1
|
Liang J, Kelly DR, Pai A, Gillis LA, Sanchez LHG, Shiau HH, Wang H, Correa H, Mohammad S, Washington K. Clinicopathologic Features of Severe Acute Hepatitis Associated With Adenovirus Infection in Children. Am J Surg Pathol 2023; 47:977-989. [PMID: 37357941 DOI: 10.1097/pas.0000000000002084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
A recent increase in reports of severe acute hepatitis of unknown etiology in children is under investigation. Although adenovirus has been frequently detected, its role remains unclear, and systematic histopathologic analysis is lacking. We conducted a retrospective study of 11 children hospitalized between October 2021 and May 2022 with unexplained acute hepatitis and concurrent adenovirus infection. Liver biopsies collected shortly after admission demonstrated moderately to severely active hepatitis in 8/11 (73%) cases, characterized by marked portal mixed inflammation, moderate-to-severe interface activity, and milder lobular inflammation. Clusters of plasma cells were present in 6/11 (55%) cases, mimicking autoimmune hepatitis. Semiquantitative scoring of 17 discrete histologic features found that greater degrees of portal inflammation, interface activity, bile duct injury, bile ductular reaction, lobular inflammation, Kupffer cell activation, and hepatocyte focal necrosis were significantly more common in these cases in comparison to the control group of unexplained acute severe hepatitis without adenovirus infection. Liver biopsy immunohistochemistry was negative for adenovirus in all cases. Polymerase chain reaction testing of liver tissue was positive for the enteric adenovirus serotypes 41 (species F) in 10/11 (91%) cases. An immunoprofile study of hepatic infiltrating lymphocytes in 1 patient revealed the presence of large numbers of CD3 + and CD4 + lymphocytes. Nine patients received supportive treatment without steroids and recovered without the need for liver transplantation. In summary, liver injury in children with severe acute hepatitis and adenovirus infection is characterized by a hepatitic pattern that resembles severe autoimmune hepatitis and may represent an immune-mediated process associated with viral infection.
Collapse
Affiliation(s)
- Jiancong Liang
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center
| | - David R Kelly
- Department of Pathology and Laboratory Medicine, Children's of Alabama
| | - Anita Pai
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Lynette A Gillis
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Luz Helena Gutierrez Sanchez
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The University of Alabama at Birmingham, Birmingham, AL
| | - Henry H Shiau
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The University of Alabama at Birmingham, Birmingham, AL
| | - Huiying Wang
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center
| | - Hernan Correa
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center
| | - Saeed Mohammad
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Kay Washington
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center
| |
Collapse
|
2
|
Mitchell MM, Leng Y, Boppana S, Britt WJ, Gutierrez Sanchez LH, Elledge SJ. Signatures of AAV-2 immunity are enriched in children with severe acute hepatitis of unknown etiology. Sci Transl Med 2023; 15:eadh9917. [PMID: 37494473 PMCID: PMC10501808 DOI: 10.1126/scitranslmed.adh9917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/21/2023] [Indexed: 07/28/2023]
Abstract
Severe acute hepatitis of unknown etiology in children is under investigation in 35 countries. Although several potential etiologic agents have been investigated, a clear cause for the liver damage observed in these cases remains to be identified. Using VirScan, a high-throughput antibody profiling technology, we probed the antibody repertoires of nine cases of severe acute hepatitis of unknown etiology treated at Children's of Alabama and compared their antibody responses with 38 pediatric and 470 adult controls. We report increased adeno-associated dependoparvovirus A (AAV-A) breadth in cases relative to controls and adeno-associated virus 2 (AAV-2) peptide responses that were conserved in seven of nine cases but rarely observed in pediatric and adult controls. These findings suggest that AAV-2 is a likely etiologic agent of severe acute hepatitis of unknown etiology.
Collapse
Affiliation(s)
- Moriah M. Mitchell
- Division of Genetics, Department of Medicine, Howard Hughes Medical Institute, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Department of Genetics, Harvard Medical School, Boston, MA 02115, USA
- Program in Systems, Synthetic, and Quantitative Biology, Harvard University, Boston, MA 02115, USA
| | - Yumei Leng
- Division of Genetics, Department of Medicine, Howard Hughes Medical Institute, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Department of Genetics, Harvard Medical School, Boston, MA 02115, USA
| | - Suresh Boppana
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - William J. Britt
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Luz Helena Gutierrez Sanchez
- Division of Gastroenterology, Hepatitis, and Nutrition, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Stephen J. Elledge
- Division of Genetics, Department of Medicine, Howard Hughes Medical Institute, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Department of Genetics, Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
3
|
Servellita V, Sotomayor Gonzalez A, Lamson DM, Foresythe A, Huh HJ, Bazinet AL, Bergman NH, Bull RL, Garcia KY, Goodrich JS, Lovett SP, Parker K, Radune D, Hatada A, Pan CY, Rizzo K, Bertumen JB, Morales C, Oluniyi PE, Nguyen J, Tan J, Stryke D, Jaber R, Leslie MT, Lyons Z, Hedman HD, Parashar U, Sullivan M, Wroblewski K, Oberste MS, Tate JE, Baker JM, Sugerman D, Potts C, Lu X, Chhabra P, Ingram LA, Shiau H, Britt W, Gutierrez Sanchez LH, Ciric C, Rostad CA, Vinjé J, Kirking HL, Wadford DA, Raborn RT, St George K, Chiu CY. Adeno-associated virus type 2 in US children with acute severe hepatitis. Nature 2023; 617:574-580. [PMID: 36996871 PMCID: PMC10170441 DOI: 10.1038/s41586-023-05949-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 43.0] [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: 09/11/2022] [Accepted: 03/10/2023] [Indexed: 04/01/2023]
Abstract
As of August 2022, clusters of acute severe hepatitis of unknown aetiology in children have been reported from 35 countries, including the USA1,2. Previous studies have found human adenoviruses (HAdVs) in the blood from patients in Europe and the USA3-7, although it is unclear whether this virus is causative. Here we used PCR testing, viral enrichment-based sequencing and agnostic metagenomic sequencing to analyse samples from 16 HAdV-positive cases from 1 October 2021 to 22 May 2022, in parallel with 113 controls. In blood from 14 cases, adeno-associated virus type 2 (AAV2) sequences were detected in 93% (13 of 14), compared to 4 (3.5%) of 113 controls (P < 0.001) and to 0 of 30 patients with hepatitis of defined aetiology (P < 0.001). In controls, HAdV type 41 was detected in blood from 9 (39.1%) of the 23 patients with acute gastroenteritis (without hepatitis), including 8 of 9 patients with positive stool HAdV testing, but co-infection with AAV2 was observed in only 3 (13.0%) of these 23 patients versus 93% of cases (P < 0.001). Co-infections by Epstein-Barr virus, human herpesvirus 6 and/or enterovirus A71 were also detected in 12 (85.7%) of 14 cases, with higher herpesvirus detection in cases versus controls (P < 0.001). Our findings suggest that the severity of the disease is related to co-infections involving AAV2 and one or more helper viruses.
Collapse
Affiliation(s)
- Venice Servellita
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
| | | | - Daryl M Lamson
- Wadsworth Center, New York State Department of Health, David Axelrod Institute, Albany, NY, USA
| | - Abiodun Foresythe
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Hee Jae Huh
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Adam L Bazinet
- National Biodefense Analysis and Countermeasures Center (NBACC), Frederick, MD, USA
| | - Nicholas H Bergman
- National Biodefense Analysis and Countermeasures Center (NBACC), Frederick, MD, USA
| | - Robert L Bull
- Federal Bureau of Investigation Laboratory Division/Scientific Response and Analysis Unit, Quantico, VA, USA
| | - Karla Y Garcia
- National Biodefense Analysis and Countermeasures Center (NBACC), Frederick, MD, USA
| | - Jennifer S Goodrich
- National Biodefense Analysis and Countermeasures Center (NBACC), Frederick, MD, USA
| | - Sean P Lovett
- National Biodefense Analysis and Countermeasures Center (NBACC), Frederick, MD, USA
| | - Kisha Parker
- National Biodefense Analysis and Countermeasures Center (NBACC), Frederick, MD, USA
| | - Diana Radune
- National Biodefense Analysis and Countermeasures Center (NBACC), Frederick, MD, USA
| | - April Hatada
- California Department of Public Health, Richmond, CA, USA
| | - Chao-Yang Pan
- California Department of Public Health, Richmond, CA, USA
| | - Kyle Rizzo
- California Department of Public Health, Richmond, CA, USA
| | - J Bradford Bertumen
- California Department of Public Health, Richmond, CA, USA
- Centers for Disease Control and Prevention, Atlanta, CA, USA
| | | | - Paul E Oluniyi
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Jenny Nguyen
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Jessica Tan
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Doug Stryke
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Rayah Jaber
- Florida Department of Health, Tallahassee, FL, USA
| | | | - Zin Lyons
- North Carolina Department of Health and Human Services, Raleigh, NC, USA
| | - Hayden D Hedman
- Centers for Disease Control and Prevention, Atlanta, CA, USA
- South Dakota Department of Health, Pierre, SD, USA
| | - Umesh Parashar
- Centers for Disease Control and Prevention, Atlanta, CA, USA
| | - Maureen Sullivan
- Association for Public Health Laboratories, Silver Spring, MD, USA
| | - Kelly Wroblewski
- Association for Public Health Laboratories, Silver Spring, MD, USA
| | | | | | - Julia M Baker
- Centers for Disease Control and Prevention, Atlanta, CA, USA
| | - David Sugerman
- Centers for Disease Control and Prevention, Atlanta, CA, USA
| | - Caelin Potts
- Centers for Disease Control and Prevention, Atlanta, CA, USA
| | - Xiaoyan Lu
- Centers for Disease Control and Prevention, Atlanta, CA, USA
| | - Preeti Chhabra
- Centers for Disease Control and Prevention, Atlanta, CA, USA
| | | | - Henry Shiau
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - William Britt
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Caroline Ciric
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Christina A Rostad
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Jan Vinjé
- Centers for Disease Control and Prevention, Atlanta, CA, USA
| | | | | | - R Taylor Raborn
- National Biodefense Analysis and Countermeasures Center (NBACC), Frederick, MD, USA
| | - Kirsten St George
- Wadsworth Center, New York State Department of Health, David Axelrod Institute, Albany, NY, USA
- Department of Biomedical Science, University at Albany, SUNY, Albany, NY, USA
| | - Charles Y Chiu
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA.
- Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, San Francisco, CA, USA.
- Chan-Zuckerberg Biohub, San Francisco, CA, USA.
| |
Collapse
|
4
|
Banc-Husu AM, Moulton EA, Shiau H, Gutierrez Sanchez LH, Desai MS, Cerminara D, Munoz FM, Buffaloe LM, Valencia-Deray KG, Galvan NTN, Bhatnagar J, Estetter L, Rassaei N, Reagan-Steiner S, Wicker J, Dunn JJ, Allen CE, Patel KR, Harpavat S, Goss JA, Leung DH. Acute liver failure and unique challenges of pediatric liver transplantation amidst a worldwide cluster of adenovirus-associated hepatitis. Am J Transplant 2023; 23:93-100. [PMID: 36695626 DOI: 10.1016/j.ajt.2022.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 01/13/2023]
Abstract
Investigation into a recent cluster of acute hepatitis in children from the southeastern United States identified human adenovirus (HAdV) DNAemia in all 9 cases. Molecular genotyping in 5 of 9 (56%) children identified HAdV type 41 in all cases (100%). Importantly, 2 children from this cluster progressed rapidly to pediatric acute liver failure (PALF) and required liver transplantation. HAdV type 41, a known cause of self-limited gastroenteritis, has not previously been associated with severe cholestatic hepatitis and liver failure in healthy children. Adenovirus polymerase chain reaction assay and sequencing of amplicons performed on DNA extracted from formalin-fixed, paraffin-embedded liver tissue also identified adenovirus species F (HAdV type 40 or 41) in these 2 children with PALF. Transplant considerations and successful liver transplantation in such situations remain scarce. In this report, we describe the clinical course, laboratory results, liver pathology, and treatment of 2 children with PALF associated with HAdV type 41, one of whom developed secondary hemophagocytic lymphohistiocytosis. Their successful posttransplant outcomes demonstrate the importance of early multidisciplinary medical management and the feasibility of liver transplantation in some children with PALF and HAdV DNAemia.
Collapse
Affiliation(s)
- Anna M Banc-Husu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Elizabeth A Moulton
- Division of Infectious Disease, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Henry Shiau
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA; Children's of Alabama, Birmingham, Alabama, USA
| | - Luz Helena Gutierrez Sanchez
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA; Children's of Alabama, Birmingham, Alabama, USA
| | - Moreshwar S Desai
- Pediatric Critical Care and Liver ICU, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Dana Cerminara
- Department of Pharmacy, Texas Children's Hospital, Houston, Texas, USA
| | - Flor M Munoz
- Division of Infectious Disease, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Leanne M Buffaloe
- Division of Infectious Disease, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Kristen G Valencia-Deray
- Division of Infectious Disease, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - N Thao N Galvan
- Division of Abdominal Transplantation and Hepatobiliary Surgery, Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Julu Bhatnagar
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lindsey Estetter
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Negar Rassaei
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sarah Reagan-Steiner
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jason Wicker
- Children's of Alabama, Birmingham, Alabama, USA; Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James J Dunn
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Carl E Allen
- Division of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Kalyani R Patel
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Sanjiv Harpavat
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - John A Goss
- Division of Abdominal Transplantation and Hepatobiliary Surgery, Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.
| |
Collapse
|
5
|
Buchfellner MA, Amanda Ingram L, Shiau H, Sanchez LHG, Saaybi S, Britt W, Sanchez V, Potter JL, Kelly D, Lu X, Ayers-Millsap S, Willeford WG, Rassaei N, Bullock H, Reagen-Steiner S, Martin A, Lamson DM, Parashar UD, Hall AJ, MacNeil A, Tate JE, Kirking HL. 1356. Case Series of Children with Hepatitis and Adenovirus Infection, Alabama, October 2021—February 2022. Open Forum Infect Dis 2022. [PMCID: PMC9752984 DOI: 10.1093/ofid/ofac492.1185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Human adenoviruses (HAdV) are a common cause of respiratory and gastrointestinal infections but rarely cause end-organ disease in children. From October 2021 to February 2022, several previously healthy children admitted to a single center for significant hepatitis also tested positive for HAdV. The aim of this investigation is to describe characteristics of these children. Methods Children admitted to Children’s of Alabama (COA) from October 2021 to February 2022 with hepatitis who tested positive for HAdV by whole blood RT-PCR were included. Demographic, clinical, laboratory and treatment data were collected from medical records. Residual blood specimens were sent for adenovirus typing. Results Nine pediatric patients with hepatitis and HAdV infection were identified (78% female; median age 3.0 years; IQR 1.7-3.0). Before admission, six reported diarrhea and three had respiratory symptoms. At presentation, eight had scleral icterus, six had jaundice, seven had hepatomegaly, and one was encephalopathic. All patients had elevated transaminases (AST range: 447-4000 U/L, ALT range: 784-4695 U/L); initial total bilirubin varied [range 0.23-13.5 mg/dL]). All had confirmed HAdV by RT-PCR on whole blood (initial qPCR range: 991-70,680 copies/mL). Notably, two children who transferred to another facility were negative for HAdV by RT-PCR when plasma was tested (instead of whole blood). Six children underwent liver biopsy showing varying degrees of hepatitis with no adenovirus detected on immunohistochemistry stains. Five children had HAdV type 41 confirmed. Three children presented or progressed to acute liver failure, two children were treated with cidofovir, and two underwent successful liver transplantation. No known epidemiologic links between patients were identified and all were from geographically distinct parts of Alabama. Conclusion HAdV is a potentially underrecognized cause of hepatitis. Whole blood specimens may be preferred over plasma for HAdV RT-PCR testing. HAdV type 41 was identified in all patients with typing results available. Improved type-based surveillance may help determine HAdV patterns of circulation and inform future diagnostic testing. Disclosures William Britt, MD, First Energy Corporation: Stocks/Bonds|Hookipa Pharma: Advisor/Consultant|Kroger Care: Stocks/Bonds|MDU Resources Group: Stocks/Bonds|PG&E Corporation: Stocks/Bonds.
Collapse
Affiliation(s)
- Markus A Buchfellner
- Division of Pediatric Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Henry Shiau
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Luz Helena Gutierrez Sanchez
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Stephanie Saaybi
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Alabama at Birmingham, Birmingham, Alabama
| | - William Britt
- Division of Pediatric Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama
| | - Veronica Sanchez
- Division of Pediatric Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jennifer L Potter
- Division of Pediatric Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama
| | - David Kelly
- Division of Pathology, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Xiaoyan Lu
- Centers for Disease Control and Prevention, Atalnta, Georgia
| | | | | | - Negar Rassaei
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, CDC, Atlanta, Georgia
| | - Hannah Bullock
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, CDC, Atlanta, Georgia
| | - Sarah Reagen-Steiner
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, CDC, Atlanta, Georgia
| | - Ali Martin
- Alabama Department of Public Health, Montgomery, Alabama
| | - Daryl M Lamson
- Wadsworth Center, New York State Department of Health, Albany, New York
| | - Umesh D Parashar
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC, Atlanta, Georgia
| | - Aron J Hall
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC, Atlanta, Georgia
| | - Adam MacNeil
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC, Atlanta, Georgia
| | - Jacqueline E Tate
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC, Atlanta, Georgia
| | | |
Collapse
|
6
|
Baker JM, Buchfellner M, Britt W, Sanchez V, Potter JL, Ingram LA, Shiau H, Sanchez LHG, Saaybi S, Kelly D, Lu X, Vega EM, Ayers-Millsap S, Willeford WG, Rassaei N, Bullock H, Reagan-Steiner S, Martin A, Moulton EA, Lamson DM, St George K, Parashar UD, Hall AJ, MacNeil A, Tate JE, Kirking HL. Acute hepatitis and adenovirus infection among children-Alabama, October 2021-February 2022. Am J Transplant 2022; 22:1919-1921. [PMID: 35789534 DOI: 10.1111/ajt.16665] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Julia M Baker
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC.,Epidemic Intelligence Service, CDC
| | - Markus Buchfellner
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama
| | - William Britt
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama
| | - Veronica Sanchez
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jennifer L Potter
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Henry Shiau
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Alabama at Birmingham, Birmingham, Alabama.,Children's of Alabama, Birmingham, Alabama
| | - Luz Helena Gutierrez Sanchez
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Alabama at Birmingham, Birmingham, Alabama.,Children's of Alabama, Birmingham, Alabama
| | - Stephanie Saaybi
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Alabama at Birmingham, Birmingham, Alabama
| | - David Kelly
- Children's of Alabama, Birmingham, Alabama.,Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Xiaoyan Lu
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC
| | - Everardo M Vega
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC
| | | | | | - Negar Rassaei
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, CDC
| | - Hannah Bullock
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, CDC.,Synergy America, Inc., Duluth, Georgia
| | - Sarah Reagan-Steiner
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, CDC
| | | | - Elizabeth A Moulton
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Baylor College of Medicine, Houston, Texas.,Texas Children's Hospital, Houston, Texas
| | | | - Kirsten St George
- Wadsworth Center, New York State Department of Health.,Department of Biomedical Sciences, University at Albany, Albany, New York
| | - Umesh D Parashar
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC
| | - Aron J Hall
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC
| | - Adam MacNeil
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC
| | - Jacqueline E Tate
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC
| | - Hannah L Kirking
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC
| |
Collapse
|
7
|
Baker JM, Buchfellner M, Britt W, Sanchez V, Potter JL, Ingram LA, Shiau H, Gutierrez Sanchez LH, Saaybi S, Kelly D, Lu X, Vega EM, Ayers-Millsap S, Willeford WG, Rassaei N, Bullock H, Reagan-Steiner S, Martin A, Moulton EA, Lamson DM, St. George K, Parashar UD, Hall AJ, MacNeil A, Tate JE, Kirking HL. Acute Hepatitis and Adenovirus Infection Among Children - Alabama, October 2021-February 2022. MMWR Morb Mortal Wkly Rep 2022; 71:638-640. [PMID: 35511732 PMCID: PMC9098244 DOI: 10.15585/mmwr.mm7118e1] [Citation(s) in RCA: 80] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
8
|
Purvis JW, Orandi BJ, Dhall D, McLeod C, Sanchez LHG, Gray M, Frey K, Sheikh SS, Cannon RM, Terrault NA, Lewis CE, Locke JE. Hepatic macrosteatosis in the US pediatric deceased liver donor population. Pediatr Transplant 2022; 26:e14155. [PMID: 34590386 PMCID: PMC8752486 DOI: 10.1111/petr.14155] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/04/2021] [Accepted: 09/19/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The pediatric obesity epidemic is associated with early development of hepatic macrosteatosis, a hallmark of non-alcoholic fatty LI disease, which is thought to be more rapidly progressive in children than adults. Macrosteatosis in adult allografts is associated with allograft loss, but this has not been examined in pediatric donors. METHODS We studied all pediatric potential whole LI donors (2005-2018) who had a LI biopsy in the SRTR (n = 862) and whose LI was transplanted (n = 862). Macrosteatosis was abstracted from biopsy reports and compared to values in the SRTR standard analytic file. Recipients of macrosteatotic pediatric allografts were matched 1:1 to recipients of non-macrosteatotic pediatric allografts by propensity score matching on donor/recipient variables. All-cause allograft loss was estimated via Kaplan-Meier analysis and Cox proportional hazards model. RESULTS From 2005 to 2018, the proportion of pediatric donors (age ≥2 years) with obesity increased (14.8% to 21.7%; p < .001), as did the proportion of pediatric deceased whole LI-only donor allografts with macrosteatosis (n = 10 648; 1.8% to 3.9%; p < .001). The median degree of macrosteatosis among macrosteatotic donors was 10% (IQR 5-30). There were no significant differences in all-cause allograft loss between recipients of pediatric LI allografts with and without macrosteatosis at 90 days (p = .11) or 1 year (p = .14) post-transplant in Kaplan-Meier analysis or a Cox proportional hazards model (p > .05). CONCLUSION Obese pediatric LI donors have increased over time and were more likely to have hepatic macrosteatosis; however, pediatric macrosteatosis did not appear to adversely affect recipient outcomes.
Collapse
Affiliation(s)
- Joshua W. Purvis
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
| | - Babak J. Orandi
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
| | - Deepti Dhall
- University of Alabama at Birmingham, Department of Pathology; Birmingham, AL
| | - Chandler McLeod
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
| | - Luz Helena Gutierrez Sanchez
- University of Alabama at Birmingham, Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Birmingham, Alabama
| | - Meagan Gray
- University of Alabama at Birmingham, Department of Medicine, Division of Gastroenterology and Hepatology
| | - Kayla Frey
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
| | - Saulat S. Sheikh
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
| | - Robert M. Cannon
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
| | - Norah A. Terrault
- University of Southern California Keck School of Medicine, Department of Medicine, Division of Gastrointestinal and Liver Diseases
| | - Cora E. Lewis
- University of Alabama at Birmingham, School of Public Health, Department of Epidemiology
| | - Jayme E. Locke
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation; Birmingham, AL
| |
Collapse
|
9
|
Smith M, Ryan KJ, Gutierrez H, Sanchez LHG, Anderson JN, Acosta EP, Benner KW, Guimbellot JS. Ivacaftor-elexacaftor-tezacaftor and tacrolimus combination in cystic fibrosis. J Cyst Fibros 2022; 21:e8-e10. [PMID: 34130909 PMCID: PMC8665941 DOI: 10.1016/j.jcf.2021.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/05/2021] [Accepted: 05/14/2021] [Indexed: 01/03/2023]
Abstract
The CFTR modulator combination elexacaftor/tezacaftor/ivacaftor (ETI) is a genetic mutation-targeted treatment in cystic fibrosis that results in profound improvements in clinical outcomes. Each of the compounds are substrates of CYP3A4/5, the cytochrome P450 enzyme family for which tacrolimus is also a substrate. The use of these compounds in an individual with a solid organ transplant has not been previously studied and there is potential for a drug interaction. In this report, we describe a pediatric liver transplant recipient with clinical decline related to cystic fibrosis who improved substantially with ETI, without significant impact on the systemic exposure of either ETI or tacrolimus.
Collapse
Affiliation(s)
- Megan Smith
- McWhorter School of Pharmacy, Samford University, Birmingham, AL
| | - Kevin J. Ryan
- Department of Pharmacology and Toxicology, UAB, Birmingham, AL
| | - Hector Gutierrez
- Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham (UAB), Birmingham, AL,Department of Pediatrics, Division of Pulmonary and Sleep Medicine, UAB, Birmingham, AL
| | | | - Janaina Nogueira Anderson
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Medical University of South Carolina, Charleston, SC
| | - Edward P. Acosta
- Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham (UAB), Birmingham, AL,Department of Pharmacology and Toxicology, UAB, Birmingham, AL
| | - Kim W. Benner
- McWhorter School of Pharmacy, Samford University, Birmingham, AL
| | - Jennifer S. Guimbellot
- Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham (UAB), Birmingham, AL,Department of Pediatrics, Division of Pulmonary and Sleep Medicine, UAB, Birmingham, AL,Corresponding Author: , University of Alabama at Birmingham, Department of Pediatrics, Pediatric Pulmonary & Sleep Medicine, Lowder Building, Suite 620, 1600 7 Avenue South, Birmingham, AL 35233
| |
Collapse
|
10
|
Orandi BJ, Li G, Dhall D, Bajpai P, Manne U, Arora N, Lu A, Coronado AC, Kassel R, Pinninti S, Lewis CE, Chapleau C, Locke JE, Gutierrez Sanchez LH. Acute Liver Failure in a Healthy Young Female With COVID-19. JPGN Rep 2021; 2:e108. [PMID: 37205955 PMCID: PMC10191572 DOI: 10.1097/pg9.0000000000000108] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/09/2021] [Indexed: 05/21/2023]
Abstract
Several well-described manifestations of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been reported. Among them, a transient elevation of liver enzymes is the typical presentation of coronavirus disease 2019 (COVID-19) liver-related injury. The mechanism of liver involvement is likely a combination of viral injury and immune-mediated inflammation. In contrast, acute liver failure in the setting of COVID-19 has rarely been reported. Herein, we report a case of pediatric acute liver failure in a previously healthy female adolescent infected with SARS-CoV-2 with biopsy evidence of replicating virus in hepatocytes, which has not been previously reported.
Collapse
Affiliation(s)
- Babak John Orandi
- From the Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Geling Li
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL
| | - Deepti Dhall
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL
| | - Prachi Bajpai
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL
| | - Upender Manne
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL
| | - Nitin Arora
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Ailing Lu
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Ana Carolina Coronado
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Rachel Kassel
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Swetha Pinninti
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | - Luz Helena Gutierrez Sanchez
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| |
Collapse
|
11
|
Ibrahim SH, Jonas MM, Taylor SA, Sanchez LHG, Wolf JL, Sundaram SS. Liver Diseases in the Perinatal Period: Interactions Between Mother and Infant. Hepatology 2020; 71:1474-1485. [PMID: 31925801 PMCID: PMC7150638 DOI: 10.1002/hep.31109] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 12/19/2019] [Indexed: 12/19/2022]
Abstract
Liver diseases affecting the mother and infant dyad may present in the perinatal period from 20 weeks of gestation to 28 days of life. This review will focus on the current approach to neonatal acute liver failure and the progress made in the diagnosis and management of gestational alloimmune liver disease. It will highlight mother-to-child transmission of viral hepatitis, both management and public health implications. Emerging concepts implicating maternal obesity and nutrition in the development of a rapidly progressive nonalcoholic steatohepatitis phenotype in the offspring will be discussed. Finally, the presentation and management of acute fatty liver of pregnancy and intrahepatic cholestasis of pregnancy, and their impact on the fetus, will be reviewed.
Collapse
Affiliation(s)
- Samar H. Ibrahim
- Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Maureen M. Jonas
- Division of Pediatric Gastroenterology and Hepatology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sarah A. Taylor
- Division of Pediatric Gastroenterology and Hepatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University, Chicago, Illinois
| | | | - Jaqueline L. Wolf
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Shikha S. Sundaram
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| |
Collapse
|
12
|
Cousin MA, Conboy E, Wang JS, Lenz D, Schwab TL, Williams M, Abraham RS, Barnett S, El-Youssef M, Graham RP, Gutierrez Sanchez LH, Hasadsri L, Hoffmann GF, Hull NC, Kopajtich R, Kovacs-Nagy R, Li JQ, Marx-Berger D, McLin V, McNiven MA, Mounajjed T, Prokisch H, Rymen D, Schulze RJ, Staufner C, Yang Y, Clark KJ, Lanpher BC, Klee EW. RINT1 Bi-allelic Variations Cause Infantile-Onset Recurrent Acute Liver Failure and Skeletal Abnormalities. Am J Hum Genet 2019; 105:108-121. [PMID: 31204009 DOI: 10.1016/j.ajhg.2019.05.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 05/13/2019] [Indexed: 01/12/2023] Open
Abstract
Pediatric acute liver failure (ALF) is life threatening with genetic, immunologic, and environmental etiologies. Approximately half of all cases remain unexplained. Recurrent ALF (RALF) in infants describes repeated episodes of severe liver injury with recovery of hepatic function between crises. We describe bi-allelic RINT1 alterations as the cause of a multisystem disorder including RALF and skeletal abnormalities. Three unrelated individuals with RALF onset ≤3 years of age have splice alterations at the same position (c.1333+1G>A or G>T) in trans with a missense (p.Ala368Thr or p.Leu370Pro) or in-frame deletion (p.Val618_Lys619del) in RINT1. ALF episodes are concomitant with fever/infection and not all individuals have complete normalization of liver function testing between episodes. Liver biopsies revealed nonspecific liver damage including fibrosis, steatosis, or mild increases in Kupffer cells. Skeletal imaging revealed abnormalities affecting the vertebrae and pelvis. Dermal fibroblasts showed splice-variant mediated skipping of exon 9 leading to an out-of-frame product and nonsense-mediated transcript decay. Fibroblasts also revealed decreased RINT1 protein, abnormal Golgi morphology, and impaired autophagic flux compared to control. RINT1 interacts with NBAS, recently implicated in RALF, and UVRAG, to facilitate Golgi-to-ER retrograde vesicle transport. During nutrient depletion or infection, Golgi-to-ER transport is suppressed and autophagy is promoted through UVRAG regulation by mTOR. Aberrant autophagy has been associated with the development of similar skeletal abnormalities and also with liver disease, suggesting that disruption of these RINT1 functions may explain the liver and skeletal findings. Clarifying the pathomechanism underlying this gene-disease relationship may inform therapeutic opportunities.
Collapse
|
13
|
Gutierrez Sanchez LH, Tomita K, Guo Q, Furuta K, Alhuwaish H, Hirsova P, Baheti S, Alver B, Hlady R, Robertson KD, Ibrahim SH. Perinatal Nutritional Reprogramming of the Epigenome Promotes Subsequent Development of Nonalcoholic Steatohepatitis. Hepatol Commun 2018; 2:1493-1512. [PMID: 30556038 PMCID: PMC6287484 DOI: 10.1002/hep4.1265] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 09/07/2018] [Indexed: 12/28/2022] Open
Abstract
With the epidemic of obesity, nonalcoholic fatty liver disease (NAFLD) has become the most common pediatric liver disease. The influence of a perinatal obesity‐inducing diet (OID) on the development and progression of NAFLD in offspring is important but incompletely studied. Hence, we fed breeding pairs of C57BL/6J mice during gestation and lactation (perinatally) either chow or an OID rich in fat, fructose, and cholesterol (FFC). The offspring were weaned to either chow or an FFC diet, generating four groups: perinatal (p)Chow‐Chow, pChow‐FFC, pFFC‐Chow, and pFFC‐FFC. Mice were sacrificed at 10 weeks of age. We examined the whole‐liver transcriptome by RNA sequencing (RNA‐seq) and whole‐liver genome methylation by reduced representation bisulfite sequencing (RRBS). Our results indicated that the pFFC‐FFC mice had a significant increase in hepatic steatosis, injury, inflammation, and fibrosis, as assessed histologically and biochemically. We identified 189 genes that were differentially expressed and methylated in the pFFC‐FFC mice versus the pChow‐FFC mice. Gene set enrichment analysis identified hepatic fibrosis/hepatic stellate cell activation as the top canonical pathway, suggesting that the differential DNA methylation events in the mice exposed to the FFC diet perinatally were associated with a profibrogenic transcriptome. To verify that this finding was consistent with perinatal nutritional reprogramming of the methylome, we exposed pFFC‐Chow mice to an FFC diet in adulthood. These mice developed significant hepatic steatosis, injury, inflammation, and more importantly fibrosis when compared to the appropriate controls. Conclusion: Perinatal exposure to an OID primes the immature liver for an accentuated fibrosing nonalcoholic steatohepatitis (NASH) phenotype, likely through nutritional reprogramming of the offspring methylome. These data have potential clinical implications for monitoring children of obese mothers and risk stratification of children with NAFLD.
Collapse
Affiliation(s)
| | - Kyoko Tomita
- Division of Gastroenterology and Hepatology Mayo Clinic Rochester MN
| | - Qianqian Guo
- Division of Gastroenterology and Hepatology Mayo Clinic Rochester MN
| | - Kunimaro Furuta
- Division of Gastroenterology and Hepatology Mayo Clinic Rochester MN
| | - Husam Alhuwaish
- Division of Gastroenterology and Hepatology Mayo Clinic Rochester MN
| | - Petra Hirsova
- Division of Gastroenterology and Hepatology Mayo Clinic Rochester MN.,Institute of Clinical Biochemistry and Diagnostics University Hospital Hradec Kralove Hradec Kralove Czech Republic
| | - Saurabh Baheti
- Division of Biomedical Statistics and Informatics Mayo Clinic Rochester MN
| | - Bonnie Alver
- Department of Molecular Pharmacology and Experimental Therapeutics Mayo Clinic Rochester MN
| | - Ryan Hlady
- Department of Molecular Pharmacology and Experimental Therapeutics Mayo Clinic Rochester MN
| | - Keith D Robertson
- Department of Molecular Pharmacology and Experimental Therapeutics Mayo Clinic Rochester MN
| | - Samar H Ibrahim
- Division of Pediatric Gastroenterology and Hepatology Mayo Clinic Rochester MN.,Division of Gastroenterology and Hepatology Mayo Clinic Rochester MN
| |
Collapse
|