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Bochennek K, Hogardt M, Lehrnbecher T. Immune signatures, testing, and management of febrile neutropenia in pediatric cancer patients. Expert Rev Clin Immunol 2023; 19:267-277. [PMID: 36635981 DOI: 10.1080/1744666x.2023.2168646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Infectious complications, particularly invasive bacterial and fungal infections, are still a major cause of morbidity in pediatric cancer patients and are associated with significant mortality. Over the last few years, there has been much effort in defining risk groups to tailor antimicrobial therapy, and in establishing pediatric-specific guidelines for antimicrobial strategies. AREAS COVERED This review provides a critical overview of defining risk groups for infection, diagnostic work-up, antimicrobial prophylaxis, empirical therapy, and treatment of established infections. EXPERT OPINION To date, no generalizable risk prediction model has been established for pediatric cancer patients. There is growing interest in defining the impact of the individual genetic background on infectious complications. New diagnostic tools have been developed over the last few years, but they need to be validated in pediatric cancer patients. International, pediatric-specific guidelines for antimicrobial prophylaxis, empirical therapy, and treatment of established infections have recently been published and will harmonize antimicrobial strategies in the future.
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Affiliation(s)
- Konrad Bochennek
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University Hospital, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Michael Hogardt
- Institute of Medical Microbiology and Infection Control, University Hospital, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Thomas Lehrnbecher
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University Hospital, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
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Serum Beta-D-Glucan in the Diagnosis of Invasive Fungal Disease in Neonates, Children and Adolescents: A Critical Analysis of Current Data. J Fungi (Basel) 2022; 8:jof8121262. [PMID: 36547595 PMCID: PMC9783846 DOI: 10.3390/jof8121262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 11/27/2022] [Accepted: 11/29/2022] [Indexed: 12/02/2022] Open
Abstract
β-D-glucan (BDG) is a cell wall component of many pathogenic fungi. The detection of BDG as an assay is clinically broadly used as a diagnostic tool. However, the current data on BDG in paediatrics are limited, prompting specific considerations about when BDG can be used in neonates and children. We aimed to analyse the available data for the use of serum BDG in neonates and immunocompromised children and adolescents; as well as to understand the extent and characteristics of the use of BDG in children in Europe.
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Bain V, Barrientos ACMGDA, Suzuki L, Oliveira LAND, Litvinov N, Peron KR, Fernandes JF, Marques HHDS. Radiological patterns of pulmonary fungal infection in pediatric hematology and oncology patients. Radiol Bras 2022; 55:78-83. [PMID: 35414734 PMCID: PMC8993174 DOI: 10.1590/0100-3984.2021.0055] [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: 03/30/2021] [Accepted: 05/20/2021] [Indexed: 11/22/2022] Open
Abstract
Abstract Objective: To describe the radiological findings in pediatric patients with hematological or oncological diseases who also have an invasive fungal infection (IFI). Materials and Methods: This was a retrospective study of all patients with IFI admitted to a pediatric hematology and oncology hospital in Brazil between 2008 and 2014. Clinical and demographic data were collected. Chest computed tomography (CT) scans of the patients were reviewed by two independent radiologists. Results: We evaluated the chest CT scans of 40 pediatric patients diagnosed with an IFI. Twenty-seven patients (67.5%) had nodules with the halo sign, seven (17.5%) had cavities, two (5.0%) had nodules without the halo sign, and seven (17.5%) had consolidation. The patients with the halo sign and cavities were older (123 vs. 77 months of age; p = 0.03) and had less severe disease (34% vs. 73%; p = 0.04). Ten patients had a proven IFI: with Aspergillus sp. (n = 4); with Candida sp. (n = 5); or with Fusarium sp. (n = 1). Conclusion: A diagnosis of IFI should be considered in children and adolescents with risk factors and abnormal CT scans, even if the imaging findings are nonspecific.
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Antifungal Combination Therapy in Children with Cancer-A 4-Year Analysis of Real-Life Data of Two Major Pediatric Cancer Centers. J Fungi (Basel) 2021; 7:jof7080604. [PMID: 34436143 PMCID: PMC8396953 DOI: 10.3390/jof7080604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 07/22/2021] [Accepted: 07/23/2021] [Indexed: 11/17/2022] Open
Abstract
Clinical data on antifungal combination therapy are limited, in particular in the pediatric setting. We analyzed real-life data collected in two major pediatric cancer centers over a period of 4 years. Patients were identified in an observational study on children with acute leukemia and lymphoma or undergoing hematopoietic cell transplantation. Out of 438 patients, 19 patients received 21 episodes of antifungal combination therapy. Therapy was mostly started for sepsis (n = 5) or clinical deterioration with pulmonary infiltrates (n = 10), and less often for periorbital swelling with suspected mold infection (n = 2), clinical deterioration and new skin lesions, secondary antifungal prophylaxis, a persistently elevated galactomannan index, or as pre-emptive treatment (n = 1 each). Diagnostics revealed proven, probable, and possible invasive fungal disease in two, seven and four episodes, respectively. Most regimens included caspofungin (n = 19), and treatment was initiated as first line therapy in 10 episodes. The median duration was 13 days (4-46 days). Nine of the 13 patients with proven, probable, or possible invasive fungal disease survived, which was comparable to patients receiving antifungal monotherapy. Our analysis demonstrates that combination therapy has mainly been prescribed in selected immunocompromised patients with clinical deterioration due to suspected invasive fungal disease or those with sepsis, and is well tolerated. Future studies need to better characterize clinical settings in which patients may benefit from antifungal combination therapy.
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Luckowitsch M, Rudolph H, Bochennek K, Porto L, Lehrnbecher T. Central Nervous System Mold Infections in Children with Hematological Malignancies: Advances in Diagnosis and Treatment. J Fungi (Basel) 2021; 7:168. [PMID: 33652605 PMCID: PMC7996787 DOI: 10.3390/jof7030168] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/21/2021] [Accepted: 02/22/2021] [Indexed: 12/11/2022] Open
Abstract
The incidence of invasive mold disease (IMD) has significantly increased over the last decades, and IMD of the central nervous system (CNS) is a particularly severe form of this infection. Solid data on the incidence of CNS IMD in the pediatric setting are lacking, in which Aspergillus spp. is the most prevalent pathogen, followed by mucorales. CNS IMD is difficult to diagnose, and although imaging tools such as magnetic resonance imaging have considerably improved, these techniques are still unspecific. As microscopy and culture have a low sensitivity, non-culture-based assays such as the detection of fungal antigens (e.g., galactomannan or beta-D-glucan) or the detection of fungal nucleic acids by molecular assays need to be validated in children with suspected CNS IMD. New and potent antifungal compounds helped to improve outcome of CNS IMD, but not all agents are approved for children and a pediatric dosage has not been established. Therefore, studies have to rapidly evaluate dosage, safety and efficacy of antifungal compounds in the pediatric setting. This review will summarize the current knowledge on diagnostic tools and on the management of CNS IMD with a focus on pediatric patients.
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Affiliation(s)
- Marie Luckowitsch
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany; (M.L.); (H.R.); (K.B.)
| | - Henriette Rudolph
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany; (M.L.); (H.R.); (K.B.)
| | - Konrad Bochennek
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany; (M.L.); (H.R.); (K.B.)
| | - Luciana Porto
- Institute for Neuroradiology, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany;
| | - Thomas Lehrnbecher
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, University Hospital Frankfurt, Goethe University, 60590 Frankfurt am Main, Germany; (M.L.); (H.R.); (K.B.)
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Otto WR, Green AM. Fungal infections in children with haematologic malignancies and stem cell transplant recipients. Br J Haematol 2020; 189:607-624. [PMID: 32159231 DOI: 10.1111/bjh.16452] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 10/23/2019] [Indexed: 12/11/2022]
Abstract
Children with haematologic malignancies and haematopoietic stem cell transplant recipients are at high risk for invasive fungal diseases (IFD). There has been an increased number of at-risk children over the past two decades due to improvements in cancer therapies resulting in improved survival of children with high-risk and refractory malignancies. The predominant organisms that cause IFD include Candida spp., Aspergillus spp. and the Mucorales molds. Clinical presentations of IFD vary based on host immune status and the causative organism. Though serum biomarkers such as the galactomannan assay and beta-D-glucan assay have been validated in adults, there are limited data regarding their diagnostic value in children. Thus, the gold standard for IFD diagnosis remains tissue biopsy with histopathological and microbiological evaluation. Treatment of IFD is multimodal and involves antifungal drugs, correction of immune dysfunction and surgical resection when feasible. Paediatric practice regarding IFD is largely extrapolated from data generated in adult patients; in this review, we evaluate both primary paediatric studies and guidelines intended for adult patients that are applied to paediatric patients. There remain significant knowledge gaps with respect to the prevention, diagnosis and treatment of IFD in immunocompromised children, and further research is needed to help guide management decisions.
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Affiliation(s)
- William R Otto
- Division of Infectious Diseases, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Abby M Green
- Division of Infectious Diseases, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Infectious Diseases, Department of Pediatrics, Washington University, St. Louis, MO, USA
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Bochennek K, Luckowitsch M, Lehrnbecher T. Recent advances and future directions in the management of the immunocompromised host. Semin Oncol 2020; 47:40-47. [DOI: 10.1053/j.seminoncol.2020.02.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 02/05/2020] [Accepted: 02/05/2020] [Indexed: 02/07/2023]
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Lehrnbecher T, Rath PM, Attarbaschi A, Cario G, Döring M, Moser O, Mücke U, Poyer F, Rieken S, Temme C, Voigt S, Groll AH, Lauten M. Galactomannan and PCR in the Central Nervous System to Detect Invasive Mold Disease - A Retrospective Analysis in Immunocompromised Children. Sci Rep 2019; 9:12950. [PMID: 31506548 PMCID: PMC6736859 DOI: 10.1038/s41598-019-49426-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 08/23/2019] [Indexed: 01/01/2023] Open
Abstract
Invasive mold disease (IMD) of the central nervous system (CNS) is a severe infectious complication in immunocompromised patients, but early microbiological diagnosis is difficult. As data on the value of biomarkers in the CNS are scarce, in particular in children, we retrospectively analyzed the performance of galactomannan (GM) and PCR assays in CNS samples of 15 children with proven and probable CNS IMD and of 32 immunocompromised children without fungal infection. Galactomannan in the cerebrospinal fluid (CSF) was assessed in nine of the 15 pediatric patients and was positive in five of them. Polymerase chain reaction (PCR) was performed in eight of the 15 patients and detected nucleic acids from molds in six patients. Galactomannan and PCR in CNS samples were the only positive microbiologic parameter in the CNS in three and two patients, respectively. In four patients, PCR specified the pathogen detected in microscopy. Galactomannan and PCR results remained negative in the CSF of all immunocompromised children without evidence for CNS IMD. Our data suggest that GM and PCR in CNS specimens are valuable additional tools in diagnosing CNS IMD and should be included in the work up of all pediatric patients with suspected mold disease of the CNS.
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Affiliation(s)
- Thomas Lehrnbecher
- Pediatric Hematology and Oncology, Hospital for Children and Adolescents, University of Frankfurt, Frankfurt, Germany.
| | - Peter Michael Rath
- Institute of Medical Microbiology, University Hospital Essen, Essen, Germany
| | - Andishe Attarbaschi
- St. Anna Children's Hospital, Medical University of Vienna, Pediatric Hematology and Oncology, Vienna, Austria
| | - Gunnar Cario
- Christian Albrechts University Kiel, Department of Pediatrics, Pediatric Hematology and Oncology, Kiel, Germany
| | - Michaela Döring
- University Children's Hospital Tübingen, Department of Paediatric Haematology and Oncology, Tübingen, Germany
| | - Olga Moser
- University Hospital Aachen, Division of Pediatric Hematology and Oncology, Aachen, Germany
| | - Urs Mücke
- Hannover Medical School, Department of Paediatric Haematology and Oncology, Hannover, Germany
| | - Fiona Poyer
- St. Anna Children's Hospital, Medical University of Vienna, Pediatric Hematology and Oncology, Vienna, Austria
| | - Sarah Rieken
- University of Lübeck, Department of Paediatrics, Paediatric Haematology and Oncology, Lübeck, Germany
| | - Christian Temme
- University Hospital Essen, Department of Paediatrics III, Essen, Germany
| | - Sebastian Voigt
- University Hospital Charité Berlin, Department of Paediatric Haematology and Oncology, Berlin, Germany
| | - Andreas H Groll
- University Children's Hospital Münster, Infectious Disease Research Program, Department of Paediatric Haematology and Oncology, Münster, Germany
| | - Melchior Lauten
- University of Lübeck, Department of Paediatrics, Paediatric Haematology and Oncology, Lübeck, Germany
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Lehrnbecher T. The clinical management of invasive mold infection in children with cancer or undergoing hematopoietic stem cell transplantation. Expert Rev Anti Infect Ther 2019; 17:489-499. [DOI: 10.1080/14787210.2019.1626718] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Thomas Lehrnbecher
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany
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Lehrnbecher T, Schöning S, Poyer F, Georg J, Becker A, Gordon K, Attarbaschi A, Groll AH. Incidence and Outcome of Invasive Fungal Diseases in Children With Hematological Malignancies and/or Allogeneic Hematopoietic Stem Cell Transplantation: Results of a Prospective Multicenter Study. Front Microbiol 2019; 10:681. [PMID: 31040830 PMCID: PMC6476895 DOI: 10.3389/fmicb.2019.00681] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 03/19/2019] [Indexed: 11/23/2022] Open
Abstract
Background: Available data on the incidence and outcome of invasive fungal diseases (IFD) in children with hematological malignancies or after allogeneic hematopoietic stem cell transplantation (HSCT) are mostly based on monocenter, retrospective studies or on studies performed prior to the availability of newer triazoles or echinocandins. Procedure: We prospectively collected clinical data on incidence, diagnostic procedures, management and outcome of IFD in children treated for hematological malignancies or undergoing HSCT in three major European pediatric cancer centers. Results: A total of 304 children (median age 6.0 years) who underwent 360 therapies (211 chemotherapy treatments, 138 allogeneic HSCTs and/or 11 investigational chemotherapeutic treatments) were included in the analysis. Nineteen children developed proven/probable IFD, mostly due to Aspergillus (n = 10) and Candida spp. (n = 5), respectively. In patients receiving chemotherapy, 11 IFDs occurred, all during induction or re-induction therapy. None of these patients died due to IFD, whereas IFD was lethal in 3 of the 8 HSCT recipients with IFD. Significant differences among centers were observed with regard to the use of imaging diagnostics and the choice, initiation and duration of antifungal prophylaxis. Conclusion: This prospective multicenter study provides information on the current incidence and outcome of IFD in the real life setting. Practice variation between the centers may help to ultimately improve antifungal management in children at highest risk for IFDs.
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Affiliation(s)
- Thomas Lehrnbecher
- Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Stefan Schöning
- Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Fiona Poyer
- Pediatric Hematology and Oncology, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Jamina Georg
- Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Andreas Becker
- Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Kathrin Gordon
- Department of Pediatric Hematology and Oncology, Infectious Disease Research Program, Center for Bone Marrow Transplantation, University Children's Hospital Münster, Münster, Germany
| | - Andishe Attarbaschi
- Pediatric Hematology and Oncology, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Andreas H Groll
- Department of Pediatric Hematology and Oncology, Infectious Disease Research Program, Center for Bone Marrow Transplantation, University Children's Hospital Münster, Münster, Germany
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Abstract
PURPOSE OF REVIEW Fever during neutropenia is a common occurrence in children with cancer. A number of studies have recently been performed to refine algorithms regarding initiation, modification, and termination of antimicrobial treatment and are the basis for international pediatric-specific guidelines for the treatment of fever and neutropenia in children with cancer. RECENT FINDINGS Although hospitalization and prompt initiation of intravenous broad-spectrum antibiotics remains the mainstay in the treatment of febrile neutropenic children with cancer, recent research has addressed a number of questions to optimize the management of these patients. Risk prediction rules have been evaluated to allow for individualized treatment intensity and to evaluate the safety of early discontinuation of empirical antibiotic therapy. In addition, the use of preemptive antifungal therapy has been evaluated to decrease the use of antifungal agents. SUMMARY Based on the results of studies in children, pediatric-specific guidelines have been established and are regularly updated.
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Lehrnbecher T, Hassler A, Groll AH, Bochennek K. Diagnostic Approaches for Invasive Aspergillosis-Specific Considerations in the Pediatric Population. Front Microbiol 2018; 9:518. [PMID: 29632518 PMCID: PMC5879093 DOI: 10.3389/fmicb.2018.00518] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 03/07/2018] [Indexed: 11/13/2022] Open
Abstract
Invasive aspergillosis (IA) is a major cause of morbidity and mortality in children with hematological malignancies and those undergoing hematopoietic stem cell transplantation. Similar to immunocompromised adults, clinical signs, and symptoms of IA are unspecific in the pediatric patient population. As early diagnosis and prompt treatment of IA is associated with better outcome, imaging and non-invasive antigen-based such as galactomannan or ß-D-glucan and molecular biomarkers in peripheral blood may facilitate institution and choice of antifungal compounds and guide duration of therapy. In patients in whom imaging studies suggest IA or another mold infection, invasive diagnostics such as bronchoalveolar lavage and/or bioptic procedures should be considered. Here we review the current data of diagnostic approaches for IA in the pediatric setting and highlight the major differences of performance and clinical utility of the tests between children and adults.
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Affiliation(s)
- Thomas Lehrnbecher
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Angela Hassler
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Andreas H Groll
- Infectious Disease Research Program, Center for Bone Marrow Transplantation, Department of Pediatric Hematology/Oncology, University Children's Hospital, Münster, Germany
| | - Konrad Bochennek
- Division of Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany
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Consideration of Invasive Fungal Infections in Immunocompetent Hosts. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2017. [DOI: 10.5812/archcid.66111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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