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Lan Q, Shu Y, Li L, Shan X, Ma D, Li T, Wang X, Pan Y, Chen J, Zhang J, Liu P, Sun Q. Molecular characterization of structural protein genes of dengue virus serotype 1 epidemic in Yunnan, Southwest China, in 2018. Arch Virol 2021; 166:863-870. [PMID: 33495898 PMCID: PMC7831630 DOI: 10.1007/s00705-020-04942-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 11/12/2020] [Indexed: 01/02/2023]
Abstract
A dengue virus serotype 1 (DENV-1) epidemic occurred from October to December 2018 in Xishuangbanna, Yunnan, Southwest China, neighboring Myanmar, Laos, and Vietnam. In this study, we investigated the molecular characteristics, evolution, and potential source of DENV from Xishuangbanna. The C (capsid), prM (premembrane), and E (envelope) genes of DENV isolated from 87 serum samples obtained from local patients were amplified and sequenced, and the sequences were evaluated by identification of mutations, phylogenetic and homologous recombination analysis, and secondary structure prediction. Phylogenetic analysis showed that all of the epidemic DENV strains from Xishuangbanna could be grouped in a branch with DENV-1 isolates, and were most similar to the Fujian 2005 (China, DQ193572) and Singapore 2016 (MF314188) strains. When compared with DENV-1SS (the standard strain), there were 31 non-synonymous mutations, but no obvious homologous recombination signal was found. Secondary structure prediction showed that some changes had occurred in a helical region in proteins of the MN123849 and MN123854 strains, but there were few changes in the disordered region. This study reveals the molecular characteristics of the structural genes of the Xishuangbanna epidemic strains in 2018 and provides a reference for molecular epidemiology, infection, and pathogenicity research and vaccine development.
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Affiliation(s)
- Qingping Lan
- Institute of Medical Biology, Chinese academy of Medical Sciences, and Peking Union Medical College, Kunming, People's Republic of China.,Yunnan Key Laboratory of Vaccine Research and Development on Severe Infectious Diseases, Kunming, People's Republic of China.,Yunnan Key Laboratory of Vector-borne Infectious Disease, Kunming, People's Republic of China
| | - Yun Shu
- Xishuangbanna Dai Autonomous Prefecture People's Hospital, Xishuangbanna, People's Republic of China
| | - Linhao Li
- Institute of Medical Biology, Chinese academy of Medical Sciences, and Peking Union Medical College, Kunming, People's Republic of China.,Yunnan Key Laboratory of Vaccine Research and Development on Severe Infectious Diseases, Kunming, People's Republic of China.,Yunnan Key Laboratory of Vector-borne Infectious Disease, Kunming, People's Republic of China.,Kunming Medical University, Kunming, People's Republic of China
| | - Xiyun Shan
- Xishuangbanna Dai Autonomous Prefecture People's Hospital, Xishuangbanna, People's Republic of China
| | - Dehong Ma
- Xishuangbanna Dai Autonomous Prefecture People's Hospital, Xishuangbanna, People's Republic of China
| | - Tingting Li
- Xishuangbanna Dai Autonomous Prefecture People's Hospital, Xishuangbanna, People's Republic of China
| | - Xiaodan Wang
- Institute of Medical Biology, Chinese academy of Medical Sciences, and Peking Union Medical College, Kunming, People's Republic of China.,Yunnan Key Laboratory of Vaccine Research and Development on Severe Infectious Diseases, Kunming, People's Republic of China.,Yunnan Key Laboratory of Vector-borne Infectious Disease, Kunming, People's Republic of China
| | - Yue Pan
- Institute of Medical Biology, Chinese academy of Medical Sciences, and Peking Union Medical College, Kunming, People's Republic of China.,Yunnan Key Laboratory of Vaccine Research and Development on Severe Infectious Diseases, Kunming, People's Republic of China.,Yunnan Key Laboratory of Vector-borne Infectious Disease, Kunming, People's Republic of China
| | - Junying Chen
- Institute of Medical Biology, Chinese academy of Medical Sciences, and Peking Union Medical College, Kunming, People's Republic of China.,Yunnan Key Laboratory of Vaccine Research and Development on Severe Infectious Diseases, Kunming, People's Republic of China.,Yunnan Key Laboratory of Vector-borne Infectious Disease, Kunming, People's Republic of China
| | - Juan Zhang
- Institute of Medical Biology, Chinese academy of Medical Sciences, and Peking Union Medical College, Kunming, People's Republic of China.,Yunnan Key Laboratory of Vaccine Research and Development on Severe Infectious Diseases, Kunming, People's Republic of China.,Yunnan Key Laboratory of Vector-borne Infectious Disease, Kunming, People's Republic of China.,Kunming Medical University, Kunming, People's Republic of China
| | - Pinghua Liu
- Xishuangbanna Dai Autonomous Prefecture People's Hospital, Xishuangbanna, People's Republic of China.
| | - Qiangming Sun
- Institute of Medical Biology, Chinese academy of Medical Sciences, and Peking Union Medical College, Kunming, People's Republic of China. .,Yunnan Key Laboratory of Vaccine Research and Development on Severe Infectious Diseases, Kunming, People's Republic of China. .,Yunnan Key Laboratory of Vector-borne Infectious Disease, Kunming, People's Republic of China.
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El Hadad S, Alhebshi A, Al Amri H. Molecular Characterization of Dengue E/NS1 Junction Genotype 2 Isolated From Saudi Patients, Jeddah Province. Pak J Biol Sci 2018; 21:38-50. [PMID: 30187718 DOI: 10.3923/pjbs.2018.38.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE Dengue is the most important arthropod-borne viral disease which caused by the four-dengue virus serotypes (1-4) and its incidence has grown dramatically around the world in the recent decades. This study was conducted to determine the molecular characterization of dengue virus genotypes spreading in Jeddah province. METHODOLOGY To distinguish dengue virus genotypes, serum samples from 13 infected patients were subjected to envelop and non-structural 1 (E/NS1) gene amplification and sequence analysis at the nucleotide and amino acid levels. RESULTS The present partial dengue virus phylogenetic analysis announced the domination of dengue virus 2 genotype among the current dengue virus samples circulating in Jeddah province. Dengue virus 2 current isolates were grouped in one branch and seemed to be more closely related to various strains isolated from Sri-Lanka, Australia and Singapore and confirmed by internucleotide distance average ranged +/-0.01. Interestingly, sequences analysis of amino acids confirmed substitution of 8 amino acid residue (Ser729Gua, Ser729Arg, Val762Gau, Val780phe, Val781Leu, Val781Ala, Glu858Asp and Gln873His) among the present isolates comparing with previous references strains isolated from different countries. Remarkably, one unique amino acid residue Ala741Val was verified in the 10 present isolates compared to the reference sequence previously isolated from Jeddah. CONCLUSION Notably, the present study demonstrated the sequencing analysis of the dengue virus 2-E/NS1 on both nucleotide and amino acid levels and confirmed its endogenously prevalence in Jeddah.
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Ramos-Castañeda J, Barreto dos Santos F, Martínez-Vega R, Galvão de Araujo JM, Joint G, Sarti E. Dengue in Latin America: Systematic Review of Molecular Epidemiological Trends. PLoS Negl Trop Dis 2017; 11:e0005224. [PMID: 28068335 PMCID: PMC5221820 DOI: 10.1371/journal.pntd.0005224] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 12/01/2016] [Indexed: 01/02/2023] Open
Abstract
Dengue, the predominant arthropod-borne viral disease affecting humans, is caused by one of four distinct serotypes (DENV-1, -2, -3 or -4). A literature analysis and review was undertaken to describe the molecular epidemiological trends in dengue disease and the knowledge generated in specific molecular topics in Latin America, including the Caribbean islands, from 2000 to 2013 in the context of regional trends in order to identify gaps in molecular epidemiological knowledge and future research needs. Searches of literature published between 1 January 2000 and 30 November 2013 were conducted using specific search strategies for each electronic database that was reviewed. A total of 396 relevant citations were identified, 57 of which fulfilled the inclusion criteria. All four dengue virus serotypes were present and co-circulated in many countries over the review period (with the predominance of individual serotypes varying by country and year). The number of countries in which more than one serotype circulated steadily increased during the period under review. Molecular epidemiology data were found for Argentina, Bolivia, Brazil, the Caribbean region, Colombia, Ecuador, Mexico and Central America, Paraguay, Peru and Venezuela. Distinct lineages with different dynamics were found in each country, with co-existence, extinction and replacement of lineages occurring over the review period. Despite some gaps in the literature limiting the possibility for comparison, our review has described the molecular epidemiological trends of dengue infection. However, several gaps in molecular epidemiological information across Latin America and the Caribbean were identified that provide avenues for future research; in particular, sequence determination of the dengue virus genome is important for more precise phylogenetic classification and correlation with clinical outcome and disease severity. The wide distribution of the mosquito vector and the co-circulation of multiple dengue virus serotypes has led to increases in the incidence of dengue in the Americas, where it is a major public health concern. Identifying molecular epidemiological trends may help to identify the reasons for the re-emergence of dengue across Latin America and the Caribbean, and, in turn, enable disease control and management. We conducted this review using well defined methods to search for and identify relevant research according to predetermined inclusion criteria. The objective was to obtain a clearer understanding of changes occurring within dengue serotypes that have resulted in substantial genetic diversity and the emergence of endemic and epidemic strains in different parts of the region. There remain fundamental gaps in our understanding of the epidemiological and evolutionary dynamics of dengue and its relation with disease, and it is not possible to correlate accurately spatial or temporal trends in disease epidemiology, disease severity, or the genetic diversity of DENV. It is important to maintain comprehensive epidemiological surveillance throughout the region (including sequencing of viral strains) to detect new DENV lineages and to understand the regional patterns of DENV dissemination.
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Affiliation(s)
- José Ramos-Castañeda
- Instituto Nacional de Salud Publica, Centro de Investigaciones sobre Enfermedades Infecciosas, Morelos, Mexico
| | - Flavia Barreto dos Santos
- Laboratório de Imunologia Viral, Instituto Oswaldo Cruz/ Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | - Josélio Maria Galvão de Araujo
- Laboratório de Biologia Molecular de Doenças Infecciosas e do Câncer, Departamento de Microbiologia e Parasitologia; Instituto de Medicina Tropical do Rio Grande do Norte; Universidade Federal do Rio Grande do Norte, Natal, Brazil
| | - Graham Joint
- Synercom Ltd, Macclesfield, Cheshire, United Kingdom
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Huang YJS, Higgs S, Horne KM, Vanlandingham DL. Flavivirus-mosquito interactions. Viruses 2014; 6:4703-30. [PMID: 25421894 PMCID: PMC4246245 DOI: 10.3390/v6114703] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 11/17/2014] [Accepted: 11/20/2014] [Indexed: 12/20/2022] Open
Abstract
The Flavivirus genus is in the family Flaviviridae and is comprised of more than 70 viruses. These viruses have a broad geographic range, circulating on every continent except Antarctica. Mosquito-borne flaviviruses, such as yellow fever virus, dengue virus serotypes 1-4, Japanese encephalitis virus, and West Nile virus are responsible for significant human morbidity and mortality in affected regions. This review focuses on what is known about flavivirus-mosquito interactions and presents key data collected from the field and laboratory-based molecular and ultrastructural evaluations.
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Affiliation(s)
- Yan-Jang S Huang
- Department of Diagnostic Medicine and Pathobiology, College of Veterinary Medicine, Kansas State University, Manhattan, KS 66506, USA.
| | - Stephen Higgs
- Department of Diagnostic Medicine and Pathobiology, College of Veterinary Medicine, Kansas State University, Manhattan, KS 66506, USA.
| | - Kate McElroy Horne
- Biosecurity Research Institute, Kansas State University, Manhattan, KS 66506, USA.
| | - Dana L Vanlandingham
- Department of Diagnostic Medicine and Pathobiology, College of Veterinary Medicine, Kansas State University, Manhattan, KS 66506, USA.
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Anoop M, Mathew AJ, Jayakumar B, Issac A, Nair S, Abraham R, Anupriya MG, Sreekumar E. Complete genome sequencing and evolutionary analysis of dengue virus serotype 1 isolates from an outbreak in Kerala, South India. Virus Genes 2012; 45:1-13. [PMID: 22729802 DOI: 10.1007/s11262-012-0756-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 05/05/2012] [Indexed: 11/26/2022]
Abstract
In this study, dengue virus (DENV) isolates from a localized, small-scale, non-seasonal dengue outbreak were genetically characterized. The outbreak occurred during the pre-monsoon months (April-May) in a medical college campus in Kerala, South India in 2009 affecting 76 people. Analysis of 39 viral RNA positive serum samples by a serotype specific reverse-transcription polymerase chain reaction identified dengue virus serotype 1 (DENV1) as the causative strain. Formation of a distinct genetic clade was revealed in the initial phylogenetic analysis using nucleotide sequences of a partial (303 bp) Capsid-Pre-membrane protein (C-PrM) coding region of 37 outbreak strains. The sequences of these strains clustered with that of the Genotype III DENV-1 strains from India, and 32 among them formed a single major sub-clade. Whole-genome sequencing (10,693 bp) of two strains (RGCB585/2009 and RGCB592/2009) selected from this major sub-clade, and subsequent phylogenetic analysis using the full-length coding region sequence showed that the sequences grouped with that of the isolates from Thailand (1980), Comoros (1993), Singapore (1993), and Brunei (2005) among the Indo-Pacific isolates. The sequences of the two strains had a nucleotide identity of 97-98 % and an amino acid identity of 98-99 % with these closely related strains. Maximum amino acid similarity was shown with the Singapore 8114/93 isolate (99.6 %). Four mutations-L46M in the capsid, D278N in the NS1, L123I, and L879S in the NS5 protein coding regions-were seen as signature substitutions uniformly in RGCB585/2009 and RGCB592/2009; in another isolate from Kerala (RGCB419/2008) and in the Brunei isolate (DS06-210505). These four isolates also had in common a 21-nucleotide deletion in the hyper-variable region of the 3'-non-translated region. This first report on the complete genome characterization of DENV-1 isolates from India reveals a dengue outbreak caused by a genetically different viral strain. The results point to the possibility of exotic introduction of these circulating viral strains in the region.
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Affiliation(s)
- M Anoop
- Rajiv Gandhi Centre for Biotechnology, Thycaud PO, Thiruvananthapuram, 695014 Kerala, India
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Chen R, Vasilakis N. Dengue--quo tu et quo vadis? Viruses 2011; 3:1562-608. [PMID: 21994796 PMCID: PMC3187692 DOI: 10.3390/v3091562] [Citation(s) in RCA: 182] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 08/12/2011] [Accepted: 08/12/2011] [Indexed: 02/08/2023] Open
Abstract
Dengue viruses (DENV) are by far the most important arboviral pathogens in the tropics around the world, putting at risk of infection nearly a third of the global human population. DENV are members of the genus Flavivirus in the Family Flaviviridae and comprise four antigenically distinct serotypes (DENV-1-4). Although they share almost identical epidemiological features, they are genetically distinct. Phylogenetic analyses have revealed valuable insights into the origins, epidemiology and the forces that shape DENV evolution in nature. In this review, we examine the current status of DENV evolution, including but not limited to rates of evolution, selection pressures, population sizes and evolutionary constraints, and we discuss how these factors influence transmission, pathogenesis and emergence.
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Affiliation(s)
- Rubing Chen
- Department of Pathology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555, USA; E-Mail:
| | - Nikos Vasilakis
- Department of Pathology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555, USA; E-Mail:
- Center for Biodefense and Emerging Infectious Diseases, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555, USA
- Institute for Human Infection and Immunity, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555, USA
- Center for Tropical Diseases, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555, USA
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Weaver SC, Vasilakis N. Molecular evolution of dengue viruses: contributions of phylogenetics to understanding the history and epidemiology of the preeminent arboviral disease. INFECTION, GENETICS AND EVOLUTION : JOURNAL OF MOLECULAR EPIDEMIOLOGY AND EVOLUTIONARY GENETICS IN INFECTIOUS DISEASES 2009; 9:523-40. [PMID: 19460319 PMCID: PMC3609037 DOI: 10.1016/j.meegid.2009.02.003] [Citation(s) in RCA: 302] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Revised: 02/04/2009] [Accepted: 02/05/2009] [Indexed: 12/31/2022]
Abstract
Dengue viruses (DENV) are the most important arboviral pathogens in tropical and subtropical regions throughout the world, putting at risk of infection nearly a third of the global human population. Evidence from the historical record suggests a long association between these viruses and humans. The transmission of DENV includes a sylvatic, enzootic cycle between nonhuman primates and arboreal mosquitoes of the genus Aedes, and an urban, endemic/epidemic cycle between Aedes aegypti, a mosquito with larval development in peridomestic water containers, and human reservoir hosts. DENV are members of the genus Flavivirus in the Family Flaviviridae and comprise of 4 antigenically distinct serotypes (DENV-1-4). Although they are nearly identical epidemiologically, the 4 DENV serotypes are genetically quite distinct. Utilization of phylogenetic analyses based on partial and/or complete genomic sequences has elucidated the origins, epidemiology (genetic diversity, transmission dynamics and epidemic potential), and the forces that shape DENV molecular evolution (rates of evolution, selection pressures, population sizes, putative recombination and evolutionary constraints) in nature. In this review, we examine how phylogenetics have improved understanding of DENV population dynamics and sizes at various stages of infection and transmission, and how this information may influence pathogenesis and improve our ability to understand and predict DENV emergence.
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Affiliation(s)
- Scott C Weaver
- Department of Pathology, Center for Tropical Diseases, University of Texas Medical Branch, Galveston, TX 77555-0609, USA.
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Molecular epidemiology of dengue virus serotypes 2 and 3 in Paraguay during 2001–2006: The association of viral clade introductions with shifting serotype dominance. Virus Res 2008; 137:266-70. [DOI: 10.1016/j.virusres.2008.07.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Revised: 07/04/2008] [Accepted: 07/09/2008] [Indexed: 11/21/2022]
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Vezzani D, Carbajo AE. Aedes aegypti, Aedes albopictus, and dengue in Argentina: current knowledge and future directions. Mem Inst Oswaldo Cruz 2008; 103:66-74. [DOI: 10.1590/s0074-02762008005000003] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 01/08/2008] [Indexed: 11/22/2022] Open
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Regato M, Recarey R, Moratorio G, de Mora D, Garcia-Aguirre L, Gónzalez M, Mosquera C, Alava A, Fajardo A, Alvarez M, D' Andrea L, Dubra A, Martínez M, Khan B, Cristina J. Phylogenetic analysis of the NS5 gene of dengue viruses isolated in Ecuador. Virus Res 2007; 132:197-200. [PMID: 18063164 DOI: 10.1016/j.virusres.2007.10.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2007] [Revised: 10/10/2007] [Accepted: 10/17/2007] [Indexed: 11/18/2022]
Abstract
Dengue virus (DENV) is a member of the genus Flavivirus of the family Flaviviridae. DENV causes a wide range of diseases in humans, from the acute febrile illness dengue fever (DF) to life-threatening dengue hemorrhagic fever/dengue shock syndrome (DHF/DSS). There is not knowledge of the genetic relations among DENV circulating in Ecuador. Given the emerging behaviour of DENV, a single tube RT-PCR assay using a pair of consensus primers to target the NS5 coding region has been recently validated for rapid detection of flaviviruses. In order to gain insight into the degree of genetic variation of DENV strains isolated in Ecuador, DENV NS5 sequences from 23 patients were obtained by direct sequencing of PCR fragments using the mentioned one step RT-PCR assay. Phylogenetic analysis carried out using the 23 Ecuadorian DENV NS5 sequences, as well as 56 comparable sequences from DENV strains isolated elsewhere, revealed a close genetic relation among Ecuadorian strains and DENV isolates of Caribbean origin. The use of partial NS5 gene sequences may represent a useful alternative for a rapid phylogenetic analysis of DENV outbreaks.
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Affiliation(s)
- Mary Regato
- Instituto Nacional de Higiene y Medicina Tropical Leopoldo Inquieta Perez, Julian Coronel 905 y Esmeraldas, Guayaquil, Ecuador
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Pires Neto RJ, Lima DM, de Paula SO, Lima CM, Rocco IM, Fonseca BAL. Molecular epidemiology of type 1 and 2 dengue viruses in Brazil from 1988 to 2001. Braz J Med Biol Res 2005; 38:843-52. [PMID: 15933777 DOI: 10.1590/s0100-879x2005000600005] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Dengue is a mosquito-borne viral infection that in recent decades has become a major international public health concern. Epidemic dengue fever reemerged in Brazil in 1981. Since 1990 more than one dengue virus serotype has been circulating in this tropical country and increasing rates of dengue hemorrhagic fever and dengue shock syndrome have been detected every year. Some evidence supports the association between the introduction of a new serotype and/or genotype in a region and the appearance of dengue hemorrhagic fever. In order to study the evolutionary relationships and possible detection of the introduction of new dengue virus genotypes in Brazil in the last years, we analyzed partial nucleotide sequences of 52 Brazilian samples of both dengue type 1 and dengue type 2 isolated from 1988 to 2001 from highly endemic regions. A 240-nucleotide-long sequence from the envelope/nonstructural protein 1 gene junction was used for phylogenetic analysis. After comparing the nucleotide sequences originally obtained in this study to those previously studied by others, and analyzing the phylogenetic trees, we conclude that, after the initial introduction of the currently circulating dengue-1 and dengue-2 genotypes in Brazil, there has been no evidence of introduction of new genotypes since 1988. The increasing number of dengue hemorrhagic fever cases seen in Brazil in the last years is probably associated with secondary infections or with the introduction of new serotypes but not with the introduction of new genotypes.
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Affiliation(s)
- R J Pires Neto
- Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
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