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Marshall VA, Cornejo Castro EM, Goodman CA, Labo N, Liu I, Fisher NC, Moore KN, Nair A, Immonen T, Keele BF, Polizzotto MN, Uldrick TS, Mu Y, Saswat T, Krug LT, McBride KM, Lurain K, Ramaswami R, Yarchoan R, Whitby D. Sequencing of Kaposi's Sarcoma Herpesvirus (KSHV) genomes from persons of diverse ethnicities and provenances with KSHV-associated diseases demonstrate multiple infections, novel polymorphisms, and low intra-host variance. PLoS Pathog 2024; 20:e1012338. [PMID: 39008527 PMCID: PMC11271956 DOI: 10.1371/journal.ppat.1012338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 07/25/2024] [Accepted: 06/11/2024] [Indexed: 07/17/2024] Open
Abstract
Recently published near full-length KSHV genomes from a Cameroon Kaposi sarcoma case-control study showed strong evidence of viral recombination and mixed infections, but no sequence variations associated with disease. Using the same methodology, an additional 102 KSHV genomes from 76 individuals with KSHV-associated diseases have been sequenced. Diagnoses comprise all KSHV-associated diseases (KAD): Kaposi sarcoma (KS), primary effusion lymphoma (PEL), KSHV-associated large cell lymphoma (KSHV-LCL), a type of multicentric Castleman disease (KSHV-MCD), and KSHV inflammatory cytokine syndrome (KICS). Participants originated from 22 different countries, providing the opportunity to obtain new near full-length sequences of a wide diversity of KSHV genomes. These include near full-length sequence of genomes with KSHV K1 subtypes A, B, C, and F as well as subtype E, for which no full sequence was previously available. High levels of recombination were observed. Fourteen individuals (18%) showed evidence of infection with multiple KSHV variants (from two to four unique genomes). Twenty-six comparisons of sequences, obtained from various sampling sites including PBMC, tissue biopsies, oral fluids, and effusions in the same participants, identified near complete genome conservation between different biological compartments. Polymorphisms were identified in coding and non-coding regions, including indels in the K3 and K15 genes and sequence inversions here reported for the first time. One such polymorphism in KSHV ORF46, specific to the KSHV K1 subtype E2, encoded a mutation in the leucine loop extension of the uracil DNA glycosylase that results in alteration of biochemical functions of this protein. This confirms that KSHV sequence variations can have functional consequences warranting further investigation. This study represents the largest and most diverse analysis of KSHV genome sequences to date among individuals with KAD and provides important new information on global KSHV genomics.
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Affiliation(s)
- Vickie A. Marshall
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Elena M. Cornejo Castro
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Charles A. Goodman
- Retroviral Evolution Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Nazzarena Labo
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Isabella Liu
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Nicholas C. Fisher
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Kyle N. Moore
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Ananthakrishnan Nair
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Taina Immonen
- Retroviral Evolution Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Brandon F. Keele
- Retroviral Evolution Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
| | - Mark N. Polizzotto
- HIV and AIDS Malignancy Branch, National Cancer Institute, Bethesda, Maryland, United States of America
| | - Thomas S. Uldrick
- HIV and AIDS Malignancy Branch, National Cancer Institute, Bethesda, Maryland, United States of America
| | - Yunxiang Mu
- Department of Epigenetics and Molecular Carcinogenesis, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Tanuja Saswat
- HIV and AIDS Malignancy Branch, National Cancer Institute, Bethesda, Maryland, United States of America
| | - Laurie T. Krug
- HIV and AIDS Malignancy Branch, National Cancer Institute, Bethesda, Maryland, United States of America
| | - Kevin M. McBride
- Department of Epigenetics and Molecular Carcinogenesis, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Kathryn Lurain
- HIV and AIDS Malignancy Branch, National Cancer Institute, Bethesda, Maryland, United States of America
| | - Ramya Ramaswami
- HIV and AIDS Malignancy Branch, National Cancer Institute, Bethesda, Maryland, United States of America
| | - Robert Yarchoan
- HIV and AIDS Malignancy Branch, National Cancer Institute, Bethesda, Maryland, United States of America
| | - Denise Whitby
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, United States of America
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Gong H, Zhang S, Dou J, Chen J. Is human herpesvirus 8 infection more common in men than in women? an updated meta-analysis. BMC Infect Dis 2024; 24:454. [PMID: 38684967 PMCID: PMC11059601 DOI: 10.1186/s12879-024-09346-5] [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] [Received: 10/22/2023] [Accepted: 04/23/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Clinically, most patients with Kaposi's sarcoma (KS) are male, and several direct and indirect mechanisms may underlie this increased susceptibility in men, Kaposi's sarcoma-associated herpesvirus (KSHV), also known as human herpesvirus 8 (HHV-8), is considered to be the primary etiological agent responsible for KS. Thus, we propose the hypothesis that men are more susceptible to HHV-8 infection, leading to a higher incidence of Kaposi's sarcoma among males. A meta-analysis was conducted to evaluate the association between gender and HHV-8 seropositivity in the general population. METHODS A comprehensive literature search was performed using 6 online databases: PubMed, EMBASE, Cochrane library, Web of Science, CNKI, and Wanfang. Studies published before March 15, 2023, were included. RESULTS In all, 33 articles including 41 studies were included in the meta-analysis. In the included adult population. men had a higher risk of HHV-8 infection than did women in adult populations from all over the world (odds ratio [OR]: 1.08, 95% confidence interval [CI]: 1.01-1.15), but no differences were found in child population from all over the world (OR: 0.90, 95% CI: 0.79-1.01). There was a significant difference in HHV-8 seroprevalence between men and women in sub-Saharan Africa (SSA) adult population (OR: 1.15, 95% CI: 1.05-1.26). However, no significant differences were observed in sub-Saharan Africa (SSA) child population (OR: 0.90, 95%CI 0.78-1.03). As for other continents, the results showed no significant difference, such as the Asian population (OR: 1.03, 95%CI: 0.92-1.16). or the European and American populations (OR 1.01, 95%CI 0.87-1.17). CONCLUSION There was a slight gender disparity for HHV-8 infection in the adult population. Among the adult populations from SSA and globally, men were more likely to be infected with HHV-8 than were women. However, no statistical significance was observed in the child populations from SSA and globally. In the future, the inclusion of more standardized studies may strengthen the results of this study.
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Affiliation(s)
- Haibo Gong
- Department of Dermatology, Henan Provincial People's Hospital; People's Hospital of Zhengzhou University, No. 7 Weiwu Road, Zhengzhou, Zhengzhou, Henan, 450003, China.
| | - Shuai Zhang
- Department of Dermatology, Henan Provincial People's Hospital; People's Hospital of Zhengzhou University, No. 7 Weiwu Road, Zhengzhou, Zhengzhou, Henan, 450003, China
| | - Jinfa Dou
- Department of Dermatology, Henan Provincial People's Hospital; People's Hospital of Zhengzhou University, No. 7 Weiwu Road, Zhengzhou, Zhengzhou, Henan, 450003, China
| | - Jing Chen
- Department of Dermatology, Henan Provincial People's Hospital; People's Hospital of Zhengzhou University, No. 7 Weiwu Road, Zhengzhou, Zhengzhou, Henan, 450003, China
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3
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Kuriyama K, Watanabe T, Ohno S. Analysis of the interaction between the ORF42 and ORF55 proteins encoded by Kaposi's sarcoma-associated herpesvirus. Arch Virol 2024; 169:98. [PMID: 38619650 DOI: 10.1007/s00705-024-06021-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 02/01/2024] [Indexed: 04/16/2024]
Abstract
Kaposi's sarcoma-associated herpesvirus (KSHV) causes Kaposi's sarcoma, primary effusion lymphoma, and multicentric Castleman disease. The tegument is a structure that is unique to herpesviruses that includes host and viral proteins, including the viral ORF42 and ORF55 proteins. Alphaherpesvirus tegument proteins have been well studied, but much is unknown regarding KSHV. Here, we report an interaction between the ORF42 and ORF55 proteins. ORF55 interacted with and recruited ORF42 from the nucleus to the cytoplasm. When ORF42 and ORF55 were expressed simultaneously in cultured cells, the expression level of these two viral proteins was higher than when either was expressed independently. ORF55, but not ORF42, was polyubiquitinated, suggesting that an unidentified regulatory mechanism may be present. A recombinant virus with an ectopic stop codon in ORF42 exhibited normal replication of genomic DNA, but fewer virus particles were released with the recombinant than with the wild-type virus. A unique R136Q mutation in ORF42, which is found in a KSHV strain that is prevalent on Miyako Island, Okinawa Prefecture, Japan, further increased the expression of ORF42 and ORF55 when these proteins were expressed simultaneously. However, the ORF42 R136Q mutation did not affect the localization pattern of ORF42 itself or of ORF55. In addition, experiments with a recombinant virus possessing the ORF42 R136Q mutation showed lower levels of production of the mutant virus than of the wild-type virus, despite similar levels of genome replication. We suggest that the R136Q mutation in ORF42 plays an important role in ORF55 protein expression and virus production.
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Affiliation(s)
- Kazushi Kuriyama
- Department of Virology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Nakagami, Okinawa, 903-0215, Japan
| | - Tadashi Watanabe
- Department of Virology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Nakagami, Okinawa, 903-0215, Japan
| | - Shinji Ohno
- Department of Virology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Nakagami, Okinawa, 903-0215, Japan.
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4
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Marshall VA, Fisher NC, Goodman CA, Castro EMC, Liu I, Khanal S, Holdridge BM, Thorpe AL, Labo N, Stolka KB, Hemingway-Foday JJ, Abassora M, N’Dom P, Smith JS, Sallah N, Palser AL, Kellam P, Keele BF, Whitby D. Systematic analysis of Kaposi's sarcoma (KS)-associated herpesvirus genomes from a KS case-control study in Cameroon: Evidence of dual infections but no association between viral sequence variation and KS risk. Int J Cancer 2022; 151:1127-1141. [PMID: 35608873 PMCID: PMC10043945 DOI: 10.1002/ijc.34136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/12/2022] [Accepted: 04/23/2022] [Indexed: 11/06/2022]
Abstract
In sub-Saharan Africa, Kaposi's sarcoma-associated herpesvirus (KSHV) is endemic, and Kaposi's sarcoma (KS) is a significant public health problem. Until recently, KSHV genotype analysis was performed using variable gene regions, representing a small fraction of the genome, and thus the contribution of sequence variation to viral transmission or pathogenesis are understudied. We performed near full-length KSHV genome sequence analysis on samples from 43 individuals selected from a large Cameroonian KS case-control study. KSHV genomes were obtained from 21 KS patients and 22 control participants. Phylogenetic analysis of the K1 region indicated the majority of sequences were A5 or B1 subtypes and all three K15 alleles were represented. Unique polymorphisms in the KSHV genome were observed including large gene deletions. We found evidence of multiple distinct KSHV genotypes in three individuals. Additionally, our analyses indicate that recombination is prevalent suggesting that multiple KSHV infections may not be uncommon overall. Most importantly, a detailed analysis of KSHV genomes from KS patients and control participants did not find a correlation between viral sequence variations and disease. Our study is the first to systematically compare near full-length KSHV genome sequences between KS cases and controls in the same endemic region to identify possible sequence variations associated with disease risk.
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Affiliation(s)
- Vickie A. Marshall
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Nicholas C. Fisher
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Charles A. Goodman
- Retroviral Evolution Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Elena M. Cornejo Castro
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Isabella Liu
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Sirish Khanal
- Retroviral Evolution Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Benjamin M. Holdridge
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Abigail L. Thorpe
- Retroviral Evolution Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Nazzarena Labo
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | | | | | | | | | | | - Neneh Sallah
- Wellcome Sanger Institute, Wellcome Genome Campus, Cambridge, UK
| | | | - Paul Kellam
- Kymab Ltd., Babraham Research Campus, Cambridge, UK
- Department of Medicine, Division of Infectious Diseases, Imperial College London, London, UK
| | - Brandon F. Keele
- Retroviral Evolution Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Denise Whitby
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
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5
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Moorad R, Juarez A, Landis JT, Pluta LJ, Perkins M, Cheves A, Dittmer DP. Whole-genome sequencing of Kaposi sarcoma-associated herpesvirus (KSHV/HHV8) reveals evidence for two African lineages. Virology 2022; 568:101-114. [PMID: 35152042 PMCID: PMC8915436 DOI: 10.1016/j.virol.2022.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 01/07/2022] [Accepted: 01/16/2022] [Indexed: 12/28/2022]
Abstract
Kaposi sarcoma (KS)-associated herpesvirus (KSHV/HHV-8) was first sequenced from the body cavity (BC) lymphoma cell line, BC-1, in 1996. Few other KSHV genomes have been reported. Our knowledge of sequence variation for this virus remains spotty. This study reports additional genomes from historical US patient samples and from African KS biopsies. It describes an assay that spans regions of the virus that cannot be covered by short read sequencing. These include the terminal repeats, the LANA repeats, and the origins of replication. A phylogenetic analysis, based on 107 genomes, identified three distinct clades; one containing isolates from USA/Europe/Japan collected in the 1990s and two of Sub-Saharan Africa isolates collected since 2010. This analysis indicates that the KSHV strains circulating today differ from the isolates collected at the height of the AIDS epidemic. This analysis helps experimental designs and potential vaccine studies.
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Affiliation(s)
- Razia Moorad
- Lineberger Comprehensive Cancer Center, School of Medicine, Department of Immunology and Microbiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Angelica Juarez
- Lineberger Comprehensive Cancer Center, School of Medicine, Department of Immunology and Microbiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Justin T Landis
- Lineberger Comprehensive Cancer Center, School of Medicine, Department of Immunology and Microbiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Linda J Pluta
- Lineberger Comprehensive Cancer Center, School of Medicine, Department of Immunology and Microbiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Megan Perkins
- Lineberger Comprehensive Cancer Center, School of Medicine, Department of Immunology and Microbiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Avery Cheves
- Lineberger Comprehensive Cancer Center, School of Medicine, Department of Immunology and Microbiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Dirk P Dittmer
- Lineberger Comprehensive Cancer Center, School of Medicine, Department of Immunology and Microbiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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6
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Matsunami M, Koganebuchi K, Imamura M, Ishida H, Kimura R, Maeda S. Fine-Scale Genetic Structure and Demographic History in the Miyako Islands of the Ryukyu Archipelago. Mol Biol Evol 2021; 38:2045-2056. [PMID: 33432348 PMCID: PMC8097307 DOI: 10.1093/molbev/msab005] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The Ryukyu Archipelago is located in the southwest of the Japanese islands and is composed of dozens of islands, grouped into the Miyako Islands, Yaeyama Islands, and Okinawa Islands. Based on the results of principal component analysis on genome-wide single-nucleotide polymorphisms, genetic differentiation was observed among the island groups of the Ryukyu Archipelago. However, a detailed population structure analysis of the Ryukyu Archipelago has not yet been completed. We obtained genomic DNA samples from 1,240 individuals living in the Miyako Islands, and we genotyped 665,326 single-nucleotide polymorphisms to infer population history within the Miyako Islands, including Miyakojima, Irabu, and Ikema islands. The haplotype-based analysis showed that populations in the Miyako Islands were divided into three subpopulations located on Miyakojima northeast, Miyakojima southwest, and Irabu/Ikema. The results of haplotype sharing and the D statistics analyses showed that the Irabu/Ikema subpopulation received gene flows different from those of the Miyakojima subpopulations, which may be related with the historically attested immigration during the Gusuku period (900 − 500 BP). A coalescent-based demographic inference suggests that the Irabu/Ikema population firstly split away from the ancestral Ryukyu population about 41 generations ago, followed by a split of the Miyako southwest population from the ancestral Ryukyu population (about 16 generations ago), and the differentiation of the ancestral Ryukyu population into two populations (Miyako northeast and Okinawajima populations) about seven generations ago. Such genetic information is useful for explaining the population history of modern Miyako people and must be taken into account when performing disease association studies.
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Affiliation(s)
- Masatoshi Matsunami
- Department of Advanced Genomic and Laboratory Medicine, Graduate School of Medicine, University of the Ryukyus, Nishihara-Cho, Japan
| | - Kae Koganebuchi
- Advanced Medical Research Center, Faculty of Medicine, University of the Ryukyus, Nishihara-Cho, Japan
| | - Minako Imamura
- Department of Advanced Genomic and Laboratory Medicine, Graduate School of Medicine, University of the Ryukyus, Nishihara-Cho, Japan.,Division of Clinical Laboratory and Blood Transfusion, University of the Ryukyus Hospital, Nishihara-Cho, Japan
| | - Hajime Ishida
- Department of Human Biology and Anatomy, Graduate School of Medicine, University of the Ryukyus, Nishihara-Cho, Japan
| | - Ryosuke Kimura
- Department of Human Biology and Anatomy, Graduate School of Medicine, University of the Ryukyus, Nishihara-Cho, Japan
| | - Shiro Maeda
- Department of Advanced Genomic and Laboratory Medicine, Graduate School of Medicine, University of the Ryukyus, Nishihara-Cho, Japan.,Division of Clinical Laboratory and Blood Transfusion, University of the Ryukyus Hospital, Nishihara-Cho, Japan
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7
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Intra-host changes in Kaposi sarcoma-associated herpesvirus genomes in Ugandan adults with Kaposi sarcoma. PLoS Pathog 2021; 17:e1008594. [PMID: 33465147 PMCID: PMC7845968 DOI: 10.1371/journal.ppat.1008594] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 01/29/2021] [Accepted: 11/24/2020] [Indexed: 12/14/2022] Open
Abstract
Intra-host tumor virus variants may influence the pathogenesis and treatment responses of some virally-associated cancers. However, the intra-host variability of Kaposi sarcoma-associated herpesvirus (KSHV), the etiologic agent of Kaposi sarcoma (KS), has to date been explored with sequencing technologies that possibly introduce more errors than that which occurs in the viral population, and these studies have only studied variable regions. Here, full-length KSHV genomes in tumors and/or oral swabs from 9 Ugandan adults with HIV-associated KS were characterized. Furthermore, we used deep, short-read sequencing using duplex unique molecular identifiers (dUMI)–random double-stranded oligonucleotides that barcode individual DNA molecules before library amplification. This allowed suppression of PCR and sequencing errors to ~10−9/base as well as afforded accurate determination of KSHV genome numbers sequenced in each sample. KSHV genomes were assembled de novo, and rearrangements observed were confirmed by PCR and Sanger sequencing. 131-kb KSHV genome sequences, excluding major repeat regions, were successfully obtained from 23 clinical specimens, averaging 2.3x104 reads/base. Strikingly, KSHV genomes were virtually identical within individuals at the point mutational level. The intra-host heterogeneity that was observed was confined to tumor-associated KSHV mutations and genome rearrangements, all impacting protein-coding sequences. Although it is unclear whether these changes were important to tumorigenesis or occurred as a result of genomic instability in tumors, similar changes were observed across individuals. These included inactivation of the K8.1 gene in tumors of 3 individuals and retention of a region around the first major internal repeat (IR1) in all instances of genomic deletions and rearrangements. Notably, the same breakpoint junctions were found in distinct tumors within single individuals, suggesting metastatic spread of rearranged KSHV genomes. These findings define KSHV intra-host heterogeneity in vivo with greater precision than has been possible in the past and suggest the possibility that aberrant KSHV genomes may contribute to aspects of KS tumorigenesis. Furthermore, study of KSHV with use of dUMI provides a proof of concept for utilizing this technique for detailed study of other virus populations in vivo. Kaposi sarcoma (KS) is a leading cancer in sub-Saharan Africa and in persons with HIV co-infection. Kaposi sarcoma-associated herpesvirus (KSHV, also referred to as human herpesvirus-8, or HHV-8) is the etiologic agent of KS, but the factors that contribute to the development of KS, which occurs in only a small subset of infected individuals, remain largely unknown. While strain differences or mutations in other tumor viruses are known to affect the risk and progression of their associated cancers, whether genetic variation in KSHV is important to the natural history of KS is unclear. Most studies of KSHV diversity have only characterized ~4% of its 165-kb genome, and the observed variation in some studies is likely to have been impacted by PCR or cloning artifacts. To precisely define genomic diversity of KSHV in vivo, we evaluated full-length viral genomes (except the internal repeat regions) using a technique that greatly lowers sequencing error rates and thus measures genomic diversity much more accurately than previous studies. In addition, we extended our analyses to look for potential tumor-specific changes in the KSHV genomes by examining viruses in both tumor and non-tumor tissues. To these ends, we performed highly sensitive, single-molecule sequencing of whole KSHV genomes in paired KS tumors and oral swabs from 9 individuals with KS. We found that KSHV genomes were virtually identical within the 9 individuals, with no evidence of quasispecies formation or multi-strain infection. However, KSHV genome aberrations and gene-inactivating mutations were found to be common in KS tumors, often impacting the same genes and genomic regions across individuals. Whether theses mutations influence KS tumorigenesis or result from genomic instability commonly found in tumors warrants further study. Lastly, aberrant KSHV genomes were found to be shared by distinct tumors within individuals, suggesting the capacity of KS tumor cells to metastasize and seed new lesions.
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8
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Cornejo Castro EM, Marshall V, Lack J, Lurain K, Immonen T, Labo N, Fisher NC, Ramaswami R, Polizzotto MN, Keele BF, Yarchoan R, Uldrick TS, Whitby D. Dual infection and recombination of Kaposi sarcoma herpesvirus revealed by whole-genome sequence analysis of effusion samples. Virus Evol 2020; 6:veaa047. [PMID: 34211736 PMCID: PMC7474928 DOI: 10.1093/ve/veaa047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Kaposi sarcoma herpesvirus (KSHV) is the etiological agent of three malignancies, Kaposi sarcoma (KS), primary effusion lymphoma (PEL) and KSHV-associated multicentric Castelman disease. KSHV infected patients may also have an interleukin six-related KSHV-associated inflammatory cytokine syndrome. KSHV-associated diseases occur in only a minority of chronically KSHV-infected individuals and often in the setting of immunosuppression. Mechanisms by which KSHV genomic variations and systemic co-infections may affect the pathogenic pathways potentially leading to these diseases have not been well characterized in vivo. To date, the majority of comparative genetic analyses of KSHV have been focused on a few regions scattered across the viral genome. We used next-generation sequencing techniques to investigate the taxonomic groupings of viruses from malignant effusion samples from fourteen participants with advanced KSHV-related malignancies, including twelve with PEL and two with KS and elevated KSHV viral load in effusions. The genomic diversity and evolutionary characteristics of nine isolated, near full-length KSHV genomes revealed extensive evidence of mosaic patterns across all these genomes. Further, our comprehensive NGS analysis allowed the identification of two distinct KSHV genome sequences in one individual, consistent with a dual infection. Overall, our results provide significant evidence for the contribution of KSHV phylogenomics to the origin of KSHV subtypes. This report points to a wider scope of studies to establish genome-wide patterns of sequence diversity and define the possible pathogenic role of sequence variations in KSHV-infected individuals.
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Affiliation(s)
- Elena M Cornejo Castro
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, P.O. Box B, Frederick, MD 21702, USA
| | - Vickie Marshall
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, P.O. Box B, Frederick, MD 21702, USA
| | - Justin Lack
- Advanced Biomedical Computing Center, Leidos Biomedical Research, Inc., Frederick, MD 21702, USA
| | - Kathryn Lurain
- HIV and AIDS Malignancy Branch, National Cancer Institute, 10 Center Dr, Bethesda, MD 20814, USA
| | - Taina Immonen
- Retroviral Evolution Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, P.O. Box B, Frederick, MD 21702, USA
| | - Nazzarena Labo
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, P.O. Box B, Frederick, MD 21702, USA
| | - Nicholas C Fisher
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, P.O. Box B, Frederick, MD 21702, USA
| | - Ramya Ramaswami
- HIV and AIDS Malignancy Branch, National Cancer Institute, 10 Center Dr, Bethesda, MD 20814, USA
| | - Mark N Polizzotto
- HIV and AIDS Malignancy Branch, National Cancer Institute, 10 Center Dr, Bethesda, MD 20814, USA
| | - Brandon F Keele
- Retroviral Evolution Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, P.O. Box B, Frederick, MD 21702, USA
| | - Robert Yarchoan
- HIV and AIDS Malignancy Branch, National Cancer Institute, 10 Center Dr, Bethesda, MD 20814, USA
| | - Thomas S Uldrick
- HIV and AIDS Malignancy Branch, National Cancer Institute, 10 Center Dr, Bethesda, MD 20814, USA
| | - Denise Whitby
- Viral Oncology Section, AIDS and Cancer Virus Program, Frederick National Laboratory for Cancer Research, P.O. Box B, Frederick, MD 21702, USA
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9
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Quadruple Multiple Primary Malignancies: Early Detection of Second Primary Malignancy by Esophagogastroduodenoscopy/Colonoscopy Is Crucial for Patients with Classic Kaposi's Sarcoma. Diagnostics (Basel) 2020; 10:diagnostics10040218. [PMID: 32295165 PMCID: PMC7235704 DOI: 10.3390/diagnostics10040218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/04/2020] [Accepted: 04/09/2020] [Indexed: 02/06/2023] Open
Abstract
Currently, Kaposi's sarcoma (KS) is treated following the recommendations of international guidelines. These guidelines recommend esophagogastroduodenoscopy/colonoscopy for detecting multicentric KS of visceral lesions. Second primary malignancies (SPMs) are also a common KS complication; however, information on their detection and treatment is unfortunately not yet indicated in these guidelines. This paper reports on an 86-year-old man who suffered from quadruple primary malignancies: skin classic KS with colon adenocarcinoma, oral squamous cell carcinoma (maxilla), and well-differentiated stomach adenocarcinoma. Gastric cancer was incidentally detected during esophagogastroduodenoscopy, which was performed to detect visceral KS. We suggest that esophagogastroduodenoscopy/colonoscopy be routinely performed during the follow-up of patients with KS. As SPMs are crucial complications in patients with KS, these malignancies should be detected as early as possible.
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Omine T, Yamaguchi S, Yasumura R, Asakura Y, Takahashi K. Iatrogenic Kaposi's sarcoma in a myelofibrosis patient treated with ruxolitinib. J Dermatol 2020; 47:e131-e132. [PMID: 32056237 DOI: 10.1111/1346-8138.15259] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Takuya Omine
- Department of Dermatology, Graduate School of Medicine, University of the Ryukyus, Nishihara, Japan
| | - Sayaka Yamaguchi
- Department of Dermatology, Graduate School of Medicine, University of the Ryukyus, Nishihara, Japan
| | - Ryo Yasumura
- Department of Dermatology, Graduate School of Medicine, University of the Ryukyus, Nishihara, Japan
| | - Yoshitaka Asakura
- Department of Hematology, Okinawa Prefectural Chubu Hospital, Uruma, Japan
| | - Kenzo Takahashi
- Department of Dermatology, Graduate School of Medicine, University of the Ryukyus, Nishihara, Japan
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11
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Houldcroft CJ. Human Herpesvirus Sequencing in the Genomic Era: The Growing Ranks of the Herpetic Legion. Pathogens 2019; 8:E186. [PMID: 31614759 PMCID: PMC6963362 DOI: 10.3390/pathogens8040186] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 10/10/2019] [Accepted: 10/11/2019] [Indexed: 12/19/2022] Open
Abstract
The nine human herpesviruses are some of the most ubiquitous pathogens worldwide, causing life-long latent infection in a variety of different tissues. Human herpesviruses range from mild childhood infections to known tumour viruses and 'trolls of transplantation'. Epstein-Barr virus was the first human herpesvirus to have its whole genome sequenced; GenBank now includes thousands of herpesvirus genomes. This review will cover some of the recent advances in our understanding of herpesvirus diversity and disease that have come about as a result of new sequencing technologies, such as target enrichment and long-read sequencing. It will also look at the problem of resolving mixed-genotype infections, whether with short or long-read sequencing methods; and conclude with some thoughts on the future of the field as herpesvirus population genomics becomes a reality.
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Affiliation(s)
- Charlotte J Houldcroft
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambs CB2 0QQ UK.
- Parasites and Microbes, Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambs CB10 1SA, UK.
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Koganebuchi K, Kimura R. Biomedical and genetic characteristics of the Ryukyuans: demographic history, diseases and physical and physiological traits. Ann Hum Biol 2019; 46:354-366. [PMID: 31116031 DOI: 10.1080/03014460.2019.1582699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Context: The Ryukyu Islands stretch across a southwestern area of the Japanese Archipelago. Because of their unique geographical and historical backgrounds, Ryukyuans have their own genetic and phenotypic characteristics, which have been disclosed in previous anthropological and biomedical studies. Objective: The history, peopling and biomedical and genetic characteristics of Ryukyuans are reviewed and future research directions are discussed. Conclusion: Morphological and genetic studies have suggested the complex demographic history of Ryukyuans and their relationships with other Asian populations. Knowledge of population formation processes is important to understand the distribution of pathogens. In viral infectious diseases, some strains that may be associated with disease symptoms are specific to Ryukyuans. Dramatic changes in diet have played an important role among Ryukyuans in terms of increases in lifestyle-related diseases and mortality risks. To achieve a better understanding of pathogenic disease factors, further integration of findings regarding the genetic and biomedical characteristics of the Ryukyuans is needed.
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Affiliation(s)
- Kae Koganebuchi
- Department of Human Biology and Anatomy, Graduate School of Medicine, University of the Ryukyus , Okinawa , Japan
| | - Ryosuke Kimura
- Department of Human Biology and Anatomy, Graduate School of Medicine, University of the Ryukyus , Okinawa , Japan
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13
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Tamanaha-Nakasone A, Uehara K, Tanabe Y, Ishikawa H, Yamakawa N, Toyoda Z, Kurima K, Kina S, Tsuneki M, Okubo Y, Yamaguchi S, Utsumi D, Takahashi K, Arakawa H, Arasaki A, Kinjo T. K1 gene transformation activities in AIDS-related and classic type Kaposi's sarcoma: Correlation with clinical presentation. Sci Rep 2019; 9:6416. [PMID: 31015491 PMCID: PMC6478685 DOI: 10.1038/s41598-019-42763-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 01/31/2019] [Indexed: 12/23/2022] Open
Abstract
Kaposi's sarcoma-associated herpesvirus (KSHV) causes both AIDS-related Kaposi's sarcoma (KS) and classic KS, but their clinical presentations are different, and respective mechanisms remain to be elucidated. The KSHV K1 gene is reportedly involved in tumorigenesis through the immunoreceptor tyrosine-based activation motif (ITAM). Since we found the sequence variations in the K1 gene of KSHV isolated from AIDS-related KS and classic KS, we hypothesized that the transformation activity of the K1 gene contributes to the different clinical presentations. To evaluate our hypothesis, we compared the transformation activities of the K1 gene between AIDS-related KS and classic KS. We also analyzed ITAM activities and the downstream AKT and NF-κB. We found that the transformation activity of AIDS-related K1 was greater than that of classic K1, and that AIDS-related K1 induced higher ITAM activity than classic K1, causing more potent Akt and NF-κB activities. K1 downregulation by siRNA in AIDS-related K1 expressing cells induced a loss of transformation properties and decreased both Akt and NF-κB activities, suggesting a correlation between the transformation activity of K1 and ITAM signaling. Our study indicates that the increased transformation activity of AIDS-related K1 is associated with its clinical aggressiveness, whereas the weak transformation activity of classic type K1 is associated with a mild clinical presentation and spontaneous regression. The mechanism of spontaneous regression of classic KS may provide new therapeutic strategy to cancer.
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Affiliation(s)
- Ayumi Tamanaha-Nakasone
- Division of Morphological Pathology, Department of Basic Laboratory Sciences, School of Health Sciences, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Karina Uehara
- Division of Morphological Pathology, Department of Basic Laboratory Sciences, School of Health Sciences, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan.,Department of Oral and Maxillofacial Functional Rehabilitation, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Yasuka Tanabe
- Division of Morphological Pathology, Department of Basic Laboratory Sciences, School of Health Sciences, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Haruna Ishikawa
- Division of Morphological Pathology, Department of Basic Laboratory Sciences, School of Health Sciences, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Natsuko Yamakawa
- Division of Morphological Pathology, Department of Basic Laboratory Sciences, School of Health Sciences, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Zensei Toyoda
- Division of Morphological Pathology, Department of Basic Laboratory Sciences, School of Health Sciences, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Kiyoto Kurima
- Division of Morphological Pathology, Department of Basic Laboratory Sciences, School of Health Sciences, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Shinichiro Kina
- Department of Oral and Maxillofacial Functional Rehabilitation, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan.,Department of Molecular Pharmacology and Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa, Maebashi, Gunma, 371-8511, Japan
| | - Masayuki Tsuneki
- Division of Oral Pathology, Department of Tissue Regeneration and Reconstruction, Niigata University Graduate School of Medical and Dental Sciences, 2-5274 Gakkomachidori, Chuo, Niigata, Niigata, 951-8514, Japan
| | - Yuko Okubo
- Department of Dermatology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Sayaka Yamaguchi
- Department of Dermatology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Daisuke Utsumi
- Department of Dermatology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Kenzo Takahashi
- Department of Dermatology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Hirofumi Arakawa
- Division of Cancer Biology, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo, Tokyo, 104-0045, Japan
| | - Akira Arasaki
- Department of Oral and Maxillofacial Functional Rehabilitation, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Takao Kinjo
- Division of Morphological Pathology, Department of Basic Laboratory Sciences, School of Health Sciences, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan.
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Sallah N, Palser AL, Watson SJ, Labo N, Asiki G, Marshall V, Newton R, Whitby D, Kellam P, Barroso I. Genome-Wide Sequence Analysis of Kaposi Sarcoma-Associated Herpesvirus Shows Diversification Driven by Recombination. J Infect Dis 2018; 218:1700-1710. [PMID: 30010810 PMCID: PMC6195662 DOI: 10.1093/infdis/jiy427] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 07/11/2018] [Indexed: 12/29/2022] Open
Abstract
Background Kaposi sarcoma-associated herpesvirus (KSHV) establishes lifelong infection in the human host and has been associated with a variety of malignancies. KSHV displays striking geographic variation in prevalence, which is highest in sub-Saharan Africa. The current KSHV genome sequences available are all tumor cell line-derived or primary tumor-associated viruses, which have provided valuable insights into KSHV genetic diversity. Methods Here, we sequenced 45 KSHV genomes from a Ugandan population cohort in which KSHV is endemic; these are the only genome sequences obtained from nondiseased individuals and of KSHV DNA isolated from saliva. Results Population structure analysis, along with the 25 published genome sequences from other parts of the world, showed whole-genome variation, separating sequences and variation within the central genome contributing to clustering of genomes by geography. We reveal new evidence for the presence of intragenic recombination and multiple recombination events contributing to the divergence of genomes into at least 5 distinct types. Discussion This study shows that large-scale genome-wide sequencing from clinical and epidemiological samples is necessary to capture the full extent of genetic diversity of KSHV, including recombination, and provides evidence to suggest a revision of KSHV genotype nomenclature.
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Affiliation(s)
- Neneh Sallah
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridge
| | | | | | - Nazzarena Labo
- AIDS and Cancer Virus Program, Viral Oncology Section, Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, Maryland
| | - Gershim Asiki
- Medical Research Council/Uganda Virus Research Institute, Uganda Research Unit, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Vickie Marshall
- AIDS and Cancer Virus Program, Viral Oncology Section, Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, Maryland
| | - Robert Newton
- Medical Research Council/Uganda Virus Research Institute, Uganda Research Unit, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Denise Whitby
- AIDS and Cancer Virus Program, Viral Oncology Section, Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, Maryland
| | - Paul Kellam
- Kymab Ltd, Babraham Research Complex, Cambridge
- Department of Medicine, Imperial College London, United Kingdom
| | - Inês Barroso
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, Cambridge
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15
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Yuan H, Liu Z, Wu X, Fang Q, Zheng J, Zeng Y, Zhang T. Social behavioral correlates of Kaposi sarcoma-associated herpesvirus infection among Han and Uygur populations in Xinjiang, China. J Med Virol 2018; 91:457-462. [DOI: 10.1002/jmv.25332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 09/26/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Huangbo Yuan
- Department of Epidemiology; School of Public Health, Fudan University; Shanghai China
- Key Laboratory of Public Health Safety; Ministry of Education, Fudan University; Shanghai China
| | - Zhenqiu Liu
- Department of Epidemiology; School of Public Health, Fudan University; Shanghai China
- Key Laboratory of Public Health Safety; Ministry of Education, Fudan University; Shanghai China
| | - Xuefu Wu
- Department of Epidemiology; School of Public Health, Fudan University; Shanghai China
- Key Laboratory of Public Health Safety; Ministry of Education, Fudan University; Shanghai China
| | - Qiwen Fang
- Department of Epidemiology; School of Public Health, Fudan University; Shanghai China
- Key Laboratory of Public Health Safety; Ministry of Education, Fudan University; Shanghai China
| | - Jun Zheng
- Key Laboratory of Xinjiang Endemic and Ethnic Diseases, Department of Biochemistry; Shihezi University School of Medicine; Shihezi China
| | - Yan Zeng
- Key Laboratory of Xinjiang Endemic and Ethnic Diseases, Department of Biochemistry; Shihezi University School of Medicine; Shihezi China
| | - Tiejun Zhang
- Department of Epidemiology; School of Public Health, Fudan University; Shanghai China
- Key Laboratory of Public Health Safety; Ministry of Education, Fudan University; Shanghai China
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Yamashiro A, Awazawa R, Ohira A, Hirata T, Zamami R, Miyagi T, Takahashi K. Successful treatment of iatrogenic Kaposi's sarcoma with low-dose docetaxel therapy. J Dermatol 2018; 45:e96-e97. [DOI: 10.1111/1346-8138.14135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Atsushi Yamashiro
- Department of Dermatology; University of the Ryukyus; Graduate School of Medicine; Okinawa Japan
| | - Ryoko Awazawa
- Department of Dermatology; University of the Ryukyus; Graduate School of Medicine; Okinawa Japan
| | - Aoi Ohira
- Department of Dermatology; University of the Ryukyus; Graduate School of Medicine; Okinawa Japan
| | - Tetsuo Hirata
- Health Information Management Center; University of the Ryukyus Hospital; Okinawa Japan
| | - Ryo Zamami
- Department of Cardiovascular Medicine, Nephrology and Neurology; University of the Ryukyus; Graduate School of Medicine; Okinawa Japan
| | - Takuya Miyagi
- Department of Dermatology; University of the Ryukyus; Graduate School of Medicine; Okinawa Japan
| | - Kenzo Takahashi
- Department of Dermatology; University of the Ryukyus; Graduate School of Medicine; Okinawa Japan
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