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Esteves MAC, Viana AS, Viçosa GN, Botelho AMN, Moustafa AM, Mansoldo FRP, Ferreira ALP, Vermelho AB, Ferreira-Carvalho BT, Planet PJ, Figueiredo AMS. RdJ detection tests to identify a unique MRSA clone of ST105-SCC mecII lineage and its variants disseminated in the metropolitan region of Rio de Janeiro. Front Microbiol 2023; 14:1275918. [PMID: 38053559 PMCID: PMC10694290 DOI: 10.3389/fmicb.2023.1275918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/31/2023] [Indexed: 12/07/2023] Open
Abstract
Hospital bloodstream infection (BSI) caused by methicillin-resistant Staphylococcus aureus (MRSA) is a major cause of morbidity and mortality and is frequently related to invasive procedures and medically complex patients. An important feature of MRSA is the clonal structure of its population. Specific MRSA clones may differ in their pathogenic, epidemiological, and antimicrobial resistance profiles. Whole-genome sequencing is currently the most robust and discriminatory technique for tracking hypervirulent/well-adapted MRSA clones. However, it remains an expensive and time-consuming technique that requires specialized personnel. In this work, we describe a pangenome protocol, based on binary matrix (1,0) of open reading frames (ORFs), that can be used to quickly find diagnostic, apomorphic sequence mutations that can serve as biomarkers. We use this technique to create a diagnostic screen for MRSA isolates circulating in the Rio de Janeiro metropolitan area, the RdJ clone, which is prevalent in BSI. The method described here has 100% specificity and sensitivity, eliminating the need to use genomic sequencing for clonal identification. The protocol used is relatively simple and all the steps, formulas and commands used are described in this work, such that this strategy can also be used to identify other MRSA clones and even clones from other bacterial species.
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Affiliation(s)
| | - Alice Slotfeldt Viana
- Departamento de Microbiologia Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Gabriela Nogueira Viçosa
- Departamento de Microbiologia Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Ahmed M. Moustafa
- Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, United States
| | | | - Adriana Lucia Pires Ferreira
- Hospital Universitário Clementino Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Dasa Medicina Diagnóstica, Duque de Caxias, Brazil
| | - Alane Beatriz Vermelho
- Departamento de Microbiologia Geral, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Paul Joseph Planet
- Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, United States
| | - Agnes Marie Sá Figueiredo
- Departamento de Microbiologia Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Faculdade de Medicina, Programa de Pós-graduação em Patologia, Universidade Federal Fluminense, Niterói, Brazil
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Viana AS, Botelho AMN, Feder A, Moustafa AM, Santos Silva DN, Martini CL, Ferreira ALP, Silva-Carvalho MC, Ferreira-Carvalho BT, Planet PJ, Sá Figueiredo AM. High frequency of increased triclosan MIC among CC5 MRSA and risk of misclassification of the SCCmec into types. J Antimicrob Chemother 2022; 77:3340-3348. [PMID: 36173394 DOI: 10.1093/jac/dkac322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/31/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Typing of staphylococcal cassette chromosome mec (SCCmec) elements is commonly used for studies on the molecular epidemiology of MRSA. OBJECTIVES To perform an investigation centred on uncovering the reasons for misclassification of MRSA clonal complex 5 (CC5) SCCmec type II clinical isolates in our laboratory. METHODS MRSA isolates from CC5 were subjected to WGS and SCCmec typing. RESULTS This investigation led to the discovery that the classification failure was due to an insertion of IS1272 carrying the fabI gene on a transposable element (TnSha1) that confers increased MIC to the biocide triclosan. Genomic analysis revealed that fabI was present in 25% of the CC5 MRSA isolates sampled. The frequency of TnSha1 in our collection was much higher than that observed among publicly available genomes (0.8%; n = 24/3142 CC5 genomes). Phylogenetic analyses revealed that genomes in different CC5 clades carry TnSha1 inserted in different integration sites, suggesting that this transposon has entered CC5 MRSA genomes on multiple occasions. In at least two genotypes, ST5-SCCmecII-t539 and ST5-SCCmecII-t2666, TnSha1 seems to have entered prior to their divergence. CONCLUSIONS Our work highlights an important misclassification problem of SCCmecII in isolates harbouring TnSha1 when Boye's method is used for typing, which could have important implications for molecular epidemiology of MRSA. The importance of increased-MIC phenotype is still a matter of controversy that deserves more study given the widespread use of triclosan in many countries. Our results suggest expanding prevalence that may indicate strong selection for this phenotype.
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Affiliation(s)
- Alice Slotfeldt Viana
- Department of Medical Microbiology, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Ana Maria Nunes Botelho
- Department of Medical Microbiology, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Andries Feder
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Ahmed Magdi Moustafa
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.,Children's Hospital of Philadelphia, Philadelphia, PA 19106, USA
| | | | - Caroline Lopes Martini
- Department of Medical Microbiology, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Adriana Lucia Pires Ferreira
- Department of Medical Microbiology, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, 21941-902, Brazil.,Diagnósticos da América S.A., Duque de Caxias, RJ, 25085-007, Brazil
| | - Maria Cícera Silva-Carvalho
- Department of Medical Microbiology, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, 21941-902, Brazil
| | | | - Paul Joseph Planet
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.,Children's Hospital of Philadelphia, Philadelphia, PA 19106, USA
| | - Agnes Marie Sá Figueiredo
- Department of Medical Microbiology, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, 21941-902, Brazil
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Penna B, Silva MB, Soares AER, Vasconcelos ATR, Ramundo MS, Ferreira FA, Silva-Carvalho MC, de Sousa VS, Rabello RF, Bandeira PT, de Souza VS, Planet PJ, Vieira-da-Motta O, Botelho AMN, Figueiredo AMS. Comparative genomics of MRSA strains from human and canine origins reveals similar virulence gene repertoire. Sci Rep 2021; 11:4724. [PMID: 33633263 PMCID: PMC7907190 DOI: 10.1038/s41598-021-83993-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 02/09/2021] [Indexed: 01/31/2023] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) is an important pathogen associated with a wide variety of infections in humans. The ability of MRSA to infect companion animals has gained increasing attention in the scientific literature. In this study, 334 dogs were screened for MRSA in two cities located in Rio de Janeiro State. The prevalence of MRSA in dogs was 2.7%. Genotyping revealed isolates from sequence types (ST) 1, 5, 30, and 239 either colonizing or infecting dogs. The genome of the canine ST5 MRSA (strain SA112) was compared with ST5 MRSA from humans-the main lineage found in Rio de Janeiro hospitals-to gain insights in the origin of this dog isolate. Phylogenetic analysis situated the canine genome and human strain CR14-035 in the same clade. Comparative genomics revealed similar virulence profiles for SA112 and CR14-035. Both genomes carry S. aureus genomic islands νSAα, νSAβ, and νSAγ. The virulence potential of the canine and human strains was similar in a Caenorhabditis elegans model. Together, these results suggest a potential of canine MRSA to infect humans and vice versa. The circulation in community settings of a MRSA lineage commonly found in hospitals is an additional challenge for public health surveillance authorities.
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Affiliation(s)
- Bruno Penna
- grid.411173.10000 0001 2184 6919Instituto Biomédico, Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brazil
| | - Marcella B. Silva
- grid.412331.60000 0000 9087 6639Laboratório de Sanidade Animal, Centro de Ciências e Tecnologias Agropecuárias, Universidade Estadual do Norte Fluminense, Campos dos Goytacazes, Rio de Janeiro, Brazil
| | - André E. R. Soares
- grid.452576.70000 0004 0602 9007Laboratório Nacional de Computação Científica, Petrópolis, Rio de Janeiro, Brazil
| | - Ana T. R. Vasconcelos
- grid.452576.70000 0004 0602 9007Laboratório Nacional de Computação Científica, Petrópolis, Rio de Janeiro, Brazil
| | - Mariana S. Ramundo
- grid.8536.80000 0001 2294 473XDepartment of Medical Microbiology, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Fabienne A. Ferreira
- grid.411237.20000 0001 2188 7235Departamento de Microbiologia, Imunologia e Parasitologia, Universidade Federal de Santa Catarina, Florianópolis, Santa Catarina Brazil
| | - Maria C. Silva-Carvalho
- grid.8536.80000 0001 2294 473XDepartment of Medical Microbiology, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Viviane S. de Sousa
- grid.8536.80000 0001 2294 473XDepartment of Medical Microbiology, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Renata F. Rabello
- grid.411173.10000 0001 2184 6919Instituto Biomédico, Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brazil
| | - Paula T. Bandeira
- grid.8536.80000 0001 2294 473XDepartment of Medical Microbiology, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil ,grid.8536.80000 0001 2294 473XInstituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Viviane S. de Souza
- grid.8536.80000 0001 2294 473XInstituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paul J. Planet
- grid.25879.310000 0004 1936 8972Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Olney Vieira-da-Motta
- grid.412331.60000 0000 9087 6639Laboratório de Sanidade Animal, Centro de Ciências e Tecnologias Agropecuárias, Universidade Estadual do Norte Fluminense, Campos dos Goytacazes, Rio de Janeiro, Brazil
| | - Ana M. N. Botelho
- grid.411173.10000 0001 2184 6919Instituto Biomédico, Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brazil ,grid.8536.80000 0001 2294 473XDepartment of Medical Microbiology, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Agnes M. S. Figueiredo
- grid.8536.80000 0001 2294 473XDepartment of Medical Microbiology, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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4
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Viana AS, Nunes Botelho AM, Moustafa AM, Boge CL, Pires Ferreira AL, da Silva Carvalho MC, Guimarães MA, Costa BDSS, de Mattos MC, Maciel SP, Echevarria-Lima J, Narechania A, O’Brien K, Ryan C, Gerber JS, Carvalho BTF, Figueiredo AMS, Planet PJ. Multidrug-Resistant Methicillin-Resistant Staphylococcus aureus Associated with Bacteremia and Monocyte Evasion, Rio de Janeiro, Brazil. Emerg Infect Dis 2021; 27:2825-2835. [PMID: 34670645 PMCID: PMC8544994 DOI: 10.3201/eid2711.210097] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We typed 600 methicillin-resistant Staphylococcus aureus (MRSA) isolates collected in 51 hospitals in the Rio de Janeiro, Brazil, metropolitan area during 2014-2017. We found that multiple new clonal complex (CC) 5 sequence types had replaced previously dominant MRSA lineages in hospitals. Whole-genome analysis of 208 isolates revealed an emerging sublineage of multidrug-resistant MRSA, sequence type 105, staphylococcal cassette chromosome mec II, spa t002, which we designated the Rio de Janeiro (RdJ) clone. Using molecular clock analysis, we hypothesized that this lineage began to expand in the Rio de Janeiro metropolitan area in 2009. Multivariate analysis supported an association between bloodstream infections and the CC5 lineage that includes the RdJ clone. Compared with other closely related isolates, representative isolates of the RdJ clone more effectively evaded immune function related to monocytic cells, as evidenced by decreased phagocytosis rate and increased numbers of viable unphagocytosed (free) bacteria after in vitro exposure to monocytes.
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Affiliation(s)
| | | | | | - Craig L.K. Boge
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (A.S. Viana, A.M.N. Botelho, A.L.P. Ferreira, M.C.S. Carvalho, M.A. Guimarães, B.S.S. Costa, M.C. Mattos, S.P. Maciel, J. Echevarria-Lima, B.T.F. Carvalho, A.M.S. Figueiredo)
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA (A.M. Moustafa, C.L.K. Boge, K. O’Brien, C. Ryan, J.S. Gerber, P.J. Planet)
- Diagnósticos da América S.A., Duque de Caxias, Brazil (A.L.P. Ferreira)
- American Museum of Natural History, New York, New York, USA (A. Narechania, P.J. Planet)
- University of Pennsylvania, Philadelphia (J.S. Gerber, P.J. Planet)
| | - Adriana Lucia Pires Ferreira
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (A.S. Viana, A.M.N. Botelho, A.L.P. Ferreira, M.C.S. Carvalho, M.A. Guimarães, B.S.S. Costa, M.C. Mattos, S.P. Maciel, J. Echevarria-Lima, B.T.F. Carvalho, A.M.S. Figueiredo)
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA (A.M. Moustafa, C.L.K. Boge, K. O’Brien, C. Ryan, J.S. Gerber, P.J. Planet)
- Diagnósticos da América S.A., Duque de Caxias, Brazil (A.L.P. Ferreira)
- American Museum of Natural History, New York, New York, USA (A. Narechania, P.J. Planet)
- University of Pennsylvania, Philadelphia (J.S. Gerber, P.J. Planet)
| | - Maria Cícera da Silva Carvalho
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (A.S. Viana, A.M.N. Botelho, A.L.P. Ferreira, M.C.S. Carvalho, M.A. Guimarães, B.S.S. Costa, M.C. Mattos, S.P. Maciel, J. Echevarria-Lima, B.T.F. Carvalho, A.M.S. Figueiredo)
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA (A.M. Moustafa, C.L.K. Boge, K. O’Brien, C. Ryan, J.S. Gerber, P.J. Planet)
- Diagnósticos da América S.A., Duque de Caxias, Brazil (A.L.P. Ferreira)
- American Museum of Natural History, New York, New York, USA (A. Narechania, P.J. Planet)
- University of Pennsylvania, Philadelphia (J.S. Gerber, P.J. Planet)
| | - Márcia Aparecida Guimarães
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (A.S. Viana, A.M.N. Botelho, A.L.P. Ferreira, M.C.S. Carvalho, M.A. Guimarães, B.S.S. Costa, M.C. Mattos, S.P. Maciel, J. Echevarria-Lima, B.T.F. Carvalho, A.M.S. Figueiredo)
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA (A.M. Moustafa, C.L.K. Boge, K. O’Brien, C. Ryan, J.S. Gerber, P.J. Planet)
- Diagnósticos da América S.A., Duque de Caxias, Brazil (A.L.P. Ferreira)
- American Museum of Natural History, New York, New York, USA (A. Narechania, P.J. Planet)
- University of Pennsylvania, Philadelphia (J.S. Gerber, P.J. Planet)
| | | | - Marcos Corrêa de Mattos
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (A.S. Viana, A.M.N. Botelho, A.L.P. Ferreira, M.C.S. Carvalho, M.A. Guimarães, B.S.S. Costa, M.C. Mattos, S.P. Maciel, J. Echevarria-Lima, B.T.F. Carvalho, A.M.S. Figueiredo)
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA (A.M. Moustafa, C.L.K. Boge, K. O’Brien, C. Ryan, J.S. Gerber, P.J. Planet)
- Diagnósticos da América S.A., Duque de Caxias, Brazil (A.L.P. Ferreira)
- American Museum of Natural History, New York, New York, USA (A. Narechania, P.J. Planet)
- University of Pennsylvania, Philadelphia (J.S. Gerber, P.J. Planet)
| | - Sabrina Pires Maciel
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (A.S. Viana, A.M.N. Botelho, A.L.P. Ferreira, M.C.S. Carvalho, M.A. Guimarães, B.S.S. Costa, M.C. Mattos, S.P. Maciel, J. Echevarria-Lima, B.T.F. Carvalho, A.M.S. Figueiredo)
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA (A.M. Moustafa, C.L.K. Boge, K. O’Brien, C. Ryan, J.S. Gerber, P.J. Planet)
- Diagnósticos da América S.A., Duque de Caxias, Brazil (A.L.P. Ferreira)
- American Museum of Natural History, New York, New York, USA (A. Narechania, P.J. Planet)
- University of Pennsylvania, Philadelphia (J.S. Gerber, P.J. Planet)
| | - Juliana Echevarria-Lima
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (A.S. Viana, A.M.N. Botelho, A.L.P. Ferreira, M.C.S. Carvalho, M.A. Guimarães, B.S.S. Costa, M.C. Mattos, S.P. Maciel, J. Echevarria-Lima, B.T.F. Carvalho, A.M.S. Figueiredo)
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA (A.M. Moustafa, C.L.K. Boge, K. O’Brien, C. Ryan, J.S. Gerber, P.J. Planet)
- Diagnósticos da América S.A., Duque de Caxias, Brazil (A.L.P. Ferreira)
- American Museum of Natural History, New York, New York, USA (A. Narechania, P.J. Planet)
- University of Pennsylvania, Philadelphia (J.S. Gerber, P.J. Planet)
| | - Apurva Narechania
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (A.S. Viana, A.M.N. Botelho, A.L.P. Ferreira, M.C.S. Carvalho, M.A. Guimarães, B.S.S. Costa, M.C. Mattos, S.P. Maciel, J. Echevarria-Lima, B.T.F. Carvalho, A.M.S. Figueiredo)
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA (A.M. Moustafa, C.L.K. Boge, K. O’Brien, C. Ryan, J.S. Gerber, P.J. Planet)
- Diagnósticos da América S.A., Duque de Caxias, Brazil (A.L.P. Ferreira)
- American Museum of Natural History, New York, New York, USA (A. Narechania, P.J. Planet)
- University of Pennsylvania, Philadelphia (J.S. Gerber, P.J. Planet)
| | - Kelsey O’Brien
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (A.S. Viana, A.M.N. Botelho, A.L.P. Ferreira, M.C.S. Carvalho, M.A. Guimarães, B.S.S. Costa, M.C. Mattos, S.P. Maciel, J. Echevarria-Lima, B.T.F. Carvalho, A.M.S. Figueiredo)
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA (A.M. Moustafa, C.L.K. Boge, K. O’Brien, C. Ryan, J.S. Gerber, P.J. Planet)
- Diagnósticos da América S.A., Duque de Caxias, Brazil (A.L.P. Ferreira)
- American Museum of Natural History, New York, New York, USA (A. Narechania, P.J. Planet)
- University of Pennsylvania, Philadelphia (J.S. Gerber, P.J. Planet)
| | - Chanelle Ryan
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (A.S. Viana, A.M.N. Botelho, A.L.P. Ferreira, M.C.S. Carvalho, M.A. Guimarães, B.S.S. Costa, M.C. Mattos, S.P. Maciel, J. Echevarria-Lima, B.T.F. Carvalho, A.M.S. Figueiredo)
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA (A.M. Moustafa, C.L.K. Boge, K. O’Brien, C. Ryan, J.S. Gerber, P.J. Planet)
- Diagnósticos da América S.A., Duque de Caxias, Brazil (A.L.P. Ferreira)
- American Museum of Natural History, New York, New York, USA (A. Narechania, P.J. Planet)
- University of Pennsylvania, Philadelphia (J.S. Gerber, P.J. Planet)
| | - Jeffrey S. Gerber
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (A.S. Viana, A.M.N. Botelho, A.L.P. Ferreira, M.C.S. Carvalho, M.A. Guimarães, B.S.S. Costa, M.C. Mattos, S.P. Maciel, J. Echevarria-Lima, B.T.F. Carvalho, A.M.S. Figueiredo)
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA (A.M. Moustafa, C.L.K. Boge, K. O’Brien, C. Ryan, J.S. Gerber, P.J. Planet)
- Diagnósticos da América S.A., Duque de Caxias, Brazil (A.L.P. Ferreira)
- American Museum of Natural History, New York, New York, USA (A. Narechania, P.J. Planet)
- University of Pennsylvania, Philadelphia (J.S. Gerber, P.J. Planet)
| | - Bernadete Teixeira Ferreira Carvalho
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil (A.S. Viana, A.M.N. Botelho, A.L.P. Ferreira, M.C.S. Carvalho, M.A. Guimarães, B.S.S. Costa, M.C. Mattos, S.P. Maciel, J. Echevarria-Lima, B.T.F. Carvalho, A.M.S. Figueiredo)
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA (A.M. Moustafa, C.L.K. Boge, K. O’Brien, C. Ryan, J.S. Gerber, P.J. Planet)
- Diagnósticos da América S.A., Duque de Caxias, Brazil (A.L.P. Ferreira)
- American Museum of Natural History, New York, New York, USA (A. Narechania, P.J. Planet)
- University of Pennsylvania, Philadelphia (J.S. Gerber, P.J. Planet)
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