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Dutta K, Friscic J, Hoffmann MH. Targeting the tissue-complosome for curbing inflammatory disease. Semin Immunol 2022; 60:101644. [PMID: 35902311 DOI: 10.1016/j.smim.2022.101644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/07/2022] [Accepted: 07/12/2022] [Indexed: 01/15/2023]
Abstract
Hyperactivated local tissue is a cardinal feature of immune-mediated inflammatory diseases of various organs such as the joints, the gut, the skin, or the lungs. Tissue-resident structural and stromal cells, which get primed during repeated or long-lasting bouts of inflammation form the basis of this sensitization of the tissue. During priming, cells change their metabolism to make them fit for the heightened energy demands that occur during persistent inflammation. Epigenetic changes and, curiously, an activation of intracellularly expressed parts of the complement system drive this metabolic invigoration and enable tissue-resident cells and infiltrating immune cells to employ an arsenal of inflammatory functions, including activation of inflammasomes. Here we provide a current overview on complement activation and inflammatory transformation in tissue-occupying cells, focusing on fibroblasts during arthritis, and illustrate ways how therapeutics directed at complement C3 could potentially target the complosome to unprime cells in the tissue and induce long-lasting abatement of inflammation.
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Affiliation(s)
- Kuheli Dutta
- Department of Dermatology, Allergology, and Venereology, University of Lübeck, Lübeck, Germany
| | - Jasna Friscic
- Department of Dermatology, Allergology, and Venereology, University of Lübeck, Lübeck, Germany
| | - Markus H Hoffmann
- Department of Dermatology, Allergology, and Venereology, University of Lübeck, Lübeck, Germany.
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2
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Milosevits G, Mészáros T, Őrfi E, Bakos T, Garami M, Kovács G, Dézsi L, Hamar P, Győrffy B, Szabó A, Szénási G, Szebeni J. Complement-mediated hypersensitivity reactions to an amphotericin B-containing lipid complex (Abelcet) in pediatric patients and anesthetized rats: Benefits of slow infusion. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2021; 34:102366. [PMID: 33549818 DOI: 10.1016/j.nano.2021.102366] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/06/2021] [Accepted: 01/16/2021] [Indexed: 11/26/2022]
Abstract
Intravenous administration of lipid-based nanodrugs can cause hypersensitivity, also known as infusion reactions (IRs), that can be attenuated by slow infusion in adult patients. We studied the role of infusion rate and complement (C) activation in IRs in pediatric patients treated with Abelcet, and also in anesthetized rats. IRs were observed in 6 out of 10 (60%) patients who received Abelcet infusion in 4 h or less, while no patients who received the infusion in 6 h showed C activation or IRs. The rat model indicated an inverse relationship between infusion speed and Abelcet-induced hypotension, taken as an experimental endpoint of IRs, while the rise of C3a in blood, an index of C activation, directly correlated with hypotension. The results suggest that pediatric patients are more prone to produce IRs, and that the optimal infusion time of Abelcet may be much longer than the presently recommended 2 h.
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Affiliation(s)
- Gergely Milosevits
- Second Department of Paediatrics, Semmelweis University, Budapest, Hungary; Institute of Translational Medicine, Semmelweis University, Budapest, Hungary.
| | - Tamás Mészáros
- Institute of Translational Medicine, Semmelweis University, Budapest, Hungary; SeroScience LCC, Budapest, Hungary.
| | - Erik Őrfi
- Institute of Translational Medicine, Semmelweis University, Budapest, Hungary.
| | - Tamás Bakos
- Institute of Translational Medicine, Semmelweis University, Budapest, Hungary.
| | - Miklós Garami
- Second Department of Paediatrics, Semmelweis University, Budapest, Hungary.
| | - Gábor Kovács
- Second Department of Paediatrics, Semmelweis University, Budapest, Hungary.
| | - László Dézsi
- Institute of Translational Medicine, Semmelweis University, Budapest, Hungary.
| | - Péter Hamar
- Institute of Translational Medicine, Semmelweis University, Budapest, Hungary.
| | - Balázs Győrffy
- Second Department of Paediatrics, Semmelweis University, Budapest, Hungary; Cancer Biomarker Research Group, Institute of Enzymology, Research Center for Natural Sciences, Budapest, Hungary.
| | - András Szabó
- Second Department of Paediatrics, Semmelweis University, Budapest, Hungary.
| | - Gábor Szénási
- Institute of Translational Medicine, Semmelweis University, Budapest, Hungary.
| | - János Szebeni
- Institute of Translational Medicine, Semmelweis University, Budapest, Hungary; SeroScience LCC, Budapest, Hungary; Cancer Biomarker Research Group, Institute of Enzymology, Research Center for Natural Sciences, Budapest, Hungary; Department of Nanobiotechnology and Regenerative Medicine, Faculty of Health, Miskolc University, Miskolc, Hungary.
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3
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Moghimi SM, Simberg D, Skotland T, Yaghmur A, Hunter AC. The Interplay Between Blood Proteins, Complement, and Macrophages on Nanomedicine Performance and Responses. J Pharmacol Exp Ther 2019; 370:581-592. [PMID: 30940695 PMCID: PMC11047092 DOI: 10.1124/jpet.119.258012] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 03/28/2019] [Indexed: 12/17/2022] Open
Abstract
In the blood, depending on their physicochemical characteristics, nanoparticles attract a wide range of plasma biomolecules. The majority of blood biomolecules bind nonspecifically to nanoparticles. On the other hand, biomolecules such as pattern-recognition complement-sensing proteins may recognize some structural determinants of the pristine surface, causing complement activation. Adsorption of nonspecific blood proteins could also recruit natural antibodies and initiate complement activation, and this seems to be a global process with many preclinical and clinical nanomedicines. We discuss these issues, since complement activation has ramifications in nanomedicine stability and pharmacokinetics, as well as in inflammation and disease progression. Some studies have also predicted a role for complement systems in infusion-related reactions, whereas others show a direct role for macrophages and other immune cells independent of complement activation. We comment on these discrepancies and suggest directions for exploring the underlying mechanisms.
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Affiliation(s)
- S Moein Moghimi
- School of Pharmacy and Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom (S.M.M.); Colorado Center for Nanomedicine and Nanosafety, University of Colorado Anschutz Medical Campus (S.M.M., D.S.), and Translational Bio-Nanosciences Laboratory, Department of Pharmaceutical Sciences, The Skaggs School of Pharmacy and Pharmaceutical Sciences (D.S.), University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Molecular Cell Biology, Institute for Cancer Research, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway (T.S.); Department of Pharmacy, University of Copenhagen, Copenhagen Ø, Denmark (A.Y.); and Leicester School of Pharmacy, De Montfort University, The Gateway, Leicester, United Kingdom (A.C.H.)
| | - Dmitri Simberg
- School of Pharmacy and Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom (S.M.M.); Colorado Center for Nanomedicine and Nanosafety, University of Colorado Anschutz Medical Campus (S.M.M., D.S.), and Translational Bio-Nanosciences Laboratory, Department of Pharmaceutical Sciences, The Skaggs School of Pharmacy and Pharmaceutical Sciences (D.S.), University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Molecular Cell Biology, Institute for Cancer Research, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway (T.S.); Department of Pharmacy, University of Copenhagen, Copenhagen Ø, Denmark (A.Y.); and Leicester School of Pharmacy, De Montfort University, The Gateway, Leicester, United Kingdom (A.C.H.)
| | - Tore Skotland
- School of Pharmacy and Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom (S.M.M.); Colorado Center for Nanomedicine and Nanosafety, University of Colorado Anschutz Medical Campus (S.M.M., D.S.), and Translational Bio-Nanosciences Laboratory, Department of Pharmaceutical Sciences, The Skaggs School of Pharmacy and Pharmaceutical Sciences (D.S.), University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Molecular Cell Biology, Institute for Cancer Research, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway (T.S.); Department of Pharmacy, University of Copenhagen, Copenhagen Ø, Denmark (A.Y.); and Leicester School of Pharmacy, De Montfort University, The Gateway, Leicester, United Kingdom (A.C.H.)
| | - Anan Yaghmur
- School of Pharmacy and Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom (S.M.M.); Colorado Center for Nanomedicine and Nanosafety, University of Colorado Anschutz Medical Campus (S.M.M., D.S.), and Translational Bio-Nanosciences Laboratory, Department of Pharmaceutical Sciences, The Skaggs School of Pharmacy and Pharmaceutical Sciences (D.S.), University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Molecular Cell Biology, Institute for Cancer Research, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway (T.S.); Department of Pharmacy, University of Copenhagen, Copenhagen Ø, Denmark (A.Y.); and Leicester School of Pharmacy, De Montfort University, The Gateway, Leicester, United Kingdom (A.C.H.)
| | - A Christy Hunter
- School of Pharmacy and Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom (S.M.M.); Colorado Center for Nanomedicine and Nanosafety, University of Colorado Anschutz Medical Campus (S.M.M., D.S.), and Translational Bio-Nanosciences Laboratory, Department of Pharmaceutical Sciences, The Skaggs School of Pharmacy and Pharmaceutical Sciences (D.S.), University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Molecular Cell Biology, Institute for Cancer Research, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway (T.S.); Department of Pharmacy, University of Copenhagen, Copenhagen Ø, Denmark (A.Y.); and Leicester School of Pharmacy, De Montfort University, The Gateway, Leicester, United Kingdom (A.C.H.)
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4
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Silberreis K, Niesler N, Rades N, Haag R, Dernedde J. Sulfated Dendritic Polyglycerol Is a Potent Complement Inhibitor. Biomacromolecules 2019; 20:3809-3818. [DOI: 10.1021/acs.biomac.9b00889] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Kim Silberreis
- Institute of Chemistry and Biochemistry, Freie Universität Berlin, Takustrasse 3, 14195 Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Laboratory Medicine Clinical Chemistry and Pathobiochemistry, CVK Augustenburger Platz 1, 13353 Berlin, Germany
| | - Nicole Niesler
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Laboratory Medicine Clinical Chemistry and Pathobiochemistry, CVK Augustenburger Platz 1, 13353 Berlin, Germany
| | - Nadine Rades
- Institute of Chemistry and Biochemistry, Freie Universität Berlin, Takustrasse 3, 14195 Berlin, Germany
| | - Rainer Haag
- Institute of Chemistry and Biochemistry, Freie Universität Berlin, Takustrasse 3, 14195 Berlin, Germany
| | - Jens Dernedde
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Laboratory Medicine Clinical Chemistry and Pathobiochemistry, CVK Augustenburger Platz 1, 13353 Berlin, Germany
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5
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Clarke AR, Christophe BR, Khahera A, Sim JL, Connolly ES. Therapeutic Modulation of the Complement Cascade in Stroke. Front Immunol 2019; 10:1723. [PMID: 31417544 PMCID: PMC6682670 DOI: 10.3389/fimmu.2019.01723] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 07/09/2019] [Indexed: 01/22/2023] Open
Abstract
Stroke is a leading cause of death and disability worldwide and an increasing number of ischemic stroke patients are undergoing pharmacological and mechanical reperfusion. Both human and experimental models of reperfused ischemic stroke have implicated the complement cascade in secondary tissue injury. Most data point to the lectin and alternative pathways as key to activation, and C3a and C5a binding of their receptors as critical effectors of injury. During periods of thrombolysis use to treat stroke, acute experimental complement cascade blockade has been found to rescue tissue and improves functional outcome. Blockade of the complement cascade during the period of tissue reorganization, repair, and recovery is by contrast not helpful and in fact is likely to be deleterious with emerging data suggesting downstream upregulation of the cascade might even facilitate recovery. Successful clinical translation will require the right clinical setting and pharmacologic strategies that are capable of targeting the key effectors early while not inhibiting delayed repair. Early reports in a variety of disease states suggest that such pharmacologic strategies appear to have a favorable risk profile and offer substantial hope for patients.
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Affiliation(s)
- Alison R Clarke
- Cerebrovascular Research Laboratory, Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, United States
| | - Brandon R Christophe
- Cerebrovascular Research Laboratory, Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, United States
| | - Anadjeet Khahera
- Cerebrovascular Research Laboratory, Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, United States
| | - Justin L Sim
- Cerebrovascular Research Laboratory, Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, United States
| | - E Sander Connolly
- Cerebrovascular Research Laboratory, Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, United States
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6
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Rijkers M, Schmidt D, Lu N, Kramer CSM, Heidt S, Mulder A, Porcelijn L, Claas FHJ, Leebeek FWG, Jansen AJG, Jongerius I, Zeerleder SS, Vidarsson G, Voorberg J, de Haas M. Anti-HLA antibodies with complementary and synergistic interaction geometries promote classical complement activation on platelets. Haematologica 2018; 104:403-416. [PMID: 30262558 PMCID: PMC6355480 DOI: 10.3324/haematol.2018.201665] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 09/19/2018] [Indexed: 12/21/2022] Open
Abstract
High titers of HLA antibodies are associated with platelet refractoriness, causing poor platelet increments after transfusions in a subset of patients with HLA antibodies. Currently, we do not know the biological mechanisms that explain the variability in clinical responses in HLA alloimmunized patients receiving platelet transfusions. Previously we showed that a subset of anti-HLA IgG-antibodies induces FcγRIIa-dependent platelet activation and enhanced phagocytosis. Here, we investigated whether anti-HLA IgG can induce complement activation on platelets. We found that a subset of anti-HLA IgG induced complement activation via the classical pathway, causing C4b and C3b deposition and formation of the membrane-attack complex. This resulted in permeabilization of platelet membranes and increased calcium influx. Complement activation also caused enhanced α-granule release, as measured by CD62P surface exposure. Blocking studies revealed that platelet activation was caused by FcγRIIa-dependent signaling as well as HLA antibody induced complement activation. Synergistic complement activation employing combinations of monoclonal IgGs suggested that assembly of oligomeric IgG complexes strongly promoted complement activation through binding of IgGs to different antigenic determinants on HLA. In agreement with this, we observed that preventing anti-HLA-IgG hexamer formation using an IgG-Fc:Fc blocking peptide, completely inhibited C3b and C4b deposition. Our results show that HLA antibodies can induce complement activation on platelets including membrane attack complex formation, pore formation and calcium influx. We propose that these events can contribute to fast platelet clearance in vivo in patients refractory to platelet transfusions with HLA alloantibodies, who may benefit from functional-platelet matching and treatment with complement inhibitors.
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Affiliation(s)
- Maaike Rijkers
- Department of Cellular and Molecular Hemostasis, Sanquin Research and Landsteiner Laboratory Amsterdam UMC, University of Amsterdam
| | - David Schmidt
- Department of Experimental Immunohaematology, Sanquin Research and Landsteiner Laboratory Amsterdam UMC, University of Amsterdam
| | - Nina Lu
- Department of Cellular and Molecular Hemostasis, Sanquin Research and Landsteiner Laboratory Amsterdam UMC, University of Amsterdam
| | - Cynthia S M Kramer
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center
| | - Sebastiaan Heidt
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center
| | - Arend Mulder
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center
| | - Leendert Porcelijn
- Department of Immunohaematology Diagnostics, Sanquin Diagnostic Services, Amsterdam
| | - Frans H J Claas
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center
| | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam
| | - A J Gerard Jansen
- Department of Cellular and Molecular Hemostasis, Sanquin Research and Landsteiner Laboratory Amsterdam UMC, University of Amsterdam.,Department of Hematology, Erasmus University Medical Center, Rotterdam
| | - Ilse Jongerius
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory Amsterdam UMC, University of Amsterdam
| | - Sacha S Zeerleder
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory Amsterdam UMC, University of Amsterdam
| | - Gestur Vidarsson
- Department of Experimental Immunohaematology, Sanquin Research and Landsteiner Laboratory Amsterdam UMC, University of Amsterdam
| | - Jan Voorberg
- Department of Cellular and Molecular Hemostasis, Sanquin Research and Landsteiner Laboratory Amsterdam UMC, University of Amsterdam.,Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam
| | - Masja de Haas
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center .,Department of Immunohaematology Diagnostics, Sanquin Diagnostic Services, Amsterdam.,Center for Clinical Transfusion Research, Sanquin, Leiden, the Netherlands
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7
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Dobó J, Kocsis A, Gál P. Be on Target: Strategies of Targeting Alternative and Lectin Pathway Components in Complement-Mediated Diseases. Front Immunol 2018; 9:1851. [PMID: 30135690 PMCID: PMC6092519 DOI: 10.3389/fimmu.2018.01851] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 07/26/2018] [Indexed: 12/20/2022] Open
Abstract
The complement system has moved into the focus of drug development efforts in the last decade, since its inappropriate or uncontrolled activation has been recognized in many diseases. Some of them are primarily complement-mediated rare diseases, such as paroxysmal nocturnal hemoglobinuria, C3 glomerulonephritis, and atypical hemolytic uremic syndrome. Complement also plays a role in various multifactorial diseases that affect millions of people worldwide, such as ischemia reperfusion injury (myocardial infarction, stroke), age-related macular degeneration, and several neurodegenerative disorders. In this review, we summarize the potential advantages of targeting various complement proteins with special emphasis on the components of the lectin (LP) and the alternative pathways (AP). The serine proteases (MASP-1/2/3, factor D, factor B), which are responsible for the activation of the cascade, are straightforward targets of inhibition, but the pattern recognition molecules (mannose-binding lectin, other collectins, and ficolins), the regulatory components (factor H, factor I, properdin), and C3 are also subjects of drug development. Recent discoveries about cross-talks between the LP and AP offer new approaches for clinical intervention. Mannan-binding lectin-associated serine proteases (MASPs) are not just responsible for LP activation, but they are also indispensable for efficient AP activation. Activated MASP-3 has recently been shown to be the enzyme that continuously supplies factor D (FD) for the AP by cleaving pro-factor D (pro-FD). In this aspect, MASP-3 emerges as a novel feasible target for the regulation of AP activity. MASP-1 was shown to be required for AP activity on various surfaces, first of all on LPS of Gram-negative bacteria.
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Affiliation(s)
- József Dobó
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
| | - Andrea Kocsis
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
| | - Péter Gál
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
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Berger N, Alayi TD, Resuello RRG, Tuplano JV, Reis ES, Lambris JD. New Analogs of the Complement C3 Inhibitor Compstatin with Increased Solubility and Improved Pharmacokinetic Profile. J Med Chem 2018; 61:6153-6162. [PMID: 29920096 DOI: 10.1021/acs.jmedchem.8b00560] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Improper regulation of complement is associated with various pathologies, and the clinical demand for compounds that can regulate complement activation is therefore imperative. Cp40, an analog of the peptide compstatin, inhibits all complement pathways at the level of the central component C3. We have further developed Cp40, using either PEGylation at the N-terminus or insertion of charged amino acids at the C-terminus. The PEGylated analogs are highly soluble and retained their inhibitory activity, with C3b binding affinity dependent on the length of the PEG chain. The addition of two or three residues of lysine, in turn, not only improved the peptide's solubility but also increased the binding affinity for C3b while retaining its inhibitory potency. Three of the new derivatives showed improved pharmacokinetic profiles in vivo in non-human primates. Given their compelling solubility and pharmacokinetic profiles, these new Cp40 analogs should broaden the spectrum of administration routes, likely reducing dosing frequency during chronic treatment and potentially expanding their range of clinical application.
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Affiliation(s)
- Nadja Berger
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania 19104 , United States
| | - Tchilabalo Dilezitoko Alayi
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania 19104 , United States
| | - Ranillo R G Resuello
- Simian Conservation Breeding and Research Center (SICONBREC) , Makati City 1231 , Philippines
| | - Joel V Tuplano
- Simian Conservation Breeding and Research Center (SICONBREC) , Makati City 1231 , Philippines
| | - Edimara S Reis
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania 19104 , United States
| | - John D Lambris
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine , University of Pennsylvania , Philadelphia , Pennsylvania 19104 , United States
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