1
|
Harrison I, Patel B, Kunzler E, Walker A, Missall T, Motaparthi K. Dermatopathologist accuracy in classifying angioinvasive fungal infections using virtual microscopy. J Cutan Pathol 2024; 51:387-392. [PMID: 38366893 DOI: 10.1111/cup.14596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 12/28/2023] [Accepted: 01/28/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Due to perceived difficulty in the categorization of angioinvasive fungal infections based on histopathology, variation exists in dermatopathology reporting. METHODS This study characterized the diagnosis of angioinvasive fungal infections by light microscopy at a single academic institution over an 11-year period. Subsequently, the accuracy of blinded reclassification by virtual microscopy was measured. RESULTS Seventy-six specimens with hematoxylin-eosin slides were obtained from 33 patients. The mean diagnostic accuracy of dermatopathologists in differentiating mucormycosis, hyalohyphomycosis, and phaeohyphomycosis based on blinded reclassification via virtual microscopy was 74%, with a range of 65%-91%. CONCLUSIONS While there was a range in diagnostic accuracy, the highest score of 91% and the identification of common sources of error suggest that histopathologic categorization of angioinvasive fungal infections can frequently be performed. However, accurate identification is not always possible given common pitfalls in diagnosis. In addition, standardized and clinically useful reporting should be considered.
Collapse
Affiliation(s)
- Iris Harrison
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Basil Patel
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Elaine Kunzler
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Addie Walker
- Department of Pathology and Laboratory Medicine, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Tricia Missall
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| |
Collapse
|
2
|
Gagna CE, Yodice AN, D'Amico J, Elkoulily L, Gill SM, DeOcampo FG, Rabbani M, Kaur J, Shah A, Ahmad Z, Lambert MW, Clark Lambert W. Novel B-DNA dermatophyte assay for demonstration of canonical DNA in dermatophytes: Histopathologic characterization by artificial intelligence. Clin Dermatol 2024; 42:233-258. [PMID: 38185195 DOI: 10.1016/j.clindermatol.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
We describe a novel assay and artificial intelligence-driven histopathologic approach identifying dermatophytes in human skin tissue sections (ie, B-DNA dermatophyte assay) and demonstrate, for the first time, the presence of dermatophytes in tissue using immunohistochemistry to detect canonical right-handed double-stranded (ds) B-DNA. Immunohistochemistry was performed using anti-ds-B-DNA monoclonal antibodies with formalin-fixed paraffin-embedded tissues to determine the presence of dermatophytes. The B-DNA assay resulted in a more accurate identification of dermatophytes, nuclear morphology, dimensions, and gene expression of dermatophytes (ie, optical density values) than periodic acid-Schiff (PAS), Grocott methenamine silver (GMS), or hematoxylin and eosin (H&E) stains. The novel assay guided by artificial intelligence allowed for efficient identification of different types of dermatophytes (eg, hyphae, microconidia, macroconidia, and arthroconidia). Using the B-DNA dermatophyte assay as a clinical tool for diagnosing dermatophytes is an alternative to PAS, GMS, and H&E as a fast and inexpensive way to accurately detect dermatophytosis and reduce the number of false negatives. Our assay resulted in superior identification, sensitivity, life cycle stages, and morphology compared to H&E, PAS, and GMS stains. This method detects a specific structural marker (ie, ds-B-DNA), which can assist with diagnosis of dermatophytes. It represents a significant advantage over methods currently in use.
Collapse
Affiliation(s)
- Claude E Gagna
- Department of Biological and Chemical Sciences, College of Arts and Sciences, New York Institute of Technology, Old Westbury, New York, USA; Department of Pathology and Laboratory Medicine, Rutgers-New Jersey Medical School, Newark, New Jersey, USA; Department of Dermatology, Rutgers-New Jersey Medical School, Newark, New Jersey, USA; Department of Medicine, Rutgers-New Jersey Medical School, Newark, New Jersey, USA.
| | - Anthony N Yodice
- Department of Biological and Chemical Sciences, College of Arts and Sciences, New York Institute of Technology, Old Westbury, New York, USA
| | - Juliana D'Amico
- Department of Biological and Chemical Sciences, College of Arts and Sciences, New York Institute of Technology, Old Westbury, New York, USA
| | - Lina Elkoulily
- Department of Biological and Chemical Sciences, College of Arts and Sciences, New York Institute of Technology, Old Westbury, New York, USA
| | - Shaheryar M Gill
- Department of Biological and Chemical Sciences, College of Arts and Sciences, New York Institute of Technology, Old Westbury, New York, USA
| | - Francis G DeOcampo
- Department of Biological and Chemical Sciences, College of Arts and Sciences, New York Institute of Technology, Old Westbury, New York, USA
| | - Maryam Rabbani
- Department of Biological and Chemical Sciences, College of Arts and Sciences, New York Institute of Technology, Old Westbury, New York, USA
| | - Jai Kaur
- Department of Biological and Chemical Sciences, College of Arts and Sciences, New York Institute of Technology, Old Westbury, New York, USA
| | - Aangi Shah
- Department of Biological and Chemical Sciences, College of Arts and Sciences, New York Institute of Technology, Old Westbury, New York, USA
| | - Zainab Ahmad
- Department of Biological and Chemical Sciences, College of Arts and Sciences, New York Institute of Technology, Old Westbury, New York, USA
| | - Muriel W Lambert
- Department of Pathology and Laboratory Medicine, Rutgers-New Jersey Medical School, Newark, New Jersey, USA; Department of Dermatology, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - W Clark Lambert
- Department of Pathology and Laboratory Medicine, Rutgers-New Jersey Medical School, Newark, New Jersey, USA; Department of Dermatology, Rutgers-New Jersey Medical School, Newark, New Jersey, USA; Department of Medicine, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| |
Collapse
|
3
|
Hartsough EM, Foreman RK, Martinez-Lage M, Branda J, Sohani AR, Zukerberg L. Dematiaceous fungal infections: clinical and pathologic conundrums. J Clin Pathol 2024; 77:352-357. [PMID: 38272660 DOI: 10.1136/jcp-2023-209239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/11/2024] [Indexed: 01/27/2024]
Abstract
Dematiaceous fungi are defined by pigment within their cell walls. They are increasingly recognised human pathogens, causing a wide range of clinical presentations, from localised subcutaneous infections to disseminated disease in rare cases. We report our institutional experience with diagnosis of dematiaceous fungal infections from 2005 to 2022 and highlight four instructive cases that clinically and pathologically mimicked other diseases for which the diagnosis was confirmed by fungal culture (one case) or supported by PCR with 28S rRNA and internal transcribed spacer primers (three cases). Two patients were immunocompromised and two had presumed exposure to the organism. In each highlighted case, fungal infection was not clinically suspected, and the pathologist was critical in making the diagnosis and ensuring appropriate clinical management, which was supplemented by fungal stains and novel molecular methods.
Collapse
Affiliation(s)
- Emily Mae Hartsough
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ruth K Foreman
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maria Martinez-Lage
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John Branda
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Aliyah R Sohani
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lawerence Zukerberg
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
4
|
Graeter A, Lee D, Handley G, Baluch A, Klinkova O. Chronic disseminated candidiasis in a patient with acute leukemia - an illustrative case and brief review for clinicians. BMC Infect Dis 2024; 24:296. [PMID: 38448809 PMCID: PMC10916012 DOI: 10.1186/s12879-024-09172-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 02/24/2024] [Indexed: 03/08/2024] Open
Abstract
Chronic disseminated candidiasis (CDC) is a severe but rarely seen fungal infection presenting in patients with hematologic malignancies after a prolonged duration of neutropenia. A high index of suspicion is required to diagnose CDC as standard culture workup is often negative. While tissue biopsy is the gold standard of diagnosis, it is frequently avoided in patients with profound cytopenias and increased bleeding risks. A presumptive diagnosis can be made in patients with recent neutropenia, persistent fevers unresponsive to antibiotics, imaging findings of hypoechoic, non-rim enhancing target-like lesions in the spleen and liver, and mycologic evidence. Here, we describe the case of an 18-year-old woman with relapsed B-cell acute lymphoblastic leukemia treated with re-induction chemotherapy who subsequently developed CDC with multi-organ involvement. The diagnosis was made based on clinical and radiologic features with positive tissue culture from a skin nodule and hepatic lesion. The patient was treated for a total course of 11 months with anti-fungal therapy, most notably amphotericin B and micafungin, and splenectomy. After initial diagnosis, the patient was monitored with monthly CT abdomen imaging that showed disease control after 5 months of anti-fungal therapy and splenectomy. The diagnosis, treatment, and common challenges of CDC are outlined here to assist with better understanding, diagnosis, and treatment of this rare condition.
Collapse
Affiliation(s)
- Allison Graeter
- Department of Internal Medicine, University of South Florida, 17 Davis Blvd., Suite 308, 33606, Tampa, FL, USA
| | - Dasom Lee
- Division of Hematology, Stanford University, 94305, Stanford, CA, USA
| | - Guy Handley
- Department of Infectious Disease and International Medicine, 1 Tampa General Circle, 33606, Tampa, FL, USA
| | - Aliyah Baluch
- Infectious Disease Division, Moffitt Cancer Center, 12902 USF Magnolia Drive, 33612, Tampa, FL, USA
| | - Olga Klinkova
- Infectious Disease Division, Moffitt Cancer Center, 12902 USF Magnolia Drive, 33612, Tampa, FL, USA.
| |
Collapse
|
5
|
Kim J, Dwivedi G, Boughton BA, Sharma A, Lee S. Advances in cellular and tissue-based imaging techniques for sarcoid granulomas. Am J Physiol Cell Physiol 2024; 326:C10-C26. [PMID: 37955119 DOI: 10.1152/ajpcell.00507.2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/06/2023] [Accepted: 11/08/2023] [Indexed: 11/14/2023]
Abstract
Sarcoidosis embodies a complex inflammatory disorder spanning multiple systems, with its origin remaining elusive. It manifests as the infiltration of inflammatory cells that coalesce into distinctive noncaseous granulomas within afflicted organs. Unraveling this disease necessitates the utilization of cellular or tissue-based imaging methods to both visualize and characterize the biochemistry of these sarcoid granulomas. Although hematoxylin and eosin stain, standard in routine use alongside cytological stains have found utility in diagnosis within clinical contexts, special stains such as Masson's trichrome, reticulin, methenamine silver, and Ziehl-Neelsen provide additional varied perspectives of sarcoid granuloma imaging. Immunohistochemistry aids in pinpointing specific proteins and gene expressions further characterizing these granulomas. Finally, recent advances in spatial transcriptomics promise to divulge profound insights into their spatial orientation and three-dimensional (3-D) molecular mapping. This review focuses on a range of preexisting imaging methods employed for visualizing sarcoid granulomas at the cellular level while also exploring the potential of the latest cutting-edge approaches like spatial transcriptomics and matrix-assisted laser desorption ionization mass spectrometry imaging (MALDI-MSI), with the overarching goal of shedding light on the trajectory of sarcoidosis research.
Collapse
Affiliation(s)
- Junwoo Kim
- Department of Advanced Clinical and Translational Cardiovascular Imaging, Harry Perkins Institute of Medical Research, Murdoch, Western Australia, Australia
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Girish Dwivedi
- Department of Advanced Clinical and Translational Cardiovascular Imaging, Harry Perkins Institute of Medical Research, Murdoch, Western Australia, Australia
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
- Department of Cardiology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Berin A Boughton
- Australian National Phenome Centre, Murdoch University, Murdoch, Western Australia, Australia
| | - Ankur Sharma
- Onco-Fetal Ecosystem Laboratory, Harry Perkins Institute of Medical Research, Nedlands, Western Australia, Australia
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
| | - Silvia Lee
- Department of Advanced Clinical and Translational Cardiovascular Imaging, Harry Perkins Institute of Medical Research, Murdoch, Western Australia, Australia
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
| |
Collapse
|
6
|
Wolner ZJ, Mustin DE, Stoff BK. Preordering Periodic Acid-Schiff Staining: A Quality Improvement Study. Am J Dermatopathol 2023; 45:825-827. [PMID: 37883931 DOI: 10.1097/dad.0000000000002570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
ABSTRACT Periodic acid-Schiff (PAS) stain is a commonly used ancillary test for inflammatory and infectious dermatoses, yet infrequently changes the diagnosis. Previous studies have shown that clinical suspicion and histopathologic features are poor predictors of PAS positivity. Current appropriate use criteria from the American Society of Dermatopathology supports PAS staining when histopathologic features could be consistent with a dermatophyte infection. At the authors' institution, PAS stains are preordered on biopsies of inflammatory and infectious diagnoses to aid in a timelier sign out. Our aim was to reduce the percentage of PAS stains preordered on all dermatology specimens over a 6-month period without reducing the percentage of fungal infections identified. Review of a 12-month preintervention period found that our laboratory received 6104 biopsies for which PAS stain was preordered on 616 (10.1%). Based on a review of the preintervention period, preordering PAS on cases with clinical suspicion for cutaneous T-cell lymphoma was stopped unless there was clinical suspicion for eczematous dermatitis, vesiculobullous disorders, or fungal infection. The proposed intervention resulted in a 3.7% reduction in the number of PAS stains ordered while PAS-positivity rate remained unchanged. The described quality improvement process may be used as a model for other laboratories.
Collapse
Affiliation(s)
- Zachary J Wolner
- Department of Dermatology, Emory University, Atlanta, GA; and
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA
| | | | - Benjamin K Stoff
- Department of Dermatology, Emory University, Atlanta, GA; and
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA
| |
Collapse
|
7
|
Rodrigues Hoffmann A, Ramos MG, Walker RT, Stranahan LW. Hyphae, pseudohyphae, yeasts, spherules, spores, and more: A review on the morphology and pathology of fungal and oomycete infections in the skin of domestic animals. Vet Pathol 2023; 60:812-828. [PMID: 37222139 DOI: 10.1177/03009858231173715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Fungi are among the most common infectious agents affecting the skin of animals. The skin can serve as a port of entry for fungal infections, which can eventually become disseminated. In some regions of the world, oomycetes, such as Pythium and Lagenidium, are also responsible for a significant number of severe cutaneous infections. Histologic evaluation of fungal morphology, including size, shape, septation, branching, and budding characteristics, combined with the distribution of inflammatory infiltrates within different skin layers can potentially identify etiologic agents, guiding selection of antifungals and additional diagnostics. Fungal infections of the skin surface are typically caused by Malassezia and rarely Candida, with opportunistic fungi also capable of colonizing the skin surface, especially when the barrier is broken. Folliculocentric infections, caused by dermatophytes, result in mild to severe inflammation and can occasionally penetrate deep into the skin. A wide range of fungi, including agents of hyalohyphomycosis, phaeohyphomycosis, and dimorphic fungal infections, as well as oomycetes, result in nodular cutaneous and subcutaneous lesions. With the occasional exception of dimorphic fungi, fungal speciation often requires cultures performed on fresh tissues. However, molecular techniques such as pan-fungal polymerase chain reaction on paraffin blocks is becoming an increasingly useful tool to distinguish between cutaneous fungal pathogens. This review focuses on describing the clinical and histologic features of the most common fungal and oomycete infections affecting the skin of animals, divided according to distribution patterns of lesions and fungal or oomycete morphology.
Collapse
|
8
|
Edelkamp J, Lousada MB, Pinto D, Chéret J, Calabrese FM, Jiménez F, Erdmann H, Wessel J, Phillip B, Angelis MD, Rinaldi F, Bertolini M, Paus R. Management of the human hair follicle microbiome by a synthetic odorant. J Dermatol Sci 2023; 112:99-108. [PMID: 37858476 DOI: 10.1016/j.jdermsci.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 08/17/2023] [Accepted: 09/28/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Human scalp hair follicles (HFs) engage in olfactory receptor (OR)-dependent chemosensation. Activation of olfactory receptor family 2 subfamily AT member 4 (OR2AT4) by the synthetic, sandalwood-like odorant Sandalore® up-regulated HF antimicrobial peptide expression of dermcidin (DCD), which had previously been thought to be produced exclusively by sweat and sebaceous glands. OBJECTIVES To understand if intrafollicular DCD production can be stimulated by a commonly used cosmetic odorant, thus altering human HF microbiome composition in a clinically beneficial manner. METHODS DCD expression was compared between fresh-frozen scalp biopsies and microdissected, full-length scalp HFs, organ-cultured in the presence/absence of the OR2AT4 agonist, Sandalore® and/or antibiotics and/or the competitive OR2AT4 antagonist, Phenirat®. Amplicon-based sequencing and microbial growth assays were performed to assess how this treatment affected the HF microbiome. RESULTS Synthetic odorant treatment upregulated epithelial DCD expression and exerted antimicrobial activity in human HFs ex vivo. Combined antibiotic and odorant treatment, during an ex vivo dysbiosis event, prevented HF tissue damage and favoured a more physiological microbiome composition. Sandalore®-conditioned medium, containing higher DCD content, favoured Staphylococcus epidermidis and Malassezia restricta over S. aureus and M. globosa, while exhibiting antimicrobial activity against Cutibacterium acnes. These effects were reversed by co-administration of Phenirat®. CONCLUSIONS We provide the first proof-of-principle that a cosmetic odorant impacts the human HF microbiome by up-regulating antimicrobial peptide production in an olfactory receptor-dependent manner. Specifically, a synthetic sandalwood-like odorant stimulates intrafollicular DCD production, likely via OR2AT4, and thereby controls microbial overgrowth. Thus, deserving further exploration as an adjuvant therapeutic principle in the management of folliculitis and dysbiosis-associated hair diseases.
Collapse
Affiliation(s)
- Janin Edelkamp
- Monasterium Laboratory Skin and Hair Research Solutions GmbH, Münster, Germany.
| | - Marta B Lousada
- Monasterium Laboratory Skin and Hair Research Solutions GmbH, Münster, Germany; Zoological Institute, Christian-Albrechts, University Kiel, Kiel, Germany
| | | | - Jérémy Chéret
- Dr Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Francisco Jiménez
- Mediteknia, Skin & Hair Lab, Las Palmas de Gran Canaria, Spain; University Fernando Pessoa Canarias, Las Palmas de Gran Canaria, Spain
| | | | - Julia Wessel
- Institute of Molecular Microbiology and Biotechnology (IMMB), University of Münster, Münster, Germany
| | - Bodo Phillip
- Institute of Molecular Microbiology and Biotechnology (IMMB), University of Münster, Münster, Germany
| | - Maria De Angelis
- Department of Soil, Plant and Food Science, University of Bari Aldo Moro, Bari, Italy
| | | | - Marta Bertolini
- Monasterium Laboratory Skin and Hair Research Solutions GmbH, Münster, Germany
| | - Ralf Paus
- Monasterium Laboratory Skin and Hair Research Solutions GmbH, Münster, Germany; Mediteknia, Skin & Hair Lab, Las Palmas de Gran Canaria, Spain; CUTANEON Skin & Hair Innovations, Hamburg, Germany
| |
Collapse
|
9
|
Godse R, Rodriguez O, Ayoade KO, Rubin AI. Update on nail unit histopathology. Hum Pathol 2023; 140:214-232. [PMID: 36921726 DOI: 10.1016/j.humpath.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 03/08/2023] [Indexed: 03/18/2023]
Abstract
Histopathologic evaluation of the nail unit is an essential component in the diagnosis of nail unit disorders. This review highlights recent updates in nail unit histopathology and discusses literature covering a wide range of nail disorders including melanoma/melanocytic lesions, squamous cell carcinoma, onychomatricoma, onychopapilloma, onychomycosis, lichen planus, and other inflammatory conditions. Herein we also discuss recent literature on nail clipping histopathology, a useful and noninvasive diagnostic tool that continues to grow in popularity and importance to both dermatologists and dermatopathologists.
Collapse
Affiliation(s)
- Rama Godse
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Olaf Rodriguez
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Katherine Omueti Ayoade
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Adam I Rubin
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
10
|
Giardino L, Generali L, Del Fabbro M, Tartaglia GM, Bidossi A, Savadori P. Detection of bacteria in dental samples using the Periodic acid-Schiff (PAS) histological stain. Micron 2023; 172:103498. [PMID: 37295188 DOI: 10.1016/j.micron.2023.103498] [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: 03/24/2023] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Abstract
The bacterial cell wall mainly consists of glycoproteins and polysaccharides, which could be detected in dental tissue with specific stain protocols. The present study aimed to investigate bacteria stainability in dental histological samples of human teeth by a histochemical method. Eight extracted teeth, because severely decayed, were decalcified, dehydrated, paraffin-embedded, and serially sectioned at 4 µm thickness each. The serial sections were then stained with Periodic acid-Schiff (PAS). Furthermore, SEM analysis was performed on the same slide of one previously histologically investigated tooth to acquire more details on the structures stained by the PAS method obtained from the histological procedures. Afterward, some American Type Culture Collection (ATCC) strains, smeared on glass slides, were stained following the staining method used in histological samples. Stained rod and cocci forms by PAS stain, observed under light microscopy, were predominantly detected inside dentinal tubules and root canal space of histologically examined specimens, suggesting their bacterial origin. Additional SEM analysis on the identical histological stained slide showed the precise nature of these forms (bacteria) and supplemental information regarding their vitality status. In addition, ATCC smeared strain samples showed variable PAS stainability of microorganisms investigated. Due to its properties, the PAS histochemical stain could be a valid and helpful aid for non- or weakly stainable microorganisms in infected tissues to be associated with other methods of investigation.
Collapse
Affiliation(s)
| | - Luigi Generali
- Department of Surgery, Medicine, Dentistry and Morphological Sciences with Transplant Surgery, Oncology and Regenerative Medicine Relevance (CHIMOMO), University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Massimo Del Fabbro
- Dipartimento di Scienze Biomediche, Chirurgiche ed Odontoiatriche, Università Degli Studi di Milano, 20122 Milan, Italy; IRCCS Fondazione Cà Granda IRCCS Ospedale Maggiore Policlinico, 20133, Milano, Italy
| | - Gianluca Martino Tartaglia
- Dipartimento di Scienze Biomediche, Chirurgiche ed Odontoiatriche, Università Degli Studi di Milano, 20122 Milan, Italy; IRCCS Fondazione Cà Granda IRCCS Ospedale Maggiore Policlinico, 20133, Milano, Italy
| | | | - Paolo Savadori
- Dipartimento di Scienze Biomediche, Chirurgiche ed Odontoiatriche, Università Degli Studi di Milano, 20122 Milan, Italy; IRCCS Fondazione Cà Granda IRCCS Ospedale Maggiore Policlinico, 20133, Milano, Italy.
| |
Collapse
|
11
|
Large Lobular Capillary Hemangioma Associated with Ingrown Toenail: Histopathological Features and Case Report. Dermatopathology (Basel) 2022; 9:271-276. [PMID: 35892484 PMCID: PMC9330171 DOI: 10.3390/dermatopathology9030031] [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: 04/16/2022] [Revised: 07/19/2022] [Accepted: 07/22/2022] [Indexed: 11/18/2022] Open
Abstract
Lobular capillary hemangioma (LCH-PG) is a type of pyogenic granuloma characterized by proliferating blood vessels that resemble conventional granulation tissue. Granulation tissue is very often seen in association with ingrown toenails. Despite the close relationship between both entities, LCH-PG shows clinically different behaviors, such as rapid growth and frequent recurrence. Currently, it is unknown exactly how the different etiological factors contribute to the formation of differences between entities. We present a case of a large LCH-PG associated with chronic onychocryptosis in a 26-year-old man. Histopathological features included extensive signs of ulceration, hyperkeratosis, and patchy epidermal acanthosis with the presence of fibrous septa with lobular areas beneath the ulcerative area. The presence of stroma with a marked proliferation of blood vessels with wall thickening and mixed-type inflammatory changes was also characteristic. In advanced stages of onychocryptosis, as presented here, conventional granulation tissue or pyogenic granuloma can be clinically difficult to distinguish from other benign or malignant neoplasms. Histological examination is mandatory, and excisional biopsy can provide a definitive diagnosis.
Collapse
|
12
|
Yilmaz A, Göktay F, Varol R, Gencoglan G, Uvet H. Deep Convolutional Neural Networks for Onychomycosis Detection using Microscopic Images with KOH Examination. Mycoses 2022; 65:1119-1126. [PMID: 35842749 DOI: 10.1111/myc.13498] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/12/2022] [Accepted: 07/14/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The diagnosis of superficial fungal infections is still mostly based on direct microscopic examination with Potassium Hydroxide solution. However, this method can be time consuming and its diagnostic accuracy rates vary widely depending on the clinician's experience. OBJECTIVES This study presents a deep neural network structure that enables the rapid solutions for these problems and can perform automatic fungi detection in grayscale images without dyes. METHODS 160 microscopic full field photographs containing the fungal element, obtained from patients with onychomycosis, and 297 microscopic full field photographs containing dissolved keratin obtained from normal nails were collected. Smaller patches containing fungi (n=1835) and keratin (n=5238) were extracted from these full field images. In order to detect fungus and keratin, VGG16 and InceptionV3 models were developed by the use of these patches. The diagnostic performance of models was compared with 16 dermatologists by using 200 test patches. RESULTS For the VGG16 model, the InceptionV3 model and 16 dermatologists; mean accuracy rates were 88.10%±0.8%, 88.78%±0.35%, and 74.53%±8.57%, respectively; mean sensitivity rates were 75.04%±2.73%, 74.93%±4.52%, and 74.81%±19.51%, respectively; and mean specificity rates were 92.67%±1.17%, 93.78%±1.74%, and 74.25%±18.03%, respectively. The models were statistically superior to dermatologists according to rates of accuracy and specificity but not to sensitivity (p < 0.0001, p < 0.005, and p > 0.05, respectively). Area under curve values of the VGG16 and InceptionV3 models were 0.9339 and 0.9292, respectively. CONCLUSION Our research demonstrates that it is possible to build an automated system capable of detecting fungi present in microscopic images employing the proposed deep learning models. It has great potential for fungal detection applications based on AI.
Collapse
Affiliation(s)
- Abdurrahim Yilmaz
- Mechatronics Engineering, Yildiz Technical University, Yildiz Boulevard, Besiktas, Istanbul, Turkey
| | - Fatih Göktay
- Department of Dermatology and Venereology, University of Health Sciences Turkey, Hamidiye Medical Faculty, Haydarpasa Numune Training and Research Hospital, Uskudar, Istanbul, Turkey
| | - Rahmetullah Varol
- Mechatronics Engineering, Yildiz Technical University, Yildiz Boulevard, Besiktas, Istanbul, Turkey
| | - Gulsum Gencoglan
- Department of Dermatology, Liv Hospital Vadistanbul, Istinye University, Sariyer, Istanbul, Turkey
| | - Huseyin Uvet
- Mechatronics Engineering, Yildiz Technical University, Yildiz Boulevard, Besiktas, Istanbul, Turkey
| |
Collapse
|
13
|
Babakoohi S, McCall CM. Dermatophytosis Incognito Mimicking Cutaneous T-Cell Lymphoma. Cureus 2022; 14:e25809. [PMID: 35822141 PMCID: PMC9271217 DOI: 10.7759/cureus.25809] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2022] [Indexed: 11/18/2022] Open
Abstract
Dermatophytosis incognito can be missed in diagnosis, given its relatively low prevalence as compared with common cases of dermatophytosis and therefore, is likely under-reported. Cutaneous T-cell lymphoma (CTCL) is also a rare entity with variable clinical manifestations. While successful treatment of dermatophytosis is feasible withmultiple topical and systemic antifungal options, CTCL can present a therapeutic challenge associated with significant emotional distress for the patients. We present a case of tinea incognito initially treated for eczema, later considered biopsy-supported CTCL that was successfully treated with antifungal therapy.
Collapse
|
14
|
Barantsevich N, Barantsevich E. Diagnosis and Treatment of Invasive Candidiasis. Antibiotics (Basel) 2022; 11:antibiotics11060718. [PMID: 35740125 PMCID: PMC9219674 DOI: 10.3390/antibiotics11060718] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/14/2022] [Accepted: 05/18/2022] [Indexed: 02/06/2023] Open
Abstract
Candida species, belonging to commensal microbial communities in humans, cause opportunistic infections in individuals with impaired immunity. Pathogens encountered in more than 90% cases of invasive candidiasis include C. albicans, C. glabrata, C. krusei, C. tropicalis, and C. parapsilosis. The most frequently diagnosed invasive infection is candidemia. About 50% of candidemia cases result in deep-seated infection due to hematogenous spread. The sensitivity of blood cultures in autopsy-proven invasive candidiasis ranges from 21% to 71%. Non-cultural methods (beta-D-glucan, T2Candida assays), especially beta-D-glucan in combination with procalcitonin, appear promising in the exclusion of invasive candidiasis with high sensitivity (98%) and negative predictive value (95%). There is currently a clear deficiency in approved sensitive and precise diagnostic techniques. Omics technologies seem promising, though require further development and study. Therapeutic options for invasive candidiasis are generally limited to four classes of systemic antifungals (polyenes, antimetabolite 5-fluorocytosine, azoles, echinocandins) with the two latter being highly effective and well-tolerated and hence the most widely used. Principles and methods of treatment are discussed in this review. The emergence of pan-drug-resistant C. auris strains indicates an insufficient choice of available medications. Further surveillance, alongside the development of diagnostic and therapeutic methods, is essential.
Collapse
|
15
|
Fung MA, Vidal CI, Armbrecht EA, Andea AA, Cassarino DS, Comfere NI, Emanuel PO, Ferringer T, Hristov AC, Kim J, Lauer SR, Linos K, Missall TA, Motaparthi K, Novoa RA, Patel R, Shalin SC, Sundram U, Calame A, Bennett DD, Duncan LM, Elston DM, Hosler GA, Hurley YM, Lazar AJ, Lowe L, Messina J, Myles J, Plaza JA, Prieto VG, Reddy V, Schaffer A, Subtil A. Appropriate use criteria for ancillary diagnostic testing in dermatopathology: New recommendations for 11 tests and 220 clinical scenarios from the American Society of Dermatopathology Appropriate Use Criteria Committee. J Cutan Pathol 2022; 49:231-245. [PMID: 34536035 DOI: 10.1111/cup.14135] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Appropriate use criteria (AUC) provide patient-centered physician guidance in test selection. An initial set of AUC was reported by the American Society of Dermatopathology (ASDP) in 2018. AUC reflect evidence collected at single timepoints and may be affected by evolving evidence and experience. The objective of this study was to update and expand AUC for selected tests. METHODS RAND/UCLA (RAND Corporation [Santa Monica, CA]/University of California Los Angeles) methodology used includes the following: (a) literature review; (b) review of previously rated tests and previously employed clinical scenarios; (c) selection of previously rated tests for new ratings; (d) development of new clinical scenarios; (e) selection of additional tests; (f) three rating rounds with feedback and group discussion after rounds 1 and 2. RESULTS For 220 clinical scenarios comprising lymphoproliferative (light chain clonality), melanocytic (comparative genomic hybridization, fluorescence in situ hybridization, reverse transcription polymerase chain reaction, telomerase reverse transcriptase promoter), vascular disorders (MYC), and inflammatory dermatoses (periodic acid-Schiff, Gömöri methenamine silver), consensus by panel raters was reached in 172 of 220 (78%) scenarios, with 103 of 148 (70%) rated "usually appropriate" or "rarely appropriate" and 45 of 148 (30%), "appropriateness uncertain." LIMITATIONS The study design only measures appropriateness. Cost, availability, test comparison, and additional clinical considerations are not measured. The possibility that the findings of this study may be influenced by the inherent biases of the dermatopathologists involved in the study cannot be excluded. CONCLUSIONS AUC are reported for selected diagnostic tests in clinical scenarios that occur in dermatopathology practice. Adhering to AUC may reduce inappropriate test utilization and improve healthcare delivery.
Collapse
Affiliation(s)
- Maxwell A Fung
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, California, USA
- Department of Pathology and Laboratory Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - Claudia I Vidal
- Dermatology Center of Southern Indiana, Bloomington, Indiana, USA
| | - Eric A Armbrecht
- Center for Health Outcomes Research, Saint Louis University, Saint Louis, Missouri, USA
| | - Aleodor A Andea
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - David S Cassarino
- Department of Pathology, Kaiser Permanente Southern California, Los Angeles, California, USA
| | - Nneka I Comfere
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Tammie Ferringer
- Department of Dermatology, Geisinger Medical Center, Danville, Pennsylvania, USA
- Department of Laboratory Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Alexandra C Hristov
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jinah Kim
- Palo Alto Medical Foundation, Palo Alto, California, USA
| | - Scott R Lauer
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Konstantinos Linos
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Tricia A Missall
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Roberto A Novoa
- Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Rajiv Patel
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Sara C Shalin
- Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Uma Sundram
- Department of Anatomic Pathology, Oakland University William Beaumont School of Medicine and Beaumont Health Systems, Royal Oak, Michigan, USA
| | | | - Daniel D Bennett
- Department of Dermatology, University of Wisconsin, Madison, Wisconsin, USA
| | - Lyn M Duncan
- Pathology Service and Dermatopathology Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Dirk M Elston
- Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gregory A Hosler
- ProPath, Department of Dermatology, Dallas, Texas, USA
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Yadira M Hurley
- Department of Dermatology, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
- Department of Pathology, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
| | - Alexander J Lazar
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Dermatology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lori Lowe
- Department of Pathology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jane Messina
- Department of Dermatology and Cutaneous Surgery, University of South Florida, Moffitt Cancer Center, Tampa, Florida, USA
| | - Jonathan Myles
- Department of Pathology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jose A Plaza
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Victor G Prieto
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vijaya Reddy
- Department of Pathology, Rush Medical College, Chicago, Illinois, USA
- Department of Dermatology, Rush Medical College, Chicago, Illinois, USA
| | - András Schaffer
- Division of Dermatology, Florida State University College of Medicine, Tallahassee, Florida, USA
| | - Antonio Subtil
- Royal Jubilee Hospital, Victoria, British Columbia, Canada
- Department of Pathology, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
16
|
Identification of Pneumocystis jirovecii with Fluorescence In-Situ Hybridization (FISH) in Patient Samples-A Proof-of-Principle. J Fungi (Basel) 2021; 8:jof8010013. [PMID: 35049953 PMCID: PMC8778293 DOI: 10.3390/jof8010013] [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: 12/06/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 11/17/2022] Open
Abstract
In resource-limited settings, where pneumocystosis in immunocompromised patients is infrequently observed, cost-efficient, reliable, and sensitive approaches for the diagnostic identification of Pneumocystis jirovecii in human tissue samples are desirable. Here, an in-house fluorescence in situ hybridization assay was comparatively evaluated against Grocott’s staining as a reference standard with 30 paraffin-embedded tissue samples as well as against in-house real-time PCR with 30 respiratory secretions from immunocompromised patients with clinical suspicion of pneumocystosis. All pneumocystosis patients included in the study suffered from HIV/AIDS. Compared with Grocott’s staining as the reference standard, sensitivity of the FISH assay was 100% (13/13), specificity was 41% (7/17), and the overall concordance was 66.7% with tissue samples. With respiratory specimens, sensitivity was 83.3% (10/12), specificity was 100% (18/18), and the overall concordance was 93.3% as compared with real-time PCR. It remained unresolved to which proportions sensitivity limitations of Grocott’s staining or autofluorescence phenomena affecting the FISH assay accounted for the recorded reduced specificity with the tissue samples. The assessment confirmed Pneumocystis FISH in lung tissue as a highly sensitive screening approach; however, dissatisfying specificity in paraffin-embedded biopsies calls for confirmatory testing with other techniques in case of positive FISH screening results. In respiratory secretions, acceptable sensitivity and excellent specificity were demonstrated for the diagnostic application of the P. jirovecii-specific FISH assay.
Collapse
|
17
|
Martínez-Valenzuela L, Draibe J, Fulladosa X, Gomà M, Gómez F, Antón P, Cruzado JM, Torras J. Acute Tubulointerstitial Nephritis in Clinical Oncology: A Comprehensive Review. Int J Mol Sci 2021; 22:2326. [PMID: 33652638 PMCID: PMC7956739 DOI: 10.3390/ijms22052326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/12/2021] [Accepted: 02/22/2021] [Indexed: 01/01/2023] Open
Abstract
Acute kidney injury in patients who suffer a malignancy is a common complication. Due to its high prevalence and effective treatment, one of the most frequent causes that both oncologists and nephrologists must be aware of is acute tubulointerstitial nephritis (ATIN). ATIN is an immunomediated condition and the hallmark of the disease, with the presence of a tubulointerstitial inflammatory infiltrate in the renal parenchyma. This infiltrate is composed mainly of T lymphocytes that can be accompanied by macrophages, neutrophils, or eosinophils among other cells. One of the major causes is drug-related ATIN, and some antineoplastic treatments have been related to this condition. Worthy of note are the novel immunotherapy treatments aimed at enhancing natural immunity in order to defeat cancer cells. In the context of the immunosuppression status affecting ATIN patients, some pathogen antigens can trigger the development of the disease. Finally, hematological malignancies can also manifest in the kidney leading to ATIN, even at the debut of the disease. In this review, we aim to comprehensively examine differential diagnosis of ATIN in the setting of a neoplastic patient.
Collapse
Affiliation(s)
- Laura Martínez-Valenzuela
- Nephrology Department, Bellvitge University Hospital, Hospitalet de Llobregat, 08907 Barcelona, Spain; (L.M.-V.); (X.F.); (F.G.); (P.A.); (J.M.C.)
- IDIBELL Biomedical Research Institute, Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Juliana Draibe
- Nephrology Department, Bellvitge University Hospital, Hospitalet de Llobregat, 08907 Barcelona, Spain; (L.M.-V.); (X.F.); (F.G.); (P.A.); (J.M.C.)
- IDIBELL Biomedical Research Institute, Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Xavier Fulladosa
- Nephrology Department, Bellvitge University Hospital, Hospitalet de Llobregat, 08907 Barcelona, Spain; (L.M.-V.); (X.F.); (F.G.); (P.A.); (J.M.C.)
- IDIBELL Biomedical Research Institute, Hospitalet de Llobregat, 08907 Barcelona, Spain
- Clinical Science Department, Campus de Bellvitge, Barcelona University, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Montserrat Gomà
- Pathology Department, Bellvitge University Hospital, Hospitalet de Llobregat, 08907 Barcelona, Spain;
| | - Francisco Gómez
- Nephrology Department, Bellvitge University Hospital, Hospitalet de Llobregat, 08907 Barcelona, Spain; (L.M.-V.); (X.F.); (F.G.); (P.A.); (J.M.C.)
| | - Paula Antón
- Nephrology Department, Bellvitge University Hospital, Hospitalet de Llobregat, 08907 Barcelona, Spain; (L.M.-V.); (X.F.); (F.G.); (P.A.); (J.M.C.)
| | - Josep María Cruzado
- Nephrology Department, Bellvitge University Hospital, Hospitalet de Llobregat, 08907 Barcelona, Spain; (L.M.-V.); (X.F.); (F.G.); (P.A.); (J.M.C.)
- IDIBELL Biomedical Research Institute, Hospitalet de Llobregat, 08907 Barcelona, Spain
- Clinical Science Department, Campus de Bellvitge, Barcelona University, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Joan Torras
- Nephrology Department, Bellvitge University Hospital, Hospitalet de Llobregat, 08907 Barcelona, Spain; (L.M.-V.); (X.F.); (F.G.); (P.A.); (J.M.C.)
- IDIBELL Biomedical Research Institute, Hospitalet de Llobregat, 08907 Barcelona, Spain
- Clinical Science Department, Campus de Bellvitge, Barcelona University, L’Hospitalet de Llobregat, 08907 Barcelona, Spain
| |
Collapse
|