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Hmiel L, Zhang S, Obare LM, Santana MADO, Wanjalla CN, Titanji BK, Hileman CO, Bagchi S. Inflammatory and Immune Mechanisms for Atherosclerotic Cardiovascular Disease in HIV. Int J Mol Sci 2024; 25:7266. [PMID: 39000373 PMCID: PMC11242562 DOI: 10.3390/ijms25137266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 06/26/2024] [Accepted: 06/28/2024] [Indexed: 07/16/2024] Open
Abstract
Atherosclerotic vascular disease disproportionately affects persons living with HIV (PLWH) compared to those without. The reasons for the excess risk include dysregulated immune response and inflammation related to HIV infection itself, comorbid conditions, and co-infections. Here, we review an updated understanding of immune and inflammatory pathways underlying atherosclerosis in PLWH, including effects of viral products, soluble mediators and chemokines, innate and adaptive immune cells, and important co-infections. We also present potential therapeutic targets which may reduce cardiovascular risk in PLWH.
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Affiliation(s)
- Laura Hmiel
- Department of Medicine, Division of Infectious Disease, MetroHealth Medical Center and Case Western Reserve University, Cleveland, OH 44109, USA
| | - Suyu Zhang
- Department of Medicine, Emory University, Atlanta, GA 30322, USA
| | - Laventa M. Obare
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | | | - Celestine N. Wanjalla
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Boghuma K. Titanji
- Division of Infectious Diseases, Emory University, Atlanta, GA 30322, USA
| | - Corrilynn O. Hileman
- Department of Medicine, Division of Infectious Disease, MetroHealth Medical Center and Case Western Reserve University, Cleveland, OH 44109, USA
| | - Shashwatee Bagchi
- Division of Infectious Diseases, Washington University in St. Louis, St. Louis, MO 63110, USA
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Berenguer J, Aldámiz-Echevarría T, Hontañón V, Fanciulli C, Quereda C, Busca C, Domínguez L, Hernández C, Vergas J, Gaspar G, García-Fraile LJ, Díez C, De Miguel M, Bellón JM, Bañares R, González-García J. Clinical outcomes and prognostic factors after HCV clearance with DAA in HIV/HCV-coinfected patients with advanced fibrosis/cirrhosis. Hepatology 2024:01515467-990000000-00792. [PMID: 38452004 DOI: 10.1097/hep.0000000000000838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 02/18/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND AND AIMS We assessed long-term clinical outcomes and prognostic factors for liver disease progression after sustained viral response with direct-acting antivirals in patients coinfected with HIV/HCV with advanced fibrosis or cirrhosis. APPROACH AND RESULTS A total of 1300 patients who achieved sustained viral response with direct-acting antivirals from 2014 to 2017 in Spain were included: 1145 with compensated advanced chronic liver disease (384 advanced fibrosis and 761 compensated cirrhosis) and 155 with decompensated cirrhosis. The median follow-up was 40.9 months. Overall, 85 deaths occurred, 61 due to non-liver non-AIDS-related causes that were the leading cause of death across all stages of liver disease. The incidence (95% CI) of decompensation per 100 person-years (py) was 0 in patients with advanced fibrosis, 1.01 (0.68-1.51) in patients with compensated cirrhosis, and 8.35 (6.05-11.53) in patients with decompensated cirrhosis. The incidence (95% CI) of HCC per 100 py was 0.34 (0.13-0.91) in patients with advanced fibrosis, 0.73 (0.45-1.18) in patients with compensated cirrhosis, and 1.92 (1.00-3.70) per 100 py in patients with decompensated cirrhosis. Prognostic factors for decompensation in patients with compensated advanced chronic liver disease included serum albumin, liver stiffness measurement (LSM), and fibrosis 4. In this population, LSM and LSM-based posttreatment risk stratification models showed their predictive ability for decompensation and HCC. CONCLUSIONS Non-liver non-AIDS-related events were the leading causes of morbidity and mortality after direct-acting antiviral cure among coinfected patients with advanced fibrosis/cirrhosis. Among those with compensated advanced chronic liver disease, baseline LSM and posttreatment LSM-based models helped to assess decompensation and HCC risk.
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Affiliation(s)
- Juan Berenguer
- Infectious Diseases/Clinical Microbiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Teresa Aldámiz-Echevarría
- Infectious Diseases/Clinical Microbiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Víctor Hontañón
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
- HIV Unit/Internal Medicine, Hospital Universitario La Paz, Madrid, Spain
- Instituto de Investigación Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | - Chiara Fanciulli
- Infectious Diseases/Clinical Microbiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Carmen Quereda
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
- Infectious Diseases, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Carmen Busca
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
- HIV Unit/Internal Medicine, Hospital Universitario La Paz, Madrid, Spain
- Instituto de Investigación Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
| | - Lourdes Domínguez
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
- HIV Unit/Internal Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (I+12), Madrid, Spain
| | - Cristina Hernández
- Infectious Diseases/Internal Medicine, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Spain
| | - Jorge Vergas
- Infectious Diseases/Internal Medicine, Hospital Clínico de San Carlos, Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Gabriel Gaspar
- Internal Medicine, Hospital Universitario de Getafe, Getafe, Spain
| | - Lucio J García-Fraile
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
- Infectious Diseases, Hospital Universitario de la Princesa, Madrid, Spain
- Instituto de Investigación del Hospital de La Princesa (IIS-Princesa), Madrid, Spain
| | - Cristina Díez
- Infectious Diseases/Clinical Microbiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | | | - José M Bellón
- Infectious Diseases/Clinical Microbiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Rafael Bañares
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
- Departamento de Medicina Universidad Complutense, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Liver Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Juan González-García
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
- HIV Unit/Internal Medicine, Hospital Universitario La Paz, Madrid, Spain
- Instituto de Investigación Hospital Universitario La Paz (IdiPAZ), Madrid, Spain
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Cardiometabolic effects of direct-acting antivirals in patients with hepatitis C. GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:58-66. [PMID: 35460863 DOI: 10.1016/j.gastrohep.2022.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/08/2022] [Indexed: 01/18/2023]
Abstract
Hepatitis C virus (HCV) has long been associated with several extrahepatic manifestations, including increased cardiovascular risk. The emergence of direct-acting antivirals (DAAs) has allowed us to evaluate the potential reversal of these manifestations after successful treatment. Therefore, many studies have provided significant takeaways regarding the positive effect of DAAs therapy on insulin resistance, type 2 diabetes mellitus, cardiovascular disease and atherosclerosis. In contrast, studies have shown detrimental effects on lipid metabolism and indeterminate results regarding renal function and uric acid metabolism. Nevertheless, as more and more patients achieve sustained virological response, the effects of HCV eradication on cardiometabolic processes will be extensively studied, allowing more reliable conclusions on the extent of extrahepatic outcomes.
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Lang R, Humes E, Hogan B, Lee J, D'Agostino R, Massaro J, Kim A, Meigs JB, Borowsky L, He W, Lyass A, Cheng D, Kim HN, Klein MB, Cachay ER, Bosch RJ, Gill MJ, Silverberg MJ, Thorne JE, McGinnis K, Horberg MA, Sterling TR, Triant VA, Althoff KN. Evaluating the Cardiovascular Risk in an Aging Population of People With HIV: The Impact of Hepatitis C Virus Coinfection. J Am Heart Assoc 2022; 11:e026473. [PMID: 36129038 PMCID: PMC9673707 DOI: 10.1161/jaha.122.026473] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background People with HIV (PWH) are at an increased risk of cardiovascular disease (CVD) with an unknown added impact of hepatitis C virus (HCV) coinfection. We aimed to identify whether HCV coinfection increases the risk of type 1 myocardial infarction (T1MI) and if the risk differs by age. Methods and Results We used data from NA-ACCORD (North American AIDS Cohort Collaboration on Research and Design) from January 1, 2000, to December 31, 2017, PWH (aged 40-79 years) who had initiated antiretroviral therapy. The primary outcome was an adjudicated T1MI event. Those who started direct-acting HCV antivirals were censored at the time of initiation. Crude incidence rates per 1000 person-years were calculated for T1MI by calendar time. Discrete time-to-event analyses with complementary log-log models were used to estimate adjusted hazard ratios and 95% CIs for T1MI among those with and without HCV. Among 23 361 PWH, 4677 (20%) had HCV. There were 89 (1.9%) T1MIs among PWH with HCV and 314 (1.7%) among PWH without HCV. HCV was not associated with increased T1MI risk in PWH (adjusted hazard ratio, 0.98 [95% CI, 0.74-1.30]). However, the risk of T1MI increased with age and was amplified in those with HCV (adjusted hazard ratio per 10-year increase in age, 1.85 [95% CI, 1.38-2.48]) compared with those without HCV (adjusted hazard ratio per 10-year increase in age,1.30 [95% CI, 1.13-1.50]; P<0.001, test of interaction). Conclusions HCV coinfection was not significantly associated with increased T1MI risk; however, the risk of T1MI with increasing age was greater in those with HCV compared with those without, and HCV status should be considered when assessing CVD risk in aging PWH.
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Affiliation(s)
- Raynell Lang
- Department of MedicineUniversity of CalgaryCalgaryAlbertaCanada
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | - Elizabeth Humes
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | - Brenna Hogan
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | - Jennifer Lee
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | - Ralph D'Agostino
- Department of Mathematics and StatisticsBoston UniversityBostonMA
| | - Joseph Massaro
- Department of BiostatisticsBoston University School of Public HealthBostonMA
| | - Arthur Kim
- Division of Infectious DiseasesMassachusetts General HospitalBostonMA
- Harvard Medical SchoolBostonMA
| | - James B. Meigs
- Harvard Medical SchoolBostonMA
- Division of General Internal MedicineMassachusetts General HospitalBostonMA
| | - Leila Borowsky
- Division of General Internal MedicineMassachusetts General HospitalBostonMA
| | - Wei He
- Division of General Internal MedicineMassachusetts General HospitalBostonMA
| | - Asya Lyass
- Department of Mathematics and StatisticsBoston UniversityBostonMA
| | - David Cheng
- Biostatistics CenterMassachusetts General HospitalBostonMA
| | | | | | - Edward R. Cachay
- Department of Medicine, Division of Infectious Diseases and Global Public HealthUniversity of CaliforniaSan DiegoCA
| | | | - M. John Gill
- Department of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | | | | | | | | | | | - Virginia A. Triant
- Division of Infectious DiseasesMassachusetts General HospitalBostonMA
- Division of General Internal MedicineMassachusetts General HospitalBostonMA
| | - Keri N. Althoff
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
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Ramadan MS, Boccia F, Moretto SM, De Gregorio F, Gagliardi M, Iossa D, Durante-Mangoni E, Zampino R. Cardiovascular Risk in Patients with Chronic Hepatitis C Treated with Direct Acting Antivirals. J Clin Med 2022; 11:5781. [PMID: 36233646 PMCID: PMC9572655 DOI: 10.3390/jcm11195781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Chronic hepatitis C (CHC) is associated with hepatic and extrahepatic complications, including cardiovascular disease (CVD). The effects of sustained virological response (SVR) and liver fibrosis on CVD risk are not well established. Aims: We aim to assess the dynamics of Fibrosis-4 (FIB-4) and Atherosclerotic Cardiovascular Disease 2013 (ASCVD) scores up to three years after direct acting antivirals (DAA) treatment and explore the time-dependent association between the two scores. Methods: We included consecutive CHC patients treated with DAA and followed up with them for three years. Outcomes were changes from baseline (before DAA) in ASCVD and FIB-4 scores, measured at the end of treatment, 12-, 24-, and 36-months follow-up. Results: In total, 91 patients with CHC were finally included (median age: 66 years (IQR = 58−72 years); 43% females). Median follow-up was 2 years (1−3 years) and all patients reached SVR. The ASCVD score did not significantly change from baseline (Mean = 17.2%, 95% CI 14.1, 20.3), but the FIB-4 score significantly decreased at any time-point by an average of 0.8 (95% CI 0.78, 0.82, p < 0.001). Elevated FIB-4 scores at one (β = 1.16, p < 0.001) and three years (β = 2.52, p < 0.001) were associated with an increased ASCVD score. Clinically, two participants- with non-decreasing FIB-4 scores after treatment- had acute coronary syndrome at the end of treatment and one year follow-up, respectively. Conclusions: In our study, we found that FIB-4 and ASCVD scores exhibited a positive correlation irrespective of time-point after treatment. Larger studies are essential to further investigate the utility of FIB-4 scores in cardiovascular risk assessment.
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Affiliation(s)
- Mohammad Said Ramadan
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’ Napoli, 80138 Naples, Italy
| | - Filomena Boccia
- Department of Advanced Medical and Surgical Sciences, University of Campania ‘L. Vanvitelli’, 81031 Naples, Italy
| | - Simona Maria Moretto
- Department of Advanced Medical and Surgical Sciences, University of Campania ‘L. Vanvitelli’, 81031 Naples, Italy
| | - Fabrizio De Gregorio
- Department of Advanced Medical and Surgical Sciences, University of Campania ‘L. Vanvitelli’, 81031 Naples, Italy
| | - Massimo Gagliardi
- Department of Advanced Medical and Surgical Sciences, University of Campania ‘L. Vanvitelli’, 81031 Naples, Italy
| | - Domenico Iossa
- Unit of Infectious and Transplant Medicine, AORN Ospedali dei Colli-Monaldi Hospital, Piazzale E. Ruggieri, 80131 Naples, Italy
| | - Emanuele Durante-Mangoni
- Department of Precision Medicine, University of Campania ‘L. Vanvitelli’ Napoli, 80138 Naples, Italy
- Unit of Infectious and Transplant Medicine, AORN Ospedali dei Colli-Monaldi Hospital, Piazzale E. Ruggieri, 80131 Naples, Italy
| | - Rosa Zampino
- Department of Advanced Medical and Surgical Sciences, University of Campania ‘L. Vanvitelli’, 81031 Naples, Italy
- Unit of Infectious and Transplant Medicine, AORN Ospedali dei Colli-Monaldi Hospital, Piazzale E. Ruggieri, 80131 Naples, Italy
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6
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Brochado Ó, Martínez I, Berenguer J, Medrano L, González-García J, Jiménez-Sousa MÁ, Carrero A, Hontañón V, Navarro J, Guardiola JM, Fernández-Rodríguez A, Resino S. HCV eradication with IFN-based therapy does not completely restore gene expression in PBMCs from HIV/HCV-coinfected patients. J Biomed Sci 2021; 28:23. [PMID: 33785040 PMCID: PMC8010945 DOI: 10.1186/s12929-021-00718-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/24/2021] [Indexed: 12/11/2022] Open
Abstract
Objective To evaluate the impact of hepatitis C virus (HCV) elimination via interferon (IFN)-based therapy on gene expression profiles related to the immune system in HIV/HCV-coinfected patients. Methods We conducted a prospective study in 28 HIV/HCV-coinfected patients receiving IFN-based therapy at baseline (HIV/HCV-b) and week 24 after sustained virological response (HIV/HCV-f). Twenty-seven HIV-monoinfected patients (HIV-mono) were included as a control. RNA-seq analysis was performed on peripheral blood mononuclear cells (PBMCs). Genes with a fold-change (FC) ≥ 1.5 (in either direction) and false discovery rate (FDR) ≤ 0.05 were identified as significantly differentially expressed (SDE). Results HIV/HCV-b showed six SDE genes compared to HIV-mono group, but no significantly enriched pathways were observed. For HIV/HCV-f vs. HIV/HCV-b, we found 58 SDE genes, 34 upregulated and 24 downregulated in the HIV/HCV-f group. Of these, the most overexpressed were CXCL2, PDCD6IP, ATP5B, IGSF9, RAB26, and CSRNP1, and the most downregulated were IFI44 and IFI44L. These 58 SDE genes revealed two significantly enriched pathways (FDR < 0.05), one linked to Epstein-Barr virus infection and another related to p53 signaling. For HIV/HCV-f vs. HIV-mono group, we found 44 SDE genes that revealed 31 enriched pathways (FDR < 0.05) related to inflammation, cancer/cell cycle alteration, viral and bacterial infection, and comorbidities associated with HIV/HCV-coinfection. Five genes were overrepresented in most pathways (JUN, NFKBIA, PIK3R2, CDC42, and STAT3). Conclusion HIV/HCV-coinfected patients who eradicated hepatitis C with IFN-based therapy showed profound gene expression changes after achieving sustained virological response. The altered pathways were related to inflammation and liver-related complications, such as non-alcoholic fatty liver disease and hepatocellular carcinoma, underscoring the need for active surveillance for these patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12929-021-00718-6.
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Affiliation(s)
- Óscar Brochado
- Unidad de Infección Viral E Inmunidad, Centro Nacional de Microbiología, Instituto de Salud Carlos III (Campus Majadahonda), Carretera Majadahonda-Pozuelo, Km 2.2, 28220, MajadahondaMadrid, Spain
| | - Isidoro Martínez
- Unidad de Infección Viral E Inmunidad, Centro Nacional de Microbiología, Instituto de Salud Carlos III (Campus Majadahonda), Carretera Majadahonda-Pozuelo, Km 2.2, 28220, MajadahondaMadrid, Spain.
| | - Juan Berenguer
- Unidad de Enfermedades Infecciosas/VIH, Hospital General Universitario "Gregorio Marañón", Madrid, Spain.,Instituto de Investigación Sanitaria del Gregorio Marañón, Madrid, Spain
| | - Luz Medrano
- Unidad de Infección Viral E Inmunidad, Centro Nacional de Microbiología, Instituto de Salud Carlos III (Campus Majadahonda), Carretera Majadahonda-Pozuelo, Km 2.2, 28220, MajadahondaMadrid, Spain
| | - Juan González-García
- Unidad de VIH, Servicio de Medicina Interna, Hospital Universitario "La Paz", Madrid, Spain.,Instituto de Investigacion Sanitaria La Paz (IdiPAZ), Madrid, Spain
| | - María Ángeles Jiménez-Sousa
- Unidad de Infección Viral E Inmunidad, Centro Nacional de Microbiología, Instituto de Salud Carlos III (Campus Majadahonda), Carretera Majadahonda-Pozuelo, Km 2.2, 28220, MajadahondaMadrid, Spain
| | - Ana Carrero
- Unidad de Enfermedades Infecciosas/VIH, Hospital General Universitario "Gregorio Marañón", Madrid, Spain.,Instituto de Investigación Sanitaria del Gregorio Marañón, Madrid, Spain
| | - Víctor Hontañón
- Unidad de VIH, Servicio de Medicina Interna, Hospital Universitario "La Paz", Madrid, Spain.,Instituto de Investigacion Sanitaria La Paz (IdiPAZ), Madrid, Spain
| | - Jordi Navarro
- Servicio de Enfermedades Infecciosas, Hospital Universitari Vall D'Hebron, Barcelona, Spain.,Institut de Recerca Vall D'Hebron, Barcelona, Spain
| | | | - Amanda Fernández-Rodríguez
- Unidad de Infección Viral E Inmunidad, Centro Nacional de Microbiología, Instituto de Salud Carlos III (Campus Majadahonda), Carretera Majadahonda-Pozuelo, Km 2.2, 28220, MajadahondaMadrid, Spain
| | - Salvador Resino
- Unidad de Infección Viral E Inmunidad, Centro Nacional de Microbiología, Instituto de Salud Carlos III (Campus Majadahonda), Carretera Majadahonda-Pozuelo, Km 2.2, 28220, MajadahondaMadrid, Spain.
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