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Ledina D, Ivić I, Tadin A, Bodulić K, LeDuc JW, Markotić A. A Comprehensive Analysis of Renal and Endothelium Dysfunction Markers Fourteen Years after Hemorrhagic Fever with Renal Syndrome Contraction. Life (Basel) 2024; 14:575. [PMID: 38792596 PMCID: PMC11122023 DOI: 10.3390/life14050575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 04/21/2024] [Accepted: 04/26/2024] [Indexed: 05/26/2024] Open
Abstract
While the pathology of acute hemorrhagic fever with renal syndrome (HFRS) has been widely researched, details on the chronic HFRS sequelae remain mainly unexplored. In this study, we analyzed the clinical and laboratory characteristics of 30 convalescent HFRS patients 14 years after the disease contraction, mainly emphasizing several endothelial dysfunction parameters. Convalescent HFRS patients exhibited significantly higher serum levels of erythrocyte sedimentation rate, von Willebrand factor, uric acid, C-reactive protein and immunoglobulin A when compared to healthy individuals. Furthermore, 24 h urine analyses revealed significantly lower sodium and potassium urine levels, as well as significantly higher proteinuria, microalbumin levels and β2-microglobulin levels when compared to healthy individuals. First morning urine analysis revealed significantly higher levels of hematuria in convalescent HFRS patients. None of the additional analyzed endothelium dysfunction markers were significantly different in post-HFRS patients and healthy individuals, including serum and urine P-selectin, E-selectin, soluble intercellular adhesion molecule 1, vascular intercellular adhesion molecule 1 (sVCAM-1) and vascular endothelial growth factor (VEGF). However, binary logistic regression revealed a weak association of serum sVCAM-1 and urine VEGF levels with HFRS contraction. Generally, our findings suggest mild chronic inflammation and renal dysfunction levels in convalescent HFRS patients 14 years after the disease contraction.
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Affiliation(s)
- Dragan Ledina
- Department of Infectious Diseases, Split University Hospital, 21000 Split, Croatia; (D.L.); (I.I.)
- School of Medicine, University of Split, 21000 Split, Croatia
| | - Ivo Ivić
- Department of Infectious Diseases, Split University Hospital, 21000 Split, Croatia; (D.L.); (I.I.)
- School of Medicine, University of Split, 21000 Split, Croatia
| | - Ante Tadin
- Research Department, University Hospital for Infectious Diseases “Dr. Fran Mihaljević”, 10000 Zagreb, Croatia; (A.T.); (K.B.)
| | - Kristian Bodulić
- Research Department, University Hospital for Infectious Diseases “Dr. Fran Mihaljević”, 10000 Zagreb, Croatia; (A.T.); (K.B.)
| | - James W. LeDuc
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX 77550, USA;
| | - Alemka Markotić
- Research Department, University Hospital for Infectious Diseases “Dr. Fran Mihaljević”, 10000 Zagreb, Croatia; (A.T.); (K.B.)
- School of Medicine, Catholic University of Croatia, 10000 Zagreb, Croatia
- Faculty of Medicine, University of Rijeka, 51000 Rijeka, Croatia
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Increased Heparanase Levels in Urine during Acute Puumala Orthohantavirus Infection Are Associated with Disease Severity. Viruses 2022; 14:v14030450. [PMID: 35336857 PMCID: PMC8954369 DOI: 10.3390/v14030450] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/17/2022] [Accepted: 02/19/2022] [Indexed: 02/06/2023] Open
Abstract
Old–world orthohantaviruses cause hemorrhagic fever with renal syndrome (HFRS), characterized by acute kidney injury (AKI) with transient proteinuria. It seems plausible that proteinuria during acute HFRS is mediated by the disruption of the glomerular filtration barrier (GFB) due to vascular leakage, a hallmark of orthohantavirus–caused diseases. However, direct infection of endothelial cells by orthohantaviruses does not result in increased endothelial permeability, and alternative explanations for vascular leakage and diminished GFB function are necessary. Vascular integrity is partly dependent on an intact endothelial glycocalyx, which is susceptible to cleavage by heparanase (HPSE). To understand the role of glycocalyx degradation in HFRS–associated proteinuria, we investigated the levels of HPSE in urine and plasma during acute, convalescent and recovery stages of HFRS caused by Puumala orthohantavirus. HPSE levels in urine during acute HFRS were significantly increased and strongly associated with the severity of AKI and other markers of disease severity. Furthermore, increased expression of HPSE was detected in vitro in orthohantavirus–infected podocytes, which line the outer surfaces of glomerular capillaries. Taken together, these findings suggest the local activation of HPSE in the kidneys of orthohantavirus–infected patients with the potential to disrupt the endothelial glycocalyx, leading to increased protein leakage through the GFB, resulting in high amounts of proteinuria.
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Bauer PK, Krause R, Fabian E, Aumüller ML, Schiller D, Adelsmayr G, Fuchsjäger M, Rechberger E, Schöfl R, Krejs GJ. Clinical-Pathological Conference Series from the Medical University of Graz : Case No 172: A 45-year-old truck driver with fever, vomiting, thrombocytopenia and renal failure. Wien Klin Wochenschr 2021; 133:1222-1230. [PMID: 34402989 PMCID: PMC8599315 DOI: 10.1007/s00508-021-01921-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 10/27/2022]
Affiliation(s)
- Philipp K Bauer
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Robert Krause
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Elisabeth Fabian
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Marja-Liisa Aumüller
- Department of Internal Medicine I, Barmherzige Schwestern Hospital, Ried, Austria
| | - Dietmar Schiller
- Department of Internal Medicine IV, Elisabethinen Hospital, Linz, Austria
| | - Gabriel Adelsmayr
- Division of General Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Michael Fuchsjäger
- Division of General Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Ernst Rechberger
- Department of Internal Medicine I, Barmherzige Schwestern Hospital, Ried, Austria
| | - Rainer Schöfl
- Department of Internal Medicine IV, Elisabethinen Hospital, Linz, Austria
| | - Guenter J Krejs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
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López R, Espinoza M, Graf J, Mertz G, Ferrés M, Calvo M, Vial C, Vial PA. Proteinuria in Hantavirus Cardiopulmonary Syndrome: A Frequent Finding Linked To Mortality. Int J Infect Dis 2021; 110:466-468. [PMID: 34271201 DOI: 10.1016/j.ijid.2021.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/07/2021] [Accepted: 07/09/2021] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVES To determine the relative frequency and prognosis value of proteinuria in hantavirus cardiopulmonary syndrome (HCPS) due to Andes virus. METHODS This observational analytical study prospectively obtained data from patients admitted to 12 health centers in nine Chilean cities between 2001 and 2018. Only patients with confirmed Andes virus HCPS and laboratory characterization that included qualitative proteinuria determination at admission were considered. RESULTS The database involved 175 patients, 95 of them had a measurement of urine protein at the time of hospital admission. They were mainly male (71%) and the median age was 35 [22-47] years. Median duration of the febrile prodromal time was 5 [4-7] days. Hospital length of stay and hospital mortality rate were 10 [7-14] days and 21.1%, respectively. Seventy-three patients (77%) were identified with proteinuria at admission, which was associated with increased mortality rate (26% versus 5%, p=0.036) and the relative risk was 1.3 [1.1-1.6], p=0.002. CONCLUSIONS Proteinuria is a frequent finding in patients with HCPS, which is associated with a higher mortality rate.
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Affiliation(s)
- René López
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Santiago, Chile; Escuela de Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Mauricio Espinoza
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Santiago, Chile; Escuela de Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Jerónimo Graf
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Santiago, Chile; Escuela de Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Gregory Mertz
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Marcela Ferrés
- Departamento Enfermedades Infecciosas e Inmunología Pediátrica, Laboratorio Infectología y Virología Molecular, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Mario Calvo
- Instituto de Medicina, Universidad Austral de Chile, Valdivia, Chile
| | - Cecilia Vial
- Programa Hantavirus, Instituto de Ciencias e Innovación en Medicina (ICIM), Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Pablo A Vial
- Programa Hantavirus, Instituto de Ciencias e Innovación en Medicina (ICIM), Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile; Departamento de Pediatría, Clínica Alemana de Santiago, Santiago, Chile.
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Kerkman PF, Dernstedt A, Tadala L, Mittler E, Dannborg M, Sundling C, Maleki KT, Tauriainen J, Tuiskunen‐Bäck A, Wigren Byström J, Ocaya P, Thunberg T, Jangra RK, Román‐Sosa G, Guardado‐Calvo P, Rey FA, Klingström J, Chandran K, Puhar A, Ahlm C, Forsell MNE. Generation of plasma cells and CD27 -IgD - B cells during hantavirus infection is associated with distinct pathological findings. Clin Transl Immunology 2021; 10:e1313. [PMID: 34277007 PMCID: PMC8275445 DOI: 10.1002/cti2.1313] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 04/19/2021] [Accepted: 06/23/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Human hantavirus infections can cause haemorrhagic fever with renal syndrome (HFRS). The pathogenic mechanisms are not fully understood, nor if they affect the humoral immune system. The objective of this study was to investigate humoral immune responses to hantavirus infection and to correlate them to the typical features of HFRS: thrombocytopenia and transient kidney dysfunction. METHODS We performed a comprehensive characterisation of longitudinal antiviral B-cell responses of 26 hantavirus patients and combined this with paired clinical data. In addition, we measured extracellular adenosine triphosphate (ATP) and its breakdown products in circulation and performed in vitro stimulations to address its effect on B cells. RESULTS We found that thrombocytopenia was correlated to an elevated frequency of plasmablasts in circulation. In contrast, kidney dysfunction was indicative of an accumulation of CD27-IgD- B cells and CD27-/low plasmablasts. Finally, we provide evidence that high levels of extracellular ATP and matrix metalloproteinase 8 can contribute to shedding of CD27 during human hantavirus infection. CONCLUSION Our findings demonstrate that thrombocytopenia and kidney dysfunction associate with distinctly different effects on the humoral immune system. Moreover, hantavirus-infected individuals have significantly elevated levels of extracellular ATP in circulation.
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Affiliation(s)
- Priscilla F Kerkman
- Department of Clinical MicrobiologyUmeå Centre for Microbial Research (UCMR)UmeaSweden
| | - Andy Dernstedt
- Department of Clinical MicrobiologyUmeå Centre for Microbial Research (UCMR)UmeaSweden
| | - Lalitha Tadala
- The Laboratory for Molecular Infection Medicine Sweden (MIMS)Umeå Centre for Microbial Research (UCMR)UmeaSweden
- Department of Molecular BiologyUmeå UniversityUmeaSweden
| | - Eva Mittler
- Department of Microbiology & ImmunologyAlbert Einstein College of MedicineBronxNYUSA
| | - Mirjam Dannborg
- The Laboratory for Molecular Infection Medicine Sweden (MIMS)Umeå Centre for Microbial Research (UCMR)UmeaSweden
- Department of Molecular BiologyUmeå UniversityUmeaSweden
| | - Christopher Sundling
- Department of MedicineKarolinska InstitutetSolnaSweden
- Department of Infectious DiseasesKarolinska University HospitalStockholmSweden
| | - Kimia T Maleki
- Department of MedicineKarolinska InstitutetHuddingeSweden
| | | | - Anne Tuiskunen‐Bäck
- Department of Clinical MicrobiologyUmeå Centre for Microbial Research (UCMR)UmeaSweden
| | - Julia Wigren Byström
- Department of Clinical MicrobiologyUmeå Centre for Microbial Research (UCMR)UmeaSweden
| | - Pauline Ocaya
- Department of Clinical MicrobiologyUmeå Centre for Microbial Research (UCMR)UmeaSweden
| | - Therese Thunberg
- Department of Clinical MicrobiologyUmeå Centre for Microbial Research (UCMR)UmeaSweden
| | - Rohit K Jangra
- Department of Microbiology & ImmunologyAlbert Einstein College of MedicineBronxNYUSA
| | - Gleyder Román‐Sosa
- Structural Virology UnitVirology DepartmentInstitut PasteurCNRS UMR 3569ParisFrance
| | - Pablo Guardado‐Calvo
- Structural Virology UnitVirology DepartmentInstitut PasteurCNRS UMR 3569ParisFrance
| | - Felix A Rey
- Structural Virology UnitVirology DepartmentInstitut PasteurCNRS UMR 3569ParisFrance
| | | | - Kartik Chandran
- Department of Microbiology & ImmunologyAlbert Einstein College of MedicineBronxNYUSA
| | - Andrea Puhar
- The Laboratory for Molecular Infection Medicine Sweden (MIMS)Umeå Centre for Microbial Research (UCMR)UmeaSweden
- Department of Molecular BiologyUmeå UniversityUmeaSweden
| | - Clas Ahlm
- Department of Clinical MicrobiologyUmeå Centre for Microbial Research (UCMR)UmeaSweden
| | - Mattias NE Forsell
- Department of Clinical MicrobiologyUmeå Centre for Microbial Research (UCMR)UmeaSweden
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Heterologous boosting of nonrelated toxoid immunity during acute Puumala hantavirus infection. Vaccine 2021; 39:1818-1825. [PMID: 33678453 DOI: 10.1016/j.vaccine.2021.02.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 01/01/2021] [Accepted: 02/22/2021] [Indexed: 02/08/2023]
Abstract
Persistence of immune memory in humans is a crucial yet poorly understood aspect of immunology. Here we have studied the effect of Puumala hantavirus infection on unrelated, pre-existing immune memory by studying T cell- and antibody responses against toxoid vaccine antigens of diphtheria, tetanus and pertussis in a cohort of 45 patients. We found that tetanus- and pertussis -specific IgG concentrations elevate during acute Puumala virus infection. Increase in vaccine IgG was associated with proliferation of heterologous T cells. Interestingly, increases in tetanus-specific IgG persisted a year after the infection while pertussis-specific IgG declined rapidly; a difference in IgG kinetics resembling the difference seen after vaccination against tetanus and pertussis. These results suggest that persistence of immune memory is facilitated by heterologous boosting of old memory during memory formation against newly encountered antigens. They also show that different toxoid antigens may be treated differently. Our study gives new insight into how immune memory formation may alter pre-existing immune memory, and also shows that heterologous immunity may have an impact on vaccination outcomes.
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Nusshag C, Stütz A, Hägele S, Speer C, Kälble F, Eckert C, Brenner T, Weigand MA, Morath C, Reiser J, Zeier M, Krautkrämer E. Glomerular filtration barrier dysfunction in a self-limiting, RNA virus-induced glomerulopathy resembles findings in idiopathic nephrotic syndromes. Sci Rep 2020; 10:19117. [PMID: 33154421 PMCID: PMC7644703 DOI: 10.1038/s41598-020-76050-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/20/2020] [Indexed: 02/02/2023] Open
Abstract
Podocyte injury has recently been described as unifying feature in idiopathic nephrotic syndromes (INS). Puumala hantavirus (PUUV) infection represents a unique RNA virus-induced renal disease with significant proteinuria. The underlying pathomechanism is unclear. We hypothesized that PUUV infection results in podocyte injury, similar to findings in INS. We therefore analyzed standard markers of glomerular proteinuria (e.g. immunoglobulin G [IgG]), urinary nephrin excretion (podocyte injury) and serum levels of the soluble urokinase plasminogen activator receptor (suPAR), a proposed pathomechanically involved molecule in INS, in PUUV-infected patients. Hantavirus patients showed significantly increased urinary nephrin, IgG and serum suPAR concentrations compared to healthy controls. Nephrin and IgG levels were significantly higher in patients with severe proteinuria than with mild proteinuria, and nephrin correlated strongly with biomarkers of glomerular proteinuria over time. Congruently, electron microcopy analyses showed a focal podocyte foot process effacement. suPAR correlated significantly with urinary nephrin, IgG and albumin levels, suggesting suPAR as a pathophysiological mediator in podocyte dysfunction. In contrast to INS, proteinuria recovered autonomously in hantavirus patients. This study reveals podocyte injury as main cause of proteinuria in hantavirus patients. A better understanding of the regenerative nature of hantavirus-induced glomerulopathy may generate new therapeutic approaches for INS.
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Affiliation(s)
- Christian Nusshag
- Department of Nephrology, Heidelberg University Hospital, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany. .,Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Alisa Stütz
- Department of Nephrology, Heidelberg University Hospital, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany
| | - Stefan Hägele
- Department of Nephrology, Heidelberg University Hospital, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany
| | - Claudius Speer
- Department of Nephrology, Heidelberg University Hospital, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany
| | - Florian Kälble
- Department of Nephrology, Heidelberg University Hospital, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany
| | - Christoph Eckert
- Department of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thorsten Brenner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, Essen, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Morath
- Department of Nephrology, Heidelberg University Hospital, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany
| | - Jochen Reiser
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Martin Zeier
- Department of Nephrology, Heidelberg University Hospital, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany
| | - Ellen Krautkrämer
- Department of Nephrology, Heidelberg University Hospital, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany
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Hansson M, Gustafsson R, Jacquet C, Chebaane N, Satchell S, Thunberg T, Ahlm C, Fors Connolly AM. Cystatin C and α-1-Microglobulin Predict Severe Acute Kidney Injury in Patients with Hemorrhagic Fever with Renal Syndrome. Pathogens 2020; 9:pathogens9080666. [PMID: 32824680 PMCID: PMC7460112 DOI: 10.3390/pathogens9080666] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 12/29/2022] Open
Abstract
Puumala orthohantavirus causes hemorrhagic fever with renal syndrome (HFRS) characterized by acute kidney injury (AKI), an abrupt decrease in renal function. Creatinine is routinely used to detect and quantify AKI; however, early AKI may not be reflected in increased creatinine levels. Therefore, kidney injury markers that can predict AKI are needed. The potential of the kidney injury markers urea, cystatin C, α1-microglobulin (A1M) and neutrophil gelatinase-associated lipocalin (NGAL) to detect early AKI during HFRS was studied by quantifying the levels of these markers in consecutively obtained plasma (P) and urine samples (U) for 44 HFRS patients. P-cystatin C and U-A1M levels were significantly increased during early HFRS compared to follow-up. In a receiver operating characteristic (ROC) curve analysis, P-cystatin C, U-A1M and P-urea predicted severe AKI with area under the curve 0.72, 0.73 and 0.71, respectively, whereas the traditional kidney injury biomarkers creatinine and U-albumin did not predict AKI. Nearly half of the HFRS patients (41%) fulfilled the criteria for shrunken pore syndrome, which was associated with the level of inflammation as measured by P-CRP. P-cystatin C and U-A1M are more sensitive and earlier markers compared to creatinine in predicting kidney injury during HFRS.
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Affiliation(s)
- Magnus Hansson
- Clinical Chemistry, Karolinska University Hospital, 17176 Stockholm, Sweden;
- Department of Laboratory Medicine, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Rasmus Gustafsson
- Department of Clinical Neuroscience, Karolinska Institutet, 17177 Stockholm, Sweden;
| | - Chloé Jacquet
- Department of Clinical Microbiology, Umeå University, 90185 Umeå, Sweden; (C.J.); (N.C.); (T.T.); (C.A.)
- Molecular Infection Medicine Sweden (MIMS), Umeå University, 90187 Umeå, Sweden
| | - Nedia Chebaane
- Department of Clinical Microbiology, Umeå University, 90185 Umeå, Sweden; (C.J.); (N.C.); (T.T.); (C.A.)
| | - Simon Satchell
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol BS1 3NY, UK;
| | - Therese Thunberg
- Department of Clinical Microbiology, Umeå University, 90185 Umeå, Sweden; (C.J.); (N.C.); (T.T.); (C.A.)
| | - Clas Ahlm
- Department of Clinical Microbiology, Umeå University, 90185 Umeå, Sweden; (C.J.); (N.C.); (T.T.); (C.A.)
| | - Anne-Marie Fors Connolly
- Department of Clinical Microbiology, Umeå University, 90185 Umeå, Sweden; (C.J.); (N.C.); (T.T.); (C.A.)
- Molecular Infection Medicine Sweden (MIMS), Umeå University, 90187 Umeå, Sweden
- Correspondence:
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Mantula P, Tietäväinen J, Clement J, Niemelä O, Pörsti I, Vaheri A, Mustonen J, Mäkelä S, Outinen T. Flash-Like Albuminuria in Acute Kidney Injury Caused by Puumala Hantavirus Infection. Pathogens 2020; 9:E615. [PMID: 32731475 PMCID: PMC7459820 DOI: 10.3390/pathogens9080615] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/13/2020] [Accepted: 07/24/2020] [Indexed: 12/17/2022] Open
Abstract
Transient proteinuria and acute kidney injury (AKI) are characteristics of Puumala virus (PUUV) infection. Albuminuria peaks around the fifth day and associates with AKI severity. To evaluate albuminuria disappearance rate, we quantified albumin excretion at different time points after the fever onset. The study included 141 consecutive patients hospitalized due to acute PUUV infection in Tampere University Hospital, Finland. Timed overnight albumin excretion (cU-Alb) was measured during the acute phase in 133 patients, once or twice during the convalescent phase within three months in 94 patients, and at six months in 36 patients. During hospitalization, 30% of the patients had moderately increased albuminuria (cU-Alb 20-200 μg/min), while 57% presented with severely increased albuminuria (cU-Alb >200 μg/min). Median cU-Alb was 311 μg/min (range 2.2-6460) ≤7 days after fever onset, 235 μg/min (range 6.8-5479) at 8-13 days and 2.8 μg/min (range 0.5-18.2) at 14-20 days. After that, only one of the measurements showed albuminuria (35.4 μg/min at day 44). At six months, the median cU-Alb was 2.0 μg/min (range 0.6-14.5). Albuminuria makes a flash-like appearance in PUUV infection and returns rapidly to normal levels within 2-3 weeks after fever onset. In the case of AKI, this is a unique phenomenon.
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Affiliation(s)
- Paula Mantula
- Department of Internal Medicine, Tampere University Hospital, 33521 Tampere, Finland; (J.T.); (I.P.); (J.M.); (S.M.); (T.O.)
| | - Johanna Tietäväinen
- Department of Internal Medicine, Tampere University Hospital, 33521 Tampere, Finland; (J.T.); (I.P.); (J.M.); (S.M.); (T.O.)
- Faculty of Medicine and Health Technology, Tampere University, 33100 Tampere, Finland;
| | - Jan Clement
- Department of Microbiology, Immunology and Transplantation, Rega Institute, National Reference Center for Hantaviruses, Laboratory of Clinical and Epidemiological Virology, KU Leuven, 3000 Leuven, Belgium;
| | - Onni Niemelä
- Faculty of Medicine and Health Technology, Tampere University, 33100 Tampere, Finland;
- Medical Research Unit, Seinäjoki Central Hospital, 60220 Seinäjoki, Finland
| | - Ilkka Pörsti
- Department of Internal Medicine, Tampere University Hospital, 33521 Tampere, Finland; (J.T.); (I.P.); (J.M.); (S.M.); (T.O.)
- Faculty of Medicine and Health Technology, Tampere University, 33100 Tampere, Finland;
| | - Antti Vaheri
- Department of Virology, Medicum, University of Helsinki, 00100 Helsinki, Finland;
| | - Jukka Mustonen
- Department of Internal Medicine, Tampere University Hospital, 33521 Tampere, Finland; (J.T.); (I.P.); (J.M.); (S.M.); (T.O.)
- Faculty of Medicine and Health Technology, Tampere University, 33100 Tampere, Finland;
| | - Satu Mäkelä
- Department of Internal Medicine, Tampere University Hospital, 33521 Tampere, Finland; (J.T.); (I.P.); (J.M.); (S.M.); (T.O.)
- Faculty of Medicine and Health Technology, Tampere University, 33100 Tampere, Finland;
| | - Tuula Outinen
- Department of Internal Medicine, Tampere University Hospital, 33521 Tampere, Finland; (J.T.); (I.P.); (J.M.); (S.M.); (T.O.)
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10
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Hägele S, Müller A, Nusshag C, Reiser J, Zeier M, Krautkrämer E. Motility of human renal cells is disturbed by infection with pathogenic hantaviruses. BMC Infect Dis 2018; 18:645. [PMID: 30541481 PMCID: PMC6292036 DOI: 10.1186/s12879-018-3583-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 12/03/2018] [Indexed: 12/04/2022] Open
Abstract
Background Hemorrhagic fever with renal syndrome (HFRS) caused by pathogenic hantaviruses in Europe and Asia is often characterized by acute kidney injury (AKI) with massive proteinuria. Renal filtration depends on the integrity of epithelial and endothelial monolayers in the tubular and glomerular apparatus. Tubular and glomerular cells represent target cells of hantavirus infection. However, the detailed mechanisms of renal impairment induced by hantaviruses are not well understood. Methods We analyzed the cellular consequences of hantavirus infection by measuring adhesion and migration capacity of human renal cells infected with Puumala (PUUV) or Hantaan (HTNV) virus. The impact of hantaviral nucleocapsid proteins (N proteins) on motility was examined by transfection of podocytes. Results Infection of kidney cells with hantavirus species PUUV and HTNV causes a significant reduction of migration capacity. The impaired motility depends on viral replication and transfection of podocytes with N protein of PUUV or HTNV reveals that the expression of N protein alone is sufficient to deteriorate podocyte function. The cellular effects are more pronounced for the more pathogenic HTNV than for PUUV that causes a milder form of HFRS. Conclusions The direct impairment of migration capacity of renal cells by hantaviral N proteins may contribute substantially to proteinuria observed in the clinical picture of hantavirus infection.
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Affiliation(s)
- Stefan Hägele
- Department of Nephrology, University of Heidelberg, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany
| | - Alexander Müller
- Department of Nephrology, University of Heidelberg, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany
| | - Christian Nusshag
- Department of Medicine I and Clinical Chemistry/Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Jochen Reiser
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Martin Zeier
- Department of Nephrology, University of Heidelberg, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany
| | - Ellen Krautkrämer
- Department of Nephrology, University of Heidelberg, Im Neuenheimer Feld 162, 69120, Heidelberg, Germany.
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Mantula PS, Outinen TK, Jaatinen P, Hämäläinen M, Huhtala H, Pörsti IH, Vaheri A, Mustonen JT, Mäkelä SM. High plasma resistin associates with severe acute kidney injury in Puumala hantavirus infection. PLoS One 2018; 13:e0208017. [PMID: 30517161 PMCID: PMC6281250 DOI: 10.1371/journal.pone.0208017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 11/09/2018] [Indexed: 11/26/2022] Open
Abstract
Background Puumala hantavirus (PUUV) infected patients typically suffer from acute kidney injury (AKI). Adipokines have inflammation modulating functions in acute diseases including AKI. We examined plasma levels of three adipokines (resistin, leptin, and adiponectin) in acute PUUV infection and their associations with disease severity. Methods This study included 79 patients hospitalized due to acute PUUV infection. Plasma resistin, leptin, adiponectin, as well as IL-6 and CRP, were measured at the acute phase, recovery phase and one year after hospitalization. Results Plasma resistin levels were significantly higher in the acute phase compared to the recovery phase and one year after (median resistin 28 pg/mL (11–107) vs. 17 pg/mL (7–36) vs. 14 pg/mL (7–31), p<0.001). Maximum resistin concentration correlated with maximum plasma creatinine levels (r = 0.63; p<0.001). The higher the amount of albuminuria in the urine dipstick test (0–1+, 2+ or 3+) at admission, the higher the median of maximum resistin (24.7 pg/mL, 25.4 pg/mL and 39.6 pg/mL, respectively, p = 0.002). High resistin was also an independent risk factor for severe AKI (creatinine ≥353.6μmol/L) (OR 1.08, 95% CI 1.02–1.14). Neither plasma leptin nor adiponectin level had any correlation with creatinine concentration or the amount of albuminuria. Conclusions Plasma resistin independently associates with the severity of AKI in acute PUUV infection. The association of resistin with the amount of albuminuria suggests that the level of plasma resistin is not only influenced by renal clearance but could have some role in the pathogenesis of AKI during PUUV infection.
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Affiliation(s)
- Paula S. Mantula
- Tampere University Hospital, Department of Internal Medicine, Tampere, Finland
- * E-mail:
| | - Tuula K. Outinen
- Tampere University Hospital, Department of Internal Medicine, Tampere, Finland
| | - Pia Jaatinen
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
- Division of Intermal Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Mari Hämäläinen
- The Immunopharmacology Group, Faculty of Medicine and Life Sciences, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, University of Tampere, Tampere, Finland
| | - Ilkka H. Pörsti
- Tampere University Hospital, Department of Internal Medicine, Tampere, Finland
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Antti Vaheri
- Department of Virology, Medicum, University of Helsinki, Helsinki, Finland
| | - Jukka T. Mustonen
- Tampere University Hospital, Department of Internal Medicine, Tampere, Finland
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Satu M. Mäkelä
- Tampere University Hospital, Department of Internal Medicine, Tampere, Finland
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
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Mustonen J, Outinen T, Laine O, Pörsti I, Vaheri A, Mäkelä S. Kidney disease in Puumala hantavirus infection. Infect Dis (Lond) 2017; 49:321-332. [PMID: 28049381 DOI: 10.1080/23744235.2016.1274421] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Acute kidney injury (AKI) remains a predominant clinical expression of nephropathia epidemica (NE). Its pathogenesis is not yet fully understood. Here, we describe the tissue injury comprehensively and present new data aimed to characterize the injury and explain its pathophysiology. When compared to tubulointerstitial nephritis of a wide variety of other aetiologies, a high degree of proteinuria is a distinguished trait of NE, a finding that is also helpful in the clinical suspicion of the disease. Recently, novel biomarkers for the prediction of severe AKI, including neutrophil gelatinase-associated lipocalin (NGAL), have been identified and ultrastructural tissue changes have been more accurately described. A role for soluble urokinase-type plasminogen activator (suPAR) in the pathogenesis of NE has been suggested, and data on gene polymorphisms, in relation to the severity of AKI have been presented. Smoking is a risk factor for NE and smoking is also associated with aggravated AKI in NE. Although no specific treatment is in sight, recent case reports concerning therapy directed against vascular permeability and vasodilation are of interest. In fact, future work trying to explain the pathophysiology of AKI might need concentrated efforts towards the mechanisms of increased vascular permeability and vasodilatation, which irrespective of organ manifestation, are two major determinants of NE.
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Affiliation(s)
- Jukka Mustonen
- a Faculty of Medicine and Life Sciences , University of Tampere , Tampere , Finland.,b Department of Internal Medicine , Tampere University Hospital , Tampere , Finland
| | - Tuula Outinen
- a Faculty of Medicine and Life Sciences , University of Tampere , Tampere , Finland
| | - Outi Laine
- a Faculty of Medicine and Life Sciences , University of Tampere , Tampere , Finland.,b Department of Internal Medicine , Tampere University Hospital , Tampere , Finland
| | - Ilkka Pörsti
- a Faculty of Medicine and Life Sciences , University of Tampere , Tampere , Finland.,b Department of Internal Medicine , Tampere University Hospital , Tampere , Finland
| | - Antti Vaheri
- c Department of Virology, Medicum , University of Helsinki , Helsinki , Finland
| | - Satu Mäkelä
- a Faculty of Medicine and Life Sciences , University of Tampere , Tampere , Finland.,b Department of Internal Medicine , Tampere University Hospital , Tampere , Finland
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High Triglycerides Are Associated with Low Thrombocyte Counts and High VEGF in Nephropathia Epidemica. J Immunol Res 2016; 2016:8528270. [PMID: 28053993 PMCID: PMC5178363 DOI: 10.1155/2016/8528270] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 10/24/2016] [Indexed: 01/05/2023] Open
Abstract
Nephropathia epidemica (NE) is a mild form of hemorrhagic fever with renal syndrome. Several reports have demonstrated a severe alteration in lipoprotein metabolism. However, little is known about changes in circulating lipids in NE. The objectives of this study were to evaluate changes in serum total cholesterol, high density cholesterol (HDCL), and triglycerides. In addition to evaluation of serum cytokine activation associations, changes in lipid profile and cytokine activation were determined for gender, thrombocyte counts, and VEGF. Elevated levels of triglycerides and decreased HDCL were observed in NE, while total cholesterol did not differ from controls. High triglycerides were associated with both the lowest thrombocyte counts and high serum VEGF, as well as a high severity score. Additionally, there were higher levels of triglycerides in male than female NE patients. Low triglycerides were associated with upregulation of IFN-γ and IL-12, suggesting activation of Th1 helper cells. Furthermore, levels of IFN-γ and IL-12 were increased in patients with lower severity scores, suggesting that a Th1 type immune response is playing protective role in NE. These combined data advance the understanding of NE pathogenesis and indicate a role for high triglycerides in disease severity.
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Jha V, Prasad N. CKD and Infectious Diseases in Asia Pacific: Challenges and Opportunities. Am J Kidney Dis 2016; 68:148-60. [PMID: 26943982 DOI: 10.1053/j.ajkd.2016.01.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 01/15/2016] [Indexed: 02/06/2023]
Abstract
The exact number of patients with chronic kidney disease (CKD) in Asia Pacific is uncertain. In numeric terms, the region is home to the largest population of patients with untreated chronic kidney failure. The climatic, geographic, social, cultural, economic, and environmental diversity within this region is higher than in any other part of the world. Large parts of the region face a climate-related burden of infectious diseases. Infections contribute to the development and progression of CKD and complicate the course of patients with pre-existing CKD (especially those on dialysis therapy or who are immunosuppressed), increase the cost of CKD care, and contribute to mortality and morbidity. Kidney involvement is a feature of several infectious diseases prevalent in Asia Pacific. Examples include malaria, leptospirosis, scrub typhus, tuberculosis, hepatitis B and C virus, dengue hemorrhagic fever, and Hantaan virus infections. The contribution of infection-associated acute kidney injury to the overall burden of CKD has not been evaluated systematically. Research is needed to quantify the impact of infections on kidney health by undertaking prospective studies. Nephrologists need to work with infectious disease research groups and government infection surveillance and control programs.
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Affiliation(s)
- Vivekanand Jha
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India; Department of Nephrology, George Institute for Global Health, New Delhi, India; Department of Nephrology, University of Oxford, Oxford, United Kingdom.
| | - Narayan Prasad
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Latus J, Schwab M, Tacconelli E, Pieper FM, Wegener D, Dippon J, Müller S, Zakim D, Segerer S, Kitterer D, Priwitzer M, Mezger B, Walter-Frank B, Corea A, Wiedenmann A, Brockmann S, Pöhlmann C, Alscher MD, Braun N. Clinical course and long-term outcome of hantavirus-associated nephropathia epidemica, Germany. Emerg Infect Dis 2015; 21:76-83. [PMID: 25533268 PMCID: PMC4285283 DOI: 10.3201/eid2101.140861] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The consequences of associated hematuria may be long-lasting, and hantavirus IgG is detectable years after acute infection. Human infection with Puumala virus (PUUV), the most common hantavirus in Central Europe, causes nephropathia epidemica (NE), a disease characterized by acute kidney injury and thrombocytopenia. To determine the clinical phenotype of hantavirus-infected patients and their long-term outcome and humoral immunity to PUUV, we conducted a cross-sectional prospective survey of 456 patients in Germany with clinically and serologically confirmed hantavirus-associated NE during 2001–2012. Prominent clinical findings during acute NE were fever and back/limb pain, and 88% of the patients had acute kidney injury. At follow-up (7–35 mo), all patients had detectable hantavirus-specific IgG; 8.5% had persistent IgM; 25% had hematuria; 23% had hypertension (new diagnosis for 67%); and 7% had proteinuria. NE-associated hypertension and proteinuria do not appear to have long-term consequences, but NE-associated hematuria may. All patients in this study had hantavirus-specific IgG up to years after the infection.
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Abstract
Over the past few decades understanding and recognition of hantavirus infection has greatly improved worldwide, but both the amplitude and the magnitude of hantavirus outbreaks have been increasing. Several novel hantaviruses with unknown pathogenic potential have been identified in a variety of insectivore hosts. With the new hosts, new geographical distributions of hantaviruses have also been discovered and several new species were found in Africa. Hantavirus infection in humans can result in two clinical syndromes: haemorrhagic fever with renal syndrome (HFRS) and hantavirus cardiopulmonary syndrome (HCPS) caused by Old World and New World hantaviruses, respectively. The clinical presentation of HFRS varies from subclinical, mild, and moderate to severe, depending in part on the causative agent of the disease. In general, HFRS caused by Hantaan virus, Amur virus and Dobrava virus are more severe with mortality rates from 5 to 15%, whereas Seoul virus causes moderate and Puumala virus and Saaremaa virus cause mild forms of disease with mortality rates <1%. The central phenomena behind the pathogenesis of both HFRS and HCPS are increased vascular permeability and acute thrombocytopenia. The pathogenesis is likely to be a complex multifactorial process that includes contributions from immune responses, platelet dysfunction and the deregulation of endothelial cell barrier functions. Also a genetic predisposition, related to HLA type, seems to be important for the severity of the disease. As there is no effective treatment or vaccine approved for use in the USA and Europe, public awareness and precautionary measures are the only ways to minimize the risk of hantavirus disease.
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Affiliation(s)
- T Avšič-Županc
- Institute of Microbiology and Immunology, Faculty of Medicine, Ljubljana, Slovenia.
| | - A Saksida
- Institute of Microbiology and Immunology, Faculty of Medicine, Ljubljana, Slovenia
| | - M Korva
- Institute of Microbiology and Immunology, Faculty of Medicine, Ljubljana, Slovenia
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Boehlke C, Hartleben B, Huber TB, Hopfer H, Walz G, Neumann-Haefelin E. Hantavirus Infection With Severe Proteinuria and Podocyte Foot-Process Effacement. Am J Kidney Dis 2014; 64:452-6. [DOI: 10.1053/j.ajkd.2014.04.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 04/14/2014] [Indexed: 11/11/2022]
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18
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Khaiboullina SF, Martynova EV, Khamidullina ZL, Lapteva EV, Nikolaeva IV, Anokhin VV, Lombardi VC, Rizvanov AA. Upregulation of IFN-γ and IL-12 is associated with a milder form of hantavirus hemorrhagic fever with renal syndrome. Eur J Clin Microbiol Infect Dis 2014; 33:2149-56. [PMID: 24942310 DOI: 10.1007/s10096-014-2176-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 05/29/2014] [Indexed: 01/19/2023]
Abstract
Hantavirus hemorrhagic fever with renal syndrome (HFRS) is a zoonotic disease characterized by acute onset, fever, malaise, and back pain. As the disease progresses, hemorrhagic disturbances and kidney dysfunctions predominate. The examination of tissue collected postmortem supports the premise that virus replication is not responsible for this pathology; therefore, it is widely believed that virus-induced immune responses lead to the clinical manifestations associated with HFRS. The overproduction of inflammatory cytokines is commonly reported in subjects with HFRS and has given rise to the hypothesis that a so-called "cytokine storm" may play a pivotal role in the pathogenesis of this disease. Currently, supportive care remains the only effective treatment for HFRS. Our data show that serum levels of interferon (IFN)-γ, interleukin (IL)-10, CCL2, and IL-12 are upregulated in HFRS cases when compared to healthy controls and the level of upregulation is dependent on the phase and severity of the disease. Furthermore, we observed an association between the mild form of the disease and elevated serum levels of IFN-γ and IL-12. Collectively, these observations suggest that the administration of exogenous IFN-γ and IL-12 may provide antiviral benefits for the treatment of HFRS and, thus, warrants further investigations.
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Affiliation(s)
- S F Khaiboullina
- Department of Biochemistry and Molecular Biology, University of Nevada School of Medicine, WPI, 1664 N. Virginia St., MS 0552, Reno, NV, 89557, USA
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Cochereau D, Ackermann F, Nochy D, Pouchot J, de Jauréguiberry JP. Encore un qu’aurait mieux fait de rester chez lui…. Rev Med Interne 2014; 35:144-7. [DOI: 10.1016/j.revmed.2013.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 04/20/2013] [Indexed: 10/25/2022]
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Krautkrämer E, Zeier M. Old World hantaviruses: aspects of pathogenesis and clinical course of acute renal failure. Virus Res 2014; 187:59-64. [PMID: 24412712 DOI: 10.1016/j.virusres.2013.12.043] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 12/09/2013] [Accepted: 12/24/2013] [Indexed: 12/31/2022]
Abstract
Hantavirus-associated diseases represent emerging infections that are ranked in the highest priority group of communicable diseases for surveillance and epidemiological research. In the last years, several novel hantavirus species were described and the number of host reservoir species harboring hantaviruses is also increasing. Reports of cases with severe or atypical clinical courses become also more frequent. These facts raise more and more questions concerning host reservoir specificity, pathogenicity and molecular mechanism of pathogenesis. Hantavirus disease is characterized by vascular leakage due to increased capillary permeability. The infection manifests often in the lung (hantaviral cardiopulmonary syndrome; HCPS) or in the kidney (hemorrhagic fever with renal syndrome, HFRS). The underlying mechanisms of both syndromes are probably similar despite the difference in organ tropism. Characterization of hantaviral replication cycle and of patient-specific determinants will help to identify factors responsible for the clinical symptoms and course.
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Affiliation(s)
- Ellen Krautkrämer
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany.
| | - Martin Zeier
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany.
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Mustonen J, Mäkelä S, Outinen T, Laine O, Jylhävä J, Arstila PT, Hurme M, Vaheri A. The pathogenesis of nephropathia epidemica: new knowledge and unanswered questions. Antiviral Res 2013; 100:589-604. [PMID: 24126075 DOI: 10.1016/j.antiviral.2013.10.001] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 09/27/2013] [Accepted: 10/04/2013] [Indexed: 01/20/2023]
Abstract
Puumala virus (PUUV) causes an acute hemorrhagic fever with renal syndrome (HFRS), a zoonosis also called nephropathia epidemica (NE). The reservoir host of PUUV is the bank vole (Myodes glareolus). Herein we review the main clinical manifestations of NE, acute kidney injury, increased vascular permeability, coagulation abnormalities as well as pulmonary, cardiac, central nervous system and ocular manifestations of the disease. Several biomarkers of disease severity have recently been discovered: interleukin-6, pentraxin-3, C-reactive protein, indoleamine 2,3-dioxygenase, cell-free DNA, soluble urokinase-type plasminogen activator, GATA-3 and Mac-2 binding protein. The role of cytokines, vascular endothelial growth hormone, complement, bradykinin, cellular immune response and other mechanisms in the pathogenesis of NE as well as host genetic factors will be discussed. Finally therapeutic aspects and directions for further research will be handled.
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Affiliation(s)
- Jukka Mustonen
- School of Medicine, University of Tampere, Tampere, Finland; Department of Internal Medicine, Tampere University Hospital, Tampere, Finland.
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Abstract
Hantaviruses are negative-sense single-stranded RNA viruses that infect many species of rodents, shrews, moles and bats. Infection in these reservoir hosts is almost asymptomatic, but some rodent-borne hantaviruses also infect humans, causing either haemorrhagic fever with renal syndrome (HFRS) or hantavirus cardiopulmonary syndrome (HCPS). In this Review, we discuss the basic molecular properties and cell biology of hantaviruses and offer an overview of virus-induced pathology, in particular vascular leakage and immunopathology.
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Vaheri A, Henttonen H, Voutilainen L, Mustonen J, Sironen T, Vapalahti O. Hantavirus infections in Europe and their impact on public health. Rev Med Virol 2012; 23:35-49. [PMID: 22761056 DOI: 10.1002/rmv.1722] [Citation(s) in RCA: 214] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 05/04/2012] [Accepted: 05/08/2012] [Indexed: 11/09/2022]
Abstract
Hantaviruses (genus Hantavirus, family Bunyaviridae) are enveloped tri-segmented negative-stranded RNA viruses each carried by a specific rodent or insectivore host species. Several different hantaviruses known to infect humans circulate in Europe. The most common is Puumala (PUUV) carried by the bank vole; another two important, genetically closely related ones are Dobrava-Belgrade (DOBV) and Saaremaa viruses (SAAV) carried by Apodemus mice (species names follow the International Committee on Taxonomy of Viruses nomenclature). Of the two hantaviral diseases, hemorrhagic fever with renal syndrome (HFRS) and hantaviral cardiopulmonary syndrome, the European viruses cause only HFRS: DOBV with often severe symptoms and a high case fatality rate, and PUUV and SAAV more often mild disease. More than 10,000 HFRS cases are diagnosed annually in Europe and in increasing numbers. Whether this is because of increasing recognition by the medical community or due to environmental factors such as climate change, or both, is not known. Nevertheless, in large areas of Europe, the population has a considerable seroprevalence but only relatively few HFRS cases are reported. Moreover, no epidemiological data are available from many countries. We know now that cardiac, pulmonary, ocular and hormonal disorders are, besides renal changes, common during the acute stage of PUUV and DOBV infection. About 5% of hospitalized PUUV and 16%-48% of DOBV patients require dialysis and some prolonged intensive-care treatment. Although PUUV-HFRS has a low case fatality rate, complications and long-term hormonal, renal, and cardiovascular consequences commonly occur. No vaccine or specific therapy is in general use in Europe. We conclude that hantaviruses have a significant impact on public health in Europe.
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Affiliation(s)
- Antti Vaheri
- Department of Virology, Haartman Institute, and Research Programs Unit, Infection Biology, University of Helsinki, Helsinki, Finland.
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Pathogenic old world hantaviruses infect renal glomerular and tubular cells and induce disassembling of cell-to-cell contacts. J Virol 2011; 85:9811-23. [PMID: 21775443 DOI: 10.1128/jvi.00568-11] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Viral hemorrhagic fevers are characterized by enhanced permeability. One of the most affected target organs of hantavirus-induced hemorrhagic fever with renal syndrome is the kidney, and an infection often results in acute renal failure. To study the underlying cellular effects leading to kidney dysfunction, we infected human renal cell types in vitro that are critical for the barrier functions of the kidney, and we examined kidney biopsy specimens obtained from hantavirus-infected patients. We analyzed the infection and pathogenic effects in tubular epithelial and glomerular endothelial renal cells and in podocytes. Both epithelial and endothelial cells and podocytes were susceptible to hantavirus infection in vitro. The infection disturbed the structure and integrity of cell-to-cell contacts, as demonstrated by redistribution and reduction of the tight junction protein ZO-1 and the decrease in the transepithelial resistance in infected epithelial monolayers. An analysis of renal biopsy specimens from hantavirus-infected patients revealed that the expression and the localization of the tight junction protein ZO-1 were altered compared to renal biopsy specimens from noninfected individuals. Both tubular and glomerular cells were affected by the infection. Furthermore, the decrease in glomerular ZO-1 correlates with disease severity induced by glomerular dysfunction. The finding that different renal cell types are susceptible to hantaviral infection and the fact that infection results in the breakdown of cell-to-cell contacts provide useful insights in hantaviral pathogenesis.
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Hantavirus infection—Hemorrhagic fever with renal syndrome: the first case series reported in Romania and review of the literature. Int Urol Nephrol 2011; 44:1185-91. [DOI: 10.1007/s11255-011-0013-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2011] [Accepted: 05/31/2011] [Indexed: 10/18/2022]
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Huttunen NP, Mäkelä S, Pokka T, Mustonen J, Uhari M. Systematic literature review of symptoms, signs and severity of serologically confirmed nephropathia epidemica in paediatric and adult patients. ACTA ACUST UNITED AC 2011; 43:405-10. [DOI: 10.3109/00365548.2011.559666] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Tulumovic D, Imamovic G, Mesic E, Hukic M, Tulumovic A, Imamovic A, Zerem E. Comparison of the effects of Puumala and Dobrava viruses on early and long-term renal outcomes in patients with haemorrhagic fever with renal syndrome. Nephrology (Carlton) 2010; 15:340-3. [PMID: 20470304 DOI: 10.1111/j.1440-1797.2009.01195.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM The clinical course and outcome of patients with haemorrhagic fever with renal syndrome (HFRS) caused by Puumala (PUUV) and Dobrava viruses (DOBV) were analyzed and whether it left long-term consequences on kidney function after 10 years was evaluated. METHODS Cross-sectional studies were conducted to test the kidney function and blood pressure of HFRS-affected patients and to follow them up 10 years after. Eighty-two PUUV- and 53 DOBV-induced HFRS patients and 14 and 31 participants 10 years after having contracted PUUV- and DOBV-related diseases, respectively were evaluated. RESULTS Serum creatinine concentrations were 279.5 and 410 mcmol/L in PUUV and DOBV groups, respectively (P = 0.005). There were six and 13 anuric (P < 0.05), none and seven dialysis-dependant (P < 0.05), and nine and 18 hypotensive patients (P < 0.05) in PUUV and DOBV groups, respectively. After 10 years, glomerular filtration rates were 122.1 + or - 11.1 and 104.7 + or - 20.2 mL/min (P < 0.05) in PUUV and DOBV groups, respectively. CONCLUSION During the acute phase, DOBV causes more severe renal impairment than PUUV infection. After 10 years follow up, renal function was found within normal limits, although after DOBV infection glomerular filtration rate (GFR) was significantly lower than after PUUV infection.
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Miettinen MH, Mäkelä SM, Ala-Houhala IO, Huhtala HSA, Kööbi T, Vaheri AI, Pasternack AI, Pörsti IH, Mustonen JT. Ten-year prognosis of Puumala hantavirus-induced acute interstitial nephritis. Kidney Int 2006; 69:2043-8. [PMID: 16641933 DOI: 10.1038/sj.ki.5000334] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Nephropathia epidemica (NE) is a hemorrhagic fever with renal syndrome caused by Puumala hantavirus. Its long-term prognosis is considered favorable. There are, however, some reports about subsequent hypertension, glomerular hyperfiltration, and proteinuria after previous hantavirus infection. Therefore, we studied 36 patients 5 and 10 years after acute NE, with 29 seronegative controls. Office blood pressure, ambulatory 24-h blood pressure (ABP), glomerular filtration rate (GFR), and proteinuria were examined. Hypertensive subjects were defined as those patients having increased ambulatory or office blood pressure, or receiving antihypertensive therapy. Office blood pressure was used to define hypertension only if ABP was not determined. At 5 years, the prevalence of hypertension was higher among NE patients than in controls (50 vs 21%, P=0.020). At 10 years, the difference between the groups was no more significant (39 vs 17%, P=0.098). Five years after NE, patients showed higher GFR (121+/-19 vs 109+/-16 ml/min/1.73 m(2), P=0.012) and urinary protein excretion (0.19 g/day, range 0.12-0.38 vs 0.14 g/day, range 0.09-0.24, P=<0.001) than controls. At 10 years, there were no more differences in GFR or protein excretion between the groups (GFR: 113+/-20 vs 108+/-17 ml/min/1.73 m(2), P=0.370; proteinuria: 0.14 g/day, range 0.07-0.24 vs 0.13 g/day, range 0.06-0.31, P=0.610). In conclusion, the 10-year prognosis of NE is favorable, as glomerular hyperfiltration and slight proteinuria detected at 5 years disappeared during the longer follow-up. However, the possibility exists that NE may predispose some patients to the development of hypertension.
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Affiliation(s)
- M H Miettinen
- Department of Internal Medicine, Central Hospital of Jyväskylä, Jyväskylä, Finland.
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Izzedine H, Buhaescu I, Bodaghi B, Martinez V, Caumes E, Lehoang P, Deray G. Oculo-renal disorders in infectious diseases. Int Ophthalmol 2006; 25:299-319. [PMID: 16532294 DOI: 10.1007/s10792-005-4833-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2004] [Accepted: 11/01/2005] [Indexed: 01/01/2023]
Abstract
BACKGROUND The aim of this article is to review the potential ocular and renal disorders in infectious diseases to which humans are susceptible and to determine prevalence of these diseases. METHODS Published cases of oculo-renal disorders associated with various infectious diseases were collected from the international literature by searching the MEDLINE database (PUBMED 1970-2004) for original reports and review articles published in English. Citations from papers retrieved were screened and retrieved papers were evaluated. RESULTS Based on the screened data, we propose a practical, structure-oriented checklist of such lesions divided into bacterial, viral, parasital, and fugal infections. CONCLUSION The oculorenal manifestations of infectious diseases may be flagrant or subtle. Awareness of the signs and symptoms of infections allows early recognition and prompt, appropriate management. The clinical presentation and relative frequency of those manifestations are reviewed.
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Affiliation(s)
- Hassane Izzedine
- Department of Nephrology, Pitie-Salpetriere Hospital, Paris, France.
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Rasche FM, Uhel B, Krüger DH, Karges W, Czock D, Hampl W, Keller F, Meisel H, von Müller L. Thrombocytopenia and acute renal failure in Puumala hantavirus infections. Emerg Infect Dis 2004; 10:1420-5. [PMID: 15496243 PMCID: PMC3320406 DOI: 10.3201/eid1008.031069] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Low platelet counts are a novel predictive marker suitable for risk-adapted patient management. Nephropathia epidemica, caused by Puumala virus (PUUV) infection, is a form of hemorrhagic fever with renal syndrome of variable severity. Early prognostic markers for the severity of renal failure have not been established. We evaluated clinical and laboratory parameters of 15 consecutive patients with acute PUUV infection, which is endemic in the Alb-Danube region, South Germany. Severe renal failure (serum creatinine >620 µmol/L) was observed in seven patients; four required hemodialysis treatment. Low platelet count (<60 x 109/L), but not leukocyte count, C-reactive protein, or other parameters obtained at the initial evaluation, was significantly associated with subsequent severe renal failure (p = 0.004). Maximum serum creatinine was preceded by platelet count nadirs by a median of 4 days. Thrombocytopenia <60 x 109/L appears predictive of a severe course of acute renal failure in nephropathia epidemica, with potential value for risk-adapted clinical disease management.
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Affiliation(s)
- Franz Maximilian Rasche
- Division of Nephrology, Department of Internal Medicine II, University Hospital Ulm, Ulm, Germany.
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Mäkelä S, Mustonen J, Ala-Houhala I, Hurme M, Koivisto AM, Vaheri A, Pasternack A. Urinary excretion of interleukin-6 correlates with proteinuria in acute Puumala hantavirus-induced nephritis. Am J Kidney Dis 2004; 43:809-16. [PMID: 15112171 DOI: 10.1053/j.ajkd.2003.12.044] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Nephropathia epidemica (NE) is a mild type of hemorrhagic fever with renal syndrome caused by Puumala Hantavirus. Cytokines are thought to have an important role in the pathogenesis of NE. The aim of this study is to evaluate whether cytokines contribute to renal involvement in NE. METHODS Overnight urinary excretion of interleukin-1beta (IL-1beta), IL-1 receptor antagonist (IL-1Ra), IL-6, tumor necrosis factor-alpha (TNF-alpha), albumin, immunoglobulin G (IgG), and alpha1-microglobulin and quantitative 24-hour urinary protein excretion were measured for 3 consecutive days from 70 hospitalized patients with acute NE (49 men, 21 women; age, 15 to 70 years; median age, 39 years). Plasma levels of the respective cytokines also were measured. Urinary collections were repeated after 1 year. The control group for blood samples included 400 healthy blood donors. RESULTS Maximum median urinary IL-6 excretion in the acute phase of NE was increased compared with values detected after 1 year (49.5 versus 0.7 pg/min; P < 0.001). Correspondingly, maximum median plasma IL-6 concentration in patients was increased compared with controls (14.6 versus 1.2 pg/mL; P < 0.001). Urinary IL-6 excretion correlated with urinary albumin, IgG, and protein excretion (r = 0.79; P < 0.001; r = 0.76; P < 0.001; and r = 0.65; P < 0.001, respectively), but not plasma IL-6 levels (r = 0.18; P = 0.148). CONCLUSION Plasma IL-6 concentrations and urinary IL-6 excretion were markedly increased in patients with acute NE, but there was no correlation between plasma and urinary IL-6 levels. The high urinary IL-6 levels might reflect local production of this proinflammatory cytokine in the kidneys during acute infection.
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Affiliation(s)
- Satu Mäkelä
- Medical School, University of Tampere and Tampere University Hospital, Tampere, Finland.
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Vapalahti O, Mustonen J, Lundkvist A, Henttonen H, Plyusnin A, Vaheri A. Hantavirus infections in Europe. THE LANCET. INFECTIOUS DISEASES 2003; 3:653-61. [PMID: 14522264 DOI: 10.1016/s1473-3099(03)00774-6] [Citation(s) in RCA: 444] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Hantaviruses are enveloped RNA viruses each carried by a specific rodent species. Three hantaviruses, Puumala, Dobrava, and Saaremaa viruses, are known to cause haemorrhagic fever with renal syndrome. In Europe. Puumala causes a generally mild disease, nephropathia epidemica, which presents most commonly with fever, headache, gastrointestinal symptoms, impaired renal function, and blurred vision, whereas Dobrava infections often also have haemorrhagic complications. There are few available data about the clinical picture of confirmed Saaremaa infections, but epidemiological evidence suggests that it is less pathogenic than Dobrava, and that Saaremaa infections are more similar to nephropathia epidemica caused by Puumala. Along with its rodent host, the bank vole (Clethrionomys glareolus), Puumala is reported throughout most of Europe (excluding the Mediterranean region), whereas Dobrava, carried by the yellow-necked mouse (Apodemus flavicollis), and Saaremaa, carried by the striped field mouse (Apodemus agrarius), are reported mainly in eastern and central Europe. The diagnosis of acute hantavirus infection is based on the detection of virus-specific IgM. Whereas Puumala is distinct, Dobrava and Saaremaa are genetically and antigenically very closely related and were previously thought to be variants of the same virus. Typing of a specific hantavirus infection requires neutralisation antibody assays or reverse transcriptase PCR and sequencing.
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Affiliation(s)
- Olli Vapalahti
- Division of Microbiology and Epidemiology, Faculty of Veterinary Medicine, University of Helsinki and HUCH Laboratory Diagnostics, Helsinki University Central Hospital, Finland.
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