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Barliana MI, Afifah NN, Yunivita V, Ruslami R. Genetic polymorphism related to ethambutol outcomes and susceptibility to toxicity. Front Genet 2023; 14:1118102. [PMID: 37152993 PMCID: PMC10157140 DOI: 10.3389/fgene.2023.1118102] [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: 12/07/2022] [Accepted: 04/10/2023] [Indexed: 05/09/2023] Open
Abstract
The World Health Organization (WHO) stated that ensuring access to effective and optimal treatment is a key component to eradicate tuberculosis (TB) through the End TB Strategy. Personalized medicine that depends on the genetic profile of an individual is one way to optimize treatment. It is necessary because of diverse drug responses related to the variation in human DNA, such as single-nucleotide polymorphisms (SNPs). Ethambutol (EMB) is a drug widely used as the treatment for Mycobacterium Tuberculosis (Mtb) and/non-tuberculous mycobacteria and has become a potential supplementary agent for a treatment regimen of multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB. In human genetic polymorphism studies of anti-tuberculosis, the majority focus on rifampicin or isoniazid, which discuss polymorphisms related to their toxicity. Whereas there are few studies on EMB, the incidence of EMB toxicity is lower than that of other first-line anti-TB drugs. To facilitate personalized medicine practice, this article summarizes the genetic polymorphisms associated with alterations in the pharmacokinetic profile, resistance incidence, and susceptibility to EMB toxicity. This study includes 131 total human studies from 17 articles, but only eight studies that held in the low-middle income country (LMIC), while the rest is research conducted in developed countries with high incomes. Personalized medicine practices are highly recommended to maintain and obtain the optimal therapeutic effect of EMB.
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Affiliation(s)
- Melisa Intan Barliana
- Department of Biological Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- Center of Excellence for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
- *Correspondence: Melisa Intan Barliana,
| | - Nadiya Nurul Afifah
- Department of Biological Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
| | - Vycke Yunivita
- Division of Pharmacology and Therapy, Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Rovina Ruslami
- Division of Pharmacology and Therapy, Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
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Role of CYP1A1, ABCG2, CYP24A1 and VDR gene polymorphisms on the evaluation of cardiac iron overload in thalassaemia patients. Pharmacogenet Genomics 2019; 28:199-206. [PMID: 30179981 DOI: 10.1097/fpc.0000000000000348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Iron-burden-induced arrhythmia and heart failure are among the leading causes of morbidity and mortality in β-thalassaemia major patients. T2* cardiac magnetic resonance remains the only reliable noninvasive method for the heart iron excess assessment. We explored the role of single nucleotide polymorphisms involved in vitamin D metabolism, transport and activity and in deferasirox (DFX) metabolism on cardiac iron burden. PATIENTS AND METHODS One hundred and five β-thalassaemia patients, treated with DFX, were enrolled in the present study. Drug plasma Ctrough was measured by a high-performance liquid chromatography-ultraviolet method. Allelic discrimination was carried out using the real-time PCR. RESULTS CYP1A1*1189 CC, ABCG2 421 GA, CYP24A1 8620 GG and VDR TaqI CC single nucleotide polymorphisms influenced T2* values. Age, serum ferritin, ABCG2 421 GA, ABCG2 1194 +928 TC/CC, CYP24A1 22776 TT and VDR TaqI TC/CC were retained in linear regression model. CONCLUSION Our results suggested, for the first time, the role of DFX and vitamin D pharmacogenetics on cardiac iron overload.
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Effect of pharmacogenetic markers of vitamin D pathway on deferasirox pharmacokinetics in children. Pharmacogenet Genomics 2018; 28:17-22. [PMID: 29099735 DOI: 10.1097/fpc.0000000000000315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Patients with β-thalassemia major have extremely low vitamin D levels, owing to reduced intestinal absorption, subicteric tint, and/or iron-induced higher pigmentation. We investigated whether some polymorphisms within the VDR, CYP24A1, CYP27B1, and GC genes could play a role in deferasirox pharmacokinetics in a cohort of pediatric patients. PATIENTS AND METHODS Eighteen children with β-thalassemia were enrolled. Drug plasma concentrations at the end of dosing interval (Ctrough) and after 0, 2, 4, 6, and 24 h of drug administration were measured by a HPLC-UV method. Allelic discrimination for VDR (TaqI, FokI, BsmI, Cdx2, and ApaI), CYP24A1 (22776, 3999 and 8620), CYP27B1 (2838 and -1260), and GC (1296) single nucleotide polymorphisms was performed by real-time PCR. RESULTS CYP24A1 8620 AG/GG group negatively predicted Ctrough in regression analysis (P=0.012). ApaI AA genotype resulted as a negative predictor of Ctrough (P=0.025) and area under the concentration curve (P=0.007); FoKI CC genotype remained as area under the concentration curve positive predictor (P=0.008) and TC/CC group as half-life (t1/2) (P=0.003) and volume of distribution (Vd) (P=0.011) negative one; TaqI TC/CC was retained as a negative predictor of drug maximum concentration (Cmax) (P=0.004). Moreover, GC 1296 TG/GG seemed able to predict lower time to reach drug maximum concentration (Tmax) (P=0.033). CONCLUSION Our preliminary experience suggested the potential usefulness of vitamin D pharmacogenetic to better understand deferasirox interindividual variability, also in pediatric patients.
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Cusato J, De Nicolò A, Boglione L, Favata F, Ariaudo A, Pinna SM, Carcieri C, Guido F, Cariti G, Di Perri G, D'Avolio A. Vitamin D pathway gene polymorphisms affecting daclatasvir plasma concentration at 2 weeks and 1 month of therapy. Pharmacogenomics 2018; 19:701-707. [PMID: 29790402 DOI: 10.2217/pgs-2018-0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
AIM Vitamin D (VD) influences genetic expression through its receptor (VDR). VD pathway gene polymorphisms seem to influence antiviral drug pharmacokinetics and therapeutic outcome/toxicity. We investigated the association between daclatasvir (DCV) plasma concentrations and genetic variants (SNPs) associated with the VD pathway. PATIENTS & METHODS Chronic hepatitis C patients treated with DCV from 2014 to 2016 were included. Genotypes were assessed through real-time PCR and plasma concentrations through liquid chromatography. RESULTS A total of 52 patients were analyzed. DCV levels were influenced by CYP24A1 rs2248359T>C polymorphism at 2 weeks and VDR Cdx2 A>G at 1 month of treatment. Linear regression analysis showed baseline BMI, alanine aminotransferase and hematocrit as significant predictors of DCV concentrations at 2 weeks, BMI and hematocrit at baseline, VDR Cdx2 AG/GG and FokI TC/CC at 1 month. CONCLUSION These results showed a possible role of VD pathway gene polymorphisms in influencing DCV plasma concentrations, but further studies are required.
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Affiliation(s)
- Jessica Cusato
- Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Amedeo De Nicolò
- Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Lucio Boglione
- Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Fabio Favata
- Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Alessandra Ariaudo
- Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Simone Mornese Pinna
- Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Chiara Carcieri
- Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Federica Guido
- Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Giuseppe Cariti
- Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Giovanni Di Perri
- Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Antonio D'Avolio
- Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
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Cusato J, De Nicolò A, Boglione L, Favata F, Ariaudo A, Mornese Pinna S, Carcieri C, Guido F, Avataneo V, Cariti G, Di Perri G, D'Avolio A. Vitamin D pathway genetic variants are able to influence sofosbuvir and its main metabolite pharmacokinetics in HCV mono-infected patients. INFECTION GENETICS AND EVOLUTION 2018; 60:42-47. [PMID: 29452294 DOI: 10.1016/j.meegid.2018.02.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/24/2018] [Accepted: 02/12/2018] [Indexed: 02/07/2023]
Abstract
Vitamin D levels and genetic variants were associated with drug outcome/toxicity and concentrations. The plasma exposure of GS-331007, the main sofosbuvir metabolite, has been related to SVR. We evaluated the impact of polymorphisms in genes (CYP27B1, CYP24A1, VDBP and VDR) related to vitamin D pathway on sofosbuvir and GS-331007 plasma levels in HCV mono-infected patients at one month of treatment. Polymorphisms were investigated through real-time PCR; drug plasma quantification was performed through a UHPLC-MS/MS method. GS-331007 levels were associated with CYP24A1rs2248359 and VDRCdx2 variants in all the analyzed patients and linear regression analysis showed that sex, body mass index, HCV genotype, baseline estimated glomerular filtration rate, VDRCdx2AG/GG and CYP27B1-1260TT genotypes significantly predict concentrations. We performed sub-analyses considering the HCV genotype and the concomitant drug, identifying polymorphisms associated with GS-331007 concentrations. This is the first study focusing on vitamin D pathway gene variants and DAAs concentrations, but further studies are required.
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Affiliation(s)
- Jessica Cusato
- Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital, Turin, Italy.
| | - Amedeo De Nicolò
- Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital, Turin, Italy
| | - Lucio Boglione
- Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital, Turin, Italy
| | - Fabio Favata
- Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital, Turin, Italy
| | - Alessandra Ariaudo
- Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital, Turin, Italy
| | - Simone Mornese Pinna
- Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital, Turin, Italy
| | - Chiara Carcieri
- Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital, Turin, Italy
| | - Federica Guido
- Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital, Turin, Italy
| | - Valeria Avataneo
- Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital, Turin, Italy
| | - Giuseppe Cariti
- Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital, Turin, Italy
| | - Giovanni Di Perri
- Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital, Turin, Italy
| | - Antonio D'Avolio
- Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital, Turin, Italy
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Motta I, Calcagno A, Bonora S. Pharmacokinetics and pharmacogenetics of anti-tubercular drugs: a tool for treatment optimization? Expert Opin Drug Metab Toxicol 2017; 14:59-82. [PMID: 29226732 DOI: 10.1080/17425255.2018.1416093] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION WHO global strategy is to end tuberculosis epidemic by 2035. Pharmacokinetic and pharmacogenetic studies are increasingly performed and might confirm their potential role in optimizing treatment outcome in specific settings and populations. Insufficient drug exposure seems to be a relevant factor in tuberculosis outcome and for the risk of phenotypic resistance. Areas covered: This review discusses available pharmacokinetic and pharmacogenetic data of first and second-line antitubercular agents in relation to efficacy and toxicity. Pharmacodynamic implications of optimized drugs and new options regimens are reviewed. Moreover a specific session describes innovative investigations on drug penetration. Expert opinion: The optimal use of available antitubercular drugs is paramount for tuberculosis control and eradication. Whilst trials are still on-going, higher rifampicin doses should be reserved to treatment for tubercular meningitis. Therapeutic Drug Monitoring with limiting sampling strategies is advised in patients at risk of failure or with slow treatment response. Further studies are needed in order to provide definitive recommendations of pharmacogenetic-based individualization: however lower isoniazid doses in NAT2 slow acetylators and higher rifampicin doses in individuals with SLCO1B1 loss of function genes are promising strategies. Finally in order to inform tailored strategies we need more data on tissue drug penetration and pharmacological modelling.
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Affiliation(s)
- Ilaria Motta
- a Unit of Infectious Diseases, Department of Medical Sciences , University of Torino , Torino , Italy
| | - Andrea Calcagno
- a Unit of Infectious Diseases, Department of Medical Sciences , University of Torino , Torino , Italy
| | - Stefano Bonora
- a Unit of Infectious Diseases, Department of Medical Sciences , University of Torino , Torino , Italy
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Allegra S, Cusato J, De Francia S, Arduino A, Longo F, Pirro E, Massano D, De Nicolò A, Piga A, D'Avolio A. Role of CYP24A1, VDR and GC gene polymorphisms on deferasirox pharmacokinetics and clinical outcomes. THE PHARMACOGENOMICS JOURNAL 2017; 18:506-515. [PMID: 29160302 DOI: 10.1038/tpj.2017.43] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 06/01/2017] [Accepted: 08/04/2017] [Indexed: 02/06/2023]
Abstract
β-Thalassemia patients develop deficiency in vitamin D absorption and liver hydroxylation, resulting in extremely low calcitriol levels. We explored the role of single-nucleotide polymorphisms (SNPs) involved in vitamin D metabolism, transport and activity on deferasirox pharmacokinetics and outcomes (effectiveness trough levels (Ctrough) and the area under the curve (AUC) cutoffs of 20 μg ml-1 and 360 μg ml-1 h-1, respectively; nonresponse AUC limit of 250 μg ml-1 h-1). Ninety-nine β-thalassemic patients were enrolled. Drug plasma Ctrough and AUC were measured by the high-performance liquid chromatography system coupled with an ultraviolet determination method. Allelic discrimination for VDR, CYP24A1, CYP27B1 and GC gene SNPs was performed by real-time PCR. CYP24A1 22776 TT significantly influenced Cmin and negatively predicted it in regression analysis. CYP24A1 3999 CC was associated with Ctrough and Cmin and was a negative predictor of Tmax, whereas CYP24A1 8620 GG seemed to have a role in Ctrough, AUC, t1/2 and Cmin, and was an AUC negative predictor factor. Considering treatment outcome, Cdx2 and GC 1296 were retained in regression analysis as AUC efficacy cutoff negative predictors.
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Affiliation(s)
- S Allegra
- Unit of Infectious Diseases, University of Turin, Department of Medical Sciences, Amedeo di Savoia Hospital, Turin, Italy
| | - J Cusato
- Unit of Infectious Diseases, University of Turin, Department of Medical Sciences, Amedeo di Savoia Hospital, Turin, Italy
| | - S De Francia
- Department of Biological and Clinical Sciences, University of Turin, S. Luigi Gonzaga Hospital, Orbassano, Italy
| | - A Arduino
- Unit of Infectious Diseases, University of Turin, Department of Medical Sciences, Amedeo di Savoia Hospital, Turin, Italy
| | - F Longo
- Department of Paediatrics, Centre for Microcitemie, University of Turin, S. Luigi Gonzaga Hospital, Orbassano, Italy
| | - E Pirro
- Department of Biological and Clinical Sciences, University of Turin, S. Luigi Gonzaga Hospital, Orbassano, Italy
| | - D Massano
- Department of Paediatrics, Centre for Microcitemie, University of Turin, S. Luigi Gonzaga Hospital, Orbassano, Italy
| | - A De Nicolò
- Unit of Infectious Diseases, University of Turin, Department of Medical Sciences, Amedeo di Savoia Hospital, Turin, Italy
| | - A Piga
- Department of Paediatrics, Centre for Microcitemie, University of Turin, S. Luigi Gonzaga Hospital, Orbassano, Italy
| | - A D'Avolio
- Unit of Infectious Diseases, University of Turin, Department of Medical Sciences, Amedeo di Savoia Hospital, Turin, Italy
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Ethambutol Partitioning in Tuberculous Pulmonary Lesions Explains Its Clinical Efficacy. Antimicrob Agents Chemother 2017; 61:AAC.00924-17. [PMID: 28696241 PMCID: PMC5571334 DOI: 10.1128/aac.00924-17] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 06/25/2017] [Indexed: 12/14/2022] Open
Abstract
Clinical trials and practice have shown that ethambutol is an important component of the first-line tuberculosis (TB) regime. This contrasts the drug's rather modest potency and lack of activity against nongrowing persister mycobacteria. The standard plasma-based pharmacokinetic-pharmacodynamic profile of ethambutol suggests that the drug may be of limited clinical value. Here, we hypothesized that this apparent contradiction may be explained by favorable penetration of the drug into TB lesions. First, we utilized novel in vitro lesion pharmacokinetic assays and predicted good penetration of the drug into lesions. We then employed mass spectrometry imaging and laser capture microdissection coupled to liquid chromatography and tandem mass spectrometry (LCM and LC/MS-MS, respectively) to show that ethambutol, indeed, accumulates in diseased tissues and penetrates the major human-like lesion types represented in the rabbit model of TB disease with a lesion-to-plasma exposure ratio ranging from 9 to 12. In addition, ethambutol exhibits slow but sustained passive diffusion into caseum to reach concentrations markedly higher than those measured in plasma at steady state. The results explain why ethambutol has retained its place in the first-line regimen, validate our in vitro lesion penetration assays, and demonstrate the critical importance of effective lesion penetration for anti-TB drugs. Our findings suggest that in vitro and in vivo lesion penetration evaluation should be included in TB drug discovery programs. Finally, this is the first time that LCM with LC-MS/MS has been used to quantify a small molecule at high spatial resolution in infected tissues, a method that can easily be extended to other infectious diseases.
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Cusato J, De Francia S, Allegra S, Carrella S, Pirro E, Piccione FM, De Martino F, Ferrero A, Daffara FC, Terzolo M, Berruti A, Di Carlo F, Tampellini M, D'Avolio A. Circannual variation of mitotane and its metabolites plasma levels in patients with adrenocortical carcinoma. J Pharm Pharmacol 2017; 69:1524-1530. [PMID: 28809444 DOI: 10.1111/jphp.12798] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 07/17/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Mitotane is the reference drug for the adrenocortical carcinoma treatment; its pharmacological activity seems to depend on drug transformation in two active metabolites: o,p'-DDE (dichlorodiphenylethene) and o,p'-DDA (dichlorodiphenylacetate). Mitotane and metabolites are lipophilic agents; thus, they tend to accumulate into adipose tissues (white and brown), which change their prevalence seasonally. Aim of the work was to evaluate mitotane and metabolites plasma levels variation over the year, in adrenocortical cancer patients treated with Lysodren® for at least 6 months. METHODS We enrolled a group of 86 adrenocortical carcinoma diagnosed patients, who underwent radical surgery and started mitotane as adjuvant treatment. For drug and metabolites plasma level (from samples collected ~12 h after the dose administration of mitotane, just before the subsequent administration) determination, a validated chromatographic method was used. KEY FINDINGS Results showed an evidence of a seasonal trend for the three substance (o,p'-DDD, o,p'-DDE and o,p'-DDA) plasma levels, in terms of acrophases and lower values. Furthermore, it came out that male patients need a higher significant mitotane drug dose than female patients to reach mitotane therapeutic window. CONCLUSIONS In conclusion, this is the first study assessing a mitotane plasma level variation over the year, but further studies in larger cohorts are required.
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Affiliation(s)
- Jessica Cusato
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Silvia De Francia
- Department of Biological and Clinical Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, TO, Italy
| | - Sarah Allegra
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
| | - Simona Carrella
- Department of Biological and Clinical Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, TO, Italy
| | - Elisa Pirro
- Department of Biological and Clinical Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, TO, Italy
| | - Francesca Maria Piccione
- Department of Biological and Clinical Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, TO, Italy
| | - Francesca De Martino
- Department of Biological and Clinical Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, TO, Italy
| | - Anna Ferrero
- Division of Oncology, Department of Oncology, "San Luigi" Hospital-Orbassano, University of Turin, Orbassano, TO, Italy
| | - Fulvia Claudia Daffara
- Division of Internal Medicine, Department of Oncology, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, TO, Italy
| | - Massimo Terzolo
- Division of Internal Medicine, Department of Oncology, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, TO, Italy
| | - Alfredo Berruti
- Medical Oncology Unit, Department of Medical & Surgical Specialties, Radiological Sciences & Public Health, Spedali Civili Hospital, University of Brescia, Brescia, Italy
| | - Francesco Di Carlo
- Department of Biological and Clinical Sciences, S. Luigi Gonzaga Hospital, University of Turin, Orbassano, TO, Italy
| | - Marco Tampellini
- Division of Oncology, Department of Oncology, "San Luigi" Hospital-Orbassano, University of Turin, Orbassano, TO, Italy
| | - Antonio D'Avolio
- Unit of Infectious Diseases, Department of Medical Sciences, Amedeo di Savoia Hospital, University of Turin, Turin, Italy
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