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Arworn S, Reanpang T, Apichartpiyakul P, Orrapin S, Rerkasem K. Retrospective Review of Management and Overall Survival Rate of Patients With Vascular Pythiosis of the Lower Extremity: 20 Years Experience. INT J LOW EXTR WOUND 2023:15347346231214291. [PMID: 38018022 DOI: 10.1177/15347346231214291] [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: 11/30/2023]
Abstract
Pythiosis is an infectious disease in humans and animals caused by an aquatic fungus-like micro-organism, Pythium insidiosum. Vascular pythiosis is a difficult condition to treat and can lead to loss of limb in addition to being a potentially life-threatening infection. The condition is furthermore unfamiliar among healthcare workers, which often results in delayed treatment or even misdiagnosis. In this study, we report our findings, which have been gathered over a 20-year period in caring for vascular pythiosis in Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand. We made a retrospective medical review of 32 patients presented with arterial occlusion who have serum anti-Pythium insidiosum antibodies. All patients underwent computed tomography angiography to confirm the level of arterial occlusion and decided on a treatment plan. Twelve out of 22 patients with infrainguinal disease, femoropopliteal or below-knee vascular occlusion, survived. The mean survival time is 6.58 years. Eight in 10 patients presented with suprainguinal disease died during the follow-up with a mean survival time of 31.6 months. The suprainguinal extension of the disease influenced the outcome, resulting in a higher mortality rate. However, patients presented with chronic limb ischemia had a much greater rate of survival compared to other clinical presentations. Extensive surgical resection combined with antifungal treatment and immunotherapy have proven to be effective in patients with vascular pythiosis in our findings.
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Affiliation(s)
- Supapong Arworn
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Termpong Reanpang
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Poon Apichartpiyakul
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Saranat Orrapin
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kittipan Rerkasem
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- NCD Center of Excellence, Research Institute of Health Science, Chiang Mai University, Chiang Mai, Thailand
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Medhasi S, Chindamporn A, Worasilchai N. A Review: Antimicrobial Therapy for Human Pythiosis. Antibiotics (Basel) 2022; 11:antibiotics11040450. [PMID: 35453202 PMCID: PMC9029071 DOI: 10.3390/antibiotics11040450] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/16/2022] [Accepted: 03/22/2022] [Indexed: 01/14/2023] Open
Abstract
Human pythiosis is associated with poor prognosis with significant mortality caused by Pythium insidiosum. Antimicrobials’ in vitro and in vivo results against P. insidiosum are inconsistent. Although antimicrobials are clinically useful, they are not likely to achieve therapeutic success alone without surgery and immunotherapy. New therapeutic options are therefore needed. This non-exhaustive review discusses the rationale antimicrobial therapy, minimum inhibitory concentrations, and efficacy of antibacterial and antifungal agents against P. insidiosum. This review further provides insight into the immunomodulating effects of antimicrobials that can enhance the immune response to infections. Current data support using antimicrobial combination therapy for the pharmacotherapeutic management of human pythiosis. Also, the success or failure of antimicrobial treatment in human pythiosis might depend on the immunomodulatory effects of drugs. The repurposing of existing drugs is a safe strategy for anti-P. insidiosum drug discovery. To improve patient outcomes in pythiosis, we suggest further research and a deeper understanding of P. insidiosum virulence factors, host immune response, and host immune system modification by antimicrobials.
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Affiliation(s)
- Sadeep Medhasi
- Department of Transfusion Medicine and Clinical Microbiology, Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok 10330, Thailand;
| | - Ariya Chindamporn
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand;
| | - Navaporn Worasilchai
- Department of Transfusion Medicine and Clinical Microbiology, Faculty of Allied Health Sciences, Immunomodulation of Natural Products Research Group, Chulalongkorn University, Bangkok 10330, Thailand
- Correspondence: ; Tel.: +66-2218-1065
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Chechi JL, Rotchanapreeda T, da Paz GS, Prado AC, Oliveira AL, Vieira JCS, Buzalaf MAR, Rodrigues AM, dos Santos LD, Krajaejun T, Bosco SDMG. Prospecting Biomarkers for Diagnostic and Therapeutic Approaches in Pythiosis. J Fungi (Basel) 2021; 7:423. [PMID: 34071174 PMCID: PMC8229905 DOI: 10.3390/jof7060423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/04/2021] [Accepted: 05/05/2021] [Indexed: 12/11/2022] Open
Abstract
Pythiosis, whose etiological agent is the oomycete Pythium insidiosum, is a life-threatening disease that occurs mainly in tropical and subtropical countries, affecting several animal species. It is frequently found in horses in Brazil and humans in Thailand. The disease is difficult to diagnose because the pathogen's hyphae are often misdiagnosed as mucoromycete fungi in histological sections. Additionally, there is no specific antigen to use for rapid diagnosis, the availability of which could improve the prognosis in different animal species. In this scenario, we investigated which P. insidiosum antigens are recognized by circulating antibodies in horses and humans with pythiosis from Brazil and Thailand, respectively, using 2D immunoblotting followed by mass spectrometry for the identification of antigens. We identified 23 protein spots, 14 recognized by pooled serum from horses and humans. Seven antigens were commonly recognized by both species, such as the heat-shock cognate 70 KDa protein, the heat-shock 70 KDa protein, glucan 1,3-beta-glucosidase, fructose-bisphosphate aldolase, serine/threonine-protein phosphatase, aconitate hydratase, and 14-3-3 protein epsilon. These results demonstrate that there are common antigens recognized by the immune responses of horses and humans, and these antigens may be studied as biomarkers for improving diagnosis and treatment.
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Affiliation(s)
- Jéssica Luana Chechi
- Department of Chemical and Biological Sciences, Institute of Biosciences, São Paulo State University (UNESP), Botucatu 18618-689, Brazil; (A.C.P.); (J.C.S.V.)
| | - Tiwa Rotchanapreeda
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (T.R.); (T.K.)
| | - Giselle Souza da Paz
- Faculty of Veterinary Medicine and Animal Science (FMVZ), São Paulo State University (UNESP), Botucatu 18618-681, Brazil; (G.S.d.P.); (A.L.O.)
| | - Ana Carolina Prado
- Department of Chemical and Biological Sciences, Institute of Biosciences, São Paulo State University (UNESP), Botucatu 18618-689, Brazil; (A.C.P.); (J.C.S.V.)
| | - Alana Lucena Oliveira
- Faculty of Veterinary Medicine and Animal Science (FMVZ), São Paulo State University (UNESP), Botucatu 18618-681, Brazil; (G.S.d.P.); (A.L.O.)
| | - José Cavalcante Souza Vieira
- Department of Chemical and Biological Sciences, Institute of Biosciences, São Paulo State University (UNESP), Botucatu 18618-689, Brazil; (A.C.P.); (J.C.S.V.)
| | - Marília Afonso Rabelo Buzalaf
- Department of Biological Sciences, Bauru School of Dentistry, University of São Paulo (USP), Bauru 17012-901, Brazil;
| | - Anderson Messias Rodrigues
- Department of Microbiology, Immunology and Parasitology, Cell Biology Division, Federal University of São Paulo (UNIFESP), São Paulo 04023-062, Brazil;
| | - Lucilene Delazari dos Santos
- Center for the Study of Venoms and Venomous Animals (CEVAP), São Paulo State University (UNESP), Botucatu 18610-307, Brazil;
- Graduate Program in Tropical Diseases, Botucatu Medical School (FMB), São Paulo State University (UNESP), Botucatu 18618-687, Brazil
| | - Theerapong Krajaejun
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (T.R.); (T.K.)
| | - Sandra de Moraes Gimenes Bosco
- Department of Chemical and Biological Sciences, Institute of Biosciences, São Paulo State University (UNESP), Botucatu 18618-689, Brazil; (A.C.P.); (J.C.S.V.)
- Faculty of Veterinary Medicine and Animal Science (FMVZ), São Paulo State University (UNESP), Botucatu 18618-681, Brazil; (G.S.d.P.); (A.L.O.)
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Defective cytokine production from monocytes/macrophages of E-beta thalassemia patients in response to Pythium insidiosum infection. Immunobiology 2019; 224:427-432. [DOI: 10.1016/j.imbio.2019.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 02/02/2019] [Accepted: 02/04/2019] [Indexed: 01/09/2023]
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Ribeiro TC, Weiblen C, Botton SDA, Pereira DIB, de Jesus FPK, Verdi CM, Gressler LT, Sangioni LA, Santurio JM. In vitro susceptibility of the oomycete Pythium insidiosum to metallic compounds containing cadmium, lead, copper, manganese or zinc. Med Mycol 2018; 55:669-672. [PMID: 27816906 DOI: 10.1093/mmy/myw115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 10/21/2016] [Indexed: 11/14/2022] Open
Abstract
Pythium insidiosum is an aquatic oomycete that causes pythiosis, an important and severe disease of difficult treatment that affects humans, domestic and wild animals. This infection is often described in horses in Brazil and humans in Thailand. In clinical practice, we have observed many cases that do not respond to available therapies, indicating the need to explore alternative therapeutic approaches. In this sense, studies using metal compounds in conjunction with available antimicrobial agents have been demonstrated greater antimicrobial activity. Thus, in this research, we tested in vitro activities of metallic compounds containing cadmium, lead, copper, manganese, or zinc against 23 isolates of P. insidiosum. The assays were performed by broth microdilution based on CLSI M38-A2 document. The minimum inhibitory and fungicidal concentrations were established for all isolates. Copper acetate and cadmium acetate showed the highest inhibitory effects, with minimal inhibitory concentration ranging from 4-64 μg/ml and 16-256 μg/ml, respectively. The mean geometric for minimal fungicidal concentrations were, respectively, 26 μg/ml and 111.43 μg/ml for copper acetate and cadmium acetate. These results suggest that copper and cadmium can inhibit P. insidiosum growth, highlighting the greater inhibitory activity of copper acetate. In addition, our results propose that copper and/or cadmium compounds can be used in upcoming researches to formulate effective new complexed drugs against P. insidiosum in in vitro and in vivo experimental models.
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Affiliation(s)
- Tatiana Corrêa Ribeiro
- Laboratório de Pesquisas Micológicas, Departamento de Microbiologia e Parasitologia, Universidade Federal de Santa Maria (UFSM), Campus Universitário, Prédio 20, 4139, 97105900, Santa Maria, RS, Brazil
| | - Carla Weiblen
- Departamento de Medicina Veterinária Preventiva (DMVP), Programa de Pós-graduação em Medicina Veterinária (PPGMV), Centro de Ciências Rurais, UFSM, Santa Maria, RS, Brazil
| | - Sônia de Avila Botton
- Departamento de Medicina Veterinária Preventiva (DMVP), Programa de Pós-graduação em Medicina Veterinária (PPGMV), Centro de Ciências Rurais, UFSM, Santa Maria, RS, Brazil
| | - Daniela Isabel Brayer Pereira
- Departamento de Microbiologia e Parasitologia, Instituto de Biologia, Universidade Federal de Pelotas (UFPel), Pelotas, RS, Brazil
| | - Francielli Pantella Kunz de Jesus
- Laboratório de Pesquisas Micológicas, Departamento de Microbiologia e Parasitologia, Universidade Federal de Santa Maria (UFSM), Campus Universitário, Prédio 20, 4139, 97105900, Santa Maria, RS, Brazil
| | - Camila Marina Verdi
- Laboratório de Pesquisas Micológicas, Departamento de Microbiologia e Parasitologia, Universidade Federal de Santa Maria (UFSM), Campus Universitário, Prédio 20, 4139, 97105900, Santa Maria, RS, Brazil
| | - Leticia Trevisan Gressler
- Departamento de Medicina Veterinária Preventiva (DMVP), Programa de Pós-graduação em Medicina Veterinária (PPGMV), Centro de Ciências Rurais, UFSM, Santa Maria, RS, Brazil
| | - Luís Antonio Sangioni
- Departamento de Medicina Veterinária Preventiva (DMVP), Programa de Pós-graduação em Medicina Veterinária (PPGMV), Centro de Ciências Rurais, UFSM, Santa Maria, RS, Brazil
| | - Janio Morais Santurio
- Laboratório de Pesquisas Micológicas, Departamento de Microbiologia e Parasitologia, Universidade Federal de Santa Maria (UFSM), Campus Universitário, Prédio 20, 4139, 97105900, Santa Maria, RS, Brazil
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Clinicopathological features and outcomes of pythiosis. Int J Infect Dis 2018; 71:33-41. [PMID: 29653202 DOI: 10.1016/j.ijid.2018.03.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 03/29/2018] [Accepted: 03/30/2018] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Vascular pythiosis is a life-threatening infection caused by the oomycete Pythium insidiosum. This article reports the clinical presentation, serodiagnosis, pathology, and outcomes seen at the authors' institution. METHODS The cases of patients with proven vascular pythiosis at Ramathibodi Hospital, Mahidol University, Bangkok, Thailand from January 2006 to December 2016 were analyzed retrospectively. RESULTS Thirteen patients were analyzed, eight of whom had underlying thalassemias. Of the remaining five patients, one had aplastic anemia, one had myelodysplasia, one had acute leukemia, one had cirrhosis, and one had alcoholism. Neutropenic patients showed a rapid clinical deterioration. Atypical presentations including carotid arteritis, aneurysm, brain abscess, and stroke occurred in the non-thalassemic patients. Serology yielded positive results in all cases, with a rapid turnaround time. Serology has the advantage of providing a presurgical diagnosis, which allows prompt surgery and clinical cure to be achieved. Pathology revealed a neutrophilic response in the acute phase and a later shift to granuloma. Immunotherapy in combination with itraconazole and terbinafine was given. The amputation rate was 77%, and disease-free surgical margins were achieved in five cases (38%). The mortality rate was 31%. CONCLUSIONS This study highlights new aspects of pythiosis, such as the unusual host, clinical presentation, serology as a marker for rapid diagnosis, histopathology, and outcomes. Early recognition of the disease with prompt multimodality treatment may improve survival.
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Evaluation of Moringa oleifera seed biopolymer-PVA composite hydrogel in wound healing dressing. IRANIAN POLYMER JOURNAL 2016. [DOI: 10.1007/s13726-016-0479-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Reanpang T, Orrapin S, Orrapin S, Arworn S, Kattipatanapong T, Srisuwan T, Vanittanakom N, Lekawanvijit SP, Rerkasem K. Vascular Pythiosis of the Lower Extremity in Northern Thailand. INT J LOW EXTR WOUND 2015; 14:245-50. [DOI: 10.1177/1534734615599652] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pythiosis is a disease caused by Pythium insidiosum, a fungus-like organism. P. insidiosum is pathogenic in mammals, particularly in horses, dogs, and humans. Human pythiosis can be classified into 4 types: (1) cutaneous/subcutaneous, (2) ocular, (3) vascular, and (4) disseminated pythiosis. Vascular pythiosis is a rare disease but a serious limb- and life-threatening infection. We reviewed 22 cases over a 10-year period in Maharaj Nakorn Chiang Mai/Chiang Mai University Hospital. The survival rate was around 63.6% during our follow-up period. The only effective treatment was complete excision of the infected tissue, which was done mainly by major amputation, such as above-knee amputation. This report raises awareness of this disease, which needs preemptive diagnosis and appropriate treatment.
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Affiliation(s)
- Termpong Reanpang
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Saritphat Orrapin
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Saranat Orrapin
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Supapong Arworn
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Tanop Srisuwan
- Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nongnuch Vanittanakom
- Department of Microbiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Suree P. Lekawanvijit
- Department of Pathology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kittipan Rerkasem
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Research Institute of Health Science, Chiang Mai University, Thailand
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Permpalung N, Worasilchai N, Plongla R, Upala S, Sanguankeo A, Paitoonpong L, Mendoza L, Chindamporn A. Treatment outcomes of surgery, antifungal therapy and immunotherapy in ocular and vascular human pythiosis: a retrospective study of 18 patients. J Antimicrob Chemother 2015; 70:1885-92. [PMID: 25630647 DOI: 10.1093/jac/dkv008] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 12/31/2014] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Human pythiosis is a life-threatening disease for which no standard treatment protocols with proven efficacy exist. We present the results of our institutional pythiosis treatment protocol, composed of surgery, antifungal agents, iron chelator (only vascular cases) and immunotherapy. METHODS We retrospectively analysed patients with proven vascular and ocular pythiosis in King Chulalongkorn Memorial Hospital from April 2003 to May 2013. Fisher's exact test and Wilcoxon's rank-sum test were used. The MICs of seven antifungal agents and combination drugs were investigated in eight clinical Pythium insidiosum strains. RESULTS Eighteen patients were evaluated. Disease-free surgical margins were obtained in all surviving patients with vascular pythiosis (P = 0.08). Patients who underwent eye enucleation were significantly older than those who did not (P < 0.05). Patients with vascular or ocular pythiosis did not differ significantly in the median time from disease onset to first surgery or in the relationship between the type of P. insidiosum antigen and treatment outcomes. In vitro susceptibility profiles of all isolates demonstrated that no single agent or combination treatment was substantially more effective than the others. The highest MIC was detected for amphotericin B, followed in order by voriconazole, fluconazole, anidulafungin, caspofungin, itraconazole and terbinafine. No synergistic effects of the combination drug treatments were found. CONCLUSIONS Surgery with adequate surgical margins is a crucial determinant of survival in patients with vascular pythiosis. Itraconazole and terbinafine do not have synergistic effects on Thai P. insidiosum strains. The role of immunotherapy remains inconclusive for both vascular and ocular pythiosis.
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Affiliation(s)
- Nitipong Permpalung
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand Department of Medicine, Bassett Medical Center and Columbia University College of Physicians and Surgeons, Cooperstown, NY, USA
| | | | - Rongpong Plongla
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Sikarin Upala
- Department of Medicine, Bassett Medical Center and Columbia University College of Physicians and Surgeons, Cooperstown, NY, USA Department of Preventive and Social Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand
| | - Anawin Sanguankeo
- Department of Medicine, Bassett Medical Center and Columbia University College of Physicians and Surgeons, Cooperstown, NY, USA Department of Preventive and Social Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand
| | - Leilani Paitoonpong
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Leonel Mendoza
- Microbiology and Molecular Genetics, Biomedical Laboratory Diagnostics, Michigan State University, East Lansing, MI, USA
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Loreto &ES, Tondolo JSM, Zanette RA, Alves SH, Santurio JM. Update on pythiosis immunobiology and immunotherapy. World J Immunol 2014; 4:88-97. [DOI: 10.5411/wji.v4.i2.88] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 05/06/2014] [Accepted: 06/11/2014] [Indexed: 02/05/2023] Open
Abstract
Pythiosis is an invasive, ulcerative, pyogranulomatous disease caused by Pythium insidiosum, a fungus-like oomycete that has been reported to affect humans, horses, dogs, and other mammals mainly in tropical and subtropical areas of the world. The disease is characterized by an eosinophilic granulomatous and a Th2 immune response which in turn helps to protect the fungus from the host cells. Pythiosis can present clinically in subcutaneous, gastrointestinal, and vascular tissues or in a systemically disseminated form depending on the species and site of infection. Changes in iron metabolism and anemia are commonly observed. The diagnosis is accomplished through clinical and pathological features, laboratory characteristics of cultures, serological and molecular tests. Treatment includes radical surgery, antimicrobial drugs, immunotherapy or a combination of these treatments. Immunotherapy is a practical and non-invasive alternative for treating pythiosis which is believed to promote a switch from a Th2 to Th1 immune response, resulting in a favorable clinical response. This therapy has demonstrated cure rates above 70% and 55% in horses and humans but low cure rates in dogs and cats. Despite the curative properties of this type of immunotherapy, the antibodies that are produced do not prevent host reinfection. Thus, development of effective adjuvants and new diagnostic techniques for early disease diagnosis are of utmost importance. The aim of this review was to promote pythiosis awareness and to provide an update about the immunotherapy and immunobiology of this disease.
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dos Santos CE, Ubiali DG, Pescador CA, Zanette RA, Santurio JM, Marques LC. Epidemiological Survey of Equine Pythiosis in the Brazilian Pantanal and Nearby Areas: Results of 76 Cases. J Equine Vet Sci 2014. [DOI: 10.1016/j.jevs.2013.06.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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