh, 160012, India
| | - Karthi Nallasamy
- Division of Pediatric Emergency and Intensive care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education & Research, Sector-12, Chandigarh, 160012, India.
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Abstract
Rickettsia monacensis and Orientia tsutsugamushi are bacteria of the family Rickettsiaceae, which causes fever, rash, and eschar formation; outdoor activities are a risk factor for Rickettsiaceae infection. A 75-year-old woman presented with fever, rash, and eschar and was confirmed as being scrub typhus based on a nested-polymerase chain reaction (N-PCR) test for a 56-kDa gene of O. tsutsugamushi; the genome was identified as the Boryong genotype. In addition, a pan-Rickettsia real-time PCR test was positive and a N-PCR test using a Rickettsia-specific partial outer membrane protein A (rOmpA) confirmed R. monacensis. This is the first case wherein a patient suspected of having scrub typhus owing to the presence of rash and eschar was also found to be coinfected with O. tsutsugamushi and R. monacensis based on molecular testing.
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Affiliation(s)
- Seok Won Kim
- Department of Neurosurgery, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Choon-Mee Kim
- Premedical Science, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Dong-Min Kim
- Department of Internal Medicine, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Na Ra Yun
- Department of Internal Medicine, College of Medicine, Chosun University, Gwangju, Republic of Korea
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Li W, Huang L, Zhang W. Scrub typhus with multi-organ dysfunction syndrome and immune thrombocytopenia: a case report and review of the literature. J Med Case Rep 2019; 13:358. [PMID: 31810465 PMCID: PMC6898947 DOI: 10.1186/s13256-019-2299-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 10/18/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Scrub typhus is an acute infectious zoonotic disease caused by Orientia tsutsugamushi. Multi-organ dysfunction secondary to scrub typhus is hard to diagnose and has a high mortality rate. Only one case of scrub typhus with multi-organ dysfunction syndrome and immune thrombocytopenia has been reported thus far. In this study, we report a second case of scrub typhus with multi-organ dysfunction syndrome and immune thrombocytopenia, and we summarize its diagnosis and treatment. CASE PRESENTATION A 43-year-old Han Chinese woman, a sanitation worker, was admitted to our hospital after 7 days of a skin infection and 5 days of a sore throat with fever and dizziness. A physical examination revealed the presence of an eschar on the right side of her neck. She had a history of insect bites during her sanitation work. A diagnostic evaluation identified scrub typhus as the primary illness, which was associated with multi-organ dysfunction syndrome and immune thrombocytopenia. She recovered completely after 15 days of treatment and extensive symptomatic supportive care. CONCLUSION We report a second case of tsutsugamushi disease with multi-organ dysfunction syndrome and immune thrombocytopenia, which resolved after treatment and extensive care.
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Affiliation(s)
- Weijia Li
- Department of Intensive Care Unit, Peking University Shenzhen Hospital, Shenzhen, 518036, People's Republic of China
| | - Lei Huang
- Department of Intensive Care Unit, Peking University Shenzhen Hospital, Shenzhen, 518036, People's Republic of China.
| | - Weixing Zhang
- Department of Intensive Care Unit, Peking University Shenzhen Hospital, Shenzhen, 518036, People's Republic of China.
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Park EC, Lee SY, Yun SH, Choi CW, Lee H, Song HS, Jun S, Kim GH, Lee CS, Kim SI. Clinical proteomic analysis of scrub typhus infection. Clin Proteomics 2018; 15:6. [PMID: 29449793 PMCID: PMC5812041 DOI: 10.1186/s12014-018-9181-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 01/23/2018] [Indexed: 12/14/2022] Open
Abstract
Background
Scrub typhus is an acute and febrile infectious disease caused by the Gram-negative α-proteobacterium Orientia tsutsugamushi from the family Rickettsiaceae that is widely distributed in Northern, Southern and Eastern Asia. In the present study, we analysed the serum proteome of scrub typhus patients to investigate specific clinical protein patterns in an attempt to explain pathophysiology and discover potential biomarkers of infection. Methods Serum samples were collected from three patients (before and after treatment with antibiotics) and three healthy subjects. One-dimensional sodium dodecyl sulphate–polyacrylamide gel electrophoresis followed by liquid chromatography-tandem mass spectrometry was performed to identify differentially abundant proteins using quantitative proteomic approaches. Bioinformatic analysis was then performed using Ingenuity Pathway Analysis. Results Proteomic analysis identified 236 serum proteins, of which 32 were differentially expressed in normal subjects, naive scrub typhus patients and patients treated with antibiotics. Comparative bioinformatic analysis of the identified proteins revealed up-regulation of proteins involved in immune responses, especially complement system, following infection with O. tsutsugamushi, and normal expression was largely rescued by antibiotic treatment. Conclusions This is the first proteomic study of clinical serum samples from scrub typhus patients. Proteomic analysis identified changes in protein expression upon infection with O. tsutsugamushi and following antibiotic treatment. Our results provide valuable information for further investigation of scrub typhus therapy and diagnosis. Electronic supplementary material The online version of this article (10.1186/s12014-018-9181-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Edmond Changkyun Park
- 1Drug & Disease Target Team, Korea Basic Science Institute (KBSI), Cheongju, 28119 Republic of Korea.,2Center for Convergent Research of Emerging Virus Infection, Korea Research Institute of Chemical Technology (KRICT), Daejeon, 34114 Republic of Korea.,3Department of Bio-Analytical Science, University of Science and Technology (UST), Daejeon, 34113 Republic of Korea
| | - Sang-Yeop Lee
- 1Drug & Disease Target Team, Korea Basic Science Institute (KBSI), Cheongju, 28119 Republic of Korea.,2Center for Convergent Research of Emerging Virus Infection, Korea Research Institute of Chemical Technology (KRICT), Daejeon, 34114 Republic of Korea
| | - Sung Ho Yun
- 1Drug & Disease Target Team, Korea Basic Science Institute (KBSI), Cheongju, 28119 Republic of Korea
| | - Chi-Won Choi
- 1Drug & Disease Target Team, Korea Basic Science Institute (KBSI), Cheongju, 28119 Republic of Korea.,4Division of Life Science, Tunneling Nanotube Research Center, Korea University, Seoul, 02841 Republic of Korea
| | - Hayoung Lee
- 1Drug & Disease Target Team, Korea Basic Science Institute (KBSI), Cheongju, 28119 Republic of Korea.,3Department of Bio-Analytical Science, University of Science and Technology (UST), Daejeon, 34113 Republic of Korea
| | - Hyun Seok Song
- 1Drug & Disease Target Team, Korea Basic Science Institute (KBSI), Cheongju, 28119 Republic of Korea.,2Center for Convergent Research of Emerging Virus Infection, Korea Research Institute of Chemical Technology (KRICT), Daejeon, 34114 Republic of Korea.,3Department of Bio-Analytical Science, University of Science and Technology (UST), Daejeon, 34113 Republic of Korea
| | - Sangmi Jun
- 1Drug & Disease Target Team, Korea Basic Science Institute (KBSI), Cheongju, 28119 Republic of Korea.,2Center for Convergent Research of Emerging Virus Infection, Korea Research Institute of Chemical Technology (KRICT), Daejeon, 34114 Republic of Korea.,3Department of Bio-Analytical Science, University of Science and Technology (UST), Daejeon, 34113 Republic of Korea
| | - Gun-Hwa Kim
- 1Drug & Disease Target Team, Korea Basic Science Institute (KBSI), Cheongju, 28119 Republic of Korea.,3Department of Bio-Analytical Science, University of Science and Technology (UST), Daejeon, 34113 Republic of Korea.,4Division of Life Science, Tunneling Nanotube Research Center, Korea University, Seoul, 02841 Republic of Korea
| | - Chang-Seop Lee
- 5Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, 54986 Republic of Korea.,6Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, 54907 Republic of Korea
| | - Seung Il Kim
- 1Drug & Disease Target Team, Korea Basic Science Institute (KBSI), Cheongju, 28119 Republic of Korea.,2Center for Convergent Research of Emerging Virus Infection, Korea Research Institute of Chemical Technology (KRICT), Daejeon, 34114 Republic of Korea.,3Department of Bio-Analytical Science, University of Science and Technology (UST), Daejeon, 34113 Republic of Korea
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