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Moro F, Sinagra JLM, Salemme A, Fania L, Mariotti F, Pira A, Didona B, Di Zenzo G. Pemphigus: trigger and predisposing factors. Front Med (Lausanne) 2023; 10:1326359. [PMID: 38213911 PMCID: PMC10783816 DOI: 10.3389/fmed.2023.1326359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 11/29/2023] [Indexed: 01/13/2024] Open
Abstract
Pemphigus is a life-threatening autoimmune blistering disease affecting skin and mucous membranes. Despite its etiopathogenesis remains largely unknown, several trigger and predisposing factors have been reported. Pemphigus is caused by autoantibodies that target desmoglein 1 and desmoglein 3, impacting desmosome function. However, circulating autoantibodies are often the consequence of a precipitating factor that occurs in predisposed individuals. This review aims to describe and discuss almost all trigger and predisposing factors reported as possible or probable cause of the disease. Among the reported trigger factors that may induce or exacerbate pemphigus, we have found of particular interest: drug intake (especially thiol- and phenol-containing compounds), vaccines, infections, as well as some reports about pregnancy, radiations, emotional stress, pesticides and physical trauma. Moreover, we discuss the possible role of food intake in pemphigus onset and particular attention is given to dietary factors containing thiol, phenol and tannin compounds. A trigger factor is "the straw that breaks the camel's back," and often acts together with predisposing factors. Here we discuss how pemphigus onset may be influenced by genetic susceptibility and comorbidities like thyroid diseases, malignancies and other autoimmune disorders. To identify other hitherto unknown trigger and predisposing factors, well designed prospective studies are needed. In this context, future research should explore their connection with the aim to advance our understanding of pemphigus pathogenesis.
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Affiliation(s)
- Francesco Moro
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
- Dermatology Clinic, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
| | - Jo Linda Maria Sinagra
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
- Dermatology Clinic, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
| | - Adele Salemme
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
| | - Luca Fania
- Dermatology Clinic, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
| | - Feliciana Mariotti
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
| | - Anna Pira
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
| | - Biagio Didona
- Rare Diseases Unit, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
| | - Giovanni Di Zenzo
- Molecular and Cell Biology Laboratory, Istituto Dermopatico dell’Immacolata (IDI)-IRCCS, Rome, Italy
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Ghaedi F, Etesami I, Aryanian Z, Kalantari Y, Goodarzi A, Teymourpour A, Tavakolpour S, Mahmoudi H, Daneshpazhooh M. Drug-induced pemphigus: A systematic review of 170 patients. Int Immunopharmacol 2021; 92:107299. [PMID: 33418246 DOI: 10.1016/j.intimp.2020.107299] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 02/07/2023]
Abstract
Pemphigus encompasses a rare heterogeneous group of autoimmune blistering diseases characterized by cutaneous and/or mucosal blistering. Multiple factors, such as some specific types of drugs, have been found to be involved in the induction of pemphigus. Here, we have designed a systematic review by searching PubMed/Medline and Embase databases to find the drugs, involved in pemphigus induction and exacerbation (updated on 19 August 2019). From 1856 initially found articles, 134 studies (198 patients; 170 patients in the drug-induced patients and 28 in exacerbation group) have been included. Regarding drug-induced cases, the mean age was 57.19 ± 16.9-year-old (ranged 8-105), and patients had developed pemphigus within a mean of 154.27 days. Pemphigus vulgaris (38.9%), pemphigus foliaceus (33.5%), and paraneoplastic pemphigus (3.6%) were the most common subtypes. Furthermore, penicillamine (33.1%), captopril (7.7%), and bucillamine (6.5%) were the most reported drugs related to pemphigus induction; penicillamine was associated with the most persistent disease. Regardless of disease subtype, cutaneous, mucocutaneous, and mucosal involvements were reported in 68.6%, 30.1%, and 1.3% of patients, respectively. In total, the IgG deposition in the pathological studies, being positive for autoreactive antibodies in the serum against desmoglein 3 (Dsg3), and desmoglein 1 (Dsg1), were reported in 93%, 34.9%, and 72.7% of reported patients, respectively. Regarding the management of such patients, in 75% of healed cases, treatment (mainly transient systemic and topical corticosteroids and/or azathioprine) was needed besides stopping the probable pemphigus-inducing culprit drug, while drug cessation was enough to control the disease in 25%. As the outcomes, the lesions in 129 of 147 (87.8%) patients had been healed, while in 18 (12.2%), no healing was reported; fifteen out of 18 had died. In conclusion, some specific groups of treatments can induce pemphigus, including penicillamine, captopril, and bucillamine; despite the similar clinical and pathological manifestations to classical pemphigus, most of the cases are less severe and have a better prognosis.
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Affiliation(s)
- Forugh Ghaedi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, 009821 Iran
| | - Ifa Etesami
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, 009821 Iran
| | - Zeinab Aryanian
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, 009821 Iran; Department of Dermatology, Babol University of Medical Sciences, Babol 0098111 Iran
| | - Yasamin Kalantari
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, 009821 Iran
| | - Azadeh Goodarzi
- Dermatology School of Medicine Iran University of Medical Sciences, Tehran 009821 Iran
| | - Amir Teymourpour
- Department of Epidemiology and biostaristics, school of public health, Tehran university of medical sciences, Tehran 009821 Iran
| | - Soheil Tavakolpour
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, 009821 Iran; Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, United States.
| | - HamidReza Mahmoudi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, 009821 Iran
| | - Maryam Daneshpazhooh
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, 009821 Iran
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Pathogenic and protective roles of cytokines in pemphigus: A systematic review. Cytokine 2020; 129:155026. [DOI: 10.1016/j.cyto.2020.155026] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 01/02/2020] [Accepted: 01/31/2020] [Indexed: 12/23/2022]
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Palleria C, Bennardo L, Dastoli S, Iannone LF, Silvestri M, Manti A, Nisticò SP, Russo E, De Sarro G. Angiotensin-converting-enzyme inhibitors and angiotensin II receptor blockers induced pemphigus: A case series and literature review. Dermatol Ther 2018; 32:e12748. [PMID: 30238580 DOI: 10.1111/dth.12748] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/04/2018] [Accepted: 09/16/2018] [Indexed: 11/30/2022]
Abstract
Pemphigus is a group of autoimmune diseases characterized by the formation of erosions and/or flaccid bullae of the skin and/or mucosae. The definition "drug-induced pemphigus" has been coined to indicate cases of pemphigus with clinical, histological and immunopathologic features similar to those of the idiopathic disease but induced by systemic ingestion or local use of some drugs. The present authors analyzed a case series of three case reports with clinical and pharmacological features compatible with the diagnosis of angiotensin converting enzyme inhibitors or angiotensin II receptor blocker drug-induced pemphigus. The patients were visited by the dermatological Unit of Magna Graecia University in Catanzaro. All suspected drug induced pemphigus were treated by suspending the suspected drug and by starting a treatment with systemic corticosteroid drugs, leading to a remission of the clinical manifestations in some months. When a drug induced bullous disease is probable, it is necessary to interrupt the suspected substance and to start a high dose treatment with corticosteroid drugs to resolve the clinical case in a short period of time.
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Affiliation(s)
- Caterina Palleria
- Pharmacology Unit, Department of Science of Health, Magna Graecia University, Catanzaro, Italy
| | - Luigi Bennardo
- Dermatology Unit, Department of Science of Health, Magna Graecia University, Catanzaro, Italy
| | - Stefano Dastoli
- Dermatology Unit, Department of Science of Health, Magna Graecia University, Catanzaro, Italy
| | - Luigi F Iannone
- Pharmacology Unit, Department of Science of Health, Magna Graecia University, Catanzaro, Italy
| | - Martina Silvestri
- Dermatology Unit, Department of Science of Health, Magna Graecia University, Catanzaro, Italy
| | - Antonia Manti
- Pharmacology Unit, Department of Science of Health, Magna Graecia University, Catanzaro, Italy
| | - Steven P Nisticò
- Dermatology Unit, Department of Science of Health, Magna Graecia University, Catanzaro, Italy
| | - Emilio Russo
- Pharmacology Unit, Department of Science of Health, Magna Graecia University, Catanzaro, Italy
| | - Giovambattista De Sarro
- Pharmacology Unit, Department of Science of Health, Magna Graecia University, Catanzaro, Italy
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Pemphigus trigger factors: special focus on pemphigus vulgaris and pemphigus foliaceus. Arch Dermatol Res 2017; 310:95-106. [PMID: 29110080 DOI: 10.1007/s00403-017-1790-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 10/07/2017] [Accepted: 10/30/2017] [Indexed: 12/16/2022]
Abstract
Pemphigus is a general term for a rare group of autoimmune diseases which result in the formation of blisters on the skin and oral cavity. Although there is no way to prevent autoimmune diseases, some factors may trigger pemphigus initiation in susceptible individuals or be exacerbated in affected patients. Recognition of these triggers, based on the latest studies and experiences is essential and should be updated every few years. In this study, several triggers, including different drugs and treatments, diseases, vaccines, genetic factors, nutrients, micronutrients, pregnancy, stress, and various other triggers have been discussed. Some possible triggers, such as blood antigens and the effect of seasons have also been discussed briefly. Moreover, some protective factors against pemphigus have been reviewed. Considering the molecular mechanism of pemphigus and immune response alteration during this disease, some possible triggers have been suggested and discussed. Although those triggers may be a real threat, more studies are needed to support these hypotheses.
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Ruocco E, Ruocco V, Lo Schiavo A, Brunetti G, Wolf R. Viruses and pemphigus: an intriguing never-ending story. Dermatology 2014; 229:310-5. [PMID: 25413257 DOI: 10.1159/000365845] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 07/09/2014] [Indexed: 11/19/2022] Open
Abstract
Virus infections and autoimmunity have long been linked. As to pemphigus, many studies have been directed to prove or rule out the possibility of viral induction. Herpesviruses have often been related to the onset or reactivation of pemphigus. The association may be (i) casual, (ii) due to the iatrogenic immunosuppression facilitating opportunistic viral infections or (iii) based on a pathogenic link between the viral presence and the host's dysregulated immune response leading to autoimmunity. Japanese researchers, using real-time polymerase chain reaction, lately detected herpes simplex virus DNA in the saliva from pemphigus patients at the earliest stage of the disease and with no signs or history of herpetic infection, thus confirming the possible existence of cases of pemphigus induced by herpesviruses. These selected cases could be included into the innovative concept of 'paraviral eruptions', where an inciting role for induction may be played by the concomitant intake of certain drugs.
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Affiliation(s)
- Eleonora Ruocco
- Department of Dermatology, Second University of Naples, Naples, Italy
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Mejri K, Kallel Sellami M, Tombari W, Laadhar L, Zitouni M, Makni S, Zaraa IR, Mokni M, Mokhtar I, Fezza B. Human herpesvirus-8 and hepatitis B and C virus infections in pemphigus. Int J Dermatol 2014; 53:e475-7. [DOI: 10.1111/ijd.12583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Kaouthar Mejri
- Department of Immunology; La Rabta Hospital; Tunis Tunisia
| | | | - Wafa Tombari
- Department of Immunology; La Rabta Hospital; Tunis Tunisia
| | - Lilia Laadhar
- Department of Immunology; La Rabta Hospital; Tunis Tunisia
| | | | - Sondes Makni
- Department of Immunology; La Rabta Hospital; Tunis Tunisia
| | | | - Mourad Mokni
- Department of Dermatology; La Rabta Hospital; Tunis Tunisia
| | - Insaf Mokhtar
- Department of Dermatology; Habib Thameur Hospital; Tunis Tunisia
| | - Bacima Fezza
- Department of Dermatology; Charles Nicolle Hospital; Tunis Tunisia
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Carrozzo M, Scally K. Oral manifestations of hepatitis C virus infection. World J Gastroenterol 2014; 20:7534-7543. [PMID: 24976694 PMCID: PMC4069285 DOI: 10.3748/wjg.v20.i24.7534] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Revised: 01/21/2014] [Accepted: 03/19/2014] [Indexed: 02/06/2023] Open
Abstract
Extrahepatic manifestations (EHMs) of hepatitis C virus (HCV) infection can affect a variety of organ systems with significant morbidity and mortality. Some of the most frequently reported EHM of HCV infection, involve the oral region predominantly or exclusively. Oral lichen planus (OLP) is a chronic inflammatory condition that is potentially malignant and represents cell-mediated reaction to a variety of extrinsic antigens, altered self-antigens, or super antigens. Robust epidemiological evidence support the link between OLP and HCV. As the virus may replicate in the oral mucosa and attract HCV-specific T lymphocytes, HCV may be implicated in OLP pathogenesis. Sjögren syndrome (SjS) is an autoimmune exocrinopathy, characterized by dryness of the mouth and eyes and a multitude of other systemic signs and symptoms. SjS patients have also an increased risk of non-Hodgkin lymphoma. Patients with chronic hepatitis C do frequently have histological signs of Sjögren-like sialadenitis with mild or even absent clinical symptoms. However, it is still unclear if HCV may cause a disease mimicking SjS or it is directly responsible for the development of SjS in a specific subset of patients. Oral squamous cell carcinoma is the most common oral malignant tumour and at least in some part of the world could be linked to HCV.
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Robati RM, Rahmati-Roodsari M, Dabir-Moghaddam P, Farnaghi A, Mahboobi-rad F, Rahimi H, Toossi P. Mucosal manifestations of pemphigus vulgaris in ear, nose, and throat; before and after treatment. J Am Acad Dermatol 2011; 67:e249-52. [PMID: 22015151 DOI: 10.1016/j.jaad.2011.06.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 06/14/2011] [Accepted: 06/16/2011] [Indexed: 10/16/2022]
Abstract
BACKGROUND Pemphigus vulgaris (PV) is a life-threatening autoimmune bullous disease, mediated by autoantibodies directed against antigens on the keratinocyte cell surface of stratified squamous epithelia. The frequency of ear, nose, and throat (ENT) involvement in PV is not clearly identified. OBJECTIVE We sought to evaluate the ENT involvement in new patients with PV examined by ENT endoscopy before and after treatment. METHODS This study included 41 new patients with PV. All patients were evaluated for ENT manifestations by otoscopic and endoscopic examination before treatment. After these examinations, the patients received proper treatment according to standard protocols. Thirty patients were re-evaluated by endoscopic examination after clinical remission of mucocutaneous signs. RESULTS A total of 41 (33 [80.5%] male and 8 [19.5%] female) patients with mean age of 44.56 ± 12.76 years entered this study. In ENT examination of patients before the treatment, 11 (26.8%) patients showed ear, 15 (36.6%) nasal, 37 (90.3%) oral, 25 (61%) pharyngeal, and 24 (58.5%) laryngeal involvement. Thirty patients underwent the posttreatment ENT examination. We found ear signs in 2 (6.7%), nasal involvement in 1 (3.3%), oral signs in 4 (13.3%), pharyngeal manifestations in 6 (20%), and laryngeal signs in 3 (10%) patients after treatment. The treatment was significantly effective in the improvement of mucosal lesion in different sites (P < .01). LIMITATION Eleven patients refused to undergo posttreatment ENT examination. CONCLUSION ENT evaluation may be worthwhile to evaluate the disease extension in patients with PV more definitely and exclude other potential etiologies in recalcitrant patients.
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Affiliation(s)
- Reza Mahmoud Robati
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Shohada-e Tajrish Hospital, Tehran, Iran.
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Carrozzo M. Oral diseases associated with hepatitis C virus infection. Part 2: lichen planus and other diseases. Oral Dis 2008; 14:217-28. [PMID: 18221456 DOI: 10.1111/j.1601-0825.2007.01432.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Some of the most frequent extrahepatic manifestations of hepatitis C virus (HCV) infection involve the oral region predominantly or exclusively. Part 2 of this review discusses the current evidences regarding the association of lichen planus (LP) and other diseases frequently involving the oral cavity with HCV. Epidemiological data suggest that LP may be significantly associated with HCV infections especially in southern Europe and Japan but not in northern Europe. These geographical differences are possibly influenced by immunogenetic factors, the duration of the HCV infection and the design of the published studies. Because of the fact that most of the studies published are retrospective, it is impossible to establish whether the HCV exposure occurred earlier to or after the onset of disease and more prospective studies are clearly warranted. As the virus may replicate in the skin and oral mucosa and HCV-specific T lymphocytes can be found in the oral mucosa of patients with chronic hepatitis C and LP, HCV may be implicated in the pathogenesis of LP. However, little attention has been paid to the variable effect of therapy with interferon-alpha (IFN-alpha), with or without ribavirin for LP. Conversely, it is unlikely that other oral diseases such as oral carcinoma, pemphigus and Behcet disease are triggered by HCV.
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Affiliation(s)
- M Carrozzo
- Department of Oral Medicine, School of Dental Sciences, University of Newcastle upon Tyne, Newcastle upon Tyne, UK.
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Abstract
A case of pemphigus vulgaris (PV), putatively induced by topical application of polymyxin B ear drops, is described. A 3-year-old, female Tosa Inu, presented with acute onset swelling, blistering and ulceration of the pinnae, nostrils, lips and oral mucous membranes. The dog was depressed, febrile and anorexic. For 7 days prior to the onset of the acute ulcerative disease, polymyxin B ear drops had been applied to both ears to treat an ear infection. Skin and mucosal biopsies showed suprabasilar cleft formation and acantholysis, indicative of PV. The polymyxin B ear drops were discontinued and the dog was treated with intravenous fluids, systemic and topical antibacterial therapy, and immunosuppressive therapy comprising prednisone and azathioprine. Complete remission was noted after 2 weeks, and the immunosuppressive therapy was discontinued one month later. No clinical signs of PV recurred over a 1 year follow-up period. As PV does not usually resolve spontaneously, or enter long-term remission, it was considered that the condition was most likely drug induced due to the aural application of polymyxin B.
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Affiliation(s)
- Jan Rybnícek
- Division of Companion Animal Studies, Department of Clinical Veterinary Science, University of Bristol, Langford House, Langford, Bristol BS40 5DU, UK.
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Iamaroon A, Boonyawong P, Klanrit P, Prasongtunskul S, Thongprasom K. Characterization of oral pemphigus vulgaris in Thai patients. J Oral Sci 2006; 48:43-6. [PMID: 16617201 DOI: 10.2334/josnusd.48.43] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Pemphigus vulgaris (PV) is a serious mucocutaneous disease that be fatal if left untreated. The oral mucosa is often the first site to be affected by the disease. It is thus important that the dentist is able to recognize oral manifestations of PV and refer appropriately. Although oral PV is a well-characterized condition, the disease characteristics of patients in Thailand have not been previously reported. Here, we describe patient and lesion characteristics of 18 cases of oral PV. For these 18 cases, the mean age was 38 years, and the male:female ratio was 1:2. The most commonly affected sites were the gingiva and buccal mucosa, and the duration of disease was approximately one year. Medications previously used included corticosteroids and interferon, and nine patients reported systemic disease. Histopathologic examination with/without direct immunofluorescence was the method of diagnosis in all cases.
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Affiliation(s)
- Anak Iamaroon
- Department of Odontology & Oral Pathology, Faculty of Dentistry, Chiang Mai University, Thailand.
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Abstract
Part of periodontology involves the diagnosis and treatment of a variety of non-plaque-related diseases of the periodontium. The International Workshop for a Classification of Periodontal Diseases and Conditions noted that the periodontist may be called upon to manage non-plaque-related mucocutaneous disorders either alone, or as part of a treatment team consisting of physicians, dentists or other allied health care professionals. This informational paper will review the etiology, clinical manifestations, diagnosis, and treatment of the most common chronic mucocutaneous diseases, including those that may present as desquamative gingivitis or intraoral vesiculobullous lesions. This paper is intended for the use of periodontists and other members of the dental profession.
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Affiliation(s)
- Sarah Brenner
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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