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Brasil P, Pereira JP, Moreira ME, Ribeiro Nogueira RM, Damasceno L, Wakimoto M, Rabello RS, Valderramos SG, Halai UA, Salles TS, Zin AA, Horovitz D, Daltro P, Boechat M, Raja Gabaglia C, Carvalho de Sequeira P, Pilotto JH, Medialdea-Carrera R, Cotrim da Cunha D, Abreu de Carvalho LM, Pone M, Machado Siqueira A, Calvet GA, Rodrigues Baião AE, Neves ES, Nassar de Carvalho PR, Hasue RH, Marschik PB, Einspieler C, Janzen C, Cherry JD, Bispo de Filippis AM, Nielsen-Saines K. Zika Virus Infection in Pregnant Women in Rio de Janeiro. N Engl J Med 2016; 375:2321-2334. [PMID: 26943629 PMCID: PMC5323261 DOI: 10.1056/nejmoa1602412] [Citation(s) in RCA: 1386] [Impact Index Per Article: 173.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Zika virus (ZIKV) has been linked to central nervous system malformations in fetuses. To characterize the spectrum of ZIKV disease in pregnant women and infants, we followed patients in Rio de Janeiro to describe clinical manifestations in mothers and repercussions of acute ZIKV infection in infants. METHODS We enrolled pregnant women in whom a rash had developed within the previous 5 days and tested blood and urine specimens for ZIKV by reverse-transcriptase-polymerase-chain-reaction assays. We followed women prospectively to obtain data on pregnancy and infant outcomes. RESULTS A total of 345 women were enrolled from September 2015 through May 2016; of these, 182 women (53%) tested positive for ZIKV in blood, urine, or both. The timing of acute ZIKV infection ranged from 6 to 39 weeks of gestation. Predominant maternal clinical features included a pruritic descending macular or maculopapular rash, arthralgias, conjunctival injection, and headache; 27% had fever (short-term and low-grade). By July 2016, a total of 134 ZIKV-affected pregnancies and 73 ZIKV-unaffected pregnancies had reached completion, with outcomes known for 125 ZIKV-affected and 61 ZIKV-unaffected pregnancies. Infection with chikungunya virus was identified in 42% of women without ZIKV infection versus 3% of women with ZIKV infection (P<0.001). Rates of fetal death were 7% in both groups; overall adverse outcomes were 46% among offspring of ZIKV-positive women versus 11.5% among offspring of ZIKV-negative women (P<0.001). Among 117 live infants born to 116 ZIKV-positive women, 42% were found to have grossly abnormal clinical or brain imaging findings or both, including 4 infants with microcephaly. Adverse outcomes were noted regardless of the trimester during which the women were infected with ZIKV (55% of pregnancies had adverse outcomes after maternal infection in the first trimester, 52% after infection in the second trimester, and 29% after infection in the third trimester). CONCLUSIONS Despite mild clinical symptoms in the mother, ZIKV infection during pregnancy is deleterious to the fetus and is associated with fetal death, fetal growth restriction, and a spectrum of central nervous system abnormalities. (Funded by Ministério da Saúde do Brasil and others.).
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Affiliation(s)
- Patrícia Brasil
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - José P Pereira
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - M Elisabeth Moreira
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Rita M Ribeiro Nogueira
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Luana Damasceno
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Mayumi Wakimoto
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Renata S Rabello
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Stephanie G Valderramos
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Umme-Aiman Halai
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Tania S Salles
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Andrea A Zin
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Dafne Horovitz
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Pedro Daltro
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Marcia Boechat
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Claudia Raja Gabaglia
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Patrícia Carvalho de Sequeira
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - José H Pilotto
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Raquel Medialdea-Carrera
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Denise Cotrim da Cunha
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Liege M Abreu de Carvalho
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Marcos Pone
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - André Machado Siqueira
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Guilherme A Calvet
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Ana E Rodrigues Baião
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Elizabeth S Neves
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Paulo R Nassar de Carvalho
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Renata H Hasue
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Peter B Marschik
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Christa Einspieler
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Carla Janzen
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - James D Cherry
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Ana M Bispo de Filippis
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
| | - Karin Nielsen-Saines
- From Fundação Oswaldo Cruz (P.B., J.P.P., M.E.M., R.M.R.N., L.D., M.W., R.S.R., T.S.S, A.A.Z., D.H., M.B., P.C.S., J.H.P., R.M.-C., D.C.C., L.M.A.C., M.P., A.M.S., G.A.C., A.E.R.B., E.S.N., P.R.N.C., A.M.B.F.); and Clinica de Diagnostico por Imagem (P.D.) - both in Rio de Janeiro; David Geffen UCLA School of Medicine, Los Angeles (S.G.V., U.-A.H., C.J., J.D.C., K.N.-S.), and Biomedical Research Institute of Southern California, Oceanside (C.R.G.) - both in California; Faculty of Medicine, University of São Paulo, São Paulo (R.H.H.); Medical University of Graz, Graz, Austria (P.B.M., C.E.), and Karolinska Institutet, Stockholm (P.B.M.)
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