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Differentiating central nervous system infection from disease infiltration in hematological malignancy. Sci Rep 2022; 12:15805. [PMID: 36138051 PMCID: PMC9499957 DOI: 10.1038/s41598-022-19769-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 09/05/2022] [Indexed: 11/24/2022] Open
Abstract
Hematological malignancies place individuals at risk of CNS involvement from their hematological disease and opportunistic intracranial infection secondary to disease-/treatment-associated immunosuppression. Differentiating CNS infection from hematological disease infiltration in these patients is valuable but often challenging. We sought to determine if statistical models might aid discrimination between these processes. Neuroradiology, clinical and laboratory data for patients with hematological malignancy at our institution between 2007 and 2017 were retrieved. MRI were deep-phenotyped across anatomical distribution, presence of pathological enhancement, diffusion restriction and hemorrhage and statistically modelled with Bayesian-directed probability networks and multivariate logistic regression. 109 patients were studied. Irrespective of a diagnosis of CNS infection or hematological disease, the commonest anatomical distributions of abnormality were multifocal-parenchymal (34.9%), focal-parenchymal (29.4%) and leptomeningeal (11.9%). Pathological enhancement was the most frequently observed abnormality (46.8%), followed by hemorrhage (22.9%) and restricted diffusion (19.3%). Logistic regression could differentiate CNS infection from hematological disease infiltration with an AUC of 0.85 where, with OR > 1 favoring CNS infection and < 1 favoring CNS hematological disease, significantly predictive imaging features were hemorrhage (OR 24.61, p = 0.02), pathological enhancement (OR 0.17, p = 0.04) and an extra-axial location (OR 0.06, p = 0.05). In conclusion, CNS infection and hematological disease are heterogeneous entities with overlapping radiological appearances but a multivariate interaction of MR imaging features may assist in distinguishing them.
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Basher F, Camargo JF, Diaz-Paez M, Lekakis LJ, Pereira DL. Aseptic Meningitis after Recovery from SARS-CoV-2 in an Allogeneic Stem Cell Transplant Recipient. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2021; 14:11795476211009811. [PMID: 33953633 PMCID: PMC8058782 DOI: 10.1177/11795476211009811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 03/19/2021] [Indexed: 01/10/2023]
Abstract
SARS-CoV-2 emerged as a worldwide pandemic in late 2019 and initially was described as a primary respiratory illness. The clinical manifestations of COVID-19 are now known to encompass nearly all organ systems, including the central nervous system. We present a case of an allogeneic hematopoietic stem cell transplant recipient who recovered from documented SARS-CoV-2 infection and later presented with symptoms of meningitis. While cerebrospinal fluid analysis did not reveal any bacterial or viral etiologies, evidence of an inflammatory state, including ophthalmologic findings of episcleritis, indicate what is likely the first reported case of aseptic meningitis associated with SARS-CoV-2 infection after initial clinical recovery.
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Affiliation(s)
- Fahmin Basher
- Division of General Internal Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jose F Camargo
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Meilin Diaz-Paez
- Division of Transplantation and Cellular Therapy, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Lazaros J Lekakis
- Division of Transplantation and Cellular Therapy, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Denise L Pereira
- Division of Transplantation and Cellular Therapy, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
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Neuroimaging of CNS infection in haematological malignancy: important signs and common diagnostic pitfalls. Clin Radiol 2021; 76:470.e1-470.e12. [PMID: 33610289 DOI: 10.1016/j.crad.2021.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 01/14/2021] [Indexed: 01/15/2023]
Abstract
Patients with haematological malignancy are at increased risk of developing central nervous system (CNS) infections, which are associated with significant morbidity and mortality. Neuroimaging plays a pivotal role in the diagnostic pathway of these patients; however, layers of complexity are added to image interpretation by the heterogeneity in imaging manifestations of haematological malignancies in the CNS, overlapping imaging features of CNS infection, treatment-related parenchymal changes and the presence of intracranial comorbidity. In this article, we review important intracranial findings of CNS infection cases accrued in 1,855 studies over more than a decade at a specialist tertiary centre. We offer schema to identify common and important neuroimaging features, discuss key differential diagnoses and frequent diagnostic pitfalls.
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Herpes Virus Infections Other than Cytomegalovirus in the Recipients of Hematopoietic Stem Cell Transplantation. Infect Dis Clin North Am 2019; 33:467-484. [PMID: 31005137 DOI: 10.1016/j.idc.2019.02.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This review discusses the epidemiologic and clinical aspects of herpes viruses other than cytomegalovirus in patients who have undergone hematopoietic stem cell transplantation.
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Pedroso JL, Dutra LA, Braga-Neto P, Abrahao A, Andrade JBCD, Silva GLD, Viana LA, Pestana JOM, Barsottini OG. Neurological complications of solid organ transplantation. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:736-747. [DOI: 10.1590/0004-282x20170132] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 07/12/2017] [Indexed: 01/21/2023]
Abstract
ABSTRACT Solid organ transplantation is a significant development in the treatment of chronic kidney, liver, heart and lung diseases. This therapeutic approach has increased patient survival and improved quality of life. New surgical techniques and immunosuppressive drugs have been developed to achieve better outcomes. However, the variety of neurological complications following solid organ transplantation is broad and carries prognostic significance. Patients may have involvement of the central or peripheral nervous system due to multiple causes that can vary depending on time of onset after the surgical procedure, the transplanted organ, and the intensity and type of immunosuppressive therapy. Neurological manifestations following solid organ transplantation pose a diagnostic challenge to medical specialists despite extensive investigation. This review aimed to provide a practical approach to help neurologists and clinicians assess and manage solid organ transplant patients presenting with acute or chronic neurological manifestations.
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Affiliation(s)
| | | | - Pedro Braga-Neto
- Universidade Estadual do Ceará, Brasil; Universidade Federal do Ceará, Brasil
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Ma CKK, Clancy L, Deo S, Blyth E, Micklethwaite KP, Gottlieb DJ. Herpes simplex virus type 1 (HSV-1) specific T-cell generation from HLA-A1- and HLA-A2-positive donors for adoptive immunotherapy. Cytotherapy 2016; 19:107-118. [PMID: 27793552 DOI: 10.1016/j.jcyt.2016.09.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 09/28/2016] [Accepted: 09/29/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND AIMS Herpes simplex virus (HSV) reactivation and infection is common in patients undergoing hematopoietic stem cell transplant (HSCT) and requires routine antiviral prophylaxis. Drug-resistant strains are increasingly common, and effective alternative therapy is currently unavailable. We generated and characterized HSV-1-specific T cells for use in adoptive cellular immunotherapy following allogeneic stem cell transplantation. METHODS Peripheral blood mononuclear cells from HLA-A1 and HLA-A2 HSV-seropositive hereditary hemochromatosis donors were used as the antigen source. Three HLA-A1 and four HLA-A2 specific epitopes were used for stimulation of T cells. Cells were stimulated with antigen-pulsed dendritic cells and cultured for 21 days in medium with interleukin (IL)-2. Cultured cells were phenotyped and tested for cytokine production, proliferation and cytotoxicity. RESULTS There was a 5.3-fold expansion in total cell numbers over 21 days of culture, with 35% of T cells being CD8 positive. Thirty-five percent, 21% and 5% of CD8 cells secreted interferon-γ, tumor necrosis factor-α and IL-2 upon HSV antigen re-stimulation. More than 50% of antigen-specific T cells secreted multiple cytokines. Cultured T cells proliferated upon antigen re-stimulation and lysed HSV-1 peptide and virus-infected targets. CONCLUSIONS It is feasible to generate functional HSV-1 specific T cells from the blood of HLA-A1 and HLA-A2 HSV-seropositive donors using specific peptides. The utility of these cells in preventing and treating HSV-1 reactivation in allogeneic HSCT will need to be tested clinically.
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Affiliation(s)
- Chun K K Ma
- The Westmead Institute for Medical Research, Australia; Blood and Marrow Transplant Unit, Australia
| | - Leighton Clancy
- The Westmead Institute for Medical Research, Australia; Blood and Marrow Transplant Unit, Australia; Sydney Cell and Gene Therapy Laboratory, Westmead Hospital, The University of Sydney, Sydney, Australia
| | - Shivashni Deo
- The Westmead Institute for Medical Research, Australia; Blood and Marrow Transplant Unit, Australia
| | - Emily Blyth
- The Westmead Institute for Medical Research, Australia; Blood and Marrow Transplant Unit, Australia; Sydney Cell and Gene Therapy Laboratory, Westmead Hospital, The University of Sydney, Sydney, Australia
| | - Kenneth P Micklethwaite
- The Westmead Institute for Medical Research, Australia; Blood and Marrow Transplant Unit, Australia; Sydney Cell and Gene Therapy Laboratory, Westmead Hospital, The University of Sydney, Sydney, Australia
| | - David J Gottlieb
- The Westmead Institute for Medical Research, Australia; Blood and Marrow Transplant Unit, Australia; Sydney Cell and Gene Therapy Laboratory, Westmead Hospital, The University of Sydney, Sydney, Australia.
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Hanajiri R, Kobayashi T, Yoshioka K, Watanabe D, Watakabe K, Murata Y, Hagino T, Seno Y, Najima Y, Igarashi A, Doki N, Kakihana K, Sakamaki H, Ohashi K. Central nervous system infection following allogeneic hematopoietic stem cell transplantation. Hematol Oncol Stem Cell Ther 2016; 10:22-28. [PMID: 27664550 DOI: 10.1016/j.hemonc.2016.08.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 07/21/2016] [Accepted: 08/29/2016] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE/BACKGROUND Here, we described the clinical characteristics and outcomes of central nervous system (CNS) infections occurring after allogeneic hematopoietic stem cell transplantation (allo-HSCT) in a single institution over the previous 6 years. METHODS Charts of 353 consecutive allogeneic transplant recipients were retrospectively reviewed for CNS infection. RESULTS A total of 17 cases of CNS infection were identified at a median of 38 days (range, 10-1028 days) after allo-HSCT. Causative pathogens were human herpesvirus-6 (n=6), enterococcus (n=2), staphylococcus (n=2), streptococcus (n=2), varicella zoster virus (n=1), cytomegalovirus (n=1), John Cunningham virus (n=1), adenovirus (n=1), and Toxoplasma gondii (n=1). The cumulative incidence of CNS infection was 4.1% at 1 year and 5.5% at 5 years. CONCLUSION Multivariate analysis revealed that high-risk disease status was a risk factor for developing CNS infection (p=.02), and that overall survival at 3 years after allo-HSCT was 33% in patients with CNS infection and 53% in those without CNS infection (p=.04).
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Affiliation(s)
- Ryo Hanajiri
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Takeshi Kobayashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kosuke Yoshioka
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Daisuke Watanabe
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kyoko Watakabe
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yutaka Murata
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Takeshi Hagino
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yasushi Seno
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Aiko Igarashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kazuhiko Kakihana
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Hisashi Sakamaki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kazuteru Ohashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan.
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Schmidt-Hieber M, Silling G, Schalk E, Heinz W, Panse J, Penack O, Christopeit M, Buchheidt D, Meyding-Lamadé U, Hähnel S, Wolf HH, Ruhnke M, Schwartz S, Maschmeyer G. CNS infections in patients with hematological disorders (including allogeneic stem-cell transplantation)-Guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Oncol 2016; 27:1207-25. [PMID: 27052648 PMCID: PMC4922317 DOI: 10.1093/annonc/mdw155] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 03/24/2016] [Indexed: 12/22/2022] Open
Abstract
Diagnosis of CNS infections remains a great challenge in patients with hematological disorders since symptoms might both be masked and be mimicked by other conditions such as metabolic disturbances or consequences from antineoplastic treatment. Thus, awareness of this complication is crucial and any suspicion of a CNS infection should lead to timely and adequate diagnostics and treatment to improve the outcome in this population. Infections of the central nervous system (CNS) are infrequently diagnosed in immunocompetent patients, but they do occur in a significant proportion of patients with hematological disorders. In particular, patients undergoing allogeneic hematopoietic stem-cell transplantation carry a high risk for CNS infections of up to 15%. Fungi and Toxoplasma gondii are the predominant causative agents. The diagnosis of CNS infections is based on neuroimaging, cerebrospinal fluid examination and biopsy of suspicious lesions in selected patients. However, identification of CNS infections in immunocompromised patients could represent a major challenge since metabolic disturbances, side-effects of antineoplastic or immunosuppressive drugs and CNS involvement of the underlying hematological disorder may mimic symptoms of a CNS infection. The prognosis of CNS infections is generally poor in these patients, albeit the introduction of novel substances (e.g. voriconazole) has improved the outcome in distinct patient subgroups. This guideline has been developed by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) with the contribution of a panel of 14 experts certified in internal medicine, hematology/oncology, infectious diseases, intensive care, neurology and neuroradiology. Grades of recommendation and levels of evidence were categorized by using novel criteria, as recently published by the European Society of Clinical Microbiology and Infectious Diseases.
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Affiliation(s)
- M Schmidt-Hieber
- Department of Hematology, Oncology and Tumor Immunology, HELIOS Clinic Berlin-Buch, Berlin
| | - G Silling
- Department of Hematology, Oncology and Stem Cell Transplantation, University Hospital, Aachen, Medical Faculty, RWTH Aachen, Aachen
| | - E Schalk
- Department of Hematology and Oncology, Otto-von-Guericke University Hospital Magdeburg, Magdeburg
| | - W Heinz
- Department of Internal Medicine II, University Hospital Würzburg, Center of Internal Medicine, Würzburg
| | - J Panse
- Department of Hematology, Oncology and Stem Cell Transplantation, University Hospital, Aachen, Medical Faculty, RWTH Aachen, Aachen
| | - O Penack
- Department of Hematology, Oncology and Tumor Immunology, Charité University Medicine, Campus Virchow Clinic, Berlin
| | - M Christopeit
- Department of Stem Cell Transplantation, University Medical Center Hamburg Eppendorf, Hamburg
| | - D Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, University of Heidelberg, Mannheim
| | - U Meyding-Lamadé
- Department of Neurology, Hospital Nordwest Frankfurt, Frankfurt/M., Germany Brunei Neuroscience Stroke and Rehabilitation Centre, Jerudong, Brunei Darussalam Department of Neuroinfectiology, Otto-Meyerhof-Centre, University of Heidelberg, Heidelberg
| | - S Hähnel
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg
| | - H H Wolf
- Department of Hematology and Oncology, University Hospital Halle, Halle
| | - M Ruhnke
- Paracelsus Clinic Osnabrück, Osnabrück
| | - S Schwartz
- Department of Hematology and Oncology, Charité University Medicine, Campus Benjamin Franklin, Berlin
| | - G Maschmeyer
- Department of Hematology, Oncology and Palliative Care, Ernst von Bergmann Clinic, Potsdam, Germany
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Cohen BA, Stosor V. Opportunistic Infections of the Central Nervous System in the Transplant Patient. Curr Neurol Neurosci Rep 2013; 13:376. [DOI: 10.1007/s11910-013-0376-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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10
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Infections in Leukemia and Hematopoietic Stem Cell Transplantation. LEUKEMIA AND RELATED DISORDERS 2012. [PMCID: PMC7178857 DOI: 10.1007/978-1-60761-565-1_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Infections are one of the most common complications in patients diagnosed with leukemia and serve as a major obstacle to treatment. Through the early 1970s, infections were the most common cause of death in patients diagnosed with acute leukemia, but improvement in treatment and supportive care over the past few decades, coupled with expanded prophylaxis and prevention regimens, have led to reduction in both the frequency and severity of infections. Regardless, due in part to an aging cancer population and the diversity of cancer treatments and procedures, infectious diseases remain a major cause of morbidity and mortality in patients with leukemia.
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Palmason S, Marty FM, Treister NS. How Do We Manage Oral Infections in Allogeneic Stem Cell Transplantation and Other Severely Immunocompromised Patients? Oral Maxillofac Surg Clin North Am 2011; 23:579-99, vii. [DOI: 10.1016/j.coms.2011.07.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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12
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Herpes simplex encephalitis in patients with cancer. J Neurooncol 2011; 105:415-21. [DOI: 10.1007/s11060-011-0609-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 05/22/2011] [Indexed: 10/18/2022]
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Herpes simplex encephalitis following spinal ependymoma resection: case report and literature review. J Neurooncol 2010; 103:771-6. [DOI: 10.1007/s11060-010-0438-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2010] [Accepted: 09/30/2010] [Indexed: 12/01/2022]
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Schmidt-Hieber M, Schwender J, Heinz WJ, Zabelina T, Kühl JS, Mousset S, Schüttrumpf S, Junghanss C, Silling G, Basara N, Neuburger S, Thiel E, Blau IW. Viral encephalitis after allogeneic stem cell transplantation: a rare complication with distinct characteristics of different causative agents. Haematologica 2010; 96:142-9. [PMID: 20851868 DOI: 10.3324/haematol.2010.029876] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Limited data are available on characteristics of viral encephalitis in patients after allogeneic stem cell transplantation. DESIGN AND METHODS We analyzed 2,628 patients after allogeneic stem cell transplantation to identify risk factors and characteristics of viral encephalitis. RESULTS Viral encephalitis occurred in 32 patients (1.2%, 95% confidence interval 0.8%-1.6%) and was associated with the use of OKT-3 or alemtuzumab for T-cell depletion (P < 0.001) and an increased mortality (P = 0.011) in comparison to patients without viral encephalitis. Detected viruses included human herpesvirus-6 (28%), Epstein-Barr virus (19%), herpes simplex virus (13%), JC virus (9%), varicella zoster virus (6%), cytomegalovirus (6%) and adenovirus (3%). More than one virus was identified in 16% of the patients. The median onset time was 106 days after allogeneic stem cell transplantation for the total group of 32 patients, but onset times were shortest in those with human herpesvirus-6 encephalitis and longest in those with JC virus-associated progressive multifocal leukoencephalopathy. The probability of a sustained response to treatment was 63% (95% confidence interval 44%-82%) with a median survival of 94 (95% confidence interval 36-152) days after onset, but significant variation was found when considering different causative viruses. Patients with herpes simplex virus encephalitis had the most favorable outcome with no encephalitis-related deaths. CONCLUSIONS The use of OKT-3 or alemtuzumab for in vivo T-cell depletion is associated with an increased risk of viral encephalitis after allogeneic stem cell transplantation. Different viruses are frequently associated with distinct characteristics such as onset time, response to treatment and outcome.
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Affiliation(s)
- Martin Schmidt-Hieber
- Medizinische Klinik III (Hämatologie, Onkologie and Transfusionsmedizin), Charité Campus Benjamin Franklin, Berlin, Germany.
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